Category: Blog

Do You Believe in Cats?

Posted on by Psychotherapy.net Team

“I feel utterly hopeless,” she began, and when she told me her story, I understood why.

She was fifty-five and had recently sunk all her money into a house with a man she’d known for three months. For ninety days he had been her soulmate, but weeks after moving into the house they now owned together, he’d become an emotional double for her abusive, narcissistic father. She was stuck, financially and otherwise, and she looked it. She collapsed on my couch. Her face vacillated between pleading and shame.

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“I know what I need to do, but I don’t have the heart or the will to do it. It’s completely beyond my power.” Then she added, “I’m not a religious person, but this past week I’ve actually started praying. I don’t know why I’m doing that. I don’t even believe in God.”
“Do you believe in cats?” I asked her. I really did.

There is an old river birch just outside my office window. It’s a beautiful tree with gray and black bark. Birds come and go, sometimes squirrels. Each spring a woodpecker spends three or four days gorging on bugs. The tree has thin branches that sway with the wind and brush the small span of roof beneath the window. I arranged my entire office so that people sit beside the window and I can see that tree while I look at them. That tree—its life and the life it supports—is part of what sustains me as I work.

And now, as this woman spoke, up that tree climbed a completely white cat. It stepped onto the roof, walked quietly to the window, and just as the woman said the part about not believing in God but praying anyway, the cat sat down and rested its face against the screen, watching her.

“What?”

“Do cats mean anything to you?”

She was looking at me, and the cat was outside her peripheral vision. So she was understandably confused by my questions, but she answered the second one. “Yes. I’ve got two cats, and they are a comfort to me. One of them especially. It feels like he knows when I need him. I’ve never been to therapy before so I was nervous about coming this morning, and he came and loved on me before I came. Why are you asking me this?”

I nodded at the window.

She turned and saw the cat. “Oh my goodness.” Then the cat reached its paw to the screen, towards her.

A chill ran up my back. In my mind I took off my shoes.

After a minute the cat stood, turned, and ambled away. She watched it go, then turned back to me. Her face, her entire body, had changed. “I hardly know what to say.” She waited. “There’s a lightness that’s come over me.” She waited some more. “Does that cat come up here a lot?”

And I replied, honestly, “I’ve never seen it before in my life.”
She scheduled a second appointment, then called a few days later to cancel it, saying she had decided to move out and her adult children were coming to help her. “That moment with the cat,” she said, “That’s the first time I’ve ever felt like something was protecting me.”

I never saw her again. Or the cat.
 

Whose Metaphor Is It, Anyway?

Posted on by Psychotherapy.net Team

No one had ever questioned his work ethic. No one had ever questioned his loyalty and willingness to do whatever it took to protect and serve his family—especially his family. Everyone who knew him knew they could rely on him to be there for them, even before they asked or realized they needed help. He was everyone’s early threat detection system, combing not only his own horizon for hints of danger, but theirs as well. No one ever doubted Trev, except Trev.

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Somewhere early in life, Trev had co-authored a script (with an unknown ghostwriter) for a one-man performance featuring him as the “go to” guy. “I’ve got it,” was his mantra and motto, as evident in his behavior as if it were emblazoned on his chest. He was a man with a mission; always thinking, always planning, always one step ahead of whatever came or might. But somewhere along the path from childhood to adulthood, worry had hopped aboard, burrowing deeply into his psyche and taking on the unsolicited role as navigator. Always sitting, always watching, always sending up warning flares, doing what it thought it needed to do to help Trev through the hardships and challenges, worry was there.

By the time Trev realized how committed worry was to the success of his mission, it was too late, and he couldn’t quite shake it loose. Or perhaps he really didn’t want to, because worry also kept him on his toes, preparing him not only for the possibility of threat and danger, but also for everyday challenges and obstacles.

Years later, when a pandemic hit, Trev’s steady companion, as always, was right there by his side, ready to help him make sure that all his bases were covered, all protections had been put in place, and all efforts had been made to ensure that he and his family would be safe and healthy. Together, they hunkered down to do whatever it took to keep the ravages of the pandemic from their door.

But it came at a cost, and that’s when I entered the picture as his therapist. While I initially had it in my mind that this was going to be individual therapy, it soon became evident that couples work was to be done to help Trev manage the painful separation from his companion, who had grown tiresome and burdensome to him.

Our work was a blend of cognitive reframing and narrative therapy, with just a bit of psychic- surgery aimed at carefully excising worry without harming the highly effective problem-solving skill center of Trev’s threat-detection system. But these are not the metaphors I alluded to in the title of this essay.

As our work progressed and Trev became better able to understand the toll worry had taken on him, he also began to feel freer to live in the moment and to appreciate the small moments of joy that worry’s dark shadow had so effectively obscured. He realized that the heavy psychological lifting he had done in and for his life that had gotten him and his family to a place of security and safety was behind him. He finally understood at a deep and impactful level that he had earned the right to enjoy those small moments of joy that came with playing with his children, buying a few un-needed but highly desired jazz LP’s, (safely) enjoying small family get togethers, and strolling through the garden center at the local home improvement store.

