Is Self-Regulation or Co-Regulation Better for Couples?

Posted on by Psychotherapy.net Team

Should couples in distress attempt to change their partner or themselves? Recent research discusses concerns about both of these strategies, and raises an interesting third option. Shreena Hira and Nickola Overall examined 160 couples attempting to change their partner or themselves. As they expected, attempts to change their partner didn’t make either their partner or themselves feel better. Surprisingly, however, a focus on self-change did not consistently help the relationship either. Instead, the researchers discovered that the most beneficial change occurred when one or both partners in the relationship perceived the other as changing themselves (self-regulating.)

This poses an interesting challenge for couples therapists, as partners don’t always perceive the change (or effort) made by their partners, and rarely does either partner want to “go first”.  One idea to address this dilemma, proposed by Victor Yalom, is for the therapist to help clients  tune into the changes and effort made by their partner, even if the change or effort is very small.  This can help build trust, morale and set the stage for greater changes later.  Likewise, therapists could use recognition of small-item effort or change as an assessment tool for determining when the couple is ready to work on more challenging change goals.

There is currently a hot debate in the field between therapists who promote self-regulation (differentiation) and therapists who promote co-regulation (attachment). This research suggests that couples may in fact improve co-regulation capacity by witnessing self-regulation efforts by their partner. 

From: Shreena N. Hira & Nickola C. Overall. (2010). Improving intimate relationships: Targeting the partner versus changing the self. Journal of Social and Personal Relationships 28, 610-633.

John Arden on Brain-Based Therapy

Posted on by rezendevknowfully.com

Why Brain-Based?

Rebecca Aponte: Why did you call your book Brain-Based Therapy? What does “brain-based therapy" mean?
John B. Arden: I've got to say that the actual title of the book was chosen by Wiley, the publisher. The earlier title had something to do with neuroscience—I forget, actually, what it was. But when this one was chosen, my initial reaction was, "Geez, that sounds so reductionist."
RA: That’s what I thought, too.
JA: And there's so much out there about neuroscience. A good friend of mine, Lou Cozolino, wrote a book called The Neuroscience of Psychotherapy, so maybe it was too close to his title. But from my point of view, it doesn't have anything to do with reductionism. I still regard Jung's analysis of culture and fairy tales and religion to be fascinating. In fact, I spent a lot of time sitting in yoga ashrams in different parts of the world meditating, and those parts of my development are still with me. I'm still interested in all of that, but I want to integrate it all. And it has to be integrated from a nondualistic perspective. It seems to me that for many years we were in what I call the Cartesian era.

RA: The separation of the body and the mind.
JA: Right. Between 1890 and about 1980, we were in the Cartesian era with no scientific grounding for this view whatsoever because, despite the fact that Freud was a neurologist and wrote a hundred articles in neurophysiology, on such things as the neurophysiology of the crayfish, we didn't really know much about the brain at the time. So the schools of psychotherapy just splintered all over the place—everything from primal scream all the way to radical behaviorism—because there was no common language, no common integrative core.

The picture changed around 1979 to 1981 due to the convergence of a number of different factors. For one thing, the DSM-III—the third Book of Bad Names—developed. And it was a whole lot better than DSM-II and DSM-I, because you didn't have a lot of terms like "neurosis." Even homosexuality, believe it or not, was in the DSM-I. Finally, in 1974, when the DSM-II came out, millions of Americans and Europeans became cured of their disorder. That's why people get really caught up with the diagnostic terms. So DSM-III came about, and there was a whole lot more science to it. People were saying, "Wow, geez, this is so much better. This makes a little bit more sense."

Also, up until about 1980, the efficacy studies for psychotherapy were pathetic. Way back to Hans Eysenck, the mere passage of time was as effective as psychotherapy. Before Timothy Leary went to Harvard, he actually worked for us as a chief psychologist at Kaiser Oakland. He was a pretty bright guy before he started taking acid and flipping out. And he did a study there where he found that people on the waitlist did as well as people in psychotherapy. So imagine all that.
RA: A huge crisis for the field to go through.
JA:

The Age of Pax Medica

Exactly, until the Smith and Glass studies, which came out in 1979 or 1980. I was at University of New Mexico at the time, and we were pretty excited because this big meta-analysis found that, actually, psychotherapy worked. "Oh, my god. What we're studying and what we're doing really makes sense. We're helping people. Thank God!" Then, too, the development of these SSRIs in the '80s was a major factor in the development of what we call Pax Medica.
RA: Can you elaborate on that term?
JA: Pax Romana was a term used to describe the Roman world roughly 2,000 years ago. You could travel anywhere in the Roman world, and as long as you didn't insult Roman gods and Roman law, everything was cool. Similarly, since 1980, as long as you recognize that that psychiatry is in charge and that the number one factor is psychotropic medication, everything's going to be cool. That's why we call it Pax Medica. We've been operating in Pax Medica roughly since 1980. I think we're ready to leave it.
RA: Yet you recently said in a lecture that, in some ways, Pax Medica benefitted mental health.
JA: Because it got us all on the same page. We were all over the place. We were talking about interjected self-objects on one side and behavioral reinforcement paradigms on the other. We didn’t have a common language.

But Pax Medica’s page is extremely one-dimensional. In fact, the common language that we began to use is rather clunky and presumptuous. So we became a medicalized group, and the psychotherapy world became medicalized psychotherapy. And instead of being called “psychotherapists,” we became “clinicians.” “Now, you’re talking.”
RA: “Now you sound medical.”
JA: Now you’re clinically speaking, but what were you speaking before? Is this a new language or something? I’ve sat around in these big meetings where people say, “So what’s the diagnostic picture here?” In other words, they want a name quick, from the Book of Bad Names. And then they say, “What’s medically necessary?” Medically necessary, what? The guy just had a divorce. He’s really bummed out. “Medically necessary” sounds kind of silly.
RA: It sounds you're saying there's a fundamental disagreement about what the role of the therapist is.
JA: Yeah, and I think that the disagreement resulted in a compromised agreement. And the compromised agreement became the clinical role. And the clinical role is, I think, very antiseptic and one-dimensional, and in some ways very subservient to the so-called "principal treatment," which was medication.

Now we know the efficacy studies for antidepressants are rather suspect. The negative studies outnumber the positive studies by 12 times. So the pillars of Pax Medica are actually falling apart in major studies in JAMA and New England Journal of Medicine and other places.
RA: Within the Pax Medica frame, what do you think has been the cumulative effect of the outcome studies that focus on a specific treatment for a specific problem?
JA: Another part of Pax Medica was evidence-based practice. From roughly the early '80s on, various CBT-oriented therapists were the ones doing a lot of the studies on specific methods. David Barlow and others were showing that specific approaches to panic or OCD were more efficacious, and that dovetailed really nicely with the Pax Medica model, whereby you had a diagnosis and you had a prescribed treatment for the diagnosis. There was a positive part of that, because, come on, now—a person with a panic disorder, you want to sit around and analyze their feelings about their mother endlessly? No, you want to get them doing interoceptive exposure and other approaches that have been found for the last 35 years to be much more efficacious than sitting around analyzing archetypes and other things that, even though I find them intellectually stimulating, are a waste of time with somebody with a panic disorder.

So there's a lot more science in Pax Medica, and that's a good thing. But I think we're ready to integrate many strata of science now, to emerge out of the one-dimensionality. Evidence-based practice is still going to be part of the picture, despite the knowledge that the outcome management people have provided us, which is that there are diffuse boundaries between these psychotherapeutic schools.

I'm arguing that we don't need any more gurus.
I'm arguing that we don't need any more gurus. I certainly don't want to be anybody's guru. We don't need another school. I'm not suggesting brain-based therapy is a school and now everybody's got to be an Ardenian. Oh, what a terrible burden it would be to be one of these gurus—and a hollow experience, at that.

Rather, I think we have the opportunity to integrate evidence-based practice—which still is part of the picture for anxiety disorders and depression—with a better look, for instance, at the building of the alliance. The Adult Attachment Inventory and things like that give us insight into the various types of relationships we have been taught to develop, that are going to be replicated in the therapeutic encounter anyway. So why not include that as part of the overall picture? And we know that certain types of brain dynamics and temperament are associated with relationships—neuroscience is a big part of this new equation, as well.
RA: The brain is a popular topic right now, but do you feel that we’re really there yet with the science backing biological theories about how the brain works?
JA: More than we ever have been. I’m also convinced that in five years, I’ll be looking back at what I’m saying to you right now and thinking, “God, John, you had such a limited understanding of what’s going on.” And I think that’s a good thing. So, yes, I think that we can begin to have a dialogue about neuroscience, but are we there yet? No. I don’t think we’re ever going to be totally there. There is no “there.” But we’re going to be far more enlightened about what’s going on. And certainly, not everybody’s brain is exactly the same, but we know that there are psychological syndromes, like anxiety and depression, that have some commonality across people. We ought to be talking about that among ourselves as therapists, and also in therapy with our clients. I’m always talking about the brain with my clients.
RA: A lot of people feel that there’s been an overemphasis on the brain and that therapy has really moved away from focusing on emotions and the human experience. Related to what we were talking about with Pax Medica, there’s a concern that overfocusing on biology closely ties in with overfocusing on pharmaceutical therapy.
JA: I think otherwise. In fact, I think it's an opportunity to focus less on psychopharmacology. Out of the 2,000 of us in the Kaiser system, I'm among the people who refer my clients less for medication evaluations, because I want to work with emotion. That's our province. So how do you work with emotion? Well, if you have people narcotized, you're not going to have access. And certainly with people who have anxiety disorders, anybody on a benzo I'm trying to get off of benzos as quickly as possible.

SSRIs I'm less concerned about, but I only go there when I exhaust all other avenues, including diet, which I'm always talking about at length. Exercise is the most effective biochemical boost that there is—as effective as psychotherapy. Exercise is as good as psychotherapy in alleviating depression. We ought to be doing that and psychotherapy together.

Including all these biophysiological dimensions that don't include the drug cartels is a good thing. Now, the reductionism to a specific neuron—no, I don't go there. Remember, I'm a guy steeped in psychodynamic theory, and I still love all the allure associated with it and all these characters that are battling with one another. It's fun, and it's enlightening in many ways. I think the new psychodynamic perspectives are quite a bit more advanced than the original psychoanalysis.
RA: So you see the new role of the therapist incorporating biology, traditional psychology, but also sleep hygiene, exercise, and nutrition.
JA: Absolutely. I'm not suggesting that we don't pay attention to the alliance. In fact, that's one of the principal effective agents. And we know that from psychotherapy research; the outcome management people have shown that to be pretty powerful. But why not pay attention to those parts of the brain that make that possible mirror neurons, the anterior cingulate, the orbital frontal cortex, the insula, the spindle cells? It's interesting for us to know that some people, if they've had a poor attachment history, have underdeveloped areas like the ones I just mentioned.
RA: You mentioned that you can see this information as a opportunity to teach clients about what may be happening in their brains. How does that help?
JA: Let me give a fairly common example. Say you have a client who says to you, "I just don't know why in the first part of the day, when I lie there in bed, I get so overwhelmed and I get paralyzed with this totality of anxiety. I don't know what's going on there. I get anxious and depressed. What am I going to do?"

Well, we know now from all these affective symmetry studies that people who get hyperactive right prefrontal cortex plus underactive left prefrontal cortex get more anxious and more depressed. And what kindles the right prefrontal side are withdrawal and avoidant behaviors. So when she gets into the withdraw-avoidant behavioral response, she's kindling up the right prefrontal cortex.

Now, how to get out of that? You've got to do what are called approach behaviors. The CBT people have known this a long time—it's called behavior activation. What do you do with depressed clients? Do you sit around and analyze things to death? No, you get them doing stuff. And you get them doing it quick. As soon as you start to feel overwhelmed, it's time to do something, because that kindles the left prefrontal cortex, which is about approach behaviors. But you do it incrementally, because it's always very overwhelming to do big, big projects.

