Category: Blog

The Masculinity Trap: A Science-Based Response to the APA Guidelines

Posted on by Psychotherapy.net Team

Andrew was a 13-year-old boy who walked into my counseling office with a lot of issues. He had been diagnosed with a learning disorder and ADD, and his parents felt he might be depressed. Like many male clients, he would quickly decide if I as his potential counselor knew how to work with him as a male. If I did not, he would start trying to leave therapy in a few weeks or less.

After normal intake, the first thing we did together was walk outside, talking shoulder-to-shoulder. Because the male brain is often cerebellum-dependent (it often needs physical movement) in order to connect words to feelings and memories, we sat down only after our walk was finished. By then, a great deal had happened emotionally for Andrew.

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

Once in our chairs, we talked with a ball in hand, tossing it back and forth, like fathers often do with children. This cerebellum and spatial involvement help the male brain move neuro-transmission between the limbic system and frontal lobe, where word centers are. We also used visual images, including video games, to trigger emotion centers, and we discussed manhood and masculinity a great deal, since Andrew, like every boy, yearns for mentoring in the human ontology of how to be a man.

I’ve seen hundreds of girls and women in my therapy practice. Few of them needed walking, physical movement and visual-spatial stimulation to help access memories, emotions, and feelings because most girls are better able to access words-for-feelings than boys and men are while sitting still. Girls and women have language centers on both sides of the brain connected to memory, emotion, and sensorial data, while the male brain mainly has word centers and word-feeling connectivity on the left side.

Without our realizing it over the last fifty years, we’ve set up counseling and psychological services for girls and women. “Come into my office,” we say kindly. “Sit down. Tell me how you feel/felt.” Boys and men fail out of counseling and therapy because we have not taught our psychologists and therapists about the male and female brain. Only 15% of new counselors are male. Clients in therapy skew almost 80% female–males are dragged in by moms or spouses, but generally find an environment unequipped for the nature of males.

Male nature, the male brain, and the need to contextualize boyhood into an important masculine journey to manhood are missing from the American Psychological Association’s new “Guidelines for Psychological Practice with Boys and Men.” While the document calls attention to male developmental needs and crises in our culture, which I celebrate as a researcher and practitioner in the field, it then falls into an ideological swamp.

Males, we are told, are born with dominion created by their inherent privilege; females (and males) are victims of this male privilege. The authors go further to discuss what they see as the main problem facing males—too much masculinity. They call it the root of all or most male issues including suicide, early death, depression, substance abuse, family breakups, school failure, and violence. They claim that fewer males than females seek out therapy or stay in therapy and health services because of “masculinity.” Never is the skewed female-friendly mental health environment discussed. The assumption that all systems skew in favor of males, not females, is so deeply entrenched in our culture today, the APA never has to prove it.

Perhaps most worrisome, the APA should be a science-based organization, but its guidelines lack hard science. Daniel Amen, Ruben and Raquel Gur, Tracey Shors, Louanne Brizendine, Sandra Witelson, Richard Haier, Laurie Allen, and the hundreds of scientists worldwide who use brain scan technology to understand male/female brain difference do not appear in the new Guidelines. Practitioners like myself and Leonard Sax, MD, PhD, who have conducted multiple studies in the practical application of neuroscience to male nurturance in schools, homes, and communities are not included.

Included are mainly socio-psychologists who push the idea that boys and men are socialized into “masculinities” that destroy male development. Stephanie Pappas on the APA website sums up the APA’s enemy; “Traditional masculinity—marked by stoicism, competitiveness, dominance, and aggression—is, on the whole, harmful.” Our job as therapists, the authors teach, should be to remove all but the ideologically sound “masculinities” from boys and men, and specifically remove masculinities that involve competition, aggression, strength, and power.

How much longer can our society and its professionals pretend we are developing a saner society by condemning the very parts of males that help them succeed, heal, and grow? In the same way that it is misogynistic to claim femininity is inherently flawed, it is misandrist to claim that masculinity is also thus.

