Author: Psychotherapy.net Team

Why I Hate Alzheimer’s

Posted on by Psychotherapy.net Team

Alzheimer’s is a Thief

As a therapist, to say I hate a disorder is a big deal for me. I specialize in personality disorders—narcissism, borderline, and anti-social—and have found beauty and giftedness where most see dysfunction. I don’t hate any of these disorders, even the ones that tend to be destructive for the client and their family, and exceedingly challenging to work with clinically.

But Alzheimer's is different. A personality disorder can be understood and even managed. Someone with a personality disorder can grow in their perception of how the disorder changes their perception of reality. They can learn new ways of coping and relating. But such is not the case when working with clients who struggle with Alzheimer's. Because people with a personality disorder tend to be long-term clients, I have the unique opportunity to see these clients, as opposed to Alzheimer’s patients, though many life stages, including the aging process.

“Alzheimer’s comes like a thief in the night”; except it keeps returning at random times during the same night and on nights thereafter for years at a time. Like a thief, it steals one item at a time—a memory, a possession, a skill—and moves around others, so they appear to be lost but are not. Sometimes it breaks things and leaves the pieces behind in unrecognizable forms. For the most part, it is sneaky, always moving and changing what is least expected. But in the end, it steals the whole house or the whole person leaving no remnant behind.

The worst part is not what it does to the person but what it does to the family and friends. The family remembers what was in the house and cannot forget what was lost or moved. With each visit from the thief, the family is traumatized by the stolen items or damaged goods. Bit by bit, the family suffers a new loss each time the thief comes. They cannot forget what is missing. They want to forget but are unable.
This is why I hate Alzheimer’s.

My Father’s Struggle

My dad had Alzheimer’s. Watching him fade away was one of the most difficult experiences of my life, both personally and professionally. It challenged my ideals, tested my patience, expanded my knowledge, and wore me out.

My dad was an exceptional person. He is credited as one of the pioneers of the computer age. He took the early building-size, main-frame computers and found practical applications for business such as the airline reservation system and the storage of security documents for the government.

His genius IQ, matched with a reserved but intense narcissism, made him a force to be reckoned with. In his personal life, he turned a paralyzing airplane accident into a triumph of brain over body. At 22 years old, he was told he would never walk again, but his determination, willpower and never-give-up attitude allowed him to walk until Alzheimer’s stole that ability away.

“No amount of brainpower, willpower, determination, or perseverance could stop the negative progression of Alzheimer’s”. As a therapist, I am trained to spot changes in a person’s behavior. But seeing them firsthand was difficult, and even more difficult was placing my father in a brain clinic to see how far his dementia had progressed. It was what I feared, and even worse was the realization that he was rapidly headed towards Alzheimer’s.

To test the regression, I asked my dad for a ride to a local grocery store that he had been going to weekly for over 20 years. He could not find it, he could not stay within the lanes of the road, he was driving extremely slowly, and he was yelling at the other drivers as if they were in the wrong. That was when I made the decision to take his driver’s license away. He yelled. He screamed. He threw a giant temper tantrum accusing me of trying to keep him hostage and imprisoned. I was just trying to keep him and everyone else on the road safe. But he saw it as an attack on his freedom and came after me for it.

Nearly every time I visited him, some other decision like this had to be made. He sent a $3,000 check to pay a $300 electric bill, so the bills had to be taken from him. He called old business partners and started telling them about a “new project” that occurred over 30 years ago. His phone access was then limited. He left the house in his PJ’s and we would find him wandering the neighborhood lost. An alarm was always set on the house signaling an open door. He lit a candle and nearly burned down the whole house. With each restriction came more attacks.

This was not my dad. Bit by bit, the independent, self-assured, if somewhat narcissistic, man I knew was transforming into a dependent, emotional shell of a human. Nearly every aspect of his personality was erased. I dreaded my visits to him and the realization that some new restriction would need to be placed for his safety and my mother’s. I hated what was happening to him. I hated how my mother aged 15 years in the span of three. And I hated having to make the hard decisions. I fell deeply in hate with Alzheimer’s.

The Thief Unmasked

Confusion. One of the early signs of Alzheimer's is confusion about family members, favorite locations or regular activities. In the beginning, it seems as if the patient is playing a joke about what they can and cannot remember. At first, the patient goes along with the laugh but later it turns to frustration and then anger or worse, rage. The hard part is that the confusion is different nearly every time. One day a family member is recognized and the next they are a stranger. It is terrifying for the patient to be told they should remember something that they cannot. Think of it as a wave crashing onto the shore, this wave of confusion will pass but another will be right behind it.

Anger. Also known as Sundowner’s Syndrome, the Alzheimer's patient becomes enraged late in the day resulting in temper tantrums that rival those of a two-year-old. It is as if the confusion of the day builds to a crescendo which is then released in outbursts that are uncharacteristic, intense and extremely hurtful to those around. Foul language, throwing things, abusive speech and physical aggression are common. It is often impossible for the caretaker, especially if this is a spouse or child, not to take these words personally. But that is precisely what needs to happen. It helps to disassociate by seeing the outbursts like an acting performance instead of words from a person they love. The words spoken are not reality-based, but rather exaggerations and extremes of delusional thoughts.

Disintegration. The negative progression of the disease means that one day the patient can push a button and the next, completely forgets how to do so. One day, the patient remembers to eat and the next, they do not. Simple, everyday tasks become impossible feats where everything takes much longer to complete than ever before. Like pieces falling away from a formed puzzle one at a time, such is the disintegration of the patient’s mind. This is difficult for the caretaker to absorb because the pattern of deterioration is unique to each patient. Sometimes it helps to see this process as a reverse of childhood progressions and accomplishments. As the disease progresses, the patient becomes more infantile in every way.

Delusions. One of the scariest parts of watching the progression of Alzheimer's is witnessing the impact of the patient’s delusions—on them and those around them. A patient can watch something on TV and be transported into that reality as if they were the ones experiencing the program. Or they might call a hospital a prison, identify a friend as an enemy, or walk out of the house unaware of their nakedness. The temptation for the caretaker is to point out the delusional thinking as a way of comforting the patient. But this can and often does backfire into an angry rage where the patient can become paranoid and believe that everyone is against them. As painful as it is to watch, it is far better to accept the delusion and play along until the patient is in a safe location or has settled down.

Fluidity. Occasionally, the Alzheimer's patient becomes lucid and fully aware of their circumstances to the point that they seem normal again, if only briefly. The fog from their confusion lifts, their natural mood returns, and they are thinking clearly and logically. When this happens, the caretaker gets excited, relieved, and begins to wonder if they were imagining the whole nightmare of deterioration. The caretaker questions their reactions and judgment, putting aside the negative experiences. This is where things can become traumatic for the caretaker. They can begin to believe that it is all over when suddenly out of the blue, the patient snaps. The unsuspecting caretaker is caught off guard as the Alzheimer's patient sinks to a new progressive low point. The discouragement and depression that transpires with each event take a huge emotional toll on the caretaker.

What I didn’t know then but realize now is just how those years traumatized me. It is a form of C-PTSD (Complex- PTSD) to have a parent who was never abusive act in a manner so inconsistent with their personality. It shakes the foundation of their house and yet they are not to blame. Alzheimer's is.

It wasn’t until a client had a dementia-induced manic episode that I realized the level of trauma I had experienced with my father. Listening to the client’s illogical rants followed by emotional outbursts inconsistent with the topic brought back my dad’s behavior. At least with a client, there is the ability to emotionally detach and disconnect in a way that preserves perspective and clarity of thought. But with a parent, it is different.

My dad said things that he would never say. I was adopted by him at the age of 12 and he always treated me like I was his blood child. But, in the last years of his life, he told me he didn’t want me and that I was a terrible daughter. Logically, I knew he didn’t mean it. Emotionally, I detached because there were so many decisions to make. And now, looking back, I see the traumatic impact. This was not my dad. This was Alzheimer’s and I hate what it did to him, to us, to our family.

Looking back, there were a few things I learned along the way that helped me to keep my perspective and not completely lose it during the crisis. I’m a firm believer in losing it after the crisis is over.