He was finally emerging from a state of hibernation of sorts (my metaphor, not his) having shed the worrisome winter weight of worry. He thought it was a mid-life epiphany. I thought epiphany sufficiently described his awakening because “mid-life” is a socially constructed marker, the manifestation of someone else’s or a collective notion of how long a life is or should be and the need to place arbitrary signposts along the way…you know, “steep developmental curve ahead…midlife, 5 years….last exit before death.” But again, those are my metaphors, not his.

Trev’s metaphor was a bit darker and less comedic than mine, so perhaps that’s why I struggled to contain myself from sharing it with him. Following a medical visit where Trev learned that he had lost 20 pounds over the last several months, roughly coinciding with the impact of the pandemic, he was horrified, or perhaps scared—no doubt worry’s lingering legacy. He attributed the weight loss to the lack of physical activity and worry that came with months of fear and isolation. Trev perceived the weight loss as a breaking down and weakening. I, on the other hand, preferred the metaphor of shedding the unwanted weight of worry and trimming down psychologically in preparation for a lighter and more fulfilling journey through life…free to live.

I must confess at this point that I am a metaphor junky who falls in love with his own metaphors. So, it makes sense that my metaphor for Trev’s metamorphosis was more attractive to me than his was. And I was bursting at the seams (metaphoric pun intended) to share it. After all, aren’t analysts obligated to share their interpretations and cognitive therapists compelled to point out irrational thoughts and offer corrective ones in their place? So didn’t I have that same therapeutic license or imperative to share my metaphor? It was as if the damn thing was sitting on my shoulder poking me, saying, “Tell him, tell him, tell him.” But I refrained.

Back to the title of this essay. “Whose metaphor is it, anyway?” What might have happened in that moment were I to have inserted my metaphor in place of his? Might he have accepted it? Might he have rejected it? Would doing so have advanced his progress or slowed it? Might it have reinforced his insight or created the impression that my insight was more important than his? Might I have diminished him in doing so? Was my role to have been active and directive in that moment, or supportive and non-directive?

In my lighter moments when I am not quite as hard on myself, I believe that our work together brought him to the point of clarity and a metaphor that made sense to him, and him alone.

Standing Up to Microaggression: A Clinician’s Experience

Posted on by Psychotherapy.net Team

Microaggressions (noun)—Definition: Everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership. (1) Looking back, a racial enactment between myself, a person/clinician of color, and my white therapist seemed inevitable. In our very first session, my therapist made some statements that revealed what I perceived to be her “White Savior” complex. I was taken aback by my therapist’s apparent lack of awareness of her own racism, as she had explicitly advertised herself as working through a critical post-colonial lens, and so I called her out on it. My therapist was quick to own her racist statements and take full responsibility. Despite the initial wounding and because of the subsequent repair, I continued to work with her because she did model a good relational and clinical holding style in following sessions, and I felt that she was helping me with the issues for which I was seeing her. Towards the end of our sixth session, I was sharing with my therapist how someone had explicitly sought me out for clinical supervision, mentioning familiarity with some of my work and writings, and how that had filled me with professional pride and confidence. My therapist’s exact reply is now hazy, but she said something along the lines of, “I think they chose you to be their supervisor because, as a white person, they can learn how it is for you—from your experiences as a person of color”. These words landed on me like a bolt out of the blue, and I instantly felt objectified. My therapist had unnecessarily racialized my experience, my whole identity reduced to that of “a person of color.” I had a vivid mental image of Black and Indigenous people literally being put in cages and zoos to be “observed,” and another of a laboratory rat being poked and probed—an object to be studied, “an other” whose experiences (painful or not) were being observed. A part of me still wanted to deny that it was I who was feeling the pain—to mask it as simply identifying or empathizing with those who have suffered racism. My heart began to beat fast, while my mind was trying to digest what I had just heard. Knowing very well that I have historically tended to minimize or deny micro-aggressions committed against me in the past, I resolved to be present to this current painful experience. Curiously, my heart wasn’t pounding but rather flapping—like a weak fledging trying desperately to fly away, but not having the strength or ability to do so. Instinctively, I put my hand to my heart to calm and hold the young, hurt thing, a part of me afraid that it was actually going to fly away. Anger has always been easier for me to own, so I told my white therapist with visible anger, “I am trying to calm myself before I speak.” My heart was ready to flee—and escape the pain—the pain of the blow which was multiplied in its effect, having come so hard and unexpectedly in a place that was supposed to be safe. The rest of my body, however, was ready for a fight—“I will not back down!” For the whole week, I allowed myself to fully stay and experience what had occurred in that painful therapy session. Paradoxically, this experience of staying with the pain of the micro-aggression pushed me into a spiral of transformative growth and healing, with the words of Rumi now resonating with me:

“If you desire healing, let yourself fall ill let yourself fall ill.”

