Treating Eating Disorders as Disorders of Eating

Posted on by Psychotherapy.net Team

All illnesses classified as ‘mental’ are comprised of psychological, behavioral and physical components. Treatment strategies for eating disorders vary widely from psychoanalytic exploration of the emotional origins of the disorder without physical or behavioral intervention to forced tube or intravenous feeding with no behavioral or psychological work. However, despite decades of clinical research into the ideal combinations of cognitive/psychological, behavioral, and physical interventions, the mainstream evidence base is not inspiring.

One obvious conclusion to draw is that clinicians need to redouble their efforts to address the psychological components of eating disorders. However, a different reading is that the purely psychological pathway leads us down a rabbit hole. This is the claim of a Swedish treatment method that has achieved significantly more success in treating the full range of eating disorders than any other method, but that has been more or less completely ignored by the mainstream of eating disorders researchers and practitioners.

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Having treated more than 1,400 patients with eating disorders (around 40% with anorexia), the Mando Clinic, headquartered in Stockholm and led by Cecilia Bergh and Per Södersten, has achieved a 75% remission rate with zero mortalities, and 90% of those who reach remission progress to full recovery over a five-year follow-up period. (1,2). These results are considerably stronger than those achieved by traditional methods used in the treatment of anorexia and bulimia. The secret to their success is treating eating disorders as disorders of eating, rather than as disorders of psychological functioning. Specifically, people with anorexia usually start off eating too slowly, those with other eating disorders typically too fast; and both groups fail to sense and respond to satiety cues appropriately.

Rather than downplaying the behavior of eating as a troublesome side-effect of deep-seated psychological disturbance, the eating disturbance is treated as the cause of the psychological disturbances. Primarily, this means normalizing patients’ eating habits using the Mandometer (from the Latin mando, I eat), an app which communicates with a scale underneath your plate and provides normal curves for eating speed and satiety cues according to which patients gradually learn to adjust both. Alongside restricted exercise and rest in warm-rooms for an hour after eating, this simple behavioral intervention is the essence of the treatment.

Dig into their treatment practices a little more, though, and it becomes clear that the Mandometer and the heated rooms are just one part of their plan. Mando’s “case managers” are clinically trained to support patients through the program in ways that the Mando team calls “just common sense,” but that would probably look very familiar to anyone who practices CBT or any other kind of practically-oriented psychotherapy. Mando therapists use behaviorist techniques like successive approximation to help patients eat. The patient might be given a plate of food without having to eat it, then be asked to put an empty fork into their mouth, and perhaps then be invited to smell the food on the fork. Verbal reinforcement, small gifts, and promises of future rewards are given at every step. They say this is behavioral and not cognitive therapy, but are the dividing lines between cognitive and behavioral really so clear? Is it even helpful to draw them?

The medium is behavioral, but the effects are also in the mind. Likewise, the Mando team explains that the heat treatment following meals not only allows the calories that would have otherwise been used for thermal regulation to be used for normalizing bodyweight but also helps lessen the anxiety that interferes with eating. Moreover, the method includes other strands like the development of ‘emotional regulation’, understanding and appreciation of one’s body, improvement of self-esteem and self-awareness, and managing social situations and relationships– all concepts familiar to any cognitive therapist working with eating disorders.

The remarkable solidity of Mando’s evidence base compared to other methods does suggest that without a central focus on the eating, nothing else works well. But the possibility remains, for example, that CBT plus the Mandometer would work even better than either in isolation. The Mando team have made this suggestion in print, and in a personal communication to me, a partner in the clinic speculated:

“CBT may be improved if it used Mandometers during the meals, allowed negotiated meal size and speed, prevented exercise, and provided physical warmth for anorexic patients. The Mando method may be improved if its common-sense therapy was given more structure via CBT training, as long as the focus remains on fostering normal eating behavior and minimizing caloric expenditure, not on resolving deep psychological problems.”

So, the real question that needs to be answered next isn’t really “CBT or Mando?” It’s “which elements of either?” Other distinctive features of the Mando method include withdrawing patients from all psychoactive drugs (80% are taking something when they arrive); the case manager eating all meals with the patient (not just watching them eat) to begin with, and later going to restaurants with them; not allowing patients to know their weight, but asking them to focus on eating and resting; and negotiating everything, so that nothing happens without patient agreement, and agreement is sought via reasoning and evidence. Which of these components are crucial, which are nice to have or incidental?

The constant feedback between mind, body, and behavior doesn’t mean that it doesn’t matter where in the system you intervene. It does mean that if you don’t observe improvement in the entire system, you probably chose the wrong place to start. And the Mando team’s claim is that the behavior is the right place to begin, that it’s the fulcrum between body and mind, between BMI and the EDE-Q. Their work reminds us that people will never get better if you pretend (and allow them to pretend) that they’re better when they’re not, which is easiest to do if you elevate one measure (often bodyweight) above all the others.

As one Mando partner put it to me, in a discussion of risk factors for relapse, “Not actually being in remission is the biggest factor for relapse risk.” And being in remission means all kinds of complex yet mostly definable things, to which eating behavior may well be pivotal. There’s lots left to learn but putting the behavioral back in the cognitive may prove to be the best starting point.

1) Bergh, C., Brodin, U., Lindberg, G., & Södersten, P. (2002). Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Proceedings of the National Academy of Sciences, 99(14), 9486–9491.

2) Bergh, C., Callmar, M., Danemar, S., Hölcke, M., Isberg, S., Leon, M., and Palmberg, K. (2013). Effective treatment of eating disorders: Results at multiple sites. Behavioral Neuroscience, 127(6), 878–889.

3) Södersten, P., Nergårdh, R., Bergh, C., Zandian, M., & Scheurink, A. (2008). Behavioral neuroendocrinology and treatment of anorexia nervosa. Frontiers in Neuroendocrinology, 29(4), 445–462.

The Lose-Lose Comment: A Therapist

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In my years of practicing therapy, I frequently would not know what to say. Once, a woman made a classic doorknob disclosure as the session was ending: “When I was 14,” she said, “my uncle sexually abused me.” A male patient made fun of me for not following a story organized around economic theory. A woman wanted me to praise her for resisting temptation the week before. At these moments, I would typically frame my predicament as egalitarian (be spontaneous and gratifying) versus authoritarian (be withholding and rule-bound), and I would choose the egalitarian path. Other therapists, I’ve noticed, have other ways of framing therapy dilemmas.

I wish I’d known at the time how to make a lose-lose comment. For example, with the first patient, I might have said, “If I just say goodbye right now, I seem to be communicating that what you said is not that big a deal. But if I ask you about it, I seem to be communicating that it’s such a big deal that our relationship can’t take it in stride. I don’t think this dilemma is new to you in dealing with the abuse. Since both alternatives have disadvantages, I guess I’d like to keep our agreements intact, while assuring you that we will talk it over next time.”

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Two of the many ways of understanding therapeutic success make sense of the lose-lose comment’s effectiveness. First, Gregory Bateson, the anthropologist, observed therapy in a VA hospital and concluded that therapists teach patients how to metacommunicate. He meant that many people do not take advantage of their capacity for reflection before taking action, largely because they never learned to talk things over in a reflective space, much less in their own heads. He said that almost all therapies of every orientation excel at this because virtually all therapies talk things over. The dilemmas I mentioned above pressured me to act, and the lose-lose comment demonstrates that even intense pressure can be reflected upon.