Important Lessons Learned

They are not lazy. Alzheimer’s patients are struggling to do even the most automatic routine. As Alzheimer’s progresses, the brain loses its ability to process, recall, reason, and function. What took seconds to register in the past, can now take minutes and even hours depending on the subject, time of day, emotional awareness, and significance. It is not laziness to struggle with matters such as buttoning a shirt, reading a clock, or remembering how to use the microwave. It is a result of the disorder.

There is no significance in what they do and don’t remember. Looking at an old photo album, my dad was unable to identify family members, but he could identify people he worked with. The brain organizes information in a variety of ways, almost unique to everyone. “Alzheimer’s attacks the brain in random ways with some areas of the brain deteriorating more quickly than others”. This makes the progression distinct for each patient, and the patient is not responsible for how any of these parts operate or worsen.

Their comments should not be taken personally. This is particularly difficult especially when the comments are hurtful and said in anger. Anger is a base emotion and is the easiest to express. My dad took his anger out on me. I preferred that over him taking it out on my mother, his caretaker. Alzheimer’s steals the house in pieces, changes the personality, and leaves mere shadows. When the patient speaks, they are rarely their true self. It is useful during these times to hold onto the comments that were consistent with past behavior and leave the other comments at the door.

They can perform when needed. Some Alzheimer’s patients can pull it together for a short period of time during certain special events, almost as if there is nothing wrong. This may cause family and friends to say the reports of the condition are exaggerated. They are not. Usually, after the event, the patient will become even more detached from reality and might even suffer a setback. The “show” is their survival instincts kicking in which can only be sustained for limited periods of time. Once their energy is depleted, they tend to retreat and shut down for a period of time.

They have delusions. As the disorder progresses, it is not unusual for an Alzheimer’s patient to watch something on television and believe it happened to them. These delusions are usually harmless unless they begin acting out paranoid thoughts. Think of the visions as part of an overactive imagination with no filter for what is real and what is fictional. If the fantasies are challenged, however, the patient can become unnecessarily confused, frustrated, agitated, and even violent. It is very important to remember not to challenge the delusions. Just go with them even though it might be painful to watch or hear.

They remember random events. Even the most significant days such as a wedding or birth can be impossible for an Alzheimer’s patient to remember. Showing pictures with names and dates can be useful with the expectation that it won’t work every time. The nature of the disorder causes memories to be recalled one day and lost the next, only to be recalled and forgotten again. Alzheimer’s patients are not in control of what is remembered when it is recalled, and what is not. Sometimes they assign great significance to minute moments and no value to major ones.

They still need visitors. It is easy to justify not seeing Alzheimer’s patients because they don’t remember, so there may seem to be no point in visiting. Stopping by to receive recognition, approval, or attention will not be rewarded with an Alzheimer’s patient. Often, the visits are very difficult and painful. However, it is precisely during these times that the character of a person is revealed. Spending time with them can be thankless but the internal rewards of determination, patience, and perseverance are worth the effort.

Their angry responses should be released. It is not uncommon for Alzheimer’s patients to become confused as the sun goes down, the aforementioned Sundowner’s Syndrome. As the disorder progresses, any change, including increased darkness, can be a source of uncertainty and fear. Anger is a base emotion and frequently is a go-to for anxiety, depression, loneliness, distress, and even terror. As the sun sets, the patient becomes fearful and reacts in anger usually forgetting the occurrence the next day. Holding onto the comments made in anger hurts the caregiver, not the patient.

They will not improve. This is a degenerative disorder for which there is yet no cure. Perhaps one-day things will be different as more research is conducted. The good news is that there is medication available to those who qualify to slow the progression. But there is nothing available to undo the deterioration of the brain. Hoping they will improve adds to the frustration for everyone, setting the stage for large amounts of disappointment.

They shouldn’t be compared. Each person is unique in personality, the associations they attach to an event, what they assign as significant and how they utilize information. In addition, Alzheimer’s impacts the brain in different locations at a variety of progression rates. This creates a distinctive experience for an individual. While it is helpful to be involved in a support group with others who struggle as caregivers of Alzheimer’s patients, it is not helpful to assume the journeys will be the same.

What was helpful for my family was a strong support network of empathetic people. My mother and I shared stories with each other and others who were on a similar journey. Today, we can be far more empathetic to others who are walking where we have gone. Seeking out professional assistance during this time to reset expectations, learn about the disorder, and process the difficulties is extremely beneficial.

Epilogue

As for my client with the dementia-induced manic episode, my ability to relate to the family’s experience was greatly improved because of the deep empathy I experienced rooted in the relationship with my dad and his disease. I found that I could better listen to their concerns, fears, and panic moments without judging, dismissing or overreacting. They knew, as I did, that they had shifted to a new normal and with each change, the grieving process evolved and deepened. We could work simultaneously in the present and future on behalf of the client, and of course, them.

My client will not get better. While the mania may pass, the dementia will remain, and her personality will transform into the same shell-like existence of my father’s. The thief has walked straight through the front door of their lives and begun cleaning them out, insidiously and ravenously, until there will be nothing left to devour.

I grieved when my dad was diagnosed, again when the restrictions began, once again when he had to be hospitalized, and finally when he passed. Each phase in the grieving process was familiar because it was the same issue and yet unique circumstances. What I didn’t expect was to continue my own grieving as I watched and witnessed my clients endure the same or similar loss.

But as I grieve, new insights and understandings form. I’m building a new house out of the remnants left behind by the thief. A house that embraces a new normal, gives allowances for grieving, sifts disorganized thoughts, and allows freedom of expression. And so, I am free as well. Free to hate Alzheimer’s.
 

The 7 Ways Psychotherapists Undermine Psychotherapy

Posted on by Psychotherapy.net Team

We evaluate. That’s what we do. We ask question after question after question, and when we’re not asking questions, we’re noting answers to questions we haven’t asked. We’re so curious, professionally curious. It’s a trained curiosity, and if we’re not careful, a habitual curiosity, a distractive curiosity, a harmful curiosity.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Psychologist James Hillman (1967) warned: “Curiosity awakens curiosity in the other. He then begins to look at himself as an object, to judge himself good or bad, to find faults and place blame for these faults, to develop more superego and ego at the expense of simple awareness, to see himself as a case with a label from the textbook, to consider himself as a problem rather than to feel himself as a soul.”

There is often a contradiction between my image of a person in therapy through their self-assessment of their issue and my actual experience of the person. There is also a vast gulf between the diagnosable issues as seen through the lens of psychological expertise and the essence, identity, strengths, and hopes of the person before me.

Therefore, I must cultivate space to come to know the whole person. This begs the question of what “knowing the whole person” entails. But let’s be clear: trained curiosity and assessment are not the soul of psychological change. Therapists mean well, but at times we all stray outside of the bounds of helpfulness.

Here are seven ways psychotherapists get in the way of psychotherapy—

Interrogating

When people come into session in the midst of an emotional storm, the last thing they need is to be inundated with endless questions on the basis of an agenda that is likely intended more to fulfill organizational protocols than to promote a foundation of therapeutic empathy and rapport.
Questioning always runs the risk of interrogation. The details learned about people’s lives ever tempt helping professionals toward distraction. There is a distinct difference between a personality and a person, a diagnosis and a destiny. It is our responsibility to stir hope and catalyze strengths rather than to stew history and analyze at length.

Pathologizing

The concept of “mental disorder” is rigid and misleading. In short, diagnosis is description, and by and large, mental health diagnosis provides description of “software” issues rather than “hardware,” so to speak. It’s a language of understanding what type of struggle a person is experiencing. When therapists refer to people by these diagnostic labels, we overgeneralize a person’s experience and distance ourselves from a critical resource: the powerful, complex, and fluid process of therapeutic understanding, the power center of effective therapy.

One of my professors, Bill Collins, taught me “pathology” is a dangerous categorization of a person’s experience. He contrasted “providing treatment to people” with “puzzling through a process with someone.” He told of one friend whose father, growing up, would never let him finish anything without taking over. His friend would, as his father asked, begin to screw in a nail with a screwdriver, and before he could finish, his father would grab it from him and say, “Oh, just give me that.” Those kinds of experiences, he noted, leave long-lasting impressions on a person regarding self-worth and competencies. Bill said we are to “help others to unpack their conclusions about who they are.”