It broke through my thick wall of defenses which had protected me from feeling or expressing my painful feelings in the past—especially those feelings when I had been “put down” or been the target of hate. Until then, I had vehemently denied and protested ever being cast in the role of a “victim.” Now I owned and allowed myself to feel them ALL—the feelings of indignity, humiliation, sadness, hurt, and fear—some of which were being held by very young parts of me. I became my own therapist, healing these young parts, unburdening them from the pain and hurt they had carried for years—simply waiting to finally feel acknowledged and validated, but more importantly, to be held and healed with self-compassion.

“We are healed of suffering only by experiencing it to the full.” Marcel Proust

In the next session, I clearly let my therapist know how her racist words and projections had negatively impacted me. To her credit, she took full responsibility for her racist remarks without trying to defend them in any way. This time we agreed that this was not a rupture that could be “worked through” or repaired to allow the therapeutic relationship to survive or grow stronger. Basic trust and safety had been violated by my therapist’s unexamined racist views and beliefs, and we agreed to terminate our relationship. However, having my therapist witness and listen to the impact of her words on me and take full responsibility for it was healing to me, and I did communicate that to her. In those moments, I recognized that as a therapist, irrespective of race, I have an ethical obligation not to perpetuate individual and systemic modes of oppression and racism, especially with my clients, and to pay attention to asymmetric power dynamics and intersecting identities to provide a safe relational context in therapy. I see how I have been guilty of protecting the status quo of white supremacy in my defensive denial of acts of aggression towards me (within and outside therapy settings) in the past. I have now vowed to directly challenge and dismantle oppressive thoughts and systems of power by speaking up against such micro-aggressions. Here is a list of defenses based on Internalized Racial Oppression from the People’s Institute for Survival and Beyond workshops shared with me by Nalini Kuruppu, LCSW, that I have found useful in my own self-reflections. My own defenses are highlighted. Defenses of Internalized Racial Superiority (for white-identifying people): White = Normal (unconscious understanding that white is the standard of humanity), White Denial, Intellectualizing, Individualism, White Distancing, Perfectionism, Entitlement, “Professionalism”, Expect Comfort, Rationalize, Minimize, Dominance, Demanding, Tokenism, White Saviorism, Self-Congratulations, Appropriation/Theft, Color Blindness, Addictive Behaviors, Defensive White Anger, Paternalism, White Tears, Dismissive, Arrogance/Expertism, Silence, Indifference, Need to be in control Defenses of Internalized Racial Inferiority (for Black-Indigenous-Persons-of-Culture BIPOC): Distancing (from race/ethnicity), Mimicking, Assimilation, Code Switching, Denial, Shame, Worthlessness, Fear/Hypervigilance, Guilt, Self-hate, Hopelessness, Ethnocentrism, Colorism, Protectionism (of whites), Tokenism, Invisibility, Exaggerated visibility, Addictions, Tolerance, Avoidance, Exceptionalism (the “model minority” myth). What about you? Do you directly speak to the asymmetry in power and the dynamics due to intersecting identities in sessions? Can you identify how you may be perpetuating oppression and racism? References: (1) Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons Inc.

Snatching Defeat from the Jaws of Victory

Posted on by Psychotherapy.net Team

After several tries, Jim, age twenty-five, was finally accepted into a prestigious bank management program. Once in the program, however, Jim found it difficult to make time to study. Assignments were handed in late, if even completed at all, and Jim developed severe headaches, all of which eventually led to his being the only trainee to leave the program, just days before he would have been forced to withdraw.

Alice, a first-year student in the Ph.D. program in psychology at a northern university had a similar experience. An otherwise unusually hard working and effective person, she found it easier to help others than to help herself. A cherished friend, colleague, and fellow student, Alice consistently failed to handle the demands of the graduate program, despite a well-demonstrated ability for academic work. While ably helping fellow students with their work, she neglected or mishandled her own papers, and her presentations were neglected to the point where her status in the program became jeopardized.

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Both Jim and Alice exhibit a pattern of self-defeating behaviors—clusters of thoughts, ideas and actions that sabotage success at work and in relationships. Self-defeating behaviors include a broad spectrum of self-imposed handicaps and other ploys and tactics that may suggest emotional trouble. Simply stated, a self-defeating behavior is any behavior that keeps someone from reaching their goals or sabotages their ability to be successful in ways that matter to them.

The obvious questions that arise in situations like these are “Why exactly do these people become their own worst enemies?” and “What would make bright, upwardly mobile, and ambitious individuals self-sabotage?”