And it is just plain wrong. Stoicism, aggression, self-reliance, and strength are helpful to human growth, healing, and self-development. Steven Pinker recently made this point when he asked the APA to revise its Guidelines, and put to rest “the folk theory that masculine stoicism is harmful.” And, a new study published in January 2019 in Psychology of Men and Masculinities, echoes Pinker, showing that boys and men who adhere to masculine training do better in life, are happier, and become better husbands, fathers, and partners.

I am an example: I was a sexual abuse victim in my boyhood, and a very sensitive boy. My ten years of healing from the abuse came as much from tapping into masculine strength as it did from expanding my sense of self in the 1970s toward the feminine. Both are good; neither is zero-sum, but I could not have healed without the very masculinity Pappas finds suspect.

Part of the problem with the APA guidelines is that, from a neuroscience point of view, masculinity is not as limited as Pappas’ assessment would have us believe. Masculinity is a social construct made of biological material, an amalgam of nature, nurture, and culture that forms an ontology in which a male of any race, creed, or ethnicity commits to developing and exercising strength, perseverance, work, love, honor, compassion, responsibility, character, service, and self-sacrifice.

What professional in the psychology field would not want to embolden these characteristics? Most fathers and mothers would want counselors to embolden them because, as the APA authors themselves point out (somewhat unaware, I think, of their self-contradiction), fathering and mentoring boys in masculine development has been proven among the most important determinants of child safety, school success, and emotional and physical health.

Not the erasure of masculinity but the accomplishment of it is required if we are to save our sons from the crises outlined in the APA guidelines. Without counselors and parents understanding how to raise and protect brain-based masculine development, boys like Andrew drift in and out of video games, depression, substances, half-love, and, often, violence.

As all of us in our profession know, the most dangerous males in the world are not those who feel powerful but, rather, those who feel powerless. “Toxic masculinity” is a convenient academic avenue for condemning males who search for strength, healing, and love by conflating things bad men do with an ontology that is necessary for human survival and thriving.

The masculine journey is not perfect and expanding what “masculine,” “male power,” and “man” mean to a given family and person is a point well made by the APA authors, but trying to hook mental health professionals into this ideological trinity of false ideas—

*masculinity is the problem, always on the verge of toxicity
*males do not need nurturing in male-specific ways because men have it all in society anyway; and
*masculinity is not an ontology, a way of healthy being, but a form of oppression,

—ignores one of the primary reasons for the existence of our psychology profession: not just to help girls, women, and everyone on the gender spectrum be empowered and find themselves, but also to help boys and men find their strength, their purpose, and their success in what will be, for them, a complex male and masculine journey through an increasingly difficult lifespan.

Sources:

Amen, D.G., et.al., “Women Have More Active Brains Than Men." August 7, 2017 Journal of Alzheimer’s Disease

Halpern, D.F., et.al., “The Science of Sex Differences in Science and Mathematics.” Psychological Science in the Public Interest. August 8, 2007

Burman, D., et.al., "Sex Differences in Neural Processing of Language Among Children." March 2007. Neuropsychologia

Benedict Carey, “Need Therapy: A Good Man Is Hard to Find.” New York Times. May 21,2011

APA Guidelines for Psychological Practice with Boys and Men

Stephanie Pappas, “APA issues first-ever guidelines for practice with men and boys.” APA Monitor. January 2019

Steven Pinker. Male Psychology: What is Wrong with APA’s Masculinity Guidelines.

Psychology of Men and Masculinities

Coalition to Create a White House Council on Boys and Men’s meta-study

Digital Technology and Parenting:

Posted on by Psychotherapy.net Team

As a trauma therapist I am always interested in learning about my clients’ childhood attachment patterns. Growing up with parents who were either emotionally unavailable, inconsistently responsive, frightened by or frightening to their child has a profoundly negative impact on social, behavioral, emotional, and neurological development. “Trauma-informed care” includes assessing for adverse childhood experiences and reframing clients’ subsequent “symptoms” and struggles as the inevitable by-products and coping strategies of attachment trauma. However, I am concerned that a newer version of attachment trauma has invaded even the most “loving” families. Our reliance on, and, in some cases addiction to, digital gadgets and technology has hijacked the face-to-face parent-child interactions that are necessary for consistent, sustained and secure attachment.