Shaming

We ever risk a false sense of expertise about people’s lives against the backdrop of anxiety about our own. If we’re not careful, we may find ourselves reinforcing the tyranny of the perceived should. Should is shame's accomplice, and therapists must take care not to aid and abet them.

Sympathizing

Researcher Brené Brown (2010) rightfully proclaimed, "Empathy fuels connection, while sympathy drives disconnection.” Saying you understand is unhelpful and probably not true. And let’s be honest—it’s usually a ploy to rush people out of their emotionalism, which sends the message, “I really don’t care enough to walk with you through your suffering.”

Lecturing

Psychologist and psychotherapy researcher Les Greenberg (2002) wrote, “Darwin, on jumping back from the strike of a glassed-in snake, having approached it with determination not to start back, noted that his will and reason were powerless against even the imagination of a danger that he had never even experienced. Reason is seldom sufficient to change automatic emergency-based emotional responses.”

With a surge in cognitive therapies, there has been a surge in their wrongful implementation, with many therapists engaging in power struggles to convince people of faulty beliefs in order for new, more positive truths to simply work some magic ripple effect into their lives.

As an emotion-focused therapist, I have been prone to, for instance, encourage couples to engage in safer, softer, and more emotionally responsive interactions, yet when I have stood on my own soapbox, encouraging them to do so out of pace with their own readiness, I have violated my own guidance. Miller (1986) observed that people will “persist in an action when they perceive that they have personally chosen to do so.”

Babbling

Silence can provoke anxiety, even for therapists, who think they should surely be redirecting, conjecturing, advising. I find myself observing people in therapy watch me watch them watching me watch them. And I have found a power in it. Like a Rorschach ink blot, presence has power in and of itself to nudge a person’s anxiety, so it presents and speaks up for itself.

My former colleague, Blanche Douglas (2015), wrote: “There was a method in Freud's madness when he prescribed the analyst be as undefined as possible, not disclosing details about his life and sitting behind the patient out of sight, saying little. This forced the patient to make meaning out of an ambiguous situation, and the only way he could do this was by recourse to his own experiences.”

Methodologizing

If a psychotherapist is lifeless or their technique too technical, their efforts to help may be worthless. Therapy, in this case, is not a relationship but a poor excuse for scientific experimentation. The mechanisms of some psychotherapies undermine their therapeutic value. When we fixate on therapeutic modality, we run great risk of missing prime opportunities to interject the most valuable therapeutic tool we have to offer—ourselves.

Conclusion

As a new therapist, I remember trying hard to demonstrate my own capacity for psychological insight—even though, I must confess for my wise professors’ sake, I was certainly not trained to be an egotistical show-off. Fortunately, somewhere along the way, I started to better understand and experience the disparity between knowing and being. All these years, I am still learning each day how to lean into the latter. There is something powerful in it, not just in the experience of the therapist but in the experience of the therapy.

The family therapy pioneer Lynn Hoffman, who sadly died in 2017, gave a language of values for sitting with clients—the non-expert position, relational responsibility, generous listening, one perspective is never enough.

If a therapist is not fully present as a warm, accepting, genuine, caring, and appropriately vulnerable person, the power center of therapy remains turned off. Whatever insight may come along the way, meaningful, sustainable change requires transformative experiencing. Analysis without encounter is nihilistic, all the apparatus of thought busily working in a vacuum. Far from data to be interpreted or even a patient to be treated, we are heart and soul, of the same essence, both facing existential predicament.

Only in the context of authentic relationship and therapeutic alliance can I grasp and catalyze the breadth and depth of formidable resources already existing within my clients. 

———
 

References

Brown, B. (Speaker). (2010). Brené Brown: The power of vulnerability [Video file]. Retrieved from https://www.ted.com/talks/brene_brown_on_vulnerability?language=en

Douglas, B.D. (2015). Therapeutic space and the creation of meaning. Context. Warrington, England, United Kingdom: Association for Family Therapy and Systemic Practice. [Edited by Edwards, B.G.]

Greenberg, L.S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: American Psychological Association.

Hillman, J. (1967). Insearch: Psychology and religion. New York, NY: Charles Scribner’s Sons.

Miller, W.R. (1986). Increasing motivation for change. In W.R. Miller & N.H. Heather (Eds.), Addictive behaviors: Processes of change. New York, NY: Plenum.

Coping with Infidelity in Professional Couples

Posted on by Psychotherapy.net Team

Couples seek therapy for many reasons, but among the thorniest issues are those involving infidelity. Of course, circumstances vary widely, so it’s difficult to isolate causes that are equally relevant for all. Given that, I’ll focus on themes that have emerged with some professional couples with whom I have worked that have been married for some time (10+ years), with demanding careers, and for whom these issues arise after having children.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

They may have met in college or graduate school. They became fast friends first, and they never imagined that would change. Both were career-minded and imagined living a life of significance, healthier and happier than that of their parents. They recognized one another as good, bright and hard-working persons. They felt heard, understood, and supported. They shared a vision of life.

Then, as the demands of their careers pulled them into individual tracks of ambition and responsibility, and as they began to have children, their friendship suffered—intimacy too. It wasn’t fully conscious yet, but they had become rutted in role-based “necessities” of duty and obligation. A shift occurred from a vital pursuit of happiness to accountabilities to children, home, and career—life felt burdensome.

The Sources of Disenchantment

The relative ease with which life’s demands were managed in the early, pre-parental years were gone. Back then, there was more time, unpressured and less distracted opportunities to talk. Everything was easier then, even though financial resources were limited. So, what had their success really purchased?

The couple was left feeling that life had somehow gotten away from them. They were overwhelmed and learning that feelings are a complex and nuanced form of meaning, confusing enough to experience let alone to articulate. It was easier when there was more breathing space, when they could get away for a weekend of hiking or big-city stimulation. Sometimes that alone, without talk was enough.

Taking on work-related duties, struggling to realize career aspirations, life became more serious. Then, with kids and parenting added to the mix, along with the financial demands of mortgage, child care, and interruption to a second income; it all added up to a loss of the enchanted vision of life they had in the beginning. Exchanges became strained. Soon they decided it just wasn’t worth the effort to argue.
They began wondering “is this all there is?” Exhausted by work strain, stressed by unrelenting demands, and lacking the friendship they once provided one another, they began to foreclose on the possibility of making things better. But settling is not very satisfying is it? Thus, arises the restless yearning.

Desperate Delusions

For these couples there is seldom a desire to abandon one’s partner. Very few had seriously considered divorce even as they began to look elsewhere for affection. Intact bonds remained that coexisted with urgent needs for emotional intimacy. They could not see a way to reconnect within the marriage. It’s a cognitive, emotional, and moral quandary that they’re unable to resolve, it looks impossible.
That’s where the desperation comes in. It may be equally felt by both members of the couple. But neither is able to frame the issues, broach the conversation, and make them “discussable.” They’ve learned (come to believe) that contentious tones, demanding voices and fault-finding quickly follows. So, they conclude, “I can’t meet my needs here; the situation won’t allow it.”

What they believe they cannot achieve in reality, they seek to address through fantasy and delusion, or perhaps more benignly framed—wishful thinking. Yes, there’s also the sense that they deserve something more and better given how hard they’re working. So, they seek “justice” through a kind of “let’s pretend.” They want to believe that there’ll be no harm as long as no one finds out. Sometimes drinking helps contain the cognitive dissonance. It’s regression in service of play, to invoke Freud, and a symptom of arrested development in the marriage.

The Bubble Bursts, Work Begins

When the truth comes out, a period of crisis ensues. Soon it becomes clear that the act of infidelity only ruptured a relationship that was already suffering from deep, long-standing strains. Upon reflection, both knew things were not going the way they wanted them to. In some cases, partners had even taken separate bedrooms, started vacationing separately, becoming more roommate than spouse.
But the initial disclosure brings jolting pain. Anger, embarrassment, and betrayal are only a few of the emotions that should be expected. It’s not a victimless act. The aggrieved party is deeply hurt. And the unfaithful party frequently suffers a different shame and loss of self-respect that he or she must endure without much sympathy while seeking redemption and forgiveness.