Many explanations have been proposed for these behaviors. The most traditional analysis claims that people who repeatedly “shoot themselves in the foot” fear success, feel guilty about their behavior, or simply suffer from low self-esteem. Other explanations include the possibility that self-defeatists have inflated opinions of themselves, and that they use self-defeat to take control of a fear of failure. Perhaps Jim had serious doubts about his ability to successfully make it through the bank management program, so his being “too busy” to find the time to study, as well as his headaches, provided excuses that justified his exit without having to risk failing in the actual program.

Alice might have been handling her anxieties about the graduate program by developing a praiseworthy excuse for her own self-doubts and conflicts about her performance. If her sacrifices on behalf of her fellow students led to her inability to successfully complete the program, she could take comfort in the belief that she would have succeeded if only she would have finished. Her self-defeating handicap protected her from the risk of failure.

I have had success working with self-defeating individuals like Jim and Alice by helping them to learn to reflect rather than react and by identifying the negative self-beliefs that were partly responsible for their propensity to self-sabotage. With Alice, these beliefs caused low expectations for success and, hence, little motivation to try for better performance in future endeavors. This precipitated additional failure and helped to create a cycle of self-defeating behaviors for which she constructed defenses (e.g. rationalization) as her only means of coping. Therapy consisted of eliminating the irrational negative beliefs associated with self-defeat and replacing them with positive and rational alternative ones that she could gradually accept as valid. In addition, Alice was encouraged to consider alternative explanations for her failures. This was accomplished by considering hypothetical explanations for various events in which she was unable to succeed. With Jim, we were able to shift his attribution for failure from his claim that he lacked the ability to succeed to the realization that his failure in the bank management program had more to do with his insufficient effort. This enabled him to develop an expectation of possible success and helped him to imagine that he could, in fact, succeed if he was willing to try, and try differently, a second time.

A question that has had a great deal of traction with clients like Alice and Jim has been, “If you could do this over again, what would you do differently?” This helps them to begin a conversation that allows them to consider a different pathway, one that takes them to success rather than defeat.The satisfaction I was able to enjoy with both Jim and Alice had a great deal to do with their ability to tolerate the insights that illuminated their histories of self-defeat.

Gradually, they were able to relinquish the distorted beliefs and rationalizations that camouflaged and perpetuated their self-sabotage. Both of them were good examples of how insights become a blueprint for change in the course of a psychotherapeutic experience. Too often, the people I work with become "insight rich and change poor," which is why, for some, therapy feels moderately helpful, but not sufficiently productive and fulfilling. Good therapy has both therapist and client keeping a careful eye on the extent to which insights are implemented and identifiable and measurable change is able to occur.
 

Working Towards Therapeutic Solutions with Men

Posted on by Psychotherapy.net Team

In my experience, men typically and stereotypically really don’t like opening up about their feelings and prefer not to admit there’s a problem in the first place. So how to help get them into therapy becomes a compelling challenge.

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Many years ago, I read a report that found that one in three of the young men polled within it would rather smash things up than talk about their feelings. It was a tad extreme, I thought, but there you go. Thankfully, things have moved on a bit since then. However, men are still reticent. For instance, it turns out that they would rather talk to their barber about their problems than talk to their doctor, which is why the Lions Barber Collective exists. An international organisation that recognises the unique bond formed between a man and the bloke who clips his hair, it trains members up as mental health first aiders. Not only do they listen to the guys who sit in their chairs, but they can also spot the early warning signs of a developing mental health condition and then point them in the right direction for help. This usually means a psychotherapist. Which means we are back to talking about feelings. Which, as we know, men are not wont to do.

The problem is complex. But a big part of it is that talking about their feelings is still seen as a sign of weakness among many men. And despite the prevalence of metrosexual men in our media, the strong and silent male myth still pervades. Also, when men do talk, because of said stereotypes, what is more than likely depression can often be written off as a “bit of a low mood” instead.

Another problem, to my mind at least, is that when a man who doesn’t like talking about his feelings goes looking for a therapist, he goes looking online. And practically every single therapist’s opening statement will say something along the lines of “I offer a safe and non-judgemental space in which to explore your feelings.”

Egad!, as the exclamation goes. Are you trying to scare them away? Do you want men to come to see you for help? And, if you do, how do you reel them in? (Big hint: male-orientated metaphors help.) Enter then, any form of solution-oriented therapy.

I’m a rational emotive behaviour therapist (REBT) and have found that as a form of cognitive behaviour therapy (CBT), its philosophy and structure are easily explained and understood. As an active and directive approach, it offers me a way of being actively involved in the therapeutic process rather than sitting back and offering a safe space in which my client can talk whilst I sit passively by. As a form of solution-oriented therapy, I can even discuss SMART goals from the outset. And, before it starts exploring all the emotional consequences of a person’s dysfunctional beliefs, REBT can challenge them empirically, logically, and pragmatically.