We're not talking about the left hemisphere as being the new cool one now and the right hemisphere as passé, where it was the right hemisphere that was the cool one before. No, we're going to be talking about a relative activation of the two hemispheres. In fact, we know, too, that if you get the right prefrontal cortex knocked out, you lose your sense of humor. What's that about? Well, you want to have a sense of humor, right? A sense of humor is about plays on words, metaphors, juxtapositions, and all of that. You want to have that larger picture.
RA: So all of that also really speaks to how behavior changes the brain.
JA: Absolutely.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other. Pax Medica had it one way: “Brain changes behavior. All you’ve got to do is tweak up some neurotransmitter system like serotonin, and everything’s going to be fine.”
RA: “Because you have a chemical imbalance.”
JA: "Chemical imbalance" is so American, isn't it? "Okay, let's just go in there and change that chemical imbalance. I want to fix it quick, will you, Doc?"

Come Together

RA: Where do you think we are in the grand scheme of integration?
JA: I think it's slowly developing. There will always be tidal pools that pull back. For example, you mentioned earlier that some people are saying, "Oh, neuroscience. What's the big deal? Neuroscience isn't going to be part of the picture. Get over it." It's going to be, but how is the bigger picture? I think that there are a lot of people jumping in the bandwagon who aren't paying attention to the science in neuroscience. I'm not going to get into names, but some people make it rather New-Agey, and that kind of turns my stomach.

Science is a good thing. We ought to be paying attention to how the research actually shows this or that instead of, "Well, that's kind of a cool thing. Why don't you just talk about the so-called limbic system?"
How we incorporate neuroscience, I think, is going to be a big part of how we advance toward the future. And it's not going to be reductionistic. It's going to be a part of the picture. We're still going to talk about the relationship and pay very close attention to the alliance. And as I said earlier, it works both ways, because there are parts of the brain and parts of our nervous system that respond to close relationships, and that's something we ought to be paying attention to.

The psychological theories and all the alphabet-soup therapists—EMDR, EFT, CBT—the advances in some of those areas, I think, are going to be part of the picture. But I think the allegiance to the schools is going to be increasingly less of an issue.

Reshaping Memories

RA: I think a lot of people in the field really hope that your view is right. What evidence do you see that indicates the field is moving in this direction?
JA: It seems to me that the studies that show actual change in the brain resulting from psychotherapy are what will convince everybody that we’re moving in the right direction. And there’s a wealth of information out there that’s developing and will become stronger and stronger, and it’ll be undeniable that there’s an intersection here. Again, it’s all not reductionism: it’s integration. And memory is a major part of the picture here.
RA: Say more about that.
JA: Understanding memory and the complexities of our various memory systems, including the various types of implicit and explicit memory and how those systems work together to make us who we are, and how we, as therapists, interact with these memory systems—that, to me, is the foundation of therapy. Our job is to help people reconsolidate memory in a much more adaptive and effective way, because there is no such thing as a memory encapsulated in some sealed-off portion of time, where you go back in and you pull it up. That's where the early psychodynamic theorists had it all wrong. Every time we bring up a memory, we change the memory.

That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way.
That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way. I regard memory as one of the major foundational aspects to psychotherapy in this unfolding sea change—not a paradigm shift, but actually a sea change—that's occurring in mental health.
RA: You’ve said that it really seems like we’re moving beyond brand-name therapies, but do you think we’ve just substituted techniques? You mentioned CBT. I’m not completely clear on what the theory behind CBT is, other than that it seems very removed from things like memory and emotional experience.
JA: Actually, it does incorporate them. If you think in terms of anxiety, for example, it's quite clear that avoidant behaviors make anxiety worse even though, over the short term, they make it feel less severe.

Let's say I'm a socialphobe and I walk into a room. I feel better for the first minute, and then I feel terrible, and my amygdala gets hyperactive as a result. In other words, I'm painting myself into a corner. Exposure is the antidote—the therapeutic direction that we ought to be working in. And that goes back to Joseph Wolpe, who doesn't get enough credit now, even in the CBT community. The whole idea of incremental exposure is critically important in psychotherapy for people with anxiety disorders. So the CBT people are talking about the brain even though they're not using the brain in their dialogue. They're not mentioning the brain because they haven't been really incorporating it into their understanding. But they are changing the brain, because exposure actually changes the brain. It could make the anxiety worse by flooding too quickly, but incremental change could make it much more resilient and adaptive.
RA: Let me see if I’ve got this right. It sounds like you’re expecting that there would be a much more integrated theory about how psychotherapy works, because it’s going to include neuroscience. And because we have more technology now, we’re going to be able to actually see these changes and understand it, and we’ll continue to see even more levels of complexity.
JA: We are seeing these changes. And in fact, with psychodynamic theory, the whole concept of working through is the same thing as incremental exposure. A book that I like to recommend that's now 20 years old is Psychodynamics in Cognition, by Mardi Horowitz. I really like that book. It was Horowitz's attempt by to talk about the overlap between psychodynamic theorists and cognitive theorists-maybe they aren't talking about something so different. Let's talk about how defense mechanisms and schemata have an overlap. That's what I'm talking about: finding the overlap between these therapy types. Just because they use different language doesn't necessarily mean that they're not talking about the same thing. Where there is an overlap, I get excited about it.
RA: So neuroscience is going to be what shows us that we’re all talking about the same thing.
JA: Neuroscience, and a look at these therapeutic styles. Defensive maneuvers are still relevant, and we can look at them from a cognitive perspective, and from this whole affective symmetry dynamic, as well. In other words, we could look at them from a number of different vantage points, and if all those vantage points have a cohesive quality to them, then I feel much more confident about it.

So we’re not just talking neuroscience or just talking psychodynamic or just talking CBT or memory, but rather how these all can overlap and say the same thing to give us a much more robust understanding of what goes on in psychotherapy and what goes on in our own heads.
RA: Do you believe this integrationist’s frame of reference changes the way that you work with clients?
JA: Absolutely. I've been in the mental health world for 35 years, and when I first started, I was part of this whole the institutionalization movement—we were creating alternatives to hospitals in San Francisco, and then wrote a bill for the New Mexico state legislature in 1980 to do the same thing. What I thought was going on back then is quite a bit different from what I think about what's going on now.

Even in 1976, when I was working with autistic kids—God, we had a stupid understanding of what was going on with those kids back then, because we didn't understand what was happening in their brains. We thought it had to do with these really cold mothers. Bettelheim was our popular hero. My God, what a dumb, dumb way of understanding.

It didn't mean, though, that what we were trying to do, in terms of developing a good relationship with the kids, wasn't a good thing to do. We called it reparenting, but nowadays we'd think about it as being helpful to the kids so they could acquire better social skills and develop a better ability to have human relationships.
RA: This makes me think about some of the preliminary studies in the news now about sudden-onset OCD in children after they have strep infections.
JA: And that has helped us to understand the role of the striatum very well, because that’s the area of the brain that gets attacked viciously in these kids during the infection. And we know that the front part of the striatum is kind of like a spam filter. In people with OCD, unfortunately, that striatum doesn’t work like a spam filter, and the orbital frontal cortex gets flooded with all this nuisance information: “This is wrong, this is wrong, we’ve got to do something, wash your hands, wash your hands,” or whatever it is. Baxter’s group down at UCLA showed very clearly the orbital frontal cortex being flooded with all this nuisance information, and that what can help alleviate the OCD is to “rescue” the orbital frontal cortex with the dorsal lateral prefrontal cortex (which has a lot to do with working memory) via CBT with a mindfulness approach. In these imaging studies, you could see OCD patients before and after the treatment. And the strep infection material was supports the idea that OCD involves this “gate” that is left open in the striatum.

But How Does It Work?

RA: Let's walk through a hypothetical. I come to see you because I feel depressed and generally anxious, and this has been going on for some months now. Where would you start to look for the cause of my feelings and some relief?
JA: It's interesting that you say depressed and anxious, because under Pax Medica, if you were depressed and anxious together we would have two diagnoses on Axis I—a comorbid problem. Well, you're one person. Are these two genetic disorders you have? What a silly idea. And the prescribed pharmacological agents actually work against one another. These stupid benzos, which are really a nuisance in the mental health world, would actually contribute not only to addiction, tolerance, and withdrawal problems, but also to depression. And then you'd toss in an SSRI or something like that, so you'd have this weird cocktail.

There is an interesting neurochemistry that occurs with anxiety and depression. For example, for 90 minutes after you experience a severe stressful incident, your levels of dopamine, norepinephrine, and serotonin will be down. Let's say that you've just found out that you can't get into school. All the PhD programs have turned you down. That's a pretty big blow, right?

So you're going to get a downregulation of all those neurotransmitter systems, and you're going to withdraw a little bit. But it's what you do with that neurochemistry and those neurodynamics that can tumble you into more anxiety and more depression, or get you out of it. If you do things that kindle up the same systems that would get you more anxious and depressed, you'll get more anxious and depressed.

Now, we're going to have bumps in the road. It's what you do in response—it's that resiliency. Some of the positive psychology spinoffs are paying attention to that, and of course the counseling psychologists have long done that.
RA: So, if I were your client, would you want me to tell you about something stressful that happened and what I did afterwards?
JA: I often do that, just to get an idea of how people react to certain events in their lives—to get a characteristic description. I'm also paying attention to the way they describe them to me, because that interaction between us is so important. It replicates other relationships they're having that might have great continuity with the earlier attachment-based relationships. It tells me a lot about how I can intervene, because I don't want to create more resistance. I do like Milton Erickson a lot—that indirect approach. I'm not going to want to shut you down and have you screen me off, but rather do some motivational interviewing to some degree—which is very Rogerian, in fact. Bill Miller was a Rogerian from the school that I came from.
RA: Out of curiosity, did you study with him at UNM?
JA: No, I didn't. In fact, I didn't know about him until after I left. I don't know if he was there then—that was 30 years ago. But had he been there and I missed him, I would have been disappointed, because I really like his contribution to the substance abuse community.

Addiction: A Sliding Scale?

RA: And substance abuse is one thing that we haven't really touched much on in terms of what neuroscience is really teaching us. There's big debate about whether addiction is a genetic disorder.
JA: There is some literature to suggest that if you have two alcoholic parents, your vulnerability to become an alcoholic is heightened. But let's say the concordance rate is 50 percent. Well, what about the other 50 percent? It isn't a one-and-one factor.

In a discussion I had with Fred Blume, one of the pushers of the alcohol gene concept, I asked, "How about an acquired disease? You guys are really into this disease concept." AA's really into it. AA and NA are the most powerful self-help groups in the world, in my opinion. My sister-in-law's life was saved as a result. Fantastic groups. I love their little jingles and all that. But they're too into this disease concept. It's useful in early recovery, but you could create a disease. It's bidirectional. The more I drink alcohol, the more I feel like I need alcohol, because my biology changes. I downregulate various neurotransmitter systems, so now I feel like I need to mellow out because now I'm downregulating the synthesis of GABA. That means I need more GABA-like effect because I'm always dampening down glutamate.

What I think therapists ought to be paying attention to is how these various substance abuse habits, if you want to call it that, create psychological symptomatology. “I see all sorts of people here in the North Bay who are suffering from anxiety and/or depression, and I find out they're just drinking a glass or two of wine at night.”
RA: That’s a lot of wine, though.
JA: I think it’s a lot of wine. I drink a glass every week or two. It would be nice if you could have two glasses of wine a night, but my sleep gets all messed up. You get the mid-sleep-cycle awakening and all that. And that’s a small snapshot. What about the next week? These are subtle effects, but when I used to do neuropsychological testing and psychological testing, and then later teach it, we used to say, “Don’t test a wet brain for up to three months after your last drink.” There are all sorts of artifacts to subtle alcohol consumption.