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

Is this scenario familiar? After standing in line at the post office for fifteen minutes—a somewhat inherently traumatic experience in and of itself—I witnessed a two-year-old having a complete meltdown. Her mother’s immediate response was to hand her an iPad. In her wisdom, the child initially rejected it. In a soothing yet frustrated tone, the mother said “Use your iPad! Do you want to look at pictures? Play a game?” The child was not appeased and continued to wail. As the woman bent towards the stroller, I felt a sense of relief, assuming she was about to pick up her dysregulated child. Instead, she turned on the tablet and said with greater agitation, “look at the pictures on your screen!” After several more minutes of crying, the child realized that what she wanted and needed—to be comforted by her mother, not an inanimate object—was not going to happen. I watched as she went into collapse, emotionally shutting down and compliantly staring at the screen.

Believing her baby was now soothed allowed the embarrassed mother to comfort herself with a cellphone, tapping and swiping until it was her turn to buy stamps. In essence, they were two strangers in line together. I have seen similar scenarios countless times: in airports, malls, restaurants, and my waiting room. Preoccupied parents entranced as they stare at their iPhone, seemingly oblivious to their child’s needs. They are content to use digital gadgets as pacifiers and babysitters. They are not only modeling the excessive use of cellphones, tablets, video games, and laptops, they are actually encouraging their children to be just as hypnotized, and potentially, addicted.

At the risk of sounding old fashioned and judgmental, I believe this phenomenon is worrisome. Eye gaze, appropriate loving touch, and soothing words are the hallmark features of secure attachment. In families where there is abuse or neglect, these experiences get weaponized. Eye contact becomes a vehicle for threat or intimidation, or the neglecting parent avoids eye gaze, leaving the child feeling demeaned or invisible. Touch is either physically abusive, sexually inappropriate, or unavailable to the child. Words are bullying, shaming, hypercritical or lacking in love or support. This is why caretaker perpetration is such a betrayal and profound breach of trust.

But those three critical resources for attunement are also lost when a child is offered a screen rather than the loving and grounding experience of an available parent, which makes them feel safe, calm and connected to others. It may seem unfair to associate abuse or neglect with the disconnect that happens when a child is comforted, distracted, or cajoled by a digital appliance. But what is the long-term toll it takes on healthy attachment, affect regulation, and socialization skills? Mental health researchers and therapists alike need to assess for and explore that impact, as digital technology is not going away. Questions to consider:

  • Are kids with excessive exposure to digital gadgets less comfortable with face to face interactions and more likely to struggle socially?
  • Is it harder for them to read and accurately interpret nuanced facial expressions and body language?
  • Do these kids have a healthy ability to regulate their fluctuating or overwhelming emotional states?
  • Are these kids less likely to use relationships for soothing and comfort, and more likely to numb with endeavors that are hypnotic or dissociative?
  • Despite growing up in families that are well-meaning and financially secure, are these kids actually experiencing avoidant or insecure attachment?
  • And if they are, will they struggle with the same emotional fall-out and symptomatology as abused or neglected kids?

Since technology has made our lives much easier and resources more accessible, stakeholders may be reticent about tackling this issue head-on. I believe it is our ethical responsibility to address these dynamics with the families we treat. We must empower parents to set much stricter limits on screen time and to reconnect with the relational, face-to-face-benefits of parent-child time and family time. Many kids and teenagers need to be weaned from their overuse of digital gadgets—a kind of digital detoxification—so that they can reconnect with peers and re-access their own imaginations.

For traumatized clients, the reparative experience of secure attachment often happens within the therapeutic relationship. Therapists may need to be more mindful of addressing this issue with kids who have been overexposed to digital gadgets as a resource for comfort and soothing. They should keep technology out of the therapy room and model attunement, eye gaze and appropriate words and touch so that kids and parents alike can rediscover the power of relationship. Otherwise, the next generation risks losing the ability and the desire to be fully present with others and fully engaged in the world. 