Transference resolution seems outdated as a therapy construct, but it can be understood in contemporary terms. Jonathan Shedler has said that therapy teaches the patient, “That was then; this is now.” I have long maintained that successful therapy depends on the fact that the patient will mess up the therapy in the same way that they mess up other relationships, and the therapist’s job is to help resolve these relational conflicts. In this context, many therapy dilemmas arise when the patient promotes a characteristic mode of relating and the therapist is trying to promote a therapeutic mode. The lose-lose comment is intrinsically therapeutic, even when the alternatives specified by the comment are not, so it restores or maintains the therapeutic relationship.

To the economist, I might have said, “If I fight back, our relationship becomes a stag fight, but if I don’t, I will lose your respect. I get the sense that you might not be too familiar with other ways of relating.” If the last sentence seems like a putdown, I could have said, instead, “I’m not sure how we got to this point.” To the woman wanting praise, I might have said, “If I praise you, then it might cast you as a little girl, the very image that precedes your yielding to temptation; if I don’t, you might feel lonely, which we have also identified as a precursor to temptation.”

The structure of the lose-lose comment can become monotonous, but it lends itself to other forms. I could follow up the lose-lose comment with something like “Are those my only choices? I wish I could think of a way to show you how important I think that is while also showing you that I think we can take this in stride.” Or, with the economist, just holding my hands up in a timeout signal might have gotten us back on track.
 

I Dont Know How To Be Sorry

Posted on by Psychotherapy.net Team

In my last blog post, I wrote about shame-proneness, the propensity to experience shame in response to ambiguous situations that elicit self-evaluation. For example, if Patrick failed a test and he thought “damn, I didn’t study hard enough; I’ll study more for the next one,” this would suggest that he felt guilt. But if he thought “damn, you really are a loser; you’ll never be able to do this,” this would suggest that he felt shame. When internal narratives of shame are not transient; when feeling small, worthless and insignificant permeate all experience, this is shame-proneness, which has long term adverse consequences.

When Mark and Claire came into session, I felt the tension immediately. I gave them each an opportunity to share why they had come in. Both described a history of explosive arguments and interpersonal volatility followed by calm reconciliations, then a rise in tension, then another eruption filled with angry tirades and verbal assaults.

“When he says he’s sorry I always want to believe him. He seems so sincere, but it never sticks. And I never know when things will explode again. Coming to couple’s therapy is our last chance.”

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Mark looked down the whole time Claire spoke, then with his face tight he said, “What do you want me to say. I tell you I’m sorry and it’s never enough. Nothing is ever enough and it’s your fault too. This isn’t all me.”

As I listened to their interaction, and assessed their interpersonal dynamic, I heard statements of blame thrown back and forth, which is common early in couple’s therapy, but I also heard Mark’s failure to empathize.

The ability to follow through on “I’m sorrys” implies guilt, because genuine guilt indicates the desire for reparation. In emotionally abusive relationships, such as Mark and Claire’s, what looks like contrition (which implies guilt) is really the voice of shame. If Mark had truly been able to experience Claire’s feelings (empathy), he’d feel guilty. He’d be able to tolerate the painful introspections that often lead to repair.

But their cycle continued, over and over, even after Mark said he was sorry. When this happens, it means that shame is masquerading as guilt. Shame undermines the ability to empathize with another’s emotions. Empathy requires transcending the interpersonal boundary and experiencing the emotions of another. Because shame is so painful, it disallows this from happening and instead, when the self-evaluative discomfort comes, it gets projected back onto the other; so, instead of seeing the other as the victim, they are seen as the perpetrator and hence the cycle continues.

While studying the relationship between shame, guilt and empathy, I found that there were two categories of empathy. Shame-empathy, which looks like empathy, but isn’t, because it’s not motivated by the pain of hurting someone else, but rather by the distress and fear of losing the other. It’s a self-focused experience, not an interpersonal one. Guilt-empathy, (what we think of when we think of empathy), on the other hand, leads to feeling the others pain and not wanting to do it again.

I heard Mark projecting blame. I watched his discomfort when Claire voiced her concerns. I noticed that he quickly retaliated for the smallest slight. I knew then that this was going to be a huge challenge. Empathy is fundamental to healthy relationships. When I work with couples where one has underlying shame, I know the only way it will heal is if empathy can be garnered, which means the shame needs to be processed. That type of examination is a slippery slope, because any introspection can cause more shame and more defensiveness.

I asked Mark, “What are feeling right before you respond to Claire?”

“I – I. Angry.”

“Can you say more?”

“Angry that she says those things to me. What does she want from me. If she’s going to blame me for everything, why are we even here.”

“I didn’t hear her blame you for everything.”

He folded his arms. “You’re taking her side.”

“There are no sides. My job is look at what’s happening and help you both communicate better. I have a feeling that the things Claire says make you feel bad about yourself.”

“That’s right. She’s always making me feel bad about myself.”

“I don’t mean to do that,” Claire said. “I have to be able to tell you how I feel and whenever I do, you get angry.”

“That’s not true,” Mark raised his voice. “You don’t tell me how you feel. You tell me about all of the shitty things I’ve done. What about all of the good things I do for you.”

“What do you imagine Claire is feeling right now?” I asked Mark.

“Satisfied that she got me to show you my angry side.”

“She looks like she’s about to cry. Do you see that.”

“She does that to make me feel bad.”

“You can’t see that she’s also hurting?”

“That’s because she always makes everything about her. I’m so sick of it.”

Tears rolled down Claire’s cheeks.

“Stop it,” he said. “You’re making me feel bad.”

I let this go on for a few more minutes and then I explained that I needed both of them to enter individual therapy and offered referrals.

Mark insisted that there was nothing wrong with him and that therapy took up too much time. I told them both that we weren’t going to be able to move forward in couples work unless they dealt with their individual issues.

Mark looked furious.

With some trepidation, I said, “I’m thinking that people have said things that made you feel bad as a kid. That’s not your fault, but it’s making everything you hear Claire say feel like the same harsh words. And Claire, without intending, the constant focus on what’s wrong with Mark is emasculating and evoking shame. I want you both to speak with your own therapists, otherwise this is never going to stop.”

They both conceded.

We agreed to continue our couple’s therapy, which I knew would be a difficult journey. It’s hard to get to the shame, but without doing so, empathy will remain compromised. The more Mark understood his shame, the greater his ability would be to recognize and experience Claire’s emotions within the context of their relationship. And the more he could empathize, the more Claire would feel her emotions were heard and valid. The more she felt that she had a right to her feelings the less likely she would be dissatisfied.

* Claire and Mark are amalgamates created to show the relationship between shame, guilt and empathy.  

Reflections of a Psychology Resident in Trauma and Acute Care

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“I can’t believe this is happening right now! I need to pinch myself” is a thought that has passed through my mind multiple times during my residency in trauma psychology at a level 1 trauma center. I knew it would be different from typical outpatient psychotherapy and assessment, but I still hadn’t anticipated the intensity and intricacies involved, or the adjustment required to my clinical approach. In traditional settings, we tend to encounter people months or years after major medical crises and life-changing injuries are sustained. “The cases I now faced in the trauma center were acute, often causing visceral reactions that weighed on my heart in ways I hadn’t experienced before”, and they stretched and sometimes fell beyond the schemas provided by my graduate training.