And red wine isn’t that cool, you know. It’s the resveratrol in the skin of the red grape. You can drink Welch’s grape juice and still get the same effect. You don’t need the alcohol.
RA: And what about other drugs? I haven’t heard too many therapists saying that they necessarily ask their clients, “Do you smoke pot?”
JA: Everybody here does. And pot is one that I really pay close attention to in the North Bay, because of all these people on medical marijuana cards. They have a sore back. Well, give me a break. So do I, but I don’t smoke marijuana now. I did 40 some years ago as a young hipster, but I’m glad I stopped 40 years ago, because otherwise I’d be muddled and kind of down. THC is chemically structured like a neuromodulator called anandamide, which is Sanskrit for “bliss.” It orchestrates the activity of a number of neurotransmitters, so when you’re stoned you get what we call virtual novelty. “Look at this cup! God, that is so incredible. Look at the way it’s shaped, and the colors! This is amazing.” Then the next day you get what we would call in the ’60s “jelly brain,” because everything’s downregulated now. And you never get the same high.

So now what we see are all these people smoking medical marijuana who have low-grade depression. They can’t remember much, because they downregulate the acetylcholine release in their hippocampus and have symptoms very much like ADD. God, I get people with ADD evals all the time who are smoking marijuana.

So with regard to substance abuse, psychotherapists should perform a full analysis of everything the clients are doing, instead of saying such things as, “Do you abuse alcohol?” I want to know what they’re consuming rather than ask blanket questions.
RA: Well, what’s abuse? “Yeah, I have five beers a night, but I’m fine.”
JA: Exactly. But if somebody’s drinking two, I’m concerned about that, especially if she’s anxious or depressed. Or if somebody’s taking a toke of marijuana a night, and he’s coming in with this low-grade depression, muddled thinking, and attentional problems, I’m concerned about that.

Defining Therapeutic Success

RA: In the way that you’re visualizing therapy, how do you define therapeutic success?
JA: We're always a little too symptom focused. I still think we ought to be paying attention to symptoms—that's an important part of the picture—but we also ought to pay attention to what clients are telling us about their overall improvement and their perspective in life: "I'm feeling so much more hopeful and so much more resilient and I'm not as easily stressed." And we're getting more of that from the outcome management process, instead of, "You originally came in with these panic symptoms. How's the panic doing?" "Oh, I don't have those panic symptoms anymore." Well, that's good. That's only part of the picture, though. There's got to be a larger look at things: is the relationship improved, for instance?

Therapists: The Next Generation

RA: As a mental health training director for Northern California for Kaiser, you work constantly with the next generation of therapists. What do you see in their training that concerns you?
JA: What got me intensely concerned and preceded the development of Brain-Based Therapy was typified by an answer to the question, "What do you want to do in the next year?" In the Kaiser Northern California, we have 60 postdocs in 20 medical centers, and another 50 interns. When I interview a postdoc and ask, "What do you want to do over the next year?" they say, "I really want to find my theoretical home." You want to what? We're certainly not going to be helping you find your theoretical home. In fact, I want to dissolve those theoretical homes into a grand unified area. So that's a concern.

And a lot of young therapists come out of these schools too young and inexperienced—they haven't had to go out in the world and learn business and all this, to augment their academic understanding. Between undergraduate and graduate, I spent a year in Asia and the Middle East, and I just kept circling the globe. I was gone for a year, and I don't know how many countries I visited. What an incredible education. I matured so much during that period.

Life experience is critically important. Having to deal with some stressful events can really help a therapist. Just being pumped out of all these professional schools with all these fancy degrees and all that, boy, that's such a limited area. I get a little concerned about too-young therapists being plopped out and wanting to be Dr. Somebody-or-other.
RA: That seems to address my next question: do your intern therapists seem to come with a broad base of knowledge about other aspects of the human condition—literature and art and history?
JA: That's a pretty interesting question. I remember when I was being interviewed for my PhD program, that was a question in the interview. I was in the Counseling Psych department, even though I later got involved in both departments. I was really into talking about Dostoevsky and D. H. Lawrence, and that perked up the interest of the interviewers. Contrast this with the clinical program applicants—I call them the GREs. All they got was a high GRE score and a good GPA. Big deal!
RA: In the next generation, are you seeing much of that?
JA: If you immediately go from a bachelor's to a master's and, usually, especially the professional schools, straight to a PhD program, I see a lot of that. And physicians, unfortunately, hardly read at all. It's just shocking that the educational system kills the quest for reading in diverse areas. It's amazing.

Therapists don't read enough. And when they do read, unfortunately, they read in their own little clubhouse. Where you get more cognitive reserve, if you will, is where you step out of your own zone of comfort. I particularly like to step out of all these mental health areas completely and pay attention to what other scientists are doing.

Particularly, I love complexity theory. When I'm back in Santa Fe, I like to go to the Santa Fe Institute. This place is incredible—founded by three Nobel laureates, two physicists, and an economist. And then there are biologists and computer scientists and archaeologists, all talking about the change in complex systems. Well, aren't we a complex system?

So I think we don't read enough, and not only of another psychotherapeutic school, but, also another area of science. It would be really good for us to do that on a regular basis. I'm perpetually advocating for that.
RA: There are some people who are advocating for academia to do something similar to what you’re saying psychotherapy should do, arguing that there really shouldn’t be such big walls in between each department.
JA: Yeah. In fact, in the Sonoma State University, there’s the Hutchins School, which is very much like St. John’s College in Santa Fe, whereby you have more of an interdisciplinary approach. At St. John’s it’s more of a classics approach, but at Hutchins, you have a department with anthropologists and biologists and other people all there. It’s that interdisciplinary approach that I think is so valuable.

Inside Kaiser

RA: Do you think, working at a large health maintenance organization, that this move toward integration will also eventually break down some of the barriers for clinicians to be able to determine what kind of treatment they want to give to a particular client? Right now, HMOs rely very heavily on CBT because there are so many studies of a specific symptom with a specific treatment.
JA: I don’t necessarily see Kaiser as being a CBT mental-health dispensary. I’d look around at all my colleagues, and one person might be into EMDR, another person CBT, another person steeped in psychodynamic or narrative. But we do pay attention to evidence-based practice. In fact, we have a whole administrative structure just for that. But we also have an administrative structure just for outcome management. The convergence of the two is pretty important.
RA: I’m sure that you’ve heard some of the recent complaints about Kaiser that people have a difficult time getting timely access to mental health care.
JA: That's kind of old news—20 years old. All departments are graded for access right now. I was hired during the Model of Care, which was 20 years ago, where we tripled or quadrupled the size of many departments because it was all about access. Every department now is graded on how quickly a client can come to see someone. If you call in right now, we've got to give you an appointment within two weeks. That's called initial access for the new, and there's a seen-to-seen that we're being graded in, too. We've improved dramatically in the last 20 years.
RA: There is a recent report that union leaders and employees were asking for an investigation to make sure that it was happening in a timely manner. Do you feel like the treatment model that you’re describing can fit well into an organization like Kaiser?
JA: Kaiser's in a difficult position because it's swimming in this vast sea of other medical providers, and it's trying to survive at the same time as thrive—to use that term. So I know what those folks are saying, and we're not immune from any criticism. There are always these concerns about improving, and that's a good thing.
RA: And people having access.
JA: Absolutely. Access is critically important. I know that we're trying to do whatever we can. I'm in meeting after meeting about improving access. We're always talking about improving access, while at the same time we're talking about hiring new people. But where are you going to get the money to hire the new people unless the membership rates go up? It's a complex situation.
RA: You obviously have a very expansive knowledge base that you're integrating. What wisdom do you hope the clinicians that you're training will take away from it?
JA: That there is this exciting sea change occurring in mental health, if you pay close attention to it and if you read voraciously. Just because you’re out of graduate school, we don’t want you to stop reading. We don’t want you to get rigor mortis. In fact, we want you to now read more than you read before, and go to more workshops in areas that you don’t even have any interest in initially. That’s where you get the best change, really, is if you go, “I have no idea what that person is going to be presenting over there.” Those are the ones you want to go to, rather than, “Yeah, I’m really into that kind of therapy.” How many more times are you going to hear that particular frame with a little bit of a twist to it here and there? In fact, you get more neuroplasticity if you get into an area you have no knowledge about at all. What we want to do for this next generation of therapists is to be integrators and to be active consumers of diverse areas of science.
RA: What are your hopes and concerns about the future?
JA: I'm concerned about the economy affecting mental healthcare and, again, as somebody who in the '70s and '80s was helping people who were chronically mentally ill and homeless, I'm really concerned about mental healthcare for the poor. Here I'm in Kaiser right now, and who are the Kaiser members? Well, they're people with jobs. So I'm really concerned about the disadvantaged groups, and that has a political component, too, because if we go Tea Party zone, you're talking about massive cuts in the safety net, and it's pretty primitive.

Into the more advantaged stratum, I'm concerned that, even though I think there's a sea change going on, it could go the other way—the continued focus on these clubhouses. But I'm heartened that things are going to change eventually. I'm totally convinced that they will, because of these converging fields. When it will happen is another thing. It might be more in your generation and in my son's generation who, like you, is applying for graduate schools right now, than my generation. I think for quite a while, we're still going to have the gurus out there. But hopefully they will be talking in more integrative ways and less about themselves, so to speak.

Techniques, Therapeutic Relationship and the Importance of the Body

Posted on by Psychotherapy.net Team

Throughout my career as a psychotherapist I struggled to find the right balance between using specific techniques and the importance of establishing a safe therapeutic relationship. Toward the end I veered more to the latter as I realised, rather belatedly I admit, that people sought therapy not necessarily to get better but often just to be heard. A safe haven and a sensitive, empathic and caring individual can be enough; specific techniques can get in the way. Of course this is hard to square with the demand for evidence-based psychotherapy where therapy is defined as applying identifiable techniques and improvement seen in terms of symptom reduction. This quasi-medical model is rightly seen as simplistic, ignoring both individual meaning and the influence of socio-economic factors on mental health. Nevertheless, it has certain virtues. It enables those who know very little about psychotherapy to grasp what is supposed to be happening, something that both clients and commissioners of psychotherapy legitimately wish to know. Seeing a CBT therapist, for example, means that the approach is likely be collaborative, problem-focussed and address the client’s thoughts, feelings and behaviour in an open, adult and rational way. Seeing a psychodynamic therapist, on the other hand, means the therapist is likely to be passive, say relatively little, attend to underlying meanings and dynamics and use the therapeutic relationship as the main vehicle of gaining understanding from which change may or may not happen. Neither of these descriptions captures the subtlety and complexity of psychotherapy, nor the uncertainty that is part of all therapies. But they are not unimportant especially when it comes to making useful distinctions to those who know very little about what goes on behind the therapist’s closed doors.

In researching a book about peoples’ response to major traumas, I discovered some interesting and new (to me) therapies, ones that worked primarily through the body. I watched a DVD in which therapists trained in Emotional Freedom Techniques worked with highly disturbed combat veterans with strikingly positive results. I read up on the many and varied somatic therapies and began to understand how therapists who attend to the physical body gained much from not having to work verbally or at least not as the primary means of intervention.

Peter Levine is one of the best known exponents of “somato-sensory psychotherapy,” an approach that sees traumatic reactions as largely due to undischarged energy. Therapy is geared to enabling the person to discharge energy through more sensitive and balanced physical actions. Levine is adept at seeing the embodied person in a way that most psychotherapists are not. It is easy to equate the somatic therapies with their striking physical techniques. Tapping pre-defined meridian points in a particular sequence and in relation to a particular phrase or thought is clearly one such technique. But it also reflects a general therapeutic approach, one that conceptualises the psychological impact of trauma not in terms of trauma narratives or past history but in terms of physical experience. If, as seems to be the case, people can recover remarkably quickly, sometimes in a single session, then this different approach deserves to be taken seriously.

EMDR, essentially the precursor of the somatic therapies, was very critically received precisely because it seemed too good to be true. But it has proved its worth since. Similarly, it is easy to dismiss therapies as ‘wacky’ if they draw on traditional Chinese Medicine, focus on acupressor points, use an uncertain and vague term like “energy,” and involve rather simple physical actions like tapping. Beware of not seeing the wood for the trees. Energy psychology and somatic therapies offer something radical and different. Traditional (verbal) therapists would be well advised to keep an open mind. Seduced by our Freudian heritage, we plunged into the complexities of the mind and, with some notable exceptions, forgot the body. Isn’t it about time we brought the body back?