The saving grace for many of these couples is that they usually have reason enough to at least attempt reconciliation and repair. And if they seek help soon enough, before acting out their emotions in ways that make their problem even more difficult to address, their odds improve immensely. Because they are bright and hard-working, they may be able to use that ethic to persevere with the task at hand in some or all of the following ways.

Containment. The couple must have a safe place to process their feelings, and therapy must help them learn how to do even more of this outside the consulting room. Initially, they’ll struggle with managing the intensity of their exchanges outside of therapy.

Learning. The couple must now acquire the interpersonal communications skills to navigate emotionally charged conversations that they had earlier concluded were not possible. They will learn that doing good in their relationship requires knowing how to do good.

Forgiveness. Learning that infidelity is at least partly attributable to arrested development as a couple, a lack of insight, knowledge, skill, and hope concerning what was missing and how to correct it, helps both find a way to forgive.

Forgiveness is something we do for ourselves as much as for our partner. When we lose our capacity for the love, openness, and honesty to discuss the divide that is growing between us, it is not because we willfully intend to do harm to one another. We fail due to our fears and ignorance, our desperation and loss of hope. We lose the ability to focus more on coulds than shoulds.

This is what they learn in therapy.  

Finally Getting Sober

Posted on by Psychotherapy.net Team

The email from my former client arrived on a recent Wednesday morning.

I smiled as I read it, “Just thought you would like to know that I’m celebrating my first year of sobriety and with no slips! Thanks again for all your help.”

Pausing to reflect on our work together over a three-year period of regular and very challenging therapy sessions, I marveled at his present sobriety, given how severe his drinking had become. When he had arrived at my office in early 2016, he was consuming up to two bottles of wine a night and was often experiencing blackouts.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

As with all my clients who struggle with substance abuse and related issues, we had started our work by examining the criteria for a substance use disorder, and in his situation, an alcohol use disorder. He had met 6 of the 11 criteria, including some of the most common issues I look for including tolerance and experiencing regular cravings for alcohol. It had helped my client build his motivation to change when he realized that his drinking habit was actually a diagnosable disorder, and it had allowed him to puncture some of the denial he was experiencing about the severity and destructive nature of his alcohol use.

Once we had established that he did indeed have an alcohol use disorder, I had asked about his drinking goals. I have learned that it is important to not assume a client wants to get sober. In fact, most clients, even those with severe substance issues, generally want to strive for moderation rather than abstinence. If they sense I have an agenda for them to quit, they often withdraw from therapy prematurely. Thankfully, my client had recognized that he was unable to drink moderately and was committed to finally getting sober–complete abstinence.

We had started our work with the goal of gradually reducing his drinking, with the idea that if he was unable to significantly alter his intake through individual therapy, we would consider outpatient treatment centers to further support his recovery. We aimed to reduce his drinking by 25% each week, as this would be sufficiently challenging while not overwhelming. I had asked him about his daily drinking patterns, and we paid special attention to his triggers. For him, fights with his partner would leave him feeling frustrated, angry and alone, and would inevitably lead to heavy drinking that night. He would also associate arriving home from work with going directly to the fridge to pour a sizable glass of wine, often before he had even removed his coat. Another potent trigger was social functions associated with his job—he would often drink too much and not remember much from the previous night.

“The key to getting sober is to anticipate which evenings will be threatening to your sobriety and then develop a concrete plan to get through them,” I had told him.

Each week, we spent time talking about upcoming events that worried him because there would be alcohol present. We worked out how many drinks he could have based on our reduction goals. We also reduced the window of time where he would be out of the house, thereby giving him less time and opportunity to drink. He would arrive late to the various events and leave early. We also discussed some effective strategies he could use, such as having a big glass of water between each drink, eating a meal before going out to slow the absorption of the alcohol, and only bringing the necessary cash to buy our predetermined number of drinks—he would leave his cards at home to reduce temptation.

At the beginning of each session, we would review how the previous week had transpired and we would adjust our goals or strategies accordingly. I would often remind my client that getting sober is not a linear process, there will be inevitable slips and even potentially full relapses. I assured him that this was normal and reminded him to not be too critical of himself if he drank too much one night. He just needed to continue moving forward, learning from his slips and applying that knowledge to the next experience.

My client had struggled in those initial months to meet our goals for reducing his drinking, so we had agreed that he would also start attending Smart Recovery, a weekly support and psycho-education group. This additional support was what he needed, and we began to see a steady decline in his overall drinking.

Several months into our work, I recall him arriving at our session one morning and he was beaming. He sat down, stared at me and waited for me to ask, “How did it go this week?”

“I didn’t drink a thing,” he reported through a smile. “I can’t believe I actually did it.” My client was ready in every possible way to change his relationship with alcohol and worked diligently toward that goal.

I was brought back to the present moment with the sound of my kids demanding something from upstairs. I quickly reread his email, felt quietly proud for his recovery, and continued with my day, a bit lighter. 

That Certain Feeling: “How Ya Gonna Keep ’em Down on the Farm (After They’ve Seen Paree?)”

Posted on by Psychotherapy.net Team

I used to drink bad coffee. Growing up with canned Maxwell House, how would I have known any better? Coffee shops at college served percolated coffee, which wasn’t any better. The paper filter and easy access to whole roasted beans changed things. I didn’t really want to taste the difference, because I thought the procedure of grinding and pour-overs was snooty, and because in fact the flavor (which I now recognize as “coffee”) set a new standard of expectations. It wasn’t only that I knew that from then on that there was something I had been missing; it was also that I knew not to be satisfied with less. I suppose I might move to an even higher standard someday, if exposed to something even more delicious and not too expensive.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

One thing all kinds of therapy have in common is that they produce and consolidate certain feelings and psychological states that clients are not used to experiencing. For example, a depressed client might have a moment of joy, or an anxious client may feel serene. Technique aside, if the therapy dyad or the couple or the family can appreciate the moment, a number of positive consequences may follow. The client might have proof that she is capable of serenity, for example, or a couple may recognize that they are capable of making each other laugh, or a family may see that a disruptive child is capable of cooperation. The focus then turns from whether the client is capable of positive behavior to when, under what circumstances, this occurs, and how to reproduce it.

Once a desirable feeling or psychological state occurs, clients can see what they are missing and begin to insist on it. The depressed person becomes motivated to change not by a promise of paradise but by a taste of honey. Parents relinquish the self-protection of “nothing works,” and they try to reproduce the cooperation they experienced firsthand. Just as I never knew what good coffee tasted like, some people go on dates and don’t know what curious attention feels like. They don’t then insist on it (by not continuing to date someone who doesn’t provide it). They also drive away people who do provide it, since their prospective partner’s curious attention falls on deaf ears, and the partner feels the way talented baristas feel when they prepare a delicious cup and the customer gulps it down without tasting it.

Virtually every client can be construed as wrestling with aspects of themselves that don’t fit the narrative they are promoting, internally and externally, about who they are. In whatever manner those ignored aspects of the self eventually get integrated into the total self, it goes more smoothly if they are seen as natural and welcome facets of the human condition. Thus, the feeling of being understood is central to therapeutic growth. Once the marginalized aspects of the self learn what this feels like, they can insist on it. (I’m talking about feeling understood, which is different from being catered to). Clients are then likely to stop doing things that defensively drive away other people, because the feeling of being understood undermines a sense of being repulsive or unacceptable. Clients who feel understood are likely to seek opportunities to feel it again, and collaborative, mutual relationships follow.

Therapists are people, too. No therapist can provide a collaborative mutual relationship if they don’t know what it feels like, and no therapist can provide it in therapy if they know only how to provide it in romance or friendship. You don’t necessarily need to have felt truly understood in your own therapy to become a good therapist, but it helps, just as drinking great coffee is a good foundation for becoming a master roaster. Therapists can also feel understood in supervision or peer consultation groups, where showing mistakes plays a role similar to revealing marginalized aspects of the self in therapy.