Goldilocks and the Three Couches: Finding Your Own

Posted on by Psychotherapy.net Team

Not that anyone is necessarily keeping track, but this week marks the one-year anniversary of my relationship with Psychotherapy.net as its editor. I want to thank Victor Yalom for the opportunity, although I confused him with his father during our first phone contact. Sorry, Victor. I want to thank the able and creative staff of Psychotherapy.net for welcoming me and helping me to take ownership of this complex, but deeply rewarding position. It comes at a time in my career where I find myself at the intersection of three roles-author, clinician, and counselor-educator.

I am deeply appreciative to all of those authors, clinicians, and educators out there who have shared their stories, beliefs, and challenges along the way to becoming their best selves. To those who have written blogs, articles and have allowed me the privilege of interviewing them, I want you to know that your thoughtful contributions have been important and received by an eager audience of clinicians at all levels of training, across all theoretical disciplines and around the globe.

In the course of reviewing, editing and moving those many fine contributions forward, I am struck by the parable of Goldilocks, or was it a fairytale, I do get the two confused. Some of you have fallen into the soft welcoming couch of a particular theoretical model and have never looked back as you have become the best possible practitioner of that model that you can be. Certainly, there are seductive advantages and unpredictable disadvantages to comfort and certainty. Thomas Szasz suggested that many of us choose security over freedom. Others of you choose freedom, and whether you call it prescriptive, integrative or eclectic, are restless wanderers, forever seeking out that model, that technique, that strategy that is just the right fit. There is an equally palpable price that people pay for freedom. And finally, some of you have dedicated your careers to searching, changing and finally comfortably settling into that therapeutic couch that is just right, personally and professionally.

I thank you all and applaud you all and look forward to our shared journey together.

Lawrence C Rubin, PhD, ABPP
Editor, Psychotherapy.net

Bilingualism as a Necessary Clinical Competence

Posted on by Psychotherapy.net Team

The majority of people in the world speak more than one language, but in the United States people have primarily been monolingual. This may not be sustainable. Technology, mobile dominance, the internet, economic growth, and globalization have reconstructed our social sphere, exponentially amplifying social interaction between continental and national borders. In unprecedented ways, our world has transformed into a diverse multicultural and multinational global hub that is increasingly interconnected. An essential aspect of this global diversity includes an estimated 7,105 living languages¹. Of the more than 7 billion people on our planet, the largest portion, approximately 1.2 billion people, are first-language Chinese speakers, followed by Spanish, English, and Hindi. Countless interactions between speakers of these and many other languages happen daily, and predictably, this has steadily increased demand for bilingual psychotherapists.

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

Despite the anti-immigration rhetoric prevalent in Washington, many non-English speakers continue to enter the country. In our age of technological boom and globalization, it is increasingly vital for psychotherapists to not only learn a second language but also to consider the unique and subtle implications of language differences and how an individual’s linguistic roots transect with their geographic location.

Psychotherapy, as taught in graduate programs nationwide, has recognized the need for therapists to address spirituality, religion, race, gender, ethnicity, class, gender, and sexual orientation. However, our field has only recently begun to widen its lens to address language in more depth. Language training will increasingly be not only relevant but also central in psychotherapy training curriculums as globalization, diversity, and intersections across national borders accelerate.

Psychotherapists are frequently in contact with clients whose first language is not English. The profound need for therapists to be able to communicate with non-English speaking clients already exists and is poised to expand exponentially. The most prominent language spoken in the United States after English is Spanish. Although a few graduate programs have integrated Spanish language training into their curriculum, not many recognize that this is a growing need². Currently, language training is considered supplemental, but now more than ever it must become more fundamental to training to keep up with where the world is heading.

One specific population I am passionate about working with is Spanish-speaking immigrants. They are the largest and most rapidly growing ethnic group in the United States. Not only do they underutilize mental health services, but they also tend to have high rates of mental health problems like trauma, domestic violence, depression, substance abuse, and family separations due to immigration restrictions. Research also suggests they tend to seek psychotherapy less frequently and tend not to view talk-therapy as a viable way of meeting their mental health needs, despite its demonstrated effectiveness across multiple studies, including meta-analyses.