Nordstrom: Psychotherapy Lessons From The Cathedral Of Commerce

Posted on by Psychotherapy.net Team

Let's get something straight right from the get-go. I don't work for Nordstrom, nor am I am affiliated with them in any way, shape, or form. I've never spent a dime there. Truth be told, the only time I ever set foot in a Nordstrom was to walk from the mall to the parking lot. (Elapsed time: one minute and forty-five seconds.)

But I do know this. Nordstrom has become the darling of the customer service movement. If you are searching for the prime example of the customer-is-always-right philosophy, trust me when I say, you just found it. The stories are legendary, such as the time during the mid-1970's when a customer returned a set of snows tire to Nordstrom. Yes, the customer received a cheerful refund. The only wrinkle was that Nordstrom didn't sell snow tires. Then there's the saga in which an unhappy customer returned a set of ice skates. Here again, Nordstrom took them back. Never mind that Nordstrom didn't carry ice skates.

Historians and business scholars who have investigated these transactions are still debating how much is myth and how much is fact. I don't pretend to have the answer and indeed will let the MBA's battle it out on their own turf. Nevertheless, there is no doubt that Nordstrom is the poster child for the customer is always right, even when the customer is wrong philosophy.

But do we, as helpers, always abide by this stance or do we hide behind our favorite technique, what helped us when we were wounded warriors, or what the latest evidence based practice literature tells us?
A well-known dyed-in-the-wool behaviorist once gave me an excellent clue. The therapist noted that he was seeing a client whom he was treating with behavior therapy and behavior modification techniques. But there were two problems with this approach. First, was simply that the behavioristic modalities did not seem to be working. Second, was that the client kept insisting he wanted classical psychoanalysis. This went on for a significant period of time until one day when the therapist was so frustrated he threw in towel and agreed to provide classical analysis.

The situation became a tad more bizarre when the therapist explained to the client that he was sure psychoanalysis would not work. He thus created a behavioral contract stating if the analysis didn't work in six weeks, the client (excuse me, I mean the analysand), would agree to give behavior therapy another whirl. Since a course of analysis usually runs approximately three to five years this contract was about as paradoxical, if not downright silly, as it gets! Moreover, the use of a behavioral contract in psychoanalysis is little like trying to mix purified water and used motor oil!

For the next six weeks the client made the couch his new psychotherapeutic home as he babbled on about his childhood and his dreams, while the his behavior therapist, turned Freudian analyst, sat out of his sight and took copious notes.

In less than six weeks the client reported that he had overcome his symptoms and was feeling well enough to terminate treatment. No doubt somebody had to pinch the therapist to make sure he wasn't dreaming.
So, the next time your client makes a treatment suggestion, my advice is to listen very carefully. You might just catch a rare glimpse of the path less traveled from the annals of Nordstrom.

The Whole Truth: Coping Creatively with the Dark Side of Therapeutic Practice

Posted on by rezendevknowfully.com

We are sitting down to dinner, like we do every night. My oldest son, home briefly from college, has reclaimed his seat to the left of me. Across from me sit my other two children, sweaty and satisfied by their after-school sports practices. The four of us chirp out a collective, “Thank you,” to my husband, the cook, for such a good dinner. We eat and talk and wind down our day.

Only moments before, I was finishing up one of those long, intense days, hour after hour filled with client struggle and crisis and touching connection. I had silently shooed my last client out the door, my thoughts becoming a bit frantic when I thought she was going to stop at the bathroom, further delaying my departure. I swooped out—lights off, sound machine off, alarm set—hurrying to get on the road that would take me to my daughter’s soccer practice just in time to pick her up.

Most days are like this. I dive deeply into my commitment to healing and helping clients. I work with their internal worlds, and willingly make contact with some of the most painful aspects of life. And, just as quickly, I rush up from the depths, back into daily living.

Today was more difficult than average. A long-term client came in with the news that she’d been diagnosed with an aggressive form of cancer. A 15-year-old who had been successfully using art as an alternative to self-harm arrived to session with a freshly cut X in her shoulder. I struggled to engage a new client—a sullen, depressed teen. I listened patiently to a client tell a different version of the same story about her frustrating husband. And I hosted a culminating art show (both celebration and termination) with the work done in treatment by my client, a recovering addict, for her and her large extended family.

Yet when I sit at dinner now with my own amazing family, there is nothing to say in reply to my kids’ inquiries: “How was your day, Mom?” I can’t give them details; everything is confidential. Besides, it feels impossible to convey the depth of pain and joy that my job delivers. And while I think they are actually asking, “How are you, Mom?” I haven’t even had the time to figure that out. Between racing out of the office to soccer practice pickup, and then home for dinner, there hasn’t been an ounce of room for self-reflection. And if I use the time at dinner to really see how I am, I know I will come up with confusing and disparate adjectives: drained, energized, discouraged, overwhelmed, fascinated, curious, amazed, sad. The truth is I’m full of joy and gratitude for the opportunity to midwife significant changes in so many clients’ lives. At the same time, I also have my fill of others’ pain, their traumatic stories, and the experience of feeling helpless in the face of intransigent symptoms. I know too well that, if I’m not careful, this visceral awareness of human tragedy can lead me to disconnect from even the most basic dinner conversation, or worse, cause burnout at work and alienation from family and friends.

Confronting the Dark Side

I’ve come to learn that what I once held true about my profession is in fact not the whole truth. Being a therapist is not only about being effective at helping clients reach their goals. Aspiring to help clients make significant changes, achieve their treatment goals, and improve their functioning is a worthy pursuit that requires a lifetime of work and experience, but effectiveness is only part of the story.

In 2009, psychologists David Orlinsky and Michael Ronnestad studied over 5,000 therapists’ experience and careers, and brought to light the double-edged nature that psychotherapeutic work embodies. They found that, while over half of the therapists studied feel they have effective practices that yield feelings of competence, positive relational interactions, and flow states, another quarter have what the researchers deemed a challenging practice. The therapists studied were equally likely to experience this stress across orientations, career levels, and licenses. But what is fascinating is that those therapists with challenging practices—who experienced professional self-doubt, frustrations, and difficult feelings—still reported high engagement and positive relational interactions. This challenges what therapists might assume to be true: either you feel good because you’re doing your job well, or you feel bad because you are not helping your clients effectively enough. In fact, it offers an alternate view of our work: that there really is a way to experience difficulty without being inadequate, a way to hold self-doubt without feeling incompetent. Orlinsky and Ronnestad’s research reveals that while it is important to increase effectiveness for the therapist’s sense of healing involvement and for the client’s satisfaction with the services offered, effectiveness alone will not mitigate the stress of the profession. “If we do pursue ideal effectiveness as our one and only buffer for professional stress, it seems we are setting ourselves up for burnout.”

When I started seeing therapists as individual clients, I began to hear how easily this stressful involvement can easily turn into shame. If we don’t figure out ways to cope with the difficult feelings that accompany our work, burnout and self-doubt can begin to interfere with our well being and cause emotional disconnection from our therapeutic relationship with clients.

I’ve heard the narrative many times. It goes something like this: “I’m a therapist; I’m supposed to be emotionally healthy. But every single day, hour after hour, I have the chance to feel like a failure. Whether or not I succeed in empathizing with my clients, I feel struggle and pain and tragedy. I’m supposed to be healthy enough to withstand it. If I don’t feel emotionally resilient and instead feel bored and unconnected, or dread seeing my clients, I am a failure. But I can’t be a failure, so I will cover it all up and live with shame.” It’s a closed narrative that doesn’t provide alternative reactions to feeling stress and uncertainty.

Orlinskey and Ronnestad’s study identified a dual coping strategy as the key to therapists’ ability to sustain themselves and to stay engaged in their work. Besides the development of clinical skills, the other aspect of coping had to do with self-reflection. In order to tolerate difficulties such as the distress of feeling powerless to affect a client’s tragic life situation, or needing to regulate intense feelings in order to establish the one-way intimacy of a therapeutic relationship, therapists need to use their creativity to see the problem differently and to “give themselves permission” to experience disturbing or difficult feelings.

When I was an intern twenty-odd years ago, my supervisors coached me to practice good boundaries, and they implied that any struggles I did have with my role as therapist or career choice were due to my lack of experience, my unresolved personal issues, or the fact that I wasn’t seasoned enough and didn’t know how to “leave it at the office.” In his book, A Perilous Calling: The Hazards of Psychotherapy Practice, Michael Sussman suggests that the original blank-screen approach to the therapeutic task has dangerously infiltrated modern practice: “Throughout the history of psychotherapy, the personhood of the practitioner has been all but ignored. Successive generations of therapist have received and, in turn, passed along a professional culture that often leaves little room for the clinician’s humanity.” My own experience as an intern mirrors Sussman’s warning: “I didn’t feel I was allowed to have personal feelings about my professional work as a therapist, but these feelings didn’t stop rising to the surface.” Yet, because I didn’t have a safe place to bring them or a way to work through them, I also couldn’t let myself acknowledge their looming presence.

According to psychologists John Norcross and James Guy, 75% of therapists complain that work issues spill over into their family lives. Norcross and Guy highlight the fact that increased work stress is related to decreased marital satisfaction: the emotional exhaustion of our work can leave us too tired to engage in family relationships. One might think that we therapists could just share our work drama and download to our spouses like any other stressed professional would. But confidentiality rules prevent this from happening. Besides, if we don’t understand that powerlessness and uncertainty are difficult feelings that we need to learn to allow, and instead feel inadequate for having these feelings, we are even less likely to be able to share with family or colleagues how very hard our work is.

Having weathered two decades of this amazing vocation, it’s only now that I am able to turn and look without shame or inadequacy at the shadow side of this work: the part that is painful and dark and that can become toxic, breeding isolation and disillusionment. I’ve been down that path where ineffectiveness led to powerlessness and shame, where the mask of clinical expertise and emotional stability prevented me from connecting to what was true for me, where I bought into the idea that difficult feelings were a sign of inadequacy. At one time, I thought that feeling effective was a true salve against this shadow side. I was so set on being helpful, I was willing to sacrifice almost anything. I didn’t know how to use self-reflection to process the trauma and intense emotion being poured into the core of me again and again. This is the side of my work that I don’t really want to share with my family, and the side that so few of my colleagues readily admit to experiencing.

Finding Support

Externalizing: Painting by Lisa MitchellRonnestad and Orlinksy found that quality of the work setting and available peer support are crucial in assisting therapists to cope with isolation and the sense of helplessness. This seems to be an obvious solution: a work setting in which supervision and peer support groups invite discussions about these issues. Given that the researchers found many therapists to value personal therapy as a tool that helps them engage constructively with clients and feel they are thriving in their work, it would seem like validating these messier and darker inner-world experiences should be a regular work practice among colleagues as well—not just one hidden away in the private realm of individual therapy.

Certainly, there has to be a time and place for this kind of activity. When working directly with clients, we need to exercise appropriate boundaries. We don’t want to be processing our internal experience to the exclusion of tending to our clients’ experiences. But even when I invite fellow therapists to talk about and reveal their inner worlds in a safe non-clinical setting, they have a hard time doing it without relating it back to some kind of analysis of countertransference. We are so good at trying to understand our clients that even the act of excavating our inner experience of being a therapist becomes another avenue for more insight about our clients. So often I hear therapists report a feeling like irritation, and then immediately justify their irritation with a countertranference explanation about how their client reminds them of a mother-in-law, for instance. I have to ask: when can your inner experience of irritation simply be a by-product of being a therapist?

If, as Ronnestad and Orlinsky’s research suggests, nearly half of therapists feel pressured, overwhelmed, anxious, and trapped at least occasionally in session, why don’t we take these feelings more seriously? Why can’t we be open about them with ourselves and with colleagues—collectively honoring both the light and dark of our profession? Can we allow our knee-jerk therapeutic use of self-analysis to slow down just a little so that we can look at ourselves without wearing our therapist masks?