Seven Mistakes in Clinical Supervision and How to Avoid Them

Posted on by Psychotherapy.net Team

Clinical supervision is the “signature pedagogy” of choice in psychotherapy (1). I’ve benefited a great deal from the lessons of my supervisors. Some of their words from a decade ago not only still echo but have become first principles I keep close in my own clinical and supervisory work and teaching. Most of us regard clinical supervision as highly integral to our professional development. It’s hard to imagine not having someone to turn to for case consultation and guidance, especially when stuck in a rut and not making expected or desired progress with a particular client.

Supervision and Clinical Impact

Given the benefit we often feel from clinical supervision, the logical next question to ask is whether clinical supervision actually translates into meaningful impact on our client’s wellbeing? About 8 years ago, Edward Watkins Jr., a researcher from the University of North Texas, conducted a review of 18 empirical studies that examined the impact of supervision on client outcomes. Based on the big picture analysis, Watkins said “…the collective data appears to shed little new light on the matter. We do not seem to be able to say anything new now, (as opposed to 30 years ago), that psychotherapy supervision contributes to client outcomes.” (2)

More recently, a team of researchers set out to investigate this question based on a large five-year dataset comprising 6521 clients seen in naturalistic settings by 175 therapists and guided by 23 clinical supervisors (3). Not only did factors such as supervisors’ experience level, profession (social work vs. psychology), and qualifications not predict differences between supervisors, the role of clinical supervisors explained less than 1% of the variance in client outcomes. Said in another way, and contrary to expectations, clinical supervision as we know it has little to no significant impact on improved outcomes in the lives of our client’s lives.

Taken together, we may very well feel the benefit from clinical supervision, but it doesn’t seem to translate into improved clinical outcomes.

Rethinking Clinical Supervision

This begs the question. Why is clinical supervision not translating to actual improvement of client outcomes? Given that we invest so much time and effort in our “signature pedagogy,” perhaps we need to rethink our current practices in supervision. Drawing from the existing psychotherapy evidence and the development of expertise literature outside of our field (4), here are seven supervisory mistakes I see us making, along with speculation on how these relate to apparent clinical stalemate:

1. Too Much Theory Talk

2. Pat-on-the-Back

3. Lack of Monitoring Client Progress

4. Lack of Monitoring Engagement Level in Supervision

5. Not Analyzing the Game

6. Overemphasis on the Self and Neglecting the Impact on Client

7. Lack of Focus on Therapist’s Learning Objectives

8. Too Much Theory-Talk

Often, the clinical supervision encounter revolves around cases discussion, case formulation and theorizing about the clinical pathology. This fits under the umbrella of clinical conceptual knowledge and does not actually delve into moment-by-moment interactional patterns that unfold in a therapy hour. We often end up waxing lyrical on how a case may be conceptualized in a psychodynamic framework or in an emotion focused or from a CBT perspective. Not only does this disembody the conversational nature of reality in therapy, we assume that the key is to obtain a thorough case formulation of the problem at hand. In 1939, Carl Rogers aptly pointed out, “…A full knowledge of psychiatric and psychological information, with a brilliant intellect capable of applying this knowledge, is of itself no guarantee of therapeutic skill.” (5)

2. Pat-on-the-Back

In my work with supervisors and therapists, I often hear this chant, “…But your client still comes back to see you right?” In actuality, a small percentage of clients (~10%) account for the largest percentage (~60-70%) of behavioral health care expenditures, showing a continued use of services without successful outcomes (6).

While it is vital to take care of the supervisee’s sense of self, what feels good doesn’t equate to what helps us grow. About a third of our clients continue therapy without experiencing reliable improvement in their well-being. If we continue to bolster their esteem with praises or consolations without helping them identify their growth edge and improve the outcomes of “stuck” cases, we are doing our therapists and clients a disservice.

3. Lack of Monitoring Client Progress

We therapists are an optimistic bunch. In the absence of real-time monitoring of outcomes and engagement, session-by-session, we fail to detect deterioration and dropouts. A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduces deterioration in client well-being by a third, but cuts drop-out by half, and as much as doubles the overall effectiveness of therapy (7). Even when we use routine outcome monitoring devices, like the Outcome Rating Scale (ORS) & Session Rating Scale (SRS), Outcome Questionnaire (OQ-45),or Clinical Outcome Routine Evaluation-Outcome Measure (CORE-OM),we fail to meaningfully integrate this into the supervisory process. We stick to using the measures as an assessment tool, and not as a conversational tool.

4. Lack of Monitoring Engagement Level in Supervision

For those of you who are already using routine outcome measures as a source of feedback, you know that it’s hard for clients to give feedback to the therapist. It’s also hard, if not harder, for a supervisee to provide feedback about the engagement levels in supervision — especially if the supervisor is a colleague.

The reality is, supervisors have a tough enough job of ensuring that their input has a ripple effect not only on the therapist, but also on their clients. Having some kind of formal procedure to elicit what’s been working for the learner can help the process of focus. In addition, given that supervisors and supervisees might have overlapping roles or collegial bonds outside of supervision, having a formalized feedback procedure in supervision allows for both parties to take a pit stop and address issues in real time — not 6 months down the road when it’s too late — that might be brushed aside.

5. Not Analyzing the Game

In any other domain of performance (e.g., sports, music), if one were to seek a coach’s help in improving their game, it would be unheard of for the performer not to analyze her performance. Yet, in the field of psychotherapy, we do less of examining the moment-by- moment dynamics of the therapy hour and more theorizing (see point #1). Most supervisors do not use the practice of watching snippets-segments of the video recording highlighting specific areas that the therapist can work on.

Much like other fields (music, sports), it’s important to record sessions in order to receive feedback about actual performance rather than feedback about a perceived or reported performance. Feedback is useful when it’s based on a well-defined objective, observables, and specifics.

6. Overemphasis on the Self and Neglecting the Impact on Client

You may not agree with this point, but there is an over-emphasis on the self of the therapist at the expense of impact on the client. Too much supervisory time is spent on superfluous issues such patting the supervisee on the back (see # 2), while not enough time is spent on using real-time progress monitoring to guide the conversation (see #3).

7. Lack of Focus on Therapist’s Learning Objectives

Finally, I would argue that there is a lack of focus on the therapist’s learning objectives. This is one of the four tenets in deliberate practice (8). (Stay tuned as we will cover this in future blog posts). This may be the most vital yet lacking element in a practitioner’s professional development. Too often, we engage in clinical supervision on a case-by-case basis, with no coherent thread weaving in the therapist’s learning needs and clinical case concerns. Even when we do so, there is often a lack of systematic tracking of the supervisee’s development. As useful as client feedback is to clinical practice — spotting anything glaring or missing and pointing out if the session is on-track or not — this does not help therapists improve on their therapeutic skill, based on the developmental stage of their profession.

Consider another example: A top musical performer does not benefit from the feedback of the crowd (the decibels of the audience’s applause, the verbal comments about the performance, etc.), as much as the nuanced and specific feedback they might receive from their maestro or producer.

***

In the upcoming blog posts, I will cover each of the seven points raised about the flaws in our default ways in clinical supervision, and I will provide specific pathways out for each of them.

References

(1) Watkins, C. E. (2010). Psychotherapy Supervision Since 1909: Some Friendly Observations About its First Century. Journal of Contemporary Psychotherapy, 1-11

(2) Watkins, C. E. (2011). Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. The Clinical Supervisor, 30(2), 235-256.

(3) Tony G. Rousmaniere, Joshua K. Swift, Robbie Babins-Wagner, Jason L. Whipple & Sandy Berzins (2014): Supervisor variance in psychotherapy outcome in routine practice, Psychotherapy Research, 26(2), 196-205.

(4) A. Ericsson, K. A., Hoffman, R., Kozbelt, A., & Williams, A. (Eds.). (2018). The Cambridge Handbook of Expertise and Expert Performance (2 ed.). Cambridge: Cambridge University Press. B. Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.

Miller, S. D., Hubble, M., & Chow, (2020). Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. American Psychological Association.

(5) Carl Rogers, 1939, p. 284 The Clinical Treatment of the Problem Child.

(6) Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is It Time for Clinicians to Routinely Track Patient Outcome? A Meta-Analysis. Clinical Psychology: Science and Practice, 10(3), 288-301.