The Intensity: Extreme Presenting Problems

Most of the patients I saw were admitted for treatment of injuries following vehicle collisions, falls, gunshot or stab wounds, pedestrian or bicycle vs. auto accidents, self-inflicted incidents, and periodically complex and life-threatening medical problems. The range of stories and circumstances I encountered on a regular basis were like the far-removed scenarios portrayed in entertainment or reported on the evening news, including brutal suicide attempts, physical and sexual assaults, attempted murder, hostage situations, home invasions, drownings, and almost stunt-like accidents. Some of the most disturbing, though, were the most seemingly innocuous accidents that resulted in unfathomable and devastating consequences.

“It’s no surprise that returning daily to a workplace like this one would have a personal, cumulative effect.” I noticed that I drove a bit more carefully. I evaluated my own financial situation while envisioning my own hypothetical future in which I or my spouse was in the hospital under circumstances similar to those of my patients. I imagined how I might feel, pacing the hallways, gazing at a loved one in a hospital bed, or being delivered painful news. The flip-side of being empathetic, a trait so many clinicians possess, is that we can see ourselves in the suffering of others. So, seeing the look in the eyes of those who are told they will never be independent again (e.g., due to complete SCIs-spinal cord injuries), or who are grappling with the reality that a loved one’s injuries are not or were not survivable, or when they learn they were the cause of another’s death, was profoundly painful on a human level. The mirror neurons facilitating our shared humanity fire, and someone else’s current predicament and threat of mortality became my existential discomfort and personal grief as well.

The Intricacies: Working in Medicine

In anticipation of encounters with our clients, we therapists typically wonder, “Will Sarah show up for her appointment today?” or “I wonder if Frank remembered his homework?” Questions I often found myself wondering in the trauma center went something like, “Is Jennifer in surgery again?”, “Has David been extubated yet, so we can converse?” or “What is Joe’s GCS (Glasgow Coma Scale) and/or Rancho score, and is it high enough to permit engagement in meaningful conversation?” Moreover, privacy was minimal, and I had to grow accustomed to visits with patients being interrupted by other essential (trauma surgeons) and often also comparatively non-essential (custodians) staff. I learned to discern when and how to defend our time and request, “Could you come back in 15-20 minutes?” while taking patient priorities into consideration.

Discernment was also required for determining the level of engagement with a patient and/or family based on their location in the stages of acuity. Was the patient just admitted? Is the family in the midst of the most acute stage of shock or grief? Is the patient really needing mental health triage? For some, answering questions posed by a relaxed professional is reassuring and distracting; for others, it may feel insensitive. “My initial visits typically involved collecting a brief psychosocial history, but doing so is simply not appropriate with, for example, families grieving the anticipated passing of a loved one.” In those cases, I simply helped the family to become aware of available support.

Often in trauma cases, physical recovery must make headway first, but sometimes emotional needs are salient from the get-go. Once, I visited a woman the morning after a terrible car accident. She asked her family to leave the room, allowing us to visit for the next hour or so. She had questions about pre-existing anxiety, acute stress, psychotropic medication, psychotherapy, faith, and how to overcome grief associated with another’s death from the same accident. It was perhaps one of my most memorable visits with a patient, and one of those therapeutic encounters in which what we have to offer and what the patient needs align perfectly.

I have often joked, “Which has more acronyms, the field of psychology or the military?” I think the military takes the cake on that one, but medical jargon is nearly as unfamiliar to a professional outsider without formal medical training. Terms used regularly during our morning multidisciplinary “dispo” meetings were often totally foreign: NG tubes, pigtails, cannulation, fasciotomies, TPN, rhabdomyolysis, dysphagia, Miami j collars, to name a few. What I found particularly entertaining and surprising was the assumption on the part of the medical staff that I understood what they were talking about when providing me with updates about a patient or explaining medical procedures and their complicating factors with technical language. Other concepts were easier to understand, such as “we sucked peas out of his lungs.” The first task entailed learning what many of these terms meant.

The second task was to determine if and how medical concepts might have significance for my work with the patients. Sure enough, many did. Ventilator weaning and “high flow” trials have particular significance in spinal-cord-injured patients, as these processes often elicit substantial anxiety due to uncomfortable physical sensations and often subsequent, though inaccurate, fears of suffocation. This anxiety can stall or slow progress towards independence from life support and therefore potentially shift discharge plans such as whether to consider short-term rehabilitation or long-term care. Other medical conditions also have clinical implications. Proximity of amputations (e.g., foot vs. leg) has bearing on functional outcomes and emotional adjustment. Fistulas, such as gastrointestinal fistulas, are abnormal openings between or within internal organs and other structures, often resulting as collateral damage from surgery. They are difficult to repair and complicate or substantially delay discharge plans, demoralizing many patients afflicted by them. Ostomy bags, which may be necessary for patients with fistulas, are another cause of maladaptive adjustment, especially for younger patients. Perhaps one of the most severe situations is the need for a patient’s placement on the ECMO (extracorporeal membrane oxygenation machine), a “hail Mary” medical effort to save a patient’s life. The ECMO machine functions as total life support, providing cardiac and respiratory functions, and is intended to be a bridge to other treatment. Psychological support is provided every time a patient is expected to be an ECMO candidate.

Communication with medical staff in the trauma center is not entirely dissimilar to the communication with medical staff in primary care settings which many mental health professionals are more familiar with. However, determining what is useful for them to know in the trauma surgery department strikes me as much more difficult. Conversations are not about outpatient weight loss, smoking cessation, and medication compliance, but about behavioral, psychological, and emotional factors that happen to be deeply embedded in a unique and intense medical system. “Life and death issues are more often at the forefront.” Much of what we discussed with patients’ treatment teams was problem-solving patient-specific challenges that might require increasing patient morale or adapting the environment to fit a patient’s needs. It goes without saying that we were asked to evaluate patients when apparent psychological comorbidities were interfering with treatment progress or even when ambiguous patient behaviors left their treatment teams puzzled (e.g., reported the loss of sensation or movement in limbs with no apparent medical evidence to support such deficits).

The Adjustment: Clinical Work

The sights, smells, and sounds in the hospital are unparalleled elsewhere. Gnarly bruises and X-fixes, splashes of blood on the floor, bloodshot eyes, genitalia, unidentifiable bodily fluids collecting in clear containers hooked on the end of hospital beds, the occasional stench of excrements in hallways, beeping alarms of bedside machines, images of damaged body parts from post-explosive incidents, a deceased child’s body. Once I visited a man after an assault. His eyelids were sutured closed because of the nature of the injuries his face sustained. While we were talking, he coughed, and the pressure immediately caused blood to stream from his eyes. He commented, “I think my eyes are watering…” I paused before responding. I didn’t want him to panic, but I knew my subsequent departure to get help would probably sound the alarm anyway. “Actually, I’m afraid you’re bleeding a bit. I’m going to get your nurse,” I said. He started whimpering, the panic rising. “Don’t worry; we’ll take care of you right away! Take a couple deep breaths.”