Taking Off the Mask

Just last week, in an altered book workshop that I was facilitating, I saw how sharing this inner world and this double-edged experience can benefit all who participate. The group was mixed: therapists who had been in practice for decades, a few interns, and one trainee. I invited them each to make collages that represented what they carry for themselves and for clients in their hearts. It’s always amazing to me the level of depth therapists are willing to bring to this kind of nonverbal self-reflection. The heart images were powerful and raw. One woman made a weaving that juxtaposed operating room images with strips of wholesome nature scenes. Another took large nails and screws and attached them as if they were impaling the walls of her heart. Many had innocent images of children: smooth skin, wide eyes, swaddling cloth.

Embodied: Painting by Lisa MitchellIn the course of the workshop, I coached these therapists about the creative process. The start of any artistic activity is always fraught with some level of fear. Sometimes the fear is so high, especially for people new to art making in adulthood, that they may have difficulty starting because they are not familiar with this line between stressful involvement and full engagement. But it often just takes a nudge to begin. I like to remind folks that they don’t have to know how it will turn out; they just have to start with a color or a brushstroke.

For the therapists I have encountered in my workshops, the first step in an art-making activity can be hard for this reason, and yet the process mirrors one all therapists are familiar with. Beginning without knowing where our efforts will end up is much like beginning a relationship with a new client, or starting a session and finding that the treatment plan has taken an entirely different direction, and things are no longer as they seemed.

Even for experienced artists, this starting can sometimes be hard, but it is also exhilarating at the most passionate level. Artists know, when they start, that if they plan too much, the process is going to be stifled, boring, and probably not very creative. If that exhilarating feeling of anxiety before the unknown is present—better call the feeling “anticipation”—it is an indicator of newness and risk, which will inevitably bring discovery of the highest order.

During the training, when we shared our images, there was a collective sigh of relief. One therapist said, “Sometimes there is a jolt of pain in my heart—the sheer rawness of it all. Who do you share this with? I could never go home and show this image to my husband. He wouldn’t understand. It’s so hard to express it honestly for yourself. But then to show it other people—I have so much gratitude that there are others who can see this, hold this, and still not judge me as inadequate.”

The opportunity to view others’ experience in a visceral way normalized the more difficult feelings that the group members carried as therapists. Hearing everybody talk about their art and the experiences that it represented allowed participants to stop pathologizing these feelings. “Seeing others’ openness made the darker side of being a therapist feel more okay in a very powerful way.”

In another activity, I invited the group members to make art that represented the gifts that clients had given them. They first had to get past the fear of admitting that they did actually benefit from client relationships. Then, when they were able to see how much each person’s life had been touched and changed as a result of real, concrete lessons or ideas clients had taught them, they cried. They were so relieved to see that things were actually coming in rather than just going out. One therapist would never have pursued her dream of being a professor if her client hadn’t showed her that it was possible. Another therapist credits her client with the fact that she survived cancer due to an alternative treatment approach that her client mentioned. I credit one particular teen client for teaching me how to show teens respect, and I use it every day with my own children and with all of my other teenage clients.

At the end of the workshop, after they had all made art and reflected honestly about how the profession affects their lives positively and negatively, one of the interns said that it had been an amazing gift to hear that even the most successful and seasoned therapists have difficulties in their work. She hadn’t heard about the difficulties, hadn’t seen others struggling, and hadn’t been well informed about what to expect and how to cope. The older therapists talked about the sense of validation and belongingness that the honest art expressions and discussions had allowed.

When therapists collectively allow there to be a dual experience of light and dark, abundance and depletion, there is a sigh of relief—an acceptance of the whole truth. And self-blame, inadequacy, and shame simply dissipate.

The Therapist as Artist

In the course of my trainings and also my own personal and creative life, the analogy of therapist as artist continues to take on richer, more profound meaning. Not only do therapists have amazing inner worlds that they are constantly mining for ideas, inspiration, and sustenance; to be creative, therapists have to know that anxiety, overwhelm, and uncertainty are all necessary aspects of making their art. This speaks to the idea that therapists can experience growth and depletion concurrently in their work. Just as for an artist, the therapist’s main objective becomes hanging in despite uncertainty, treating the unexpected as opportunity, seeing things from new and different perspectives, and maintaining involvement even when things get stressful. In other words, staying in flow feelings, maintaining a relational manner, and employing effective clinical skills even in the presence of stressful involvement are the ticket to being a creative therapist and staving off burnout.

Operating from the artist’s perspective, therapists can recognize that stressful involvement doesn’t have to block healing involvement. Rather, it is simply a necessary accompaniment to any creative endeavor. As Carl Rogers pointed out, constructive creativity requires openness to experience and tolerance for ambiguity: “It means the ability to receive much conflicting information without forcing closure.” The process of absorption or being wholly involved is characterized by Rollo May as “intensity of awareness and a heightened consciousness.” With this creative encounter come neurological changes—quickened heartbeat, narrowed vision, diminished appetite, loss of time awareness—that mirror physiological reactions to anxiety and fear. May suggests, however, that the artist doesn’t experience this arousal response as negative, but rather as joyful. In the creative process, flow feelings and arousal—whether experienced as anxiety or pleasure—go hand in hand. They are a result of engaging in a creative process. One without the other is impossible. The goal is not to eliminate the anxiety, but to make sure that it doesn’t block the flow.

When therapists see that their work is truly creative in nature and realize that the act of working with clients requires all the same components of any creative act, there is a built-in context for coping. How else do artists and other creatives endure their daily grind? Who else but the most creative know how to hold disparate experiences and make something of them? “Just like an artist, a therapist must hold the experience of being fully, heartfully engaged to painful experiences.” A therapist has to strive to connect on a vulnerable and intimate level with the client, yet maintain a professional boundary so as not to become merged in the relationship. And, despite scary or frustrating situations, a therapist must maintain engagement and strive to stay in contact with the relationship at hand.

As therapists then, we must stay creative: flexible, engaged, committed, willing to hang out in the unknown and greet newness and possibility as it comes. Be open to the process. This is not a passive state—it requires active exploration, self-reflection, sharing, curiosity, fearlessness to look at the unknown, risk taking to express that which is ugly, negative, or difficult. This commitment to staying creative must start with finding a way to communicate that inner-world experience to people who get it—to express these feelings without having to stay in the role of therapist, and to be in the presence of peers who understand that this kind of expression—can be the very key to sustaining self in our work. And because the creative process teaches us to welcome anxiety and other difficult feelings, doing art with other therapists can be a source of continual renewal.

At the End of the Day

If the creative process brings us freedom and new possibilities, it also brings us beauty. So when things aren’t seeming that beautiful around the office, when high healing involvement is giving way to self-doubt, frustration, and boredom, I’m remind myself that stress and flow are not mutually exclusive. I keep up a dialogue with myself on a daily basis. The question that I constantly ask is one that author Michael Ventura asks: “Where is the beauty in my work? Where is the beauty in this client?”

The other day, while sitting with a new teen client, I found myself melting into that beauty. She was reading a poem that she’d written as part of her therapy homework assignment. I instantly saw past her self-harm and angry outbursts, and said a deep thank you for the beauty that my work allows me to see. It’s been a long haul—from those days of meticulously monitoring client numbers and celebrating results to stepping into the quiet, reflective relationship between authentic self and work. I think I’m finally embracing that long, beautiful journey—no shell around my heart needed.

In my work with other therapists, I continue to emphasize what Jeffrey Kottler says in his wise book, On Being a Therapist: “[As therapists] we are touched by [our clients’] goodness and the joy and privilege we feel in being allowed to get so close to a human soul. And we are harmed by their malicious and destructive energy.” Having that focus, and the creative means with which to process all that comes with our work, will allow me to sustain myself and others for the long haul.

So the next time I’m sitting at dinner struggling to cross the bridge between my personal and professional lives, I’m going to consider that “How was your day, Mom?” as an invitation to take stock of my inner canvas. I’ll remember that my work is a creative process and feel more freedom in my reply. If it was one of those days, I think I will tell the kids all those disparate adjectives—drained, energized, discouraged, overwhelmed, fascinated, curious, amazed, sad—without feeling bad about my work. And then I will simply say, with a smile on my face, ”It’s great to be home.”

Suggested Activity

Individually, or with a group of safe colleagues, get together to create a representation of ‘Your Doorway to Therapeutic Presence.” You can do this by using magazine images and computer paper. As you prepare, think, write, and talk about the transition that you make when you begin work in session—from the moment that marks the transition between being alone in your office to your first encounter with your client in the waiting room. Consider what you leave behind as you transition—thoughts of other clients, preoccupation with family issues, plans for the weekend, etc. And consider what you welcome—awareness, presence, compassion, openness to the unknown. We do this transition over and over again, all day long. Some days we do it without effort. Other days our responses to disturbing material in client sessions or personal tragedy cause the transition to be arduous.

As you consider your internal experience of this transition and the state of being on either side of that doorway of therapeutic presence, find collage pictures that represent your experience. For most, the feeling of being present with a client comes with pictures of broad landscape, nature, the representation of awe and the feeling of being at peace with the world. And, depending on the current life situations, the experience outside of therapeutic presence ranges from blissful faces of children to painful images that depict life challenges such as illness, death, and other real struggles.

When you are finished with your doorway, share it. Really—go ahead. This opportunity to allow yourself to be seen outside of your role as therapist by other therapists is the very thing that we are conditioned not to do. This is also one of the most important coping strategies that so many of the researchers suggest. Allow difficulties to be there, honor the intense experience, increase knowledge of self and the therapeutic process, and embrace therapy as a creative process.

References

Kottler, J. (2010). On being a therapist. Jossey-Bass.
Kottler, J. (2005). The client who changed me: Stories of therapist personal transformation (p. 1). New York: Routledge.
May, Rollo. (1959). The nature of creativity. In Anderson, H. (Ed.).Creativity and its cultivation (pp. 55-68). New York, NY: Harper and Brothers.
Norcross, J., & Guy, J. (2009, August 19). Leaving it at the office: Taking care of yourself.
Orlinsky, D., & Ronnestad, M. (2009).How psychotherapists develop: A study of therapeutic work and professional growth. Washington, DC: American Psychological Association.
Rogers, Carl, R. (1954). Toward a theory of creativity. In Anderson, H. (Ed.) Creativity and its cultivation (pp.69-82). New York, NY: Harper and Brothers. 
Sussman, M. (Ed.). (1995). A perilous calling: The hazards of psychotherapy practice. New York: John Wiley and Sons, Inc.
Ventura, M. Beauty resurrected: Awakening wonder in the consulting room.

Eda Gorbis on Body Dysmorphic Disorder

Posted on by Psychotherapy.net Team

Characteristics of Body Dysmorphic Disorder (BDD)

David Bullard: To begin, could you give us a little background on BDD for our readers who may not be familiar with it?
Eda Gorbis: I began learning about treatment for obsessive-compulsive disorder (OCD) when I was helping to create day treatment protocols at UCLA Neuropsychiatric Institute in 1992, and then I furthered my knowledge by studying with Dr. Edna Foa in 1994. In 1996, I began work with a patient who had both OCD and BDD and was addicted to plastic surgery procedures. After successful treatment that was specifically designed to ameliorate the stress associated with her BDD, we were able to work with her on her remaining OCD, and my interest grew in this patient population.

Body dysmorphic disorder is self-perceived ugliness. It is when a person feels ugly inside about a minute anomaly—usually invisible to the naked eye of another—or has a markedly excessive preoccupation with even a slight defect, together with the feeling of being unable to make it right.

DB: So it’s a feeling and self-perception. I’ve noticed that, for some people with BDD, there is a vivid visual picture in their minds. One study highlighted the intrusive visual imagery these people have in addition to negative self-cognitions and feelings.
EG: When they look into the mirror, they see themselves as ugly.
They do not perceive themselves in the mirror as we perceive ourselves. They see a distortion that is invisible to others.
They do not perceive themselves in the mirror as we perceive ourselves. There is something wrong in their visual fields, from the eyes into the brain, that gives them inaccurate feedback. They see a distortion that is invisible to others.