I explain REBT to prospective clients in a very matter-of-fact way. My webpage is plain and straightforward. It attracts a large proportion of potential clients (including men) who want their therapy delivered in a similar style. This has been very helpful to anybody who is nervous about, or unable to, talk about their feelings.

Many years ago, a highly anxious man was brought to my clinic. In fact, he was so anxious that he was having a panic attack in the waiting room and was breathing deeply and slowly into a brown paper bag. It wasn’t having much effect, and it was clear his anxiety was not going to go away any time soon. I brought him into my clinic room anyway.

“Would it help if you just sat there breathing into the bag while I explain what this therapy is all about?” I asked.

He nodded. And so I discussed both REBT and the ABCDE model of psychological health, as well as the roles played by dysfunctional and functional belief systems. After a while, I simply asked him if he had noticed anything. He nodded slowly.

“What have you noticed?” I asked.

“I’ve stopped panicking,” he said.

I asked him why that was.

“Because I can see a way out,” he replied. “I’ve not been able to see one before.”

Fast forward a few years to a man who came to see me for psychosexual dysfunction, a tricky subject at the best of times. In my initial telephone consultation, before I engaged with him for therapy, this man described himself as a typical alpha male type who didn’t like all that touchy-feely stuff. He’d been living with his particular form of anxiety for over five years, hadn’t had any form of sexual contact with his wife for over three years, and was only speaking to me because his wife had delivered him an ultimatum. He’d had several courses of therapy already, including sessions with a sex specialist.

“I didn’t like it,” he said. “They were all sympathetic, but I wasn’t looking for sympathy. And they were all trying to get me to open up about my feelings, but I either couldn’t or didn’t want to.”

“So, what’s going to be different this time?” I asked.

“I really liked your website,” he said. “It was very direct. I know I will have to speak about how I feel at some point, but there’s a format there that appeals to me.”

Studies have shown that men aren’t averse to therapy per se, but they are averse to therapy that is loose, conversational, and exploratory. One study found that the best treatment styles for engaging the menfolk were, “collaborative, transparent, action-orientated, goal-focused” (Seidler, 2018).

When delivered in the correct way, I have been able to encourage men to talk about their feelings. I haven’t had to get all stoic and blokey myself, I just have to explain myself in a clear and concise way, preferably without mentioning either safe spaces or feelings. In my experience, if a man phones me up for therapy and I ask him what his goal is, he will usually commit to the process. And together, we venture forward on a journey of change

References

Seidler, Z. E., Rice, S. M., Ogrodniczuk, J. S., Oliffe, J. L., & Dhillon, H. M. (2018). Engaging Men in Psychological Treatment: A Scoping Review. American journal of men's health, 12(6), 1882–1900. https://doi.org/10.1177/1557988318792157 

Some Thoughts on What Makes A Relationship Successful

Posted on by Psychotherapy.net Team

It’s distressing when a patient tells me that they have never observed nor experienced what they would define as a successful romantic relationship. Statements like “Maybe good relationships just don't exist” or “No one in my family ever had a good relationship” usually follow. Many of my patients enter psychotherapy because of relationship-based difficulties, and some of them eventually feel that they are doomed to continuously have trouble or fail in their efforts to enjoy a successful romantic partnership.

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I am often told by clearly disheartened patients that the trajectory of their romantic lives has been downhill. Frustrations and disappointments are said to develop as early as a few years, sometimes even a few months—after the honeymoon ends and “normal life” resumes. One patient told me that he and his wife suffered from the marital equivalent of a “postpartum depression that never ended.” Frequently, to comfort themselves, they suggest that this downward trajectory is “standard,” “everyone's experience.” These assertions, I fear, while primarily designed to self-soothe, also seem to firm up the belief that any long-term romantic relationship is likely to be a doomed enterprise. When I comment that while relationships may change over time, that change does not necessarily imply that a relationship turns from positive to negative, or when I mention that some relationships have been known to deepen and improve with age, some patients look at me in disbelief.

Through my work, I have had the satisfaction of seeing positive outcomes when two people work hard at relationship self-improvement. This enables me to work with a perspective and a conviction about what may be possible that patients in distress—especially in the beginning of the therapeutic process—often lack.

The following are some of the ingredients that I believe help to make and sustain a positive and successful romantic partnership, and that I have sampled in my clinical work.

Handling anger and avoiding arguments: One of the major problems with anger and the arguments that result is that neither partner does much, if anything, to avoid them. Perhaps motivated by the need to prevail or be “right” about the conflict-arousing issue, one or the other person in the couple “takes the bait” and gets hooked into an argument that could have been avoided if one of them had seen to it that the conversation—however emotionally-charged—had remained conversational or been postponed until calm was restored. This is not always easy, but certainly possible.