As is the case in some other settings, our clients or patients were not always seeking mental health services. While some had requested it, patients in the trauma center typically are not looking for mental health care and occasionally are not very receptive to it. Normalizing talking to a psychologist right off the bat is important. So, after introducing myself and with a sincere but wry smile on my face, I tended to say something along the lines of, “Most people don’t plan on coming to the hospital, let alone the ICU. It’s pretty overwhelming. While everyone else’s job here is to take care of you physically, I’m here to check in to make sure you’re doing okay otherwise–to make sure that your time here is as smooth as possible.” The goal is to make interacting with a psychologist seem routine (as it often is) and easy, in part because there is not always much time to build rapport.

Understandably, many of the conversations center around the cause for hospitalization and related injuries and treatment. Follow-up questions will entail quality and amount of sleep, pain levels, appetite, and mood. The mode of interacting with patients, at times, differs substantially from what happens in traditional psychotherapeutic settings. Unless there is a glaring reason not to, I responded with a hug when prompted, asking no questions. “And I cried with grieving families when sincerely felt waves of emotion welled up, though I made sure to not cry more than they did!” While sitting in one family meeting in which the trauma surgeon described clearly how he had exhausted all options to save the teenage boy’s life after falling ill suddenly just several days earlier, the family broke down in tears. The patient’s nurse, my practicum student, and I could not help but also freely shed tears with them. Due to the intensity of patients’ medical circumstances and threats to life, withholding expressions of genuine emotion appears cold and overly clinical, practically inhuman.

Clinical Interventions

A state mandate requires psychological care for brain and spinal cord injured patients. In addition to those patients, we evaluated and treated patients experiencing psychological symptoms that are affecting treatment or having trouble with general coping while hospitalized. These included generalized or situational anxiety, depression, acute stress and adjustment difficulties, grief/loss (life, limb, or function), and suicidality/risk (specifically if there is a need to place a patient under suicide watch and pursue involuntary psychiatric hospitalization). Additionally, we screened patients for psychiatry services and evaluate for capacity in medical decision-making. Occasionally, particularly unique cases would come up, such as when a treatment team cannot determine a medical cause for a patient’s altered mental status. Lastly, we were consulted to provide family support when needed and to authorize child visits to loved ones in the ICU-when they were younger than 13 years old.

Due to the constraints of the setting (limited privacy, limited time per visit and number of visits, physical limitations and particular focus of stressors), many of the interventions were supportive and patient-centered. Donald Winnicott’s notion of providing a holding or “containing space” for whatever a patient needs comes to mind. Interventions frequently involved psychoeducation and coping skills development, such as relaxation strategies (deep breathing and visual guided imagery) that serve multiple purposes, from facilitation of sleep to anxiety and pain management. The monitors showing a patient’s heart rate provided accessible biofeedback to assess impact. Naturally, and unfortunately, deep breathing is not possible for intubated/ventilated patients. I encouraged patients to identify other coping skills. For example, one patient described how much she loved music, so we discussed how incorporating periods of time to listen to her favorite music each day would help to improve her mood. Also, I occasionally suggested patients utilize affective labeling1, either privately or in conversation with others, to reduce emotional distress.

It was particularly rewarding to find ways of adapting traditional psychotherapy techniques and concepts into concisely-packaged interventions in this setting. Basic cognitive-behavioral concepts could be explained to patients in ways that are easily understandable and immediately applicable. Unpleasant circumstances could be positively reframed. The relationship between automatic thoughts and emotional and behavioral consequences could be briefly outlined, and even cognitive distortions could be gently pointed out with the purpose of promoting more adaptive adjustment while under inpatient care. I might say to a patient, “You are absolutely faced with objectively legitimate physical challenges right now. That said, sometimes the particular ways in which we react to our circumstances can actually create additional obstacles that we just don’t need to deal with as well. Let me describe a bit more about what I mean, and you can tell me what you think.”

Since this was a trauma environment, and nearly all the patients we saw had undergone major traumatic events, “I got particularly excited to find ways of packaging evidence-based trauma treatment interventions or concepts for accessible use” – Cognitive Processing Therapy (CPT), being a particular favorite. After providing basic psychoeducation about acute stress and normalization of such responses, I liked to use a variety of analogies to further illustrate what acute stress responses are and how one might consider responding to them with the goal of healing in mind.

To illustrate why re-experiencing symptoms occur:

  • Our lives are generally like flat lines, stable and constant, with occasional blips (reflecting moderate stressors such as interpersonal conflicts and illnesses), and traumatic events are a major blip on that line. (This is consistent with the phenomenon of flash-bulb memories.)
  • A file folder (traumatic event) remains outside of the filing cabinet (narrative of one’s life, full of other experiences) until it can be adequately sorted and placed (This is an analogy borrowed from the CPT manual materials.)

To illustrate why avoiding avoidance and emotional processing are important:
  • Physical wounds require tending (cleaning, stitching, ointment) because, without this, they can become infected or heal improperly. Emotional wounds are similar, needing attention and care, in the form of emotional processing, for the sake of closure.
  • As children, when we learn to ride bikes, we often fall off, maybe skin a knee or bruise a thigh. If not coaxed into getting back on, fear of riding a bike will maintain or even increase. But if the fear is managed and overcome, the new skill is mastered, and the fear dissipates. (This is especially so for patients after car accidents, for instance.)

On several occasions, I noticed that maladaptive automatic thoughts-or cognitive distortions had already developed in the wake of a major trauma. From a CPT framework, these are called “stuck points” and are either “assimilated” (past-focused, typically on traumatic incident) or “over-accommodated” (present/future-oriented statements). These are problematic because they will likely interfere with healthy post-trauma adjustment. The major themes of trauma are often apparent and include control, responsibility, intimacy, trust, and safety. I recall a few instances of talking to husbands of female patients who blamed themselves for vehicular accidents that were entirely due to extenuating, external factors. Their self-concepts, characterized by competence and accomplishment, paired with immense love for their spouses, meant they pinned the blame squarely on their own shoulders, despite intellectually understanding otherwise. Emotional reasoning at its finest. I hoped that outlining some of these cognitive and emotional responses and challenging these stuck points empathically planted seeds for greater self-awareness and supported progress on a more adaptive, long-term trajectory.

Of important note, conversations about trauma in the acute phase such as this are not the same as structured crisis incident stress debriefings that are largely unsupported or even contraindicated in the literature. Patients and family members are left to determine whether or not they want to discuss the traumatizing incident, and emotional reactions are rarely therapeutically explored in significant depth. While conducting a mental status assessment, I would ask patients if they recall the incident, while informing them I am not asking them to tell me about it, though they can do so should they choose. This provides them with more control and a greater sense of security when discussing their mental health status.