What people with BDD perceive is actually similar to the reflection we have all seen in carnival funhouse mirrors. This differs from the common feelings of insecurity or self-consciousness about one's appearance that most people experience from time to time. Many people who have had cosmetic surgery are happy with the results and can move on with their lives without continuing to obsess about the original defect. With BDD, however, any surgical "correction" will itself be seen as imperfect, or an obsessive fixation with another body part will take over.

There are some theories, but the specific causes of BDD are not known. Many experts agree that sociological and biological factors play a role in the development of BDD.

DB: And it can be extremely debilitating.
EG: Yes, one of the most disabling conditions I know of. People experience extreme self-consciousness, and often avoid social situations, feeling others are judging and criticizing their self-perceived imperfections. The more the fixations intensify, the more it seems rational that others are also focusing on the “defect.” It can be a kind of paranoid ideation.

Then a person’s relationships suffer, along with many aspects of daily life. They can repeatedly request reassurances from others, but with no relief from their certainty about the ugliness. These compulsive requests for reassurance actually reinforce the false belief system and fixations; this leads to further compulsive questioning in a continuing cycle. They get so focused on their appearance that much time is spent hiding or trying to perfect the “flaw” cosmetically. These people are often unable to leave the house to make appointments, or to hold a job.

DB: Can you tell us about co-morbidity?
EG: BDD has a high co-morbidity with other anxiety disorders. The research is not perfect, but it seems that more men are treated for BDD than women. Perhaps female BDD symptoms are more likely to be interpreted as "normal" female behavior in our culture and are likely to be overlooked and remain untreated. The onset of BDD is not exclusive to a particular age, though symptoms often emerge during the teen-age years.

Treatment Considerations

DB: Could you give our readers an idea of how you work with someone with this particular disorder?
EG: More often than not, BDD is intertwined and co-morbid with OCD. Both disorders must be targeted at the same time—the perfectionistic concerns or fear of being criticized on a performance level that are characteristic of OCD, and also elements of social phobia that are associated with BDD.

BDD has certain expected features: for example, an exaggerated physical anomaly would be chin, eyelids, cheekbones—oftentimes in males, it would be penile size—with symmetry and exactness issues. I have found that women compare and contrast their breasts or their arms—any body part can be compared with the corresponding part on the other side of the body. The self-perceived anomaly also has a tendency to move from one body part into another: it can shift from the nose into the ear, for example.

DB: You mentioned that the first patient you worked with had had multiple surgeries. That’s a good example of how it shifts from one body part to another, and they get the surgery based on that.
EG: Right. That patient had more than a hundred cosmetic surgery interventions.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician, because you do not find this so much in strictly obsessive-compulsive disorder. Some of the patients with BDD have also met diagnostic criteria for sexual addiction and gambling. It is the exact opposite for people with OCD. Patients with OCD are not impulsive. They would be like Rodin's "Thinker."

With patients with body dysmorphic disorder, you have an overlap between impulsivity and compulsivity. Whereas people with OCD are extremely moral and truthful, people with this overlap of impulsivity and compulsivity would show no guilt or remorse. This overlap makes treatment extremely challenging. Some patients with BDD have also met diagnostic criteria for sexual addiction and gambling, which was a little bit surprising to me. Well, not really surprising, but interesting how impulsivity and the pleasure is associated with the alleviation of tension or excitation. For example, in gambling, it's not the reduction of anxiety that is the aim of the behavior. The aim is the attainment of tension release, like hair pulling or when they squeeze pimples, and excitation—the adrenaline rush in gambling or sexual addition. So you have very different aims of the behaviors that are intertwined in very complex ways.

DB: Some of the people who have written in the field make a distinction between delusional versus nondelusional BDD—for instance, someone who looks in the mirror and sees that his ears are too big, and he really thinks that they are too big, versus someone who looks in the mirror and knows he feels bad about it but accepts reassurance. He knows that his ears are really okay, and he recognizes that he has a problem in his perception. Do you see that distinction? Is it helpful to you in your work?
EG: Let's call it poor insight. That is a better term than "delusional." And it is classified along with other OC-spectrum disorders, such as Tourette's syndrome, eating disorders, trichotillimania, and compulsive skin picking. BDD is also often seen as part of the impulse control disorders—where impulsivity can be thought of as seeking a small, short-term gain at the expense of a large, long-term loss. People with BDD get completely dysfunctional, as I described earlier-becoming addicted to surgical procedures, getting stuck in front of mirrors, needing to ask constantly for reassurance, etc.

Cognitive-behavioral therapy

DB: Although each case is individualized, can you give us an overview of how a cognitive-behavioral approach can be utilized in treating OCD?
EG: With cognitive-behavior therapy (CBT) a person learns to change the way he or she thinks and acts. We know different people can have different attitudes about the same specific conditions: A large facial birthmark can certainly be noticeable to others, but may have no negative impact on someone who has accepted it, while being debilitating to someone with BDD. And, of course, even a nonexistent or minor flaw can be devastating to a person with BDD. It is important to help people change their thinking habits. Exposure and response prevention are taught to people with BDD to help them face their anxiety and any co-morbid BDD concerns. This means repeatedly learning to tolerate discomfort. Anxiety gradually subsides as they continue to confront situations without the avoidance response.

We also use the 4-step model of our colleague Jeffrey M. Schwartz, MD, as
outlined in his books Brain Lock and You Are Not Your Brain: The 4-step solution for changing bad habits, ending unhealthy thinking, and taking control of your life.

The steps we teach our patients to help them get freed from obsessional thinking are:
Step 1: Relabel (recognize that the intrusive obsessive thoughts and urges are the result of OCD).
Step 2: Reattribute (Realize that the intensity and intrusiveness of the thought or urge is caused by OCD).
Step 3: Refocus (Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: do another behavior).
Step 4: Revalue (Do not take the OCD thought at face value. It is not significant in itself).

The Role of Psychoeducation

DB: Yes, I've found that simple process very useful for some OCD clients, and it goes along with my favorite bumper sticker: "Don't Believe Everything You Think!"
How helpful do you find psychoeducational materials?
EG: I think psychoeducational materials are always very helpful and important, because then patients know they are not alone. In fact, we now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
We now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
DB: Isn’t it a characteristic of BDD that it feels so shameful that the majority have hidden it from the people who are closest to them?
EG: Well, the dysfunction is most often extreme, and usually afflicts young people by the time they are 18 and ready to get out of the house and into college. Then, because of the self-perceived ugliness, they are unable to get into social situations or attend lectures. They can't date. They camouflage themselves with glasses and excessive makeup. It is similar to an anorexic who is quite underweight and having cardiac problems and broken bones, and losing consciousness and so forth, but still worries that she's too fat. These people, in a very similar way, feel ugly, and there is a delusional component to this feeling ugly, as in anorexia. A distinction from anorexia, however, is that an individual with BDD would be preoccupied with the appearance of his or her face, while the anorexic will be more preoccupied with self-control strategies regarding weight and shape.
DB: Can you recommend some books for therapists who want to learn more about this disorder?
EG: The classic in the field of BDD is Dr. Katharine Phillips' The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (2005). She also has a newer one: Understanding Body Dysmorphic Disorder (2009). I have already mentioned the books of Dr. Schwartz. Other good ones are Feeling Good About the Way You Look (2006), The BDD Workbook (2002), and The Adonis Complex (2000).

We also have information on our website: hope4ocd.com. There are some other good ones such as Dr. Phillips' at www.butler.org; and the Massachusetts General Hospital BDD clinic; and www.bddcentral.com.

Mirror Externalization

DB: On the treatment end of it, would you say something about the mirror approach to your work?
EG: Because the physical anomaly is so exaggerated in the minds of these patients, I was thinking one day, "How do we externalize this self-perceived ugliness?" And I thought of the carnival funhouse mirrors, because they really exaggerate everything. It's a form of exposure. So we have a laboratory at the Westwood Institute in which a certain part is exaggerated when they're looking into a mirror. The room also has lighting controls, because different lighting and angles change our perception of the reflection. At this time the patients are just writing their anxiety levels.

We then cover all the mirrors for three days in a row, and all violations are recorded to track the compulsion. Compare-and-contrast behaviors—with those around them or with photos in magazines—are also counted as compulsive because they're done out of the anxiety. Or asking for reassurance: "Do I look good?"

The process of "externalization" works by causing the breakdown of maladaptive associations and repetitive manipulation of their external, material icons. In exposure therapy, BDD patients are provided with a symptoms list and must then induce the debilitating condition and self-monitor/rate objective signs, such as pulse rate, extent of nausea, dizziness, and cognitive distortions—for example, "My nose and forehead are too big." Cognitive restructuring through writing exercises and observational records are emphasized.

Our patients stay in the program from six to eight hours a day, and there are three clinicians working with them in shifts on a daily basis. After they work with the clinicians, I expose them in a controlled way to a regular mirror where they have to write a self-description, like someone in the police department is looking for them—a profile with no emotion associated with it.

We use cognitive-behavior therapy (CBT) with exposure and response prevention, and add mindful awareness training, cognitive restructuring, and Socratic questioning. We also use videotaping. Very often, I will use makeup artists to do an exaggerated prosthetic part. We have an interdisciplinary team. Treatment is tailored to each case. We also have six psychiatrists associated with us, who are OCD and anxiety disorder specialists.

DB: You have mentioned in the past that the model most clinicians have in private practice of the 50-minute session once or twice a week is inadequate for extreme cases of powerful dysfunctions such as BDD. It is wonderful that you are able to do such intensive work with those who are suffering with the most severe cases.
EG: We are able to do this work because we specialize only in OCD and BDD and other anxiety disorders. We don't treat anything else. And because of this narrow specialization, it is possible for one patient to work with three or four clinicians in a day. However, insurance companies just rejected one BDD case because they still don't accept the necessity for this intense treatment—they think it can be treated once a week, although this particular patient had been treated unsuccessfully once a week for years. It is a very debilitating illness—far more severe, I think, than OCD.

Medication

DB: That brings us to the issue of medications. SSRIs have been often prescribed to people with BDD. Would you say the majority of these people you work with are already on SSRIs, or do they end up on SSRIs?
EG: Based on my work with the six psychiatrists at the Institute, SSRIs alone do not seem to be helpful. There is no scientific evidence at this point for what really works with body dysmorphic disorder because of the delusional component and extremely poor insight. For people with high baseline anxiety, medication may be targeted to reduce anxiety. Depression and panic attacks can also be addressed with some medications, and atypical psychotic medications have also been used. But I have to emphasize that some kind of effective therapy is required, such as cognitive-behavioral therapy tailored to the individual case.

Families can also be a crucial part of the treatment.

It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption.
It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption. The love, support, and understanding of the family are very important, and they also have to be educated in how not to reinforce the obsessing and compulsions. Then, it is also important where they go after the treatment program.

Post-Treatment Care

DB: What are your experiences with post-treatment care?
EG: There are few referral possibilities for BDD patients to follow through. I think that these people are extremely high risk for relapse—maybe even more so than obsessive-compulsives, who have much greater compliance levels. Because of the impulsivity characteristic of BDD, you have less compliance, so even if patients do extremely well during the program, it is necessary to continue the self-therapy and self-treatment, because this illness is not really cured. I oftentimes give my patients examples: you can go through the best weight-loss program in the world, but if you then resort to your old eating habits, everything is going to come back right away. So really, I think it depends on finding out their interests or what they're best at while they're in the program, so that these dysfunctional compulsions can be immediately replaced with other activities. I tell them, "I don't care if you study Chinese, take a cooking class, or paint your house, as long as you get up in the morning and get going." Otherwise, all of the compulsions have a tendency to come back if the patients don't do anything that is productive.