Between 2011 to 2013, I completed my Master’s in International Counseling Psychology at the Mexico Campus of Alliant International University. I learned Spanish as I was completing my practicum in Mexico City, practicing solely with Spanish-speaking clients as well as speaking Spanish during class and supervision. We often discussed the nuances of the language differences and how they affected our work with clients, for better or worse. Toward the end of the degree, I completed a research project that covered this topic in greater depth³.

To briefly summarize, we found that in many instances participant clients described language differences as a non-issue, which should be encouraging to you, reading this, if you are considering strengthening your bilingual skills; you do not need to master a second language to make a difference.

Clients who are dominant in any other language than English are often honored by sincere and diligent attempts on the part of the clinician to learn their language. And, according to clients’ self-report (which may have been contaminated by wanting to please us, referred to broadly as research demand characteristics), language differences had unexpected clinical benefits, such as equalizing inherent power dynamics in therapy and strengthening rapport and collaboration as therapists and clients work to understand each other despite significant language differences. Predictably, in some ways, the language limitations of the therapists were also challenging and were related to clinical difficulties that we needed to creatively address with clients, such as not feeling understood by their therapists who were learning Spanish and psychotherapy simultaneously. Fast forward to today, my training has paid off; I work part-time at a non-profit called Palomar Family Counseling Service located in Escondido, California, with Spanish-speaking families.

Aside from broadening your opportunities as a psychotherapist and our field keeping up with our changing times, learning Spanish is a profound act of social justice: you can be the one decreasing the dire paucity of effective bilingual services as we take on the increasingly diverse mental health needs and challenges of clients whose languages and world views are different from ours.  

(1)  Paul, Simons & Fennig, 2013, Ethnologue: Languages of the world. Dallas, TX: SIL International.

(2) Platt, 2012, A Mexico City based immersion education program: Training mental health workers for practice with Latino communities. Journal of Marital and Family Therapy

(3) Linder, Platt, & Young, 2018¿Me explico?: Mexican client perspectives on therapy with Spanish as second language (SSL) Clinicians. Sage Research Methods.

Doctors Are People, Too

Posted on by Psychotherapy.net Team

John and Rebecca (pseudonyms) came into my office in tears. They were struggling with how to maintain a commitment to their medical careers while continuing to commit to their relationship and future as a married couple. They were both successfully completing their training as physicians and had promising career opportunities in their fields of speciality.

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

What was unusual about this couple was their ability to articulate exactly what “The Question” is for many professional couples: Now that we know what the future holds and how much investment of time will be required of us in this profession, we feel like we may have to choose between a healthy marriage and a healthy career. In fact, that same afternoon, I had just seen another couple with completely different careers asking almost precisely the same question, but they had some trouble putting their concerns into words. John and Rebecca nailed it. In fact, they almost whispered it, leaning tentatively toward me in my softly-lit office, divulging what they both said was pretty risky to even think about, much less say out loud.…and if we have to choose, well, we don’t know if we want to do this medical thing anymore.

What I have learned about the personalities of individuals who pursue medicine as a career is that, like those in most caregiving professions, a physician’s own self-care can be last on their list. The hours, the intense fields of study, the great responsibility and risk involved in treating other human beings—these are all are ways in which the physician can potentially be set-up to fail in their personal lives. The training requires intense scheduling, curtailing and even significantly limiting social outings, and the need for sleep contributes to putting off cherished open-ended talks with a partner.

Pursuing a medical career requires sacrifice, and as a patient, I’m glad; the more well-trained my physician is, the better I feel I can rely on her assessment and treatment recommendations. At the same time, this particularly poignant and relevant discussion in my office brought up some concerns for me, first, as a couples counselor: my desire to be empathic and validating; and secondly, in a broader sense, concerns about this couple as part of the community. I want my treating physician to be not only clinically on-point but emotionally healthy. As a therapist who has counseled many people over the past decades, it has become clear that whatever one’s profession, the healthier the personal life, the more readily one can face and overcome the enormous challenges that arise in one’s professional life. If we have healthy personal relationships, someone to talk to who can be present and comfort us in times of distress, the challenges we have outside the home seem at least somewhat more tolerable.