Other psychotherapy skills we learn as clinicians were relevant in this setting, including:

  • recognizing the time and place for silence
  • identifying and therapeutically pointing out avoidance (or when the molehill is the cover for the mountain)
  • utilizing empathy without becoming consumed by it
  • consulting when faced with ambiguity and ethical quandaries
  • getting creative in efforts to connect with others from different walks of life
  • permitting oneself to not have all the answers
  • being resourceful in clinical problem-solving, particularly in a multidisciplinary setting

In Closing, For Now

The trauma, acute care setting left me with a resounding sense of gratitude (which I also find is a terrific inoculator against anxiety and apprehension). In observing the enormity of human suffering, I was humbled when counting my blessings and reflecting on the dedication and compassion displayed by so many members of the medical teams. Friedrich Nietzsche famously stated, “He who has a why to live for can bear almost any how.” The existential significance of this work was not lost on me. What amazed me is not just that people find a way to face another day under truly dire circumstances, but that so many do. I have come to accept that, in this context, I may not always have been able to treat the diagnosis and cure all the symptoms. The environment and physical conditions provided ever-present limitations. But I developed a tremendously deep appreciation for the resilience of the human spirit and appreciated the significance, and perhaps inherently healing effect, of sitting with others during their darkest moments.

Related References
Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words. Psychological Science, 23(10), 1086-1091. 
Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist and patient materials manual. Washington, D.C.: Department of Veteran Affairs
 

A Counselor Visits the US/Mexico Border

Posted on by Psychotherapy.net Team

He sat nestled on a chair, clinging to his father. His quivering 6-year-old body told its story with every tortured word uttered by the man who tried his best to protect him. His father recounted the death of his wife at childbirth and of the life he had created for his beloved son, which included a small business and a supportive community. He recalled how one of his friends and fellow business owners had shared with him that the Mara (a violent predatory gang) had demanded a monthly payment and that he had refused. Two days later, the boy had opened the door to their apartment only to see the mutilated lifeless body of the man who had dared stand up to the gang. Later that evening, the boy’s father was visited by the very same gang who had killed his friend, and who now demanded the same payment from him. They threatened to kill both father and son if the extortion was denied.

Try as I might to engage the child as his father’s pain became more palpably agonizing, he clutched the man even tighter. The father continued telling his story to a pair of young pro-bono law students surrounded by a throng of legal advocates and other fathers recently reunited with their children. He recounted how after the threats, he had gone to the police for help and was assured of his safety and confidentiality. The next night, the child was awakened by the sight of his father being brutally beaten by both the gang members and the police. Desperate and frightened, the boy ran to the neighbors who united to save his father. With borrowed money, father and son fled the very next day. With coyotes on their heels, the journey to safety ended as he held his son aloft to protect him from the bone chilling cold of the Rio Grande.

Amidst the screaming of the men in uniforms, who flashed guns in their faces, father and son were arrested, violently separated with the sound of “How do you like your American dream, now amigo”? Two months later, the father was reunited with the boy at a Texas ICE Detention facility, awaiting probable deportation and the certainty that if he and his son were deported, he would be eagerly greeted by the Mara and killed, leaving his young son alone. If the boy remained in the US and he returned home, his boy would surely be orphaned.

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This story of human beings fleeing from Guatemala, Honduras and El Salvador was repeated over and over, replete with the most horrific violence imaginable. I thought that I had been prepared for this by my work as counselor in Greece where I bore witness to the trauma incurred by unaccompanied child refugees from Syria, Iraq, Afghanistan and other conflict zones. I thought I had been prepared by my years of counseling experience, but nothing prepared me for the trauma inflicted upon these helpless children by the United States policy of family separation. I accompanied law school students and faculty who were deeply affected by the inevitable experience of vicarious trauma and compassion fatigue.

In retrospect, I don’t believe that any educational or clinical knowledge would have adequately prepared any of us for what we encountered. ICE Detention Facilities and places where children are housed separated from their parents, are epicenters of disregard for human dignity, human rights and the immoral infliction of generational trauma on thousands of children. As mental health practitioners, we know this to be true. As lawful people we know this to be unjust. As decent human beings we know this to be immoral.

Mental health practitioners may be completely unaware of a client’s legal status because survival requires invisibility. A child may ostensibly be referred for depression, anxiety or behavioral problems, but be struggling with the pain of separation from their caretakers. Therapists need to learn the intricacies and ever-changing landscape of immigration and asylum that potentially impact their clients, whether directly or indirectly touched by the border separations. Even an otherwise healthy and intact family may in the blink of an eye be devastated by the breadwinner’s arrest and imprisonment. Therapists need to help their affected clients to identify coping skills and obtain grounding in extant and emerging pathways to the assessment and treatment of trauma. The world’s most vulnerable and most invisible will evoke an abiding respect for their unimaginable strength and resilience. If you believe in the inviolable right to the dignity and you are willing to walk the journey together with humility and heart, your client will experience love made visible through a shared humanity.   

The Luggage Tag

Posted on by Psychotherapy.net Team

I got a letter in the mail. It was from North Dakota, a place where I had never been. There were two Scooby Doo stamps on the right-hand corner, and a return address I did not recognize. I opened the envelope, and inside was an old brown leather luggage tag. I recognized my writing, and I knew the tag had once hung on the handle of my suitcase to identify that it was mine. Of course, it was meant to give information should the suitcase get lost. To let someone out there know where to find me, and where to send the suitcase.

Inside the envelope was a letter, folded in thirds. Typed out carefully in calligraphic script.

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“Hi, my name is Karen, and I work part time as a ramp agent. I found your luggage tag while working and wanted to return it to you. Here’s to many more safe travels.”

I put the letter down and I looked around my kitchen. Who sends a luggage tag through the mail? Why didn’t she just throw it away? Who was this person in North Dakota?

These questions didn’t leave easily. I thought about them all day. And the next, off and on. She must have brought it home, sat down and typed out a note, attached two stamps – worth about the cost of the contents! She had an intention to find the rightful owner of the tag, and she followed through with her intention. Luggage tag received. Made it home.

Maybe this could be really important. Maybe simply putting that tag in an envelope and sending it home could model something important and alter the course of the world just a bit.

I recalled the ideas I learned when training in a coaching program at The Arbinger Institute. I recalled learning something like this: Imagine seeing something on the ground, perhaps in your home or office, and not picking it up. And the immediate justification that follows: “Someone else will get it.” Or “not mine…” We then create a space between ourselves and the rest of the world. We put ourselves in a box of sorts. And the “other” in our mind, who will pick it up, becomes a sort of object, not a subject to whom we feel connected. What if we pick it up? Then we remind ourselves of how we are connected to humanity.

I have a similar experience at times when doing improvisational theater, a hobby I have enjoyed and studied for thirty years. Up on a stage, working with a partner, you never know what’s going to happen; brilliance or train wreck. But there you are, sharing a moment with someone, creating something. And it really only works if you care about your partner, if you are curious about who they are, what character they bring, and move the scene forward by providing gifts. A name, a place, a purpose, and the focus on your partner often helps move the scene along.

In a therapy office, whether I’m the therapist or the client, we work together back and forth to understand something new through a conversation rooted in curiosity with the potential to reach a greater sense of connection both to each other and to the world at large. We aim for less reliance on defenses, less fear of the world, and maybe even the generation of an impulse to help someone else.

A mother gazing at her infant… the infant gazing back. Back and forth they go. Like two improvisers sharing a moment. Playing and creating, taking care of each other up on stage. Like two people connecting in a psychotherapy consulting office. Exchanging ideas and feelings back and forth to reach a deeper truth. A shared experience of humanity. Like a luggage tag… traveling through the mail….to find its rightful owner.