Listening to each other: Couples in conflict often are so busy preparing their indictment of the other person or their defense of themselves that they simply do not listen and hear what is being said. Thus, their responses are often not responses at all, but their next statement—perhaps entirely unrelated to what was just said to them. This is one of the main reasons, I believe, why too many couples recycle the same issues and arguments over and over and rarely if ever feel as though any conversation (or “attack and defend” exchange) accomplishes anything. Couples often need help to learn to listen to each other so that the dynamic between them changes to one that is productive. That is the goal of good therapy to which I aspire in my couples work.

Saying “I'm sorry”: I continue to be amazed at how difficult this is for so many of the people with whom I have worked both in and out of romantic partnerships. I often hear statements like “I know it's the right thing to do, and I feel sorry…I just can't say it!” Such responses suggest the likelihood that the person might feel “weak” or “defeated” if they publicly acknowledge their sorrow or regret.

Expressing Gratitude: When partners in a couple feel and express their gratitude or appreciation for each other, each of them feels cherished and valued, and it enhances the relationship. Expressions of appreciation do not have to be confined to major gestures or actions. “Thank you, honey, for feeding the dog” or “I really appreciate your picking up my prescription” can be just as meaningful as a thank you for a monumental gift or kindness.

Changing: By this I am referring to what might be considered the “little things” that become big when they persist over time. These are the kinds of changes that, with some effort, might be easy to accomplish with far greater dividends than the investment required to achieve them. If a wife tells her husband, for example, that she really appreciates getting a greeting card on her birthday and her anniversary, I am bewildered by the husband’s seeming refusal to gratify her, regardless of whether it means anything to him. If a husband informs his wife that he would not like to be interrupted by phone calls during his gym workout unless there is an emergency, I am similarly bewildered by her not cooperating and calling about nonessential matters during that time. When people feel ignored or, worse, devalued by their partners, resentments develop that can become toxic to the relationship.

Treating each other as special: A wife with whom I worked complained that upon leaving a party, her husband helped every other woman guest with her coat—except her. When she questioned him about this, his reply was “Well, that's because you're my wife!” Her response: “That's the point!” That she felt taken for granted was not surprising. Moments like this may be insignificant if they are infrequent, but if they typify an attitude or are common in the relationship, they have the potential to cause diminished regard and affection for the offending partner.

Hurting with words: The damage potential of comments made in the heat of battle is extremely high. There is a tendency on the part of the offending partner to dismiss or trivialize those remarks afterwards. Saying “I didn't really mean it, I was just angry,” often makes things worse, especially if there is no sincere apology attached. Words can cause wounds and may not easily heal when calm is restored. They are often referenced when a subsequent argument occurs, i.e. “I'll never forget the time you told me to ‘drop dead.’”

***


In my work with couples, these are but a few of what I consider to be “ingredients” of a successful romantic relationship—aspirational for some couples, attainable for others, and sadly out of reach for still others. I have worked most successfully when some or all of these ingredients have been utilized by both partners and when they remember that the person with whom they are having conflict may be the very person whom they love the most, and who loves them similarly.
 

Eating Disorder Triggers and COVID-19: A Guide for Psychotherapists

Posted on by Psychotherapy.net Team

“I don’t know why, I just feel more like using symptoms lately. There’s no particular reason,” Margaret said*. “Um…,” I ask, endeavoring and likely failing to keep my tone neutral, “…can you brainstorm anything that might be contributing?”

“Well, I haven’t seen my friends in several months. I’m not working right now. I don’t have anything to do all day. Except check Insta, where everybody’s on some kind of weight loss or exercise plan. I can’t go anywhere or do anything, and I have no idea how long this is going to last. It’s not too far-fetched to wonder if we’re all going to live in some horrible Mad Max dystopia. And, oh yeah, I might contract a lethal virus and die.”

Chris had a similar dissociative response to our collective trauma: “Ever since March or April, I’ve been really dissatisfied with my body. Maybe because of springtime, with the beach season on the way? Except of course this year I won’t be going to any beaches…so there’s that whole thing.”

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Acknowledging Eating Disorder Triggers

As therapists, our job is often to connect dots that aren’t readily apparent to our clients. It might seem obvious that they will be affected by the events in the world but, as one of my clients put it, “It’s hard to remember that you’re actually human sometimes, and that you’re vulnerable to the same stuff everyone else is.” And so, when working with people who have eating disorders it is important to know that almost every aspect of this pandemic is rife with potential triggers. By understanding the multiple ways in which COVID-19 can affect our clients with eating disorders, we can help them to plan for healthier ways to make sure that their needs get met in this difficult time.

Dealing with Unstructured Time

Many of my clients with eating disorders have the sense that they just don’t know what to do with themselves. Without normal routines to rely on, the days have begun to feel like an endless void. For these clients, eating disorder symptoms offer a way to be engaged in something. For some, this might mean over-exercise and calorie counting. For others, overeating. Still others will cycle between back and forth between overeating and attempting to “compensate” for the intake. One college student I am working with has been using food to break up the time to give it more structure by eating on a very rigid schedule. Unfortunately, for her this means getting out of sync with her natural body rhythms and being able to listen to her hunger and fullness cues.