So, in this session, I found myself experiencing a bit of an internal quandary: How much do I empathize, or do I even encourage they choose their marriage over the intense career paths that they are sure to pursue next? Knowing what I know as a couples therapist, I can guess that the road ahead will continue to be challenging, no matter what, but the fewer external pressures, the better, right? I confess a part of me wanted to jump in and champion their relationship above all else (their upcoming job offers were appealing, but would readily require at least 50-60 hour weeks). But I also was aware that their professional dreams had been hard-won (non-stop schooling since age six; postponing having children to focus on career; hundreds of thousands of dollars in student loan debt).

What I wound up doing next was listening to their concerns, their thoughts, and especially the emotions underneath, both secondary and primary emotions, and guiding them through conversations that could draw them closer together, instead of further apart. I didn’t try to change the subject or make it all better or tell them what to do but encouraged the experience of these concerns in session. Over time, they did the hard work necessary to reach their own conclusions about their career choices (they did remain in medicine), and their relationship. They risked being vulnerable with me and with one another around their feelings about choices made and unrealistic expectations. Over time they worked their way slowly back toward one another. They reached conclusions about their careers that met their own personal sweet spot: a balance between work and home that secured one another as their source of comfort and support at the end of the day.

Not all of my clients have been this “lucky.” Of course, that sweet spot can wobble a bit: misunderstandings and arguments happen. Those nagging internal questions about self-worth and existential questions about the purpose of our lives don’t magically disappear. That’s the nature of life, relationships, and making choices about our work. Physicians can often have a greater challenge, as the nature of their work requires an extraordinary commitment, along with a very small margin for error in the many decisions they make each day. But as so many of my physician-client couples have taught me, the need for their primary relationship to come “first” when it counts, serving as a source of security, comfort, and trust, means just as much—and often much more, than their medical careers.

John and Rebecca also learned that they didn’t have to choose one over the other. What they did needed to choose were ways in which they could learn to be more intentional about their relationship, building resilience to buffet the stressful nature of their work, and learning not to “use up” all of their emotional energy in the workplace. They took a risk by coming to see me; they could have been overwhelmed with the effort it took to focus on their relationship and decided not to call my office. I’m so glad they took that risk. They had the courage to admit that, as brilliant as they were, when it came to their relationship they needed a little support and guidance along the way. After all, doctors are people, too.
 

Having the Hard Conversations in Sport

Posted on by Psychotherapy.net Team

We watch what seem to be superhuman feats of athletic performance on TV and hear about the dedicated efforts and sacrifices it took for these elite performers to achieve the impossible. While these feats may, in fact, be extraordinary, the people performing them may also be struggling with real-life issues like any other individual who turns to psychotherapy. This was a major takeaway during my masters training when I studied counseling psychology with an emphasis on sports at the University of Missouri.

With a desire to delve more deeply into the complexity that exists at the intersection of mental health and athletic performance, I sought doctoral training, and am currently in my third year of the Counseling Psychology program at the University of Wisconsin-Milwaukee. I also am the mental conditioning coach at a local high school, which is how I met Brian, a football standout. I want to provide a glimpse into the lived experience of a student-athlete whose concerns fall outside of stats and figures, and instead in the realm of mental health.

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

It’s 5 o’clock on Friday. Many have been looking forward to this all week, and the time has finally come. Some can’t wait to get home and unwind for the weekend, while others look forward to going out. If you’re in high school, there’s a good chance you’ll end up at a football game around 7 to watch your team play under those Friday night lights.

Society has a fascination with sports. People sit around for hours sharing their athletic feats that range from avoiding the gym class mile to their time playing in college. We’re willing to pay a lot of money to see our favorite teams play, and parents put hard-earned miles on the family car to drive their kids to practices and games. Sometimes, sports are associated with enjoyment and growth, while other times it’s fraught with pressure and anxiety. The student-athlete suiting up to hit the gridiron is exempt from neither.

“Hey coach, can we talk?”

This all too common question from a student-athlete to their coach could result in any number of conversations. Am I traveling this weekend? What’s the workout tomorrow