What luggage tag can I send out into the world? What can we all do to surprise someone just for a moment? An unexpected hello. An offer to someone in need. The breaking of an estrangement of one sort or another. An unexpected gift from the tarmac finding its way home.

With a pen, a paper, an envelope and two stamps, I say thank you to someone on a ramp in North Dakota for reminding me for a moment of what it means to be human. 

Choice: My Lighthouse in a Wave of Disillusionment

Posted on by Psychotherapy.net Team

I stared, hypnotized by the cursor, it’s pulsating blink, blink, blink strengthening my resolve. I had been working as a staff psychiatrist for 4 years and had become increasingly frustrated and disillusioned by what I and my colleagues were being asked to do. Sitting in front of my computer, hoping to squeeze in another patient note before the next family came into my office, I reaffirmed my limits.

“You either cooperate or get off the boat,” our newest administrator threatened during our last staff meeting. Anger, anxiety, sadness. They all battled for prime real estate in my emotional landscape. Our clinic helped underserved residents in our community who frequently came to us in crisis and despair. Their stories and lives were fragile and complicated. I often left work at the end of the day feeling depleted.

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When I initially accepted this position, the clinic seemed visionary. I was inspired by its mission to offer the highest quality care to marginalized communities in an integrated healthcare setting. I felt empowered as one of the first child psychiatrists with the organization. In all my glittery idealism, I envisioned designing programs to provide families with care and resources in a safe and supportive setting.

Four years later, sitting in a cold, barren conference room listening to our new leadership, I felt defeated. Standing in starched, black and gray suits, individuals tasked with evaluating our work by how our practices impacted the bottom line, dictated edicts of how we would have to do more, in less time, for more people or “get off the boat.” Feelings of resentment, ineffectiveness and detachment from my work had taken root as I sat in my office each day. Sitting in the conference room, I visualized walking a plank in the middle of the Pacific Ocean, a gleaning silver saber jabbing impatiently in my back while I pondered my choice.

A choice. I still had this. With the beginning stages of burnout emerging, I felt a brief flash of optimism when I spotted this buoy of hope in the distance. I clung to this as I began considering my options for an uncertain future. Choice was my greatest asset in regaining control of my future and sense of well-being.

Research has revealed that one of the most significant triggers of burnout is the stripping away of personal control. In the workplace, loss of control grows from a loss of choice or sense of being an active agent in one’s professional life. For me, it started when, one after another, ideas that I thought would improve patient care and bolster employee morale were dismissed in favor of practices that increased revenue and patient census in the clinic. This was followed by greater external control on who I saw, when I saw them, how often and for how long. The pressure of these external forces threatened to extinguish the passion and fulfillment I derived from my work. Many physicians struggle with burnout from similar factors.

I chose to leave. Exhausted from treading water in a sea of uncertainty, I recognized that my lifeboat was the power of choice. Empowered by the knowledge that I had options, I chose to run away from increasing constriction and to run towards self-determination.

At first, I felt like this:

Self-doubt, anxiety, fear, excitement, and relief jockeyed for position in my mind. I realized that as with all choices, positive and negative outcomes were both possible.

What if my husband couldn’t work? What if I never figured out what I wanted to do? However, I soon discovered one important emotion absent from the torrent filling my head, regret. While I had chosen an uncertain future, I was assured about my path towards self-preservation. I was empowered through my choice and being an active agent in my future.

The seed of any worthwhile or important choice begins with a nudge rising from within that suggests, or more forcefully urges us toward change. It involves understanding your options and the benefits and drawbacks associated with those options. Finally, it involves accepting the outcome of your choice. As in the case of addressing burnout, these choices can have a drastic impact on emotional, psychological and physical well-being. While not all choices are as dramatic as quitting a job, every choice carries with it the weight of what we will gain and what we will lose. However, our choices give us power and that power allows us to be the navigators of our own lives.
 

Should Therapists Have Scales in their Offices?

Posted on by Psychotherapy.net Team

We were scanning electronic records of patients visiting the mental health clinic of a large local hospital to find subjects for our IRB-approved research study on antidepressant associated weight gain. Our goal was to find subjects whose weight was normal prior to starting on antidepressants and who had gained weight during the subsequent 3 or four months. But there was a problem: no one weighed the patients. Thus, there was no way to learn whether the drugs were influencing weight.

Almost twenty years ago while directing a weight loss center at a psychiatric hospital affiliated with Harvard University, we were surprised by the number of clients claiming substantial weight gain while on their psychotropic medication. Unlike typical clients seeking weight loss advice, whose struggles with overeating may have a complex etiology, these clients were of normal weight, ate healthily, exercised routinely and had no issues with food until their treatment with antidepressants began. Their complaints were similar; uncontrollable urges for carbohydrate-rich foods and an inability to feel full after eating.

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Our clinic was able to stop and to some extent reverse their weight gain with a food plan that increased serotonin synthesis prior to lunch and dinner to potentiate satiety before eating began. The increase in serotonin also decreased their desire to snack on sweet or starchy foods

Unfortunately, now several years later, patients are still gaining weight on psychotropic drugs and although the literature is filled with articles confirming this side effect, patients may be denied this information along with interventions to halt or slow the process. One angry patient told me that her therapist accused her of justifying her urge to eat cookies as an effect of her medication and another, who was compelled to shop for plus size clothes after taking an antidepressant, said her physician never heard of weight gain as a side effect of her drug.

Many patients see their formerly normal, fit bodies transformed, and adding to their feelings of frustration and sometimes embarrassment, is the difficulty in explaining to others why they are now overweight or obese. One of our clients who went to Weight Watchers wasn’t believed when she said she had been thin before going on an antidepressant. “They assumed I was in denial about the reason I was always snacking.” Another told me that his mother keeps nagging him about his overeating and won’t believe that the combination of a mood stabilizer and antidepressant are responsible.

Ideally, patients should be alerted to the weight gaining potential of the drug(s) they are being prescribed. Since it is unlikely that the therapist has a scale in the office, information about weight changes or inability to fit comfortably into clothing worn before starting the drugs will have to come from the patient and tracked during subsequent visits.

Cravings for sweet and /or starchy carbohydrates and a decrease in satiety are the most commonly reported causes of overeating. A coach of a college women’s soccer team told me that after being put on an antidepressant, she craved French fries for the first time in her life and had trouble resisting eating them as a snack every day. A patient on a mood stabilizer often ate two dinners because an hour or so after the first was completed, he felt hungry again.

The therapist might suggest that the patient eat a small, 25-30-gram carbohydrate snack such as a ready-to-eat breakfast cereal (oat or wheat squares, or cheerios for example) 30-45 minutes prior to a meal or when craving a between-meal snack. The carbohydrate causes insulin to be secreted thereby potentiating tryptophan uptake into the brain and subsequent synthesis of serotonin. Carbohydrate craving is dampened, and satiety increased as a result. The snack should be very low in fat or fat–free to decrease calories and contain no more than 2-3 grams of protein as the latter nutrient prevents serotonin from being made. The patient may still want to overeat; after all, one is fighting drug-induced appetite with cheerios, but usually, a sense of fullness is reported.

Urging the patient to start to exercise as soon as possible by using a smartphone app or wristband to record physical activity has benefits of course beyond calorie utilization, but is very important in preventing weight gain. Asking to see records of weekly or monthly ‘steps walked’ or other activity may encourage compliance.