(7) Schuckard, E., Miller, S. D., & Hubble, M. A. (2017). Feedback-informed treatment: Historical and empirical foundations. Prescott, David S [Ed]; Maeschalck, Cynthia L [Ed]; Miller, Scott D [Ed] (2017) Feedback-informed treatment in clinical practice: Reaching for excellence (pp 13-35) x, 368 pp Washington, DC, US: American Psychological Association; US, 13-35.

(8) Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. In D. S. Prescott, C. L. Maeschalck, & S. D. Miller (Eds.), Feedback-informed treatment in clinical practice: Reaching for excellence (pp. 323-355). American Psychological Association.

Questions for Thought and Discussion

What kind of clinical supervision do you value and why?

Which of the author’s seven mistakes have you or do you currently engage in?

What have you done recently to improve the quality of your clinical skills?

What style of supervision do you practice, or would like to practice?

Tips for Working with Vegan Clients

Posted on by Psychotherapy.net Team

What do you do when a potential new client calls and asks if you work with vegan clients? Perhaps you say no because you never have before (or didn’t know you had) and don’t know much, if anything, about veganism. Maybe you say yes but are not sure what working with a vegan client might entail and figure you’ll wing it and hope for the best. And then it’s highly possible that no one has ever asked you that question. I think it’s fair to say that most of us don’t have experience working with every issue nor with every population that contacts us. However, as veganism continues to grow, it’s increasingly likely that we’ll be finding more vegans reaching out to us.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

The one question I am continuously asked is, does eating a diet free of animal products in itself make a person vegan? The short answer is no. The longer answer is eating plant-based is a major part of being vegan, but veganism isn’t just about what people eat; it’s about the way one views and treats all animals, human and non-human. People following a vegan lifestyle can’t help thinking about the exploitation of animals because they’re continuously confronted with it. Sitting next to people eating meat, walking behind someone wearing fur or leather, or overhearing conversations about hunting and fishing trips or visits to circuses and zoos, are all constant reminders. In my clinical experience, the thought of institutionalized animal exploitation is what prompts many vegans with whom I have worked to seek therapy for depression, anxiety, relationship issues and sometimes, trauma. How these issues may manifest in a session can be illustrated in my work with Tessa, a former client.

When 32 year-old Tessa contacted me, she announced that she was vegan and had been searching for either a vegan therapist or, she quipped, one who was “vegan-friendly, like a restaurant.” Consequently, I had a hunch her issue(s) would be vegan-related. However, I had worked with individuals requesting a vegan-friendly therapist where that wasn’t the focus-?they just wanted assurance I would be supportive, if the issue came up. And it did come up with Tessa. Parenthetically, my therapeutic style is direct and eclectic. I have been influenced by various therapeutic approaches, including psychodynamic, Somatic Experiencing, hypnotherapy, cognitive/behavioral, ecotherapy, Internal Family Systems, and Existentialism. I believe we must look not only inside ourselves for what ails us but also to our relationship with the world around us. In this context, I work with individuals who are grappling with a wide variety of issues including, but not limited to relationships, life transitions, animal bereavement and ethical veganism, which is both a mindset and lifestyle practiced by people who care deeply about all animals and oppose harming them in any way.

Tessa smiled weakly as she slumped onto my couch, silent for a few moments. She had been feeling “very low, very anxious. My heart races or my stomach feels like someone’s on a trampoline.” Her difficulties began after watching two videos detailing animal exploitation–she used the words, “animal abuse.” She transitioned to a vegan lifestyle after seeing the second video. Tessa felt immense guilt “that she had been part of the problem,” chastised herself for “not knowing sooner,” and felt “hopeless about the situation.” When confronted with the frequent images of animal abuse on social media, she’d break down. Often these images would spontaneously pop into her mind.

When discussing this subject with family and friends, responses were dismissive of her and/or the issue: “there are more important things to worry about”, “you’re being way too sensitive”, “get a life!”

Before reaching out to me, she had been seeing another therapist. While the “person was very nice,” her questions repeatedly intimated that the root of Tessa’s problems lay elsewhere. Consistently feeling misunderstood, Tessa ultimately decided to find a therapist “who got that someone could be depressed thinking about all the abused animals in the world.”

In working with Tessa, I took a three-prong approach. My first goal was validation that sensitivity to animal exploitation could lead to depression and anxiety. She also needed to trust I could handle her intense emotions, without judgment.

My next objective was helping her find effective ways to calm herself when triggered by disturbing images, thoughts, or conversations. I used various techniques, including several from somatic experiencing and hypnotherapy. For example, I helped her transform distressing images into ones less fraught. Intrusive thoughts about animal abuse were attenuated by both diverse breathing techniques and anxiety-reducing visualization exercises. To recharge and reset, she created a mental image of a special place, one filled with calming images, sounds, and smells. Formerly a meditator, I suggested she resume her practice to help let go of unwelcome thoughts. Reducing her time on social media was also discussed.

The third prong was to address her hopelessness by exploring options for helping animals. Because everyone has different talents, interests, and time constraints it was important that whatever actions we came up with were realistic. Being a “people person”, she decided to research animal welfare groups whose focus was public outreach. Tessa loved planning and hosting parties so organizing fund-raising events for animal organizations sounded appealing.

Within a few months, Tessa began feeling better. She now had tools for calming her mind and nervous system and strategies for advocating for animals. Perhaps most importantly, she felt she had been understood.

As you can see, the techniques for working with vegan clients are the same we’d use with anyone else. So with this newfound knowledge and an open mind, the next time someone calls and asks if you know anything about working with vegans, you can say, absolutely!  

Anxiety Management: It

Posted on by Psychotherapy.net Team

Les relâches is a winter break that every Swiss public-school system takes in February, though the actual dates vary from canton (state) to canton. In French, “la relâche” means “rest,” but as this week usually involves skiing in Switzerland, it is the least restful week of my year! Personally, I call it anxiety management week. It is the one week every year that this psychotherapist becomes her own private client. I set a goal each time to try to keep up with my family on the trails for at least a couple of hours during the week. Sometimes I succeed, but, mostly, I just keep trying.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

During ski week, my empathy skyrockets for past and current clients who combat anxiety on a daily and sometimes hourly basis. I join their ranks in that need for anxiety management anytime my personal context intersects with a few notable laws of physics that involve speed and momentum. I employ copious doses of the cognitive, behavioral, and affect regulation strategies I often prescribe to the people I work with. These strategies become my lifelines on those steep mountains, which are crowded with other skiers who could literally carve laps around my effort-filled descents. My five-and-a-half-year-old daughter and my eight-year-old son are two of them.

I recognize that real danger is inherent in practicing a sport in which momentum is needed to perform accurately, and where the physical environment often includes steep, rock-and-tree-filled obstacles, much less the human-made ones. Learning to ski involves mitigating the risks of navigating changing terrain and conditions, avoiding falls and collisions with stable objects or other skiers, and maintaining one’s personal equilibrium within the bounds of one’s own ability and limits, all while attempting not to become the obstacle in other skiers’ paths! (From this angle, it actually sounds a lot like practicing therapy!)

This constant processing of rapidly evolving environmental data can frankly be quite physically and mentally exhausting! However, the rewards of learning to synchronize with oneself, with nature, and with others can also be quite rewarding, sometimes comical, and usually humbling.

My daughter and I had the makings of a beautiful mother-daughter moment together one afternoon on a blue trail when she decided to ski beside me, about three feet away. She excitedly exclaimed, “Mommy, you’re going fast now!” Her broad smile showed me that she meant this as a compliment and was proud of the progress I had made through the daily lessons I had been taking during the week. Several thoughts traversed my mind in rapid succession as I processed her spontaneous and heartfelt gesture and as my anxiety welled:

“Why are you looking at me and not straight ahead where you are going?”
“How on Earth do you ski without looking where you are going?!”
“How do you manage to get so close to others and not veer into their path?”
“Oh Heavens, you are close!”

As much as I was in awe of her ability to remain calm, cool, collected, and courageous in her posture (as we were speeding downhill, nonetheless), I began to have palpable concerns for her safety in skiing so close to me. Instead of relishing that beautiful mother-daughter moment she created, my thoughts raced, my anxiety overflowed, and I awkwardly blurted out, “Honey, please ski a little further away (so that if I crash and burn with the newfound awareness your astute speed observation evokes, I won’t be able to take you down with me)! I need a little more room to turn here.” She shrugged, then proceeded full speed down the mountain, making perfect “S” turns with her skis in parallel, catching up easily with her brother and father below.