Helping clients to schedule their day can give them a sense of groundedness and prevent filling up the time with unhealthy behaviors. With Sara, we sat down with her day calendar and plotted out a week’s worth of activities. Sometimes the structure was as loose as “Thursday morning—TV in the living room”; “Thursday afternoon—reading in the bedroom.” Other times when she was really struggling, we went hour by hour—including meals. If you do this, be sure to include changes in location as a part of the schedule, and outside time if at all possible.

Addressing Role Overwhelm

For many other clients, unstructured time is not a problem at all. In fact, there may be a sense that there is no time at all. This is particularly true for parents who will no longer have the support of the school environment and are being asked to take a role in their child’s education that is outside of their expertise. Many are also attempting to care for their children while working from home, guaranteeing that they will be able to do neither effectively—a client of mine recently described a morning in which her three-year-old emptied all her kitchen cabinets while she was on a Zoom meeting. When she was done with the meeting, she had 8 or 9 follow-up tasks—plus an entire kitchen to sort out, all while entertaining her child. While moving quickly from meeting to caretaking to schooling and back, clients with eating disorders may leave their own needs on the back burner, forgetting to eat, cook nutritious foods, or take time for themselves.

Fighting Toxic Cultural Expectations

In our compulsively productive culture, having some time on your hands mandates you to do something with it to “improve yourself.” More benign manifestations of this drive include educational tasks such as reading the classics or learning to knit. For our clients with eating disorders, though, this train typically runs down the “perfect your body” track. They are reinforced by a spate of “COVID workout plans” and a social media frenzy of fears about the COVID-19 (as in, the nineteen pounds one can supposedly expect to gain during quarantine). “If I’m not getting thinner, I’m not getting better,” one client said to me. As therapists we can provide a counterpoint to toxic cultural messaging—by what we say, and through what we do.

Addressing Perceived Lack of Activity

Perceived lack of physical activity is very triggering for lots of people with eating disorders. They worry that if their routines change, they might gain weight. This in turn is correlated with immense shame and fear of being unlovable, lazy, or worthless. Some with eating disorders will restrict their food intake to supposedly “make up” for lack of activity, often wildly overestimating how much caloric cutting back would be equal to the actual amount of energy unspent. Others, because of black and white thinking, will begin to have difficulty caring for themselves in any way if they are not able to follow their previous routines. Helping clients to reality-check how inactive or active they really are can be tremendously helpful, as can helping them to sit with and manage the anxiety it brings up.

Avoiding Isolation

It’s difficult for anyone not to have access to their support systems. For people with eating disorders, this includes access to a treatment team and peer network that help to fight the eating disorder “voice” by providing context, reassurance, and normalization. Without this support it can be easy for someone with an eating disorder to be overwhelmed by their own thoughts. As therapists, we can provide an important counterbalance, but it’s also more important than ever that we encourage our clients to participate in healthy groups and online forums.

Ameliorating Anxiety

Whether or not somebody qualifies as having an anxiety disorder, this is a time of heightened anxiety for everyone. None of us knows whether we or our loved ones are going to get sick. None of us knows how this will affect our society or how long it’s going to last. Many people with eating disorders deal with anxiety by converting it—rather than feel uncertainty and dread about things that are outside of their control, they channel their uncertainty into worrying about food and body issues. Helping clients with concrete tools such as diaphragmatic breathing and progressive muscle relaxation can help them to better cope with these uncomfortable feelings and distressing concerns.

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COVID-19 is very triggering for everyone, but our clients with eating disorders will be triggered in specific ways. By keeping this in mind we can help them to maintain their gains, avoid or minimize relapse, and continue to learn to nourish their bodies and spirits.


*All names are changed, all quotes are compilations 

Reflections on a Year Soon Gone

Posted on by Psychotherapy.net Team

One of the perennial questions children ask their parents is “Who’s your favorite?” And if you are a parent like me, you have lied. You’ve looked them straight in the eye and said, “You are, of course, but don’t tell the others.” And off they go, satisfied that they hold a singular place in your heart. And off you go, breathing a sigh of relief and hoping they don’t ask again, but they do! And in the answering, you hopefully pause for a moment to reflect on just what it is about that one child, or each of the children, that you admire so.

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And so it is as this year approaches its end and I my third year with Psychotherapy.net, that I pause to reflect on the blogs, articles, and interviews I had the privilege of ushering into the world. But I don’t struggle over which ones are my favorites, nor do I need to lie when I say, “Yours is!” I am truly proud of all the fine essays from and conversations with clinicians, clinical educators, and researchers that I have had these months. I look upon the body of written work to which many of you have contributed, and I am thankful for the wisdom, insights, and experiences you’ve shared. And for that I am deeply grateful.