Weight gain on psychotropic drugs may undermine some of the beneficial effects of the drugs themselves and the psychotherapy, especially since those who gain the weight rarely announce its cause and thus are perceived as individuals who are unable to control their food intake and may be too lazy to exercise. Thus, stopping or minimizing this side effect will benefit the mental and physical health of the patient. Alert to these possibilities, psychotherapists may be in a better position to work with the prescriber, nutritional specialist or other members of the treatment community.
 

Give Me that Feedback

Posted on by Psychotherapy.net Team

Therapeutic Impasse

Rachel is a delightful patient: ambitious, creative, open about her problems and willing to work hard to overcome them. Diagnosed with bipolar II disorder, she had been seeing me in my private psychiatry practice periodically over the past four years, trying one medication, then another: the usual bipolar II fare and beyond (bupropion, citalopram, lamotrigine, aripiprazole, lithium, thyroid, selegiline patch, light therapy, omega 3’s, vit D, hormones). Some months she would be doing well, full of ideas for her business or excited about a new relationship, but these spells didn’t last. She could be depressed for months on end, mired in ruthless self-criticism, avoiding friends, neglecting her projects, spending days in bed wondering how long it would take someone to discover her dead body. “With so little success in her pharmacologic treatment, she had lost interest in trying new medications, and, well, frankly, so had I.”

Rachel had a therapist, a good one, someone I liked and with whom I collaborated well. We would exchange head-shaking messages, feeling rueful and helpless about our inability to help Rachel achieve her abundant potential. Money was tight for Rachel and her business was flagging due to her discouragement. She was in state of desperation, struggling with intense suicidal thoughts in the face of a depressive episode that had been dragging on for nearly a year. We had to do something! I still felt anemic about the idea of more medications: a stimulant? Did she need ECT? TMS? Ketamine?

She sat in my office, her head in her hands. “How is your therapy going?” I asked her after an uncomfortable silence.

 She exploded in frustration, “She’s not helping, and I can’t talk to her about it!”

“Really?” I responded, surprised, “What happens when you try to bring this up with her?”

“She just gets defensive and tells me it’s my fault, that I’m not trying hard enough!”

Huh. I did not experience her therapist as a defensive person; this must be a depressive distortion, I told myself. But if I bring that up now, Rachel is going to feel even more criticized.

A phone conversation with Rachel’s therapist did little to break the impasse. For financial reasons, Rachel was only able to afford therapy once or twice a month (even with a reduced fee), and I heard her therapist, in the midst of what must have been therapeutic despair, echo what Rachel had told me: “Rachel just can’t seem to muster the motivation to change. I really don’t think I’m able to help her, at least not until something shifts on her end.”

Challenging Tribal Suspicions

As it happens, I saw Rachel right after I’d done an intensive workshop with David Burns, learning about CBT for depression. I’d been trained psychodynamically and had harbored tribal suspicions of this other form of therapy, but “my curiosity had gotten the best of me, and I was excited to try the new techniques I’d learned”. What if I offered Rachel a brief course of CBT?

Inviting a patient who already has a therapist to see me for therapy, even briefly, is a dicey business. I could easily be helping the patient avoid some important issue that she really needs to sort out with her primary therapist. But when I mentioned this idea to Rachel’s therapist, she burst out, “By all means!” almost laughing with relief. With this blessing, I invited Rachel to come see me for time-limited weekly sessions.

The David Burns brand of CBT therapy, “TEAM therapy,” requires the patient, after every session to fill out an “evaluation of therapy” feedback form, in which the patient scores the therapist for “therapeutic empathy” (How warm, supportive, trustworthy, respectful is the therapist? Does she do a good job of listening to me? Does she understand how I feel inside?), “helpfulness of the session” (was I [the patient] able to express my feelings, did I talk about the problems bothering me, were the techniques useful?). What did I like least about the session? What did I like best?

I’d heard about this idea of getting written feedback from patients, and frankly I’d had a lot of resistance to asking my patients to fill out these forms. It seems like everyone wants your feedback these days (my breast imaging center, really?), and I generally treat these requests with irritable skepticism, believing that my negative feedback will be discounted and that my positive feedback be touted for some political end.

The conference with David Burns changed my mind about that. David Burns is a lot of what you might expect the founder of a therapy brand to be – charismatic, smart, self-confident bordering on cocky. At one point, a young woman (who was clearly still in training) questioned him challengingly. His response was brief and brutal- “I just don’t think you get the point of what I’m trying to say. Maybe you can pass the mic to someone else.” Dinner with a colleague at the end of the first day found us rolling our eyes, snickering at Burns and his narcissistic tendencies. I did not pull my punches on the required feedback form.

The second day of the workshop started with Burns reading aloud the feedback from the previous day. He started with the positive, and unabashedly read effusive comments, “I learned so much! Best conference I’ve ever attended! Love your sense of humor!” His glee at these strokes was charming, and not undeserved – he is an effective presenter and he has a rich set of ideas. Where things got interesting; however, was during his response to the negative feedback, which he read out loud as unflinchingly as he had the positive. “Dr. Burns seems kind of arrogant.” Burns looked up at us with a little grin. “You know, it’s not the first time I’ve been told that. I hope it doesn’t get in the way of your understanding the points I’m trying to make.” And then he read what I had written on my feedback form: “You were incredibly tactless to the young woman who was questioning you.” He sobered and took a pause. “Yes.” Another pause. “I was thinking about that last night. I think I was impatient and became rude, probably even harsh.” He put his hand over his eyes and peered into the audience. “Are you still here?” The young woman tentatively raised her hand. “I am so glad you came back,” he said to her, “I owe you an apology. I am very sorry that I cut you off like that. Are you free during the lunch break? I would like to see if I can do a better job addressing your question.”

As Burns spoke, I could feel my eyebrows soften as my snarky skepticism leached away. “Narcissistic guru or no, Burns had been genuinely interested in my critical feedback.” He had neither launched a counter-attack nor collapsed in self-criticism; rather, he accepted the truth of the criticism with humility and curiosity. I felt both respected and humbled; the interaction became a meeting of equals, a moment of connection between two people with different but equally legitimate perspectives. When I described the feedback component of the TEAM method to Rachel, explaining that it would be very important for her to tell me when I got off-track, Rachel got tears in her eyes. “I’ve never felt comfortable giving negative feedback directly,” she said. “The only way I can do it is if I know that I am 100% right.”

That makes sense. Perfection is an excellent defense, because what better way to deflect critical feedback than to focus on whatever part of that feedback is wrong? Of course, Rachel would be wary of criticizing me; she could be setting herself up for a counter-attack.

I should note that psychodynamic therapists also work to elicit feedback from patients – they call this “working in the transference” or the “here and now relationship”; it can lead to profound change. The trouble is that many, if not most, “patients find it scary to directly criticize someone to whom they are already intensely vulnerable”. Since this kind of communication is challenging, it tends to come out impulsively, when feelings are already running very high. More often than not, the therapist, unprepared or already activated, gets defensive and can’t see the important truth in what the patient is saying. Contrast this with asking for written feedback after every session, making it a normal and expected routine of the relationship: the therapist doesn't expect to get it right every time, or even to necessarily know in real time that things have gone wrong. The patient spends a few minutes in the waiting room, while the experience is still fresh, but apart from the direct gaze of the therapist. And likewise, while the therapist gets this feedback promptly, she can digest it away from the heat of the moment, giving her a much better shot at relaxing her own perfectionism and focusing on what is true about any criticism.