My speed on skis, and my ability to go with the flow of it (instead of fighting it), is usually a great source of vexation for me and my family. My “pilates” approach to finishing a trail involves turning with intention, methodically repeating to myself, “Up… turn… down,” and mechanically pacing my breath to the piston-like movements I consciously will my knees to make. My family is greatly annoyed about the mid-trail wait times this entails for them, especially when we agree to stay together.

When in difficulty, staying together comprises part of the rules and common-courtesy practices that skiers adhere to for safety, along with signaling dangers to others and calling for or providing help. For the most part, I have been on the receiving end of those practices. But, with a few more ski weeks and the mental and emotional strategies I employ to stave off full-blown panic attacks, I may someday be able to help others as they have helped me on the trails. Until then, skiing with anxiety will continue to be downhill all the way.

Helping clients manage their anxiety through a caring counseling relationship allows them to see that they, too, can benefit from employing strategies discussed in session on their own slippery slopes. We can help them to categorize situations like ski trails to understand how steep the slope (and the learning curve) feels for them: blue for low anxiety, red for mounting anxiety, or black for high anxiety. We can accompany them in using their available and developing resources to recognize the thoughts that make their slopes feel dangerous to them and to process how their body captures, holds, and releases their anxiety, much like skiers must do to evaluate how their skis react to shifting environmental conditions throughout the day. We can urge them to consider how their anxiety affects them and their loved ones, and to call upon those loved ones for support when needed. With time and practice, they will hopefully learn to navigate those more difficult trails with greater agility, crossing their own finish lines in their own time and on their own two skis.

Advanced Harm Reduction: Managing Intoxicated Clients

Posted on by Psychotherapy.net Team

First there was abstinence, then it was abstinence versus harm reduction. Now, “it appears that intoxication management is becoming a necessary skill for therapists”. With the ubiquity of alcohol use and its presence as an increasingly high-end activity, the growing legalization of marijuana, mini-dosing, psychedelic therapy and the ever-growing use of psychiatric drugs at younger ages … what’s a therapist to do?

The Goal of Abstinence

Abstinence has traditionally been the goal of treatment for substance use disorders. And while many therapists, particularly those with 12-step backgrounds, continue to tout abstinence, several factors have challenged its once hallowed position at the top of the treatment goal hierarchy.

Abstinence supporters and opponents alternately argue on the following grounds (supporters in plain type, opponents in italics):

  • Abstinence provides a clear and unambiguous target
  • People will refuse treatment altogether if they must quit entirely
  • In order to participate constructively in therapy, the mind and body must be clear of intoxicants
  • While living in a monastery or being in rehab encourages abstaining, living in the real world requires some substance exposure and use
  • Some drugs create such an intense rush that users must dissociate themselves in order to recalibrate their pleasure responses
  • Those on antidepressants, as well as medications for bipolar and other prescribed medications who encounter problems with using the drug, on the other hand, court lethargy and possibly intolerable dysphoria by quitting
  • While avoiding one substance may be called for, there may be little cross tolerance or susceptibility to problems with use of another
  • Giving in to the urge to use one drug reduces overall willpower strength, according to Roy Baumeister and John Tierney’s best seller on the topic

A Self-Labeled Alcoholic

Joyce drank heavily as a teenager, quitting in her early 20s. She attended AA, remade herself, and moved far away from her home state. Over the years, she smoked pot, and took medication as indicated for pain or sleep or anxiety, but with a wary eye on her penchant for addiction. She succeeded in not using anything excessively or addictively.

Along the way, Joyce developed severe depression, which antidepressants relieved. Eventually, she worried that she had become dependent on the medication, which caused her to stop. But, “when Joyce renewed use of the drug, she had a frightening suicide-ideation reaction”. She has been terrified of that medical category of drug since then. Joyce is prescribed and occasionally takes anti-anxiety medication, which she uses sparingly due to her fear of addiction. She has found opiates very helpful for her moods but understands that they should not be used that way and mindfully avoids traveling too far down that road when prescribed opioids for pain. She continues to consider reintroducing a depression medication into her life if she can get past her fear of them.

Although some cannabis advocates would say that she is using marijuana therapeutically, Joyce views her use of that drug as strictly recreational and restricts her use to evenings. Using the drug in this way doesn’t interfere with her work or other life functions, and she feels she can take the drug or leave it on any given night depending on her mood and what she’s doing. Keep in mind that Joyce remains completely “sober” with regards to alcohol, per her AA experience, though she occasionally uses Nyquil or cooks with alcohol. Many people in her current social group drink moderately, so that Joyce understands such drinking is readily possible.

Drug Use by the Formerly Addicted

An acknowledged “recovering” alcoholic, Joyce is far from being sober by strict 12-step standards. According to her former AA cohort, Joyce is living in dangerous territory. She uses mood-altering substances for fun, and she continues to take a variety of psychoactive medications. She also no longer attends meetings. Yet she is solid in her conviction that she is now a sober individual, and proud of it.

Joyce is in many ways a prototype of the modern American polydrug user. Her life calls into question the meaning of the terms abstinence, sobriety, and recovery. Of course, even the most hard-core abstinence proponents often don’t include cigarettes and coffee in their sobriety calculus, although both are addictive and can have serious negative health consequences. “There is still heated debate among 12-step adherents about taking medications”—their allegiance to abstinence precepts ranges from scorning all medication including not even taking an aspirin under any circumstances, to accepting prescribed medications, to believing use of anything that isn’t your drug of choice is okay (like Joyce’s easy use of cannabis). And this is before even considering the modern harm-reduction movement’s scope, including moderate use of a formerly abused substance, substituting a safer version of an addictive drug like taking suboxone or methadone in place of heroin and even continuing addictive or binge use under safe conditions (e.g., using heroin with clean needles or in a supervised consumption site).

Here are what we believe to be the underlying, fundamental guidelines for discussing continued substance use with people who have been diagnosed with or who themselves believe, as Joyce does regarding alcohol, that they have a substance use disorder:

  • Be open minded and willing to consider all substance use options: abstinence, substitution or replacement with other substances, moderation, safer use, occasional or regulated addictive or intense use.
  • Remain mindful of—and review—experienced outcomes with clients (this opposes the idea of “denial,” taken to mean that clients cannot accurately report their substance-use experiences).
  • Measure the success of treatments against actual life functions—work, family and friends, and especially subjective client feelings.
  • Avoid labeling the client or his or her substance use pejoratively as addictive, bad, or equally as harmful in all forms or methods of use.
  • Consider first and foremost client values and preferences by using motivational techniques in use decision-making.
  • Change is part of the process—the person, their situation, and the interchange between them are always in flux. There is no permanent solution.
We are in a sense in the new frontier of almost infinitely available substance use, considering that illicit opiates and other drugs can be ordered over the “Dark Web.” It does no good to regret or bemoan this reality. “In a sense, we are at the final societal stage of what therapists should regard as the goal in all therapy”—realizing the clients’ agency and freedom of choice in devising their best selves.

Rethinking Non-Problematic Substance Use

The 12 steps can be seen as one expression of American temperance attitudes that consider all forms of intoxicant use and intoxication to be bad or wrong—or, in modern terms, problematic, disordered, or addictive.

Consider Mary, who LOVES to smoke pot. She smokes it all day long, whenever she can, and she always strives to have a supply available. She also drinks, not heavily, but she likes to go out and get a little fuzzy and sparkly with alcohol once or twice a week. Do you think Mary has a substance problem? On the face of it, she uses substances regularly, heavily, and possibly dependently or addictively in the case of marijuana.

Mary owns and manages a local restaurant where she is beloved by workers and customers alike. She is responsible for its financial success as much as the hands-on and the public-facing part of the business. Mary also organizes large rallies and fundraisers for community causes. She is a good citizen. She is strong-willed and plain-spoken. She has a positive marriage. And she is happy with her lifestyle as it is, thank you very much.