Specialty Training in BDD

DB: I can see how important it is that they really understand what you're telling them about exposure and response prevention, and not reinforcing those dysfunctional behaviors. For any of the clinicians reading this who want to get the specific training needed to work in this arena, are you doing any training at the Westwood Institute or at UCLA?
EG: I would think that it's very important for them to go through training, but it would have to be hands on. It takes me approximately six months to train a good clinician for complicated cases, but I do specialize in extreme cases—patients who have failed a few other programs. Perhaps even a month of training would be sufficient if the clinicians saw a couple of cases that they would have to really work with intensively, because of the tailoring to the individual needs. It is not a cookie-cutter training; I couldn't tell you, "Here is a cookbook for any BDD case." Each case is like a snowflake. I've never seen two that were exactly alike, so we duly tailor the treatment to the individual needs of the patient.
DB: Absolutely. Finally, could you say something about the satisfaction you’ve gotten as a clinician in being able to help people who have experienced such terrible suffering and misery?
EG: My satisfactions are now taken with a grain of salt. Ten years ago, I was far more optimistic about the outcomes. I know now how debilitating and co-morbid this is with other illnesses, and how "feeling good" is dangerous for them. People with BDD have to be alert and vigilant to not fall into their old habits of dealing with their anxieties.

It's a medical illness that is extremely serious—like tremors of the mind. You could compare it a stroke or cancer that must be attended to. It is chronic; it waxes and wanes. People can definitely get to completely functional levels provided they attend to it on a daily basis. But, like a person with extremely high blood pressure or diabetes or even cancer, that person must be mindful and aware that there's a problem. Lately I've seen a few cases that had been in remission for 10 or 12 years and then they relapsed. I cannot tell you why. I don't even know if I have a hypothesis about the relapse after years in remission. And it sometimes takes longer to get them out of the condition the second time.

DB: That’s a very sobering indication of the great suffering and difficulty of having this disorder. I really appreciate your helping these people even without necessarily always having easy answers. On the other hand, I know of some people over the past several years that have made tremendous improvement in their functioning, even if they’ve had to come back and see you periodically. It’s made a big difference in the quality of their lives.
EG: I appreciate that, but the truth is I want to warn people against being extremely optimistic. There is no cure, and even if we ourselves have some of the highest levels of successful outcomes, let’s not forget that I’m extremely careful, having been trained by Dr. Foa to assess cases for hours and hours and to administer up to 15 tests to make our understanding of the individual even more precise. We also need to reject and refer elsewhere about 50% of the cases that come to us that I think we cannot help. People who come here are self-selected. We never have more than three cases at a time in the entire Institute, and we are able to pay a lot of personal attention to each individual and tailor the treatment. If something is not working from yesterday to today, we change it. We have that luxury. If I need to, I can dedicate the entire Saturday to this patient. That said, I don’t think other therapists have that luxury, and I think it’s very important to put this element into the level of success. It was never the quantity but the quality of the work that we have been focused on.
DB: I think that's one clear understanding that your patients have about your work—the intense dedication. Without being able to promise success, you are certainly one of the most dedicated people I know working in this challenging field
EG: You are most welcome.

Conduct Therapy Sessions Like Ellis Or Rogers In 7 Days Or Your Money Back!

Posted on by Psychotherapy.net Team

Okay Rosenthal, tell me something about psychotherapy I don't know. Fine: I will! If you've read all the textbooks, analyzed the classics, and been to enough workshops to receive frequent flyer miles, I've got something new to teach you so put down the managed care forms, and pay attention.

My secret weapon for improving your psychotherapy sessions comes from the field of copywriting. That's correct, I said copywriting. Copywriting is the act of creating written documents that persuade customers to reach into their wallet or your purse, and hand over some greenbacks, a plastic card, or simply click that familiar Paypal button.

When you receive a letter trying to sell you Ginsu knives or the latest Ab blasting exerciser, that's copywriting. Ditto for those letters begging for a contribution for your Alma Mater. According to many experts, the greatest copywriter of our time was an upbeat fellow named Gary Halbert. Now according to Gary Halbert (aka "the Prince of Print"), one of the fastest ways to become a master copywriter is to take samples of the best ads ever written and simply copy them in your own handwriting. Rumor has it that Gary did this himself for hours, if not days on end, when he first entered the business. The result was that he transformed himself (and later many of his students) into consummate professionals in weeks, rather than years, using this paradigm.

Along those same lines, I would urge you to select a well-known therapist you believe in and copy their therapy dialogues in your own handwriting. Better yet, since psychotherapy is a verbal pursuit, read the helping sessions aloud. In fact read the session (or portions of the session) again and again. Notice, I said "believe in" inasmuch as Rogers would certainly conduct a therapy session with a given client in a different manner than Ellis. O'Hanlon would no doubt rely on an intervention that bears little or no resemblance to either of the aforementioned luminaries.

When you get to the point that you can guess with a high degree of certainty what the world class therapist will say next you are well on your way to becoming an accomplished practitioner in that particular psychotherapeutic modality.

Will I really give you your money back if this strategy doesn't transform you into a world-class therapist in 7 days? Hey, I'll let you know. I'm still copying a master's ad and I haven't reached the small print section yet.
 

Ethical Guidelines: Do We Really Want What Is Best For Our Clients?

Posted on by Psychotherapy.net Team

Most therapists are familiar with the affliction of Seasonal Affective Disorder (SAD). SAD impacts approximately seven million people each year in America, mainly women.

At one point in my career I shared a private practice office with a psychiatrist. She would use the office on some days and I would use it on others. When I entered the office for the first time I was struck by the fact that she had a phototherapy apparatus in the room. It was physically huge and was much larger than any commercial unit I had ever seen. Many experts believe that SAD is caused (or at least intensified) by a lack of sunlight. Hence, when the sun is not shining very often or the days get shorter depression sets in. Phototherapy devices fight the depression and emit massive amounts of full spectrum light. The phototherapy simulates or mimics the sunlight you would receive if you more spent time outdoors.
My initial reaction to this situation was beyond positive. I was elated that this psychiatrist was utilizing cutting edge technology. I thus decided to praise her and let her know in no uncertain terms that I was impressed.

The good doctor's reaction, nevertheless, was hardly what I expected. "Oh my gosh, no, I don't use it for my clients. That's fringe psychiatry. Somebody might think it was unethical. I might even be sued or reported to the Board of Healing Arts. I might be branded as a quack."

"Well what in the world is a light therapy lamp doing in your office?" I asked inquisitively.

"In the dreary short days of winter I am stuck in this office all day and I generally become extremely depressed, so I had an engineer build me a phototherapy unit that is stronger than anything you can purchase. As soon as my current patient exits the treatment room I flip on my phototherapy device. I then turn it off before the next patient enters the office."

Oh, so now I get it: It's good enough for you, but not for your patients. Go figure.

In one of my recent books, Favorite Counseling and Therapy Techniques, I share a fascinating story about a young man I treated who had such low self-esteem that he walked bent over like an ape. The kids at school thought it was hilarious and made the situation worse by calling him the Ape Man.

One reason for the young man's Ape Man posture was that he believed he was extremely ugly and could never date a nice young woman. To counter his feelings I set up a contrived situation in which a female colleague walked in the room and said, "Gosh, is that your client, he's really cute." He seemed shocked (exactly the reaction I wanted). I told him we weren't going to discuss his looks because we both knew he was an exceptionally good looking guy and there were serious issues of his we needed to work on. He walked out with the finest posture he had displayed in years. Cured, no. Improved, yes.

Unfortunately, I also point out in my book that today's ethics which stress informed consent would not permit an intervention of this ilk. The female colleague who gave him the compliment would need to be identified as part of the treatment or therapy team up front and there is a 99% chance he would have totally discounted her remarks as being staged. (The young man's mother had repeatedly told him he was a good looking guy many times to no avail.)

Along these same lines a client I shall call John came to see me who severely depressed. John's brother was a very well-known psychiatrist. Now I was aware of the fact that ethical codes frown on (or downright prohibit) dual or multiple relationships, but certainly John's brother knew another top notch psychiatrist who could help. Why was John seeking my little old services?

When I asked John why his brother did not provide a psychiatric referral John quoted his brother verbatim. "Look I give those dangerous psychiatric medicines to my patients, but I'm not going to let my family take them. You need psychotherapy."

I so I get it. It's not good enough for your family, but it's okay for your patients. Oh sorry, I think I said something similar to that that before.

I remember hearing a presentation given by Jay Haley once. He told a powerful story regarding a difficult client he had successfully treated. I raised my hand and asked if his psychotherapeutic intervention was in violation of the ethical principle of informed consent. It certainly seemed like that was the case.

Haley was silent for a moment and then grinned. "I never let ethics get in the way of good treatment."

The problem for those of us who are mere mortals is that Haley's philosophy might leave us without a therapist's license and standing in a long unemployment line.
 

How One Desperate St. Louis Psychotherapist Cured A Schizophrenic

Posted on by Psychotherapy.net Team

Maggie began the session by telling me that she had been diagnosed by three different psychiatrists. The good news was that all three agreed on the diagnosis. The bad news was that each psychiatrist told her she was schizophrenic.

"So, what brings you here today?" I asked.

"Well, I saw something in the newspaper and it said you wrote some books on mental health and teach in the field so I thought you might know something these psychiatrists don't."

(Wow. How refreshing. A client who actually thought that a nonmedical mental health professional such as myself would know more than a bona fide MD psychiatrist. Perhaps this was my lucky day. Maybe I should purchase a lottery ticket or search Google for the nearest horse race track.)

As Maggie began talking my elevated mood and optimism began dropping like a thermometer placed in an overactive refrigerator freezer. In short order I was convinced that the psychiatrists were wrong — dead wrong. This lady wasn't just schizophrenic. Maggie displayed more hallucinations, delusions, and thought disorders, than ten schizophrenics combined. As I listened I couldn't help thinking that the folks who penned the DSM needed a new category. What? Oh heck, I didn't know, perhaps mega-psychotic or super-schizophrenic or something. Now I realize that doesn't sound nice and isn't very high on the Carkhuff Scales, but at least I was facing reality: something Maggie clearly was not doing.

The session went on for what seemed like eternity. At the end of our meeting I was faced with a dilemma. If I diagnosed Maggie as schizophrenic for the fourth time she would be devastated. I scribbled something on her insurance super bill and scheduled her for another appointment.

I continued to see Maggie weekly for approximately one year. To say that she made monumental progress would be an understatement. I thus terminated her.

About a year later I saw an article about her in the neighborhood newspaper. Maggie was being honored by her college for being the only student in her program to snare a perfect 4.0 straight A average as a chemistry major. The article also boasted that she landed a pristine job in her chosen field.

Just days after I read the article Maggie dropped in not for a therapy session (because she was doing very well), but just to say "hello."

"You are doing fantastic," I said. "Listen, I just have to know. What I'm about to ask you will help me with all the clients I will be seeing in the future. Why do you think you made such good progress in therapy? Was it because we explored the abuse in your childhood? Was it the relaxation techniques? Perhaps it was the dream work. Maybe it was the focus on your self-talk."

"Oh no," she replied. "I'm sure those things were helpful, but none of them cured me. No, not a single one of them. I can tell you precisely what it was.

Do you remember when you saw me for the first time and I mentioned that three psychiatrists had diagnosed me as schizophrenic? Well we decided right then and there that because you had written some books and taught in a college you knew a lot more than those psychiatrists. And when I left your office after my first session I felt terrific because I glanced at the insurance bill you gave me and you said I was an undifferentiated type. And that was wonderful news because schizophrenia is caused by chemical imbalances and genetics and it can't be cured. You know that.

But, I wasn't schizophrenic. I was just a normal person who was an undifferentiated type. And that meant I could be cured."

Thus, if you happen to be an advisor in a graduate program and an upbeat perky chemistry major named Maggie comes strolling in, please, pretty please with sugar on top, promise me you won't even think about letting her enroll in an abnormal psychology class.

Interrupting the Conversation: Gestalt Therapy Here and Now

Posted on by Psychotherapy.net Team

It’s well established in the clinical literature that the therapeutic relationship is of key importance; attending to client-therapist contact is a useful lens for any therapeutic practice, whatever the orientation. But how this knowledge is played out in the course of our work can be unclear. It is easy to get caught up in our clients’ ever-urgent presenting problems and try to “fix” whatever is wrong.