While the range of topics covered this year has been impressively broad and far-reaching, the content of each of the essays and interviews has been intimate and personal. Transference and countertransference, challenging pathology, traditional and non-conventional treatments, aging, mortality, and systemic treatment issues were among the rich and insightful reads. With each, I have deepened my appreciation for the fascinating nature of the human condition, its tricky and sometimes unfathomable twists and turns and the therapeutic challenges of addressing them.

But this year was different, and so too was the content it inspired.

It was a year of all-too-familiar and volcanic social upheaval rooted in the seemingly never-ending and painful reality of racism. But there you were, clinicians working at the cutting edge of racial unrest and discomfort as it unfolded in the microcosm of psychotherapy, sharing the intimacies of uncomfortable yet necessary conversations.

It was a year ushered in by a global pandemic that sunk its unforgiving and undiscriminating teeth into American society with a vengeance born of nature and perpetuated by its populace. Many died and are still dying, many more suffered and still do, families were separated, individuals isolated, and the medical system still strains to breaking. But there you were, clinicians tending to mental health needs of victims and survivors alike who struggled to make sense of the physical and financial upheaval alongside the deeper despair and wounding that comes with fear, powerlessness, isolation, and existential angst. And in the midst of it you also found your way to writing about resolve, resourcefulness, and repair.

It was also a year when telehealth finally caught on in a grand way, not by choice in most cases, but of necessity. Those of us familiar with virtual counseling made the transition with relative ease, while many others struggled to leave safe and familiar carpeted office confines behind to venture into unfamiliar digital domains. But there you were once again, clinicians demonstrating the flexibility and resourcefulness necessary to help those in your charge to respond to the many crises in their lives. You saw both sides of telehealth, and as frontline correspondents, brought the challenges and benefits of remote counseling to your colleagues.

So which were my favorites? Yours, of course. And I look forward to more, many more.

Thank you all, we appreciate you and the hard work you do in and out of therapy.

Lawrence Rubin, PhD, ABPP
Editor
 

COVID-19 and the De-Stigmatization of Therapy

Posted on by Psychotherapy.net Team

“This is my first time in therapy,” Sean tells me in our first virtual session. He is among the many who have come into therapy for the first time with the onset of the COVID-19 pandemic.

Coming from parents who suffered from alcoholism and depression for his entire childhood, he is no stranger to mental illness. Growing up, however, therapy was looked down upon as something only “broken” people do—he was one of the many recipients of the damaging fallacy that strong people solve their problems on their own and seeking help means weakness. Fortunately, many of the clients with whom I work have made the decision to fight against the silent stigma against therapy. Clients like Sean are breaking the therapy stigma in the face of the COVID-19 pandemic for several reasons.

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The Normalization of Therapy

Sean is seeing me for help with depression, which he says began right around the onset of the pandemic. COVID-19 left him unemployed and unable to see his friends, not unlike many others who have found themselves out of work and isolated. I have seen a rise in those seeking mental health services at this time, especially among first-time therapy go-ers! As Sean takes the leap with me to finally start working on his mental health, he is helping break the stigma against therapy simply by growing the population of therapy-consumers, making therapy more commonplace. He has also encouraged his sister, who has battled depression for years, to see a therapist. By doing so, he sends the message to his sister, “It’s ok to talk to someone. I do.”

Acceptance of Vulnerability

Although Sean usually doesn’t tell others in his life about his painful emotions for fear that they will reject him or he will make others feel badly, he tells me that he has been able to open up to his roommate and father like never before. Because they have also been struggling with the emotional consequences of the pandemic, Sean and those close to him have been having deeper conversations about what's really going on with them emotionally and behaviorally.

With so many others facing similar struggles, Sean has gained confidence that he will be understood and heard when he reveals what he has been experiencing. Because others in his life are more aware of the fact that many people around them, both near and far, are struggling, he feels safer to disclose his emotions and life struggles and has received an unprecedented level of acceptance and support. Sean is more emotionally open and aware of hardship in others’ lives, thus allowing him to risk being more vulnerable with others about his deeper feelings. And because he is feeling safer in expressing this vulnerability, Sean was able to come to therapy, knowing that he could expose his deeper feelings to a therapist without feeling “weak” or being judged for seeking help.

Realization of a Common Humanity

Like others who have visited with me, Sean has come to accept that he is not isolated in his suffering. Because those in his life are beginning to express similar vulnerability, Sean is beginning to realize the reality that life is hard for everyone. Instead of feeling isolated in his suffering, Sean is more in touch with a sense of common humanity. Knowing that he is not the only one who is facing a hard time, Sean felt increasingly connected and was able to take the leap to book his first therapy appointment with me. He continues to fully express his emotions without feeling that he is the only one who struggles in life.

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Sean has learned that it is ok to not be ok and that it is ok to get help. In taking care of his mental health during this time, he, like others with whom I have worked, is becoming an advocate for therapy and breaking the stigma.