Eureka!

So, it was with no small excitement that I awaited my first feedback form from Rachel. I thought our first session had gone okay. We’d focused on her frustration that she wasn’t following through with a new idea about marketing her business. Rachel’s thoughts were brutal: “I’m a failure. Nothing ever changes. I will never accomplish anything.” “Rachel’s defense of perfectionism had become a paralyzing shell”. For my part, I was anxious that I wasn’t following the steps of the technique in an organized way, and that I might have left out something important. Her first feedback reflected this – she indicated that she felt overwhelmed and that there had been too much bouncing around. In the space to write what she liked least, she said she felt kind of dumb because she had a hard time understanding me, and that I was talking fast.

Talking fast. Ouch! It wasn’t so hard to forgive myself for being new at this technique, but I was grateful to have some time to digest that last bit of feedback. Since I was a child I’ve been told, “slow down, you talk too fast!” I can remember feeling humiliated after chattering with excitement to my grandparents about a story from camp, only to have my grandmother say irritatedly, “Dearie, can’t you just slow down? I can’t understand a word of what you are saying!” It took some work to remind myself that Rachel had usually been able to understand what I was saying, and that there were circumstances that might have made me speak particularly quickly that session.

So, with a deep breath, I pulled out the feedback form the following week.

“Rachel, I see that last week, you felt overwhelmed, and that it was hard to understand the techniques we were talking about. It is a lot to cover, and I think I was kind of nervous doing this for the first time. When I’m nervous, I know I can talk even faster than I usually do!”

Rachel smiled weakly, “You know, hearing you say that is such a relief. I’ve been feeling so stupid all week because I can't keep up with you.”

Ah, one of those therapy paradoxes. I was worried about coming off as incompetent, so I crammed in too much and talked too fast, but Rachel took her difficulty following what I was saying as further proof that she is stupid.

“Hold on, are you saying that you interpreted the fact that you had a hard time understanding me as meaning that you were stupid?” We both laughed.

“Well, now that you say it that way, maybe that one is on you.”

“Yeah, I think so.”

“So maybe neither of us is stupid! And maybe I need to keep telling you when you talk too fast.”

In that moment, I felt like doing an end zone dance.

Perhaps helped along by watching me accept my imperfections, it clicked for Rachel that her recovery would involve her being more gentle and encouraging with herself. She would have to lower her standards and stop demanding that she be in a place she was not. Her feedback that next session was positive. “Heather made it okay to make mistakes.” She embraced the psychotherapy homework with enthusiasm, and by our seventh session, she was feeling motivated and optimistic. On our last visit, we used the relapse prevention technique of making a recording of herself neutralizing every one of her negative beliefs. She wrote on her final feedback form, “We knocked it out of the park!”

It would be hubris to say that the seven sessions we had together cured Rachel, though our work did illuminate her intense perfectionism, and gave her tools for softening it. When I followed up with her a year later, she reported that she was doing well after continuing to work hard in an extensive self-care practice that included 12-step work and an Ayurvedic approach to diet and lifestyle. She wrote: “From our work, I realized that I don't have to be perfect to be happy.” “Turns out I don’t have to be perfect to be an effective therapist”. I just need to get (and accept) feedback.  

When the Snow-Globe Shatters: A Counselor

Posted on by Psychotherapy.net Team

Many clinicians are comfortable and familiar with suffering – the suffering of others, that is. But what happens to us when our personal world is rocked by tragedy? Fulfilling the duty to which we are called is not an easy task when we are hit by the loss of a relationship, financial devastation, or a terminal illness that befalls us or a loved one.

Several years ago, I suffered a heartbreaking tragedy as my first marriage ended after a long separation. The years of separation were filled with marriage counseling and numerous attempts at reconciliation, but in the end, my former wife chose a different path for her life. In the wake of this were two little girls whose worlds got turned upside down. As if this wasn’t bad enough, in the years following I endured a long custody battle that involved years of court and attorneys, as I attempted to be a part of my daughter’s lives. The aftermath of all of it left me devastated financially and emotionally, and I found myself seriously doubting if I could continue on in the profession to which I had dedicated my life.

Did I mention that I’m a therapist who works with kids, teens, and families? I can’t tell you how many kids from divorced and blended families that I have worked with and when this happened, it was like staring into a black abyss of reality that was going to swallow me whole. Suddenly, it was my kids asking why mom and dad didn’t live together and begging us to work it out. It was my kids who cried when it was time to go back to the other parent’s home. I was the one scrambling to defend myself in court and keeping time logs for the attorney and being summoned to depositions over ridiculous accusations. It was me having sleepless nights wondering about the emotional and mental damage my children were having to endure, and worrying about how this would impact their future development and relationships.

Our training and expertise is a gift when it comes to helping others. But when our personal lives start to crumble, all that knowledge can work against us in knowing exactly how to deal with it. What does the clinician do when this happens? How can we endure a personal tragedy but still effectively do our work? Here are a few things that I did that kept me held together while weathering the storms of my personal tragedy.

The first thing I did was seek personal counseling. Thankfully, I found a seasoned non-biased clinician who comforted me where it was needed, but also challenged me when it came to my denial about my abilities and how my personal issues may affect my professional work. Second, I kept the vision that tragedy represents growth opportunities and the goal isn’t just to survive it, but to thrive as a result of going through the process. I took the mindset of a client in regards to addressing the issues going on in my personal world. I set to work on confronting my denial and fears. I journaled daily, addressing my thoughts, emotions, and staying grounded to the moment. Third, I took an honest look at my caseload to see which cases I needed to refer to other practitioners. This was very hard for me, but looking back was very beneficial both to myself and to the clients. I reached out to colleagues and received excellent consultation.

Now, looking back, this period in my life was one of profound suffering but also immense growth. Here are some things I learned and gained from this experience. First, I identified with my clients in a new way. Emotional pain, fear, and the experience of loss struck deep chords within me that were new levels of suffering. I became more connected to my client’s emotional experiences and found new levels of empathy upon hearing their stories. Second, I became grateful for the small things. This sounds very cliché, but the suffering made me notice the tiny kindnesses of others, the wonder of nature, and forced me to look outside of myself. Third, I learned to value relationships in a new way. It is easy in our work to see people as appointments, a simple slot on yet another full calendar of events. My time with my daughters became sacred – the time with those that loved me and the encouragement they provided was like a steady drip of precious water that one craves during a desert experience. I slowed down and took in the moments. Fourth, I came to love our profession even more after realizing that counseling and psychotherapy are effective! I realized from a client viewpoint that my life was drastically improved despite the hardships by intentional focus on different areas of myself and by following the protocol for change upheld by theory, research, and practice.

We will no doubt suffer personal tragedies during the course of our careers. We are not immune simply because we are people-helpers. However, my experience taught me that we need not abandon our work when we encounter personal challenges, and in fact, as I found, working through the challenge may produce a better person, clinician, father, and partner because of the experience.