“Mary knows something about addiction”. She used to do cocaine heavily, with terrible consequences for her and her husband’s lives. But that was many years in the past. Today, she seems dependent on pot, while her drinking is generally moderate and she doesn’t overdo her use of any other substance, including occasionally prescribed medications. Yet she rejects and is alarmed by destructive substance use, as occurred in her own life with cocaine.

Mary, like Joyce, expresses several contemporary trends in substance use attitudes and practices. She doesn’t accept standard substance use disorder definitions and recommended usage levels. She accepts, even welcomes, mood modification—a.k.a. intoxication when substances aren’t prescribed for therapeutic purposes. And she doesn’t feel limited by her intensely negative, i.e. addictive, former use of cocaine.

Consider Greg. He was a heroin addict in the late ‘60s, long before so much awareness and availability of opioids use had developed. He shot up, lived on the streets, the whole nine yards of addiction. He was lucky because he had a strong family (parents and siblings), and after many years of addiction, he went to a TC (therapeutic community) and finally quit heroin.

Those communities, at that time, allowed clients to reintroduce moderate drinking after a period of abstinence. That idea worked for many TC adherents, although Greg’s idea of moderation seriously exceeded recommended amounts for safe use. Greg drank to intoxication, specifically, two nights a week, although he never touched any other drug. He was positive that if he ever smoked a joint that he would go right back to heroin, and cocaine was just not his thing. But Greg put alcohol in a completely different category.

As he aged, Greg continued to drink two nights a week, but much less heavily. In many ways he followed a typical pathway of natural recovery with alcohol, even as he was a fully recovered heroin addict. And, we should also note, Greg identified personal emotional issues, made substantial changes to his life and created a life he could better live with than when he had been addicted to heroin.

Regarding Greg’s dual pathways to sobriety—one with opioids, one with alcohol—”do we really think that someone who has, for instance, kicked a 10-year heroin habit has relapsed if they have a beer on a hot summer day?” Greg didn’t fit this mold. He was a heavy and, for a time, potentially harmful drinker. But what if a formerly addicted person gets drunk at a class reunion every year? Should we perform an intervention? Or are these simply life events, rather than cases requiring a clinical consult?

We as Americans think use of some substances is more acceptable than others: antidepressants are consumed in enormous amounts, along with Adderall, sedatives, and anti-anxiety drugs (benzodiazepines) and other psychiatric medications. What about coffee, colas, and energy drinks? Now marijuana, depending on your residence, is used both recreationally and as medicine.

As for painkillers, we love them and we hate them. Americans have a strong urge to eradicate pain. It is normal to seek relief from pain. Yet we now have become overwhelmed by our quest for pain relief, including, seemingly, relief from the mental and emotional distress of daily life. We need to look seriously at what this need for escape says about society, particularly in areas characterized by little education, high unemployment, and so-called crises of despair.

Empowering People to Find Purpose

Allowing people to feel safe in openly discussing their lives with their counselors and providers, to convey what it is they think they are doing rather than what their counselor thinks they are or should be doing, increases trust and allows for a collaborative therapeutic relationship. This open process must include acknowledgment of and handling intoxicant use.

Such a therapeutic alliance encourages the client’s sense of agency. “A path of empowerment by clients’ self-identification of their individual values and goals is the ultimate objective” in this conception of therapy and helping. It is not a therapist’s job to identify how someone should live, but rather to explore and to help illuminate what is their best way in life, their unique purpose, with and without regard to their substance use profile.

Perhaps we should celebrate the availability of a modern cornucopia of substances for driving this point home.  

Talkspace: The New Therapy Room

Posted on by Psychotherapy.net Team

I am always on the lookout for new opportunities and exciting options through which to share my mission of promoting positive mental health. I have been a psychotherapist for over 31 years. Working with adolescents has taught me many things, foremost among which is to expect the unexpected and be open to whatever is happening in the digital world. And it’s not like I’m a dinosaur who’s ignored trends in the digital world, but when did texting become the new form of talking, and can it possibly be an effective form of communication? For therapists?

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Along came Talkspace (TS), a highly sophisticated digital therapy platform which provides for communication with clients through audio and/or video messaging and live video sessions. I thought it was an opportunity, but even more so, a resource, I could not ignore. The “on-boarding” process, as it is called, required a significant commitment including providing my professional credentials, proof of liability insurance and completion of their comprehensive Talkspace University+ training, so that I could understand and effectively use their digital platform. Yes, it is HIPAA compliant.

Clients provide informed consent along with emergency contact information. One hopes to never have to use the emergency contacts, yet it is reassuring to have them readily available, if needed. Talkspace handles all financial transactions, including insurance, private pay and EAP (employee assistance program) fees. Clients are paired with therapists or can choose their own clinician. They complete a general application outlining their presenting problem(s) which triggers an assessment designed to establish a baseline of the frequency and or intensity of the presenting problem(s). Once client and therapist are paired, the therapeutic relationship begins. Rapport building beings and expectations related to frequency and mode of communication are agreed upon. For me, it involves five twice-daily visits to my “room” each week. The client has 24/7 access to their “client room” which is where we maintain contact. The relationship can form surprisingly quickly compared to some of the typical live sessions I have had in my on-ground or in-school clinical work.

Has it been significantly different for me from the traditional face-to-face therapy that I have practiced for so long? Yes and no! The convenience for myself and my clients is incredible. If you have an iPhone or iPad with a wireless connection, you can provide psychotherapy through the Talkspace platform. Italy, here I come! Yes, that does make it sound easy, however just as I have in my on-ground office, it has been important to trust in and use the experience I have accumulated to read through the message in the messages. Do I miss the nonverbal cues? Well, yes! This introduces the challenge of asking additional questions that I might not otherwise ask in my face-to-face work. For example, “What are your feelings about this? How are you processing all of this?” Yes, you ask these questions in face-to-face therapy, however it is typically more in the flow while you are reading the client’s nonverbal cues that insight into their feelings is acquired.

Most of us do not audiotape/review our sessions, we use notes and memory, right? Think about what YOU use to recollect your session. The nature of this digital therapeutic communication is very similar to in-person communication, but the entire exchange is right there on the screen. Client and therapist can read re-read the entire communication. This has allowed me to use the CBT model with greater impact. I encourage my TS clients to reread and review some of our previous messages to reinforce interventions, sometimes cutting and pasting in order to highlight and reinforce a concept. Here is an example of part of an interchange I had with a client:

Client: “I value my friends a lot and I genuinely do whatever I can to make them feel as good as I can get them to be.”

Me: “I am wondering if you can apply that thought/ideal to yourself. I value me a lot and genuinely do whatever I can to make me feel as good as I can for myself. How would that statement/thought feel? Try it on.”

Of course, I asked my client permission to use this. Within my message to ask permission, I once again copied and pasted the previous message for the client—an effective way of reinforcing and restructuring some of the negative thinking that occurs for her. One of the advantages of this platform is the ability to go back with accuracy to reinforce while highlighting the possibility of change. Additionally, I like the use of visuals in therapy such as the CBT triangle (thought, behavior, emotion), but as yet, it has been a challenge to bring these into the Talkspace room. I’ll get there.

The one constant in life, and no less in my evolving professional role, is change. Talkspace has challenged my preconceived ideas about digital therapy and enabled me to bring my clinical skills into the digital sphere. I welcome the research and data to support this work. I recently asked one of my digital international clients to articulate their experience with me on Talkspace. She said, “I don’t know if this could be of any use, but face-to-face therapy here in Saudi Arabia is really limited…I was faced with ignorance and people didn’t know how to handle me.” She continued, “With Talkspace, I truly felt heard and comforted in ways I couldn’t in face-to-face therapy. I’m sure professionals here are extremely good at what they do, but I was blessed to have you as my therapist and like I’m taking a huge step into bettering myself.”

Face-to-face and digital therapy both include rapport building, the establishment of baseline through careful assessment, the development of treatment goals, the creation and implementation of interventions and assessment of treatment outcome. Talkspace has brought me and my therapy room to clients who I, more than likely, would never have had the opportunity to work with. The clinical effectiveness, affordability and accessibility of Talkspace have worked for both me and my clients, allowing me to continue my mission to promote positive mental health. Therapy is not about a room, it is about creating a space for connection and healing. Welcome to the new therapy room.