Part of the power of Gestalt therapy is that its focus is not on problem solving or on getting people to think differently. Rather, Gestalt calls us to attend closely to the here and now of the relationship, creating an encounter in which the client can develop awareness of the therapeutic encounter—what is happening to him between us in the moment.

Jim: A Case Study

Jim came into therapy because he was feeling “stuck” in his life. When he strode into my office for the first time, grabbed my hand, and pumped it a few times. He seemed like he was in a hurry to catch a bus. But despite his energetic demeanor and polished appearance, Jim was deeply unhappy. Forty-one years old and divorced, Jim had two children from his previous marriage. He felt that he was in a dead-end job in finance. He was also unhappy with his ability to have deep, enduring positive relationships with women and peers.

In the first two minutes of our initial session, as I went briefly over what I do and how I do it, Jim interrupted me. “That’s really good,” he said, “but here is what I want to talk to you about.”

“Jim, let me just finish,” I replied, and continued what I was saying.

“Yeah, yeah, yeah—I’ve got it.” Jim then barreled forward in great, great detail – overwhelming detail – explaining his concerns.

As he wrapped up his first monologue, I attempted to interject some thoughts about what he was saying; I particularly wanted to explore his relationships with women. As I asked my questions, he rolled right over me and continued to explain what it was that he thought I needed to know – completely oblivious to the idea that I was trying to explore what he had just said. I began to feel frustrated.

After a while, I said to him, “Jim, are you aware that every time I want to say something to you, you cut me off?”

But rather than respond to what I said, he raced on with his story about a terrible first date he’d recently been on. He explained that he had regaled his date with wild tales of his life. All the while he delivered his story, he did not look at me.

A few minutes later, I stopped him again and said, “Jim, I want you to notice as we talk what happens. I just want you to pay attention to what’s going on between us as we are talking. Not just what you’re saying to me, not just the ideas, but what’s happening between us.”

He answered me with a jerk of his head. “Okay, okay. Well, you did say that I don’t give you a chance.” He went on to tell me in greater detail the content of some of these stories with which he had entertained this beautiful young woman. “I can’t figure out,” he said, “how she couldn’t want to go out with me again!”

Now, in response to my repeated attempts to respond to him, Jim had raised his voice, was speaking even more quickly, and was leaning into me, gesticulating forcefully, as he explained to me in intricate detail how, after being so entertaining on this date, he couldn’t possibly have failed to get this woman’s attention.

Several minutes later, as I was preparing to say something, he raised his hands high, looked right at me, and said, “I know, I know. I need to let you talk.” But immediately he dropped his eyes and started up again. Clearly, he had noticed what I was doing but then had plunged forward into another rush of content.

This time I cut in firmly.

“You don’t ‘have’ to let me talk,” I said. “I’m just trying to help you notice what happens between us as I try to have this conversation. It’s very hard to get a word in edgewise.”

He stopped for a minute. Then, in a lower voice tinged at the end with an edge of sadness, he said, “You know, some of the women I’ve dated have complained to me about that.”

“Really?” I said wryly, with a slight amount of mock curiosity.

“They say I’m so enthusiastic that I never ask them about themselves.”

“What do you think it’s like to be in a relationship with somebody who does that, Jim?”

He paused again. “Ahh…Probably not great.”

“Probably not.”

“You know,” he said, “what you’re saying reminds me of the way it was at my dinner table. Everybody talked non-stop, especially my father and my brothers. It was hard to get a word in edgewise. We all fought for the mike, trying to get someone to listen to us.”

“Well, it’s obvious from the way you are now that it’s something you are still doing,” I replied.

“You’re right.” His face grew sad. “Do you think that has anything to do with my problem developing close relationships?”

“Of course I do. You’ve already told me that people have pointed this out, but clearly their pointing it out hasn’t had much of an impact on you.”

He shook his head sheepishly and looked down. “You’re right,” he repeated. After this, he began to look at me with a little bit of interest, with more respect and curiosity. He became a little more interested in what I had to say, as well as to notice his own voice. From a Gestalt perspective, he started becoming more aware of how he was interacting in the session. This, in turn, heightened his awareness of his internal experience as well as the impact of his behavior on me.

As the session continued, Jim began to be more aware not just of what he was saying, but how he was saying it. By the end, he was noticing how often he interrupted me. He seemed sadder, and his bullet-train monologue had slowed down. As I looked in his eyes, I could see a slight clouding and the beginning of a sorrowful look, as opposed to his earlier wild, intense expression. As he started to calm down, he paid more attention to me, and in the process, his sadness began to well up inside of him.

At the end of the session, he asked, “Is there something I can do?”

“I just want you to pay attention the best you can, between now and the next time we meet, to see if you can notice when you feel like interrupting anyone—before you do it.”

“This was really helpful,” he said, leaving.

The Here and Now: A Historical Perspective

Unlike other forms of psychotherapy, what was important to me with Jim in this first session was not understanding his history or his concerns in detail. Rather, from the very beginning of the session, I was paying attention to how we were together. What was important to me was the nature of contact, how we engaged each other. In this case, what I focused on was the experience of Jim not being able to listen to me, his talking a mile a minute, his inability to respond, and the fact that he was semi-disengaged from me and what I was saying.

So, from the very beginning of the session, I focused on raising his awareness, helping him to begin to notice how he was saying what he was saying as well as the quality of our engagement. Throughout the first session, I did not concentrate on gathering details of his life, trying to teach him how to combat the thoughts in his head, or trying to establish a relationship by getting to know him. I was primarily interested in helping him to experience the process of how we are together.

The Gestalt approach originated in the late ’40s with a group of New York intellectuals objected to psychoanalysis, which they saw as severely limited because it focused on pathology, as opposed to potential. These intellectuals—Laura and Fritz Perls, Paul Goodman, and Ralph Hefferline, among others—responded to this lack by creating a more open, engaged, enlivened psychotherapeutic experience, one focused on liberation and growth, which allowed the human personality to transcend the limitations of the defenses.

Gestalt took people off the couch and put them into a face-to-face encounter with the therapist. Rather than intellectual analysis, Gestalt’s primary vehicles were awareness and contact. In focusing on the “here and now” encounter, Gestalt made a left turn from psychoanalysis and brought the idea of the experience of the client into the therapy process, as well as the presence of the therapist into the encounter. It’s a relationship, and the therapeutic process emerges out of the relationship.

In its early days, Gestalt was closely connected to the work of Fritz Perls, who rightly or wrongly, was perceived as narcissistic and at times insensitive. Because of his aggressive approach, Gestalt got an unsafe, brutal, almost encounter-group-like reputation. But Perls was also incredibly bright and able to develop great insight into clients’ processes. In the years since its origins, Gestalt has emerged as a philosophy and methodological approach that is used by psychotherapists all over the world. While it is still true to the basic foundational principles outlined by its founders, Gestalt has evolved into a model that truly allows clients to experience themselves and use their resources to create fundamental change in themselves.

Moving Forward

In the Gestalt process, as the client makes contact and begins to experience himself in relationship to the other, his self becomes more visible to him and to his therapist. As Jim became more aware of what was going on inside of him, his self began to emerge in the moment. He began to be able to access his internal world in a different way than he had before, and he began to be more aware of the impact of his behavior on others.

As the therapy progressed, he began to feel and express sadness about his low quality of life; and as he experienced his feelings more, his engagement with me improved. Rather than talking at me, he made eye contact and talked to me about his sadness and loneliness, and his inability to be successful in the way he wanted to be with women and with peers.

One of the things that he discovered in our encounters was that as he began to interrupt less and focus more on what I had to say, he became more anxious and unsure of himself. He realized talking so much was an effort to relieve his anxiety—he was scared to slow down and engage people in a more intimate way. Clearly, Jim began to encounter on a deeper level the core issues that were troubling him about his current existence.

Staying in the Present While Working With the Past

One of the myths that have floated around the therapy world for many years is that Gestalt is only about the present. Somehow the here-and-now focus of the Gestalt approach created an impression that the past was never dealt with in Gestalt therapy. What is different about Gestalt is not whether the past is dealt with, but how it is dealt with.

As I worked with Jim through our relationship in the moment, his past began to emerge in a historical way. At one stage, when I pointed out to him that he never responded to what I said, but rather told me whatever came to mind in reaction to my words, some childhood memories emerged forcefully. As a child, he told me, his parents had always been telling him what to do, talking at him, and very seldom listening to him or taking what he said and making that the focus of the conversation. In other words, as I pointed out in our sessions what was happening in the present, Jim’s past began to emerge organically.

In another moment in the therapy when Jim tuned into a feeling of sadness at his current lack of relationships, he began to talk about how difficult it was that his family was isolated. They didn’t have very many family friends, and didn’t spend much time together as a unit. As a result, Jim did not have a lot of practice at engaged relationship building.

In this way, the past is slowly unwound and filtered into the present. Early childhood issues emerge in the moment and are dealt with in the moment, rather than being called up intellectually by taking a history.

When the past does emerge in Gestalt therapy, we frequently bring it back into the present. For instance, when Jim brought up his mother, I often asked him to imagine her in the room and to say something to her, so that he was able to experience vividly his feelings about the past, in the present. As a result, he was more able to encounter and engage the impact of the past on his behavior today.

Jim’s Turning Point

Jim slowly became able to notice his own tendency to coopt conversations with his own thoughts rather than respond to what others were saying. He recognized that this was keeping him from deepening his relationships. As Jim’s therapy continued, he began not only to listen, but for the first time also to respond to those around him.

At this point in the therapy process, he met a woman named Sarah. The interesting part for Jim was that he met her on a flight home from a business trip. While he was sitting next to her on the plane, he had what he called his “little Norman bird” on his shoulder, who told him he needed to listen to what she had to say, draw her out, and try to understand her perspective, instead of regaling her as he always did with vignettes from his life.

He spent time talking to Sarah and really used his newfound skills. They got into what he called “a wonderful conversation.” They had so much fun on the plane that Sarah gave him her number. He asked her out and she accepted. They began to date.

It was important for Jim to handle the dating process a completely new way. Rather than focusing on trying to interest her in himself and thereby driving her away, he actually reversed the process and listened; and as he spent time getting to know her, she became increasingly interested in learning about him.

In addition to his budding relationship with Sarah, Jim began to do a better job in his work environment. He had always been semi-successful professionally, but as he became more engagement savvy and able to build relationships with people, his rapport with his employees began to flourish. Previously, those who reported to him at work had seen him only as a windbag and taskmaster. As he began to change, his employee satisfaction scores rose and he even got promoted, solely because his employees began to experience him as a more effective manager and leader.

Jim’s Ability to Live a Fuller Life: The Goal of Gestalt

As Jim engaged more fully in life by actively listening and responding to what was happening around him, life in turn rewarded him. This is one of the most powerful parts of psychotherapy, and of Gestalt therapy specifically. Jim received more attention from women as they began to feel like he was interested in them. Jim’s colleagues noticed his new responsiveness and relative ease at engagement. All of these changes emerged as a result of struggling in the encounter.

Of course, my work with Jim was much richer and more multifaceted than it has been presented here, but focusing on this particular issue illustrates what happens in the Gestalt therapy process and how the world can begin to seem different to our clients. He heard more. He was more aware. He took more personal responsibility. He really heard what people said and it had more of an impact on him, he was able to be touched by others. He got more positive feedback and support from the world as his self evolved.

This, then, is the heart of Gestalt therapy: to help our clients expand and meet their potential for fuller, more rewarding lives, while always starting in the moment, wherever they happen to be. For Gestalt therapists, strengthening the therapeutic relationship by attending to contact in the here and now of the session is not merely an end in itself; rather, it is by attending to the quality of connection in that moment that the client learns how to be present, both with his own internal experience and in relationship with the therapist. This awareness itself is the catalyst for change, opening new doors of possibility to both the past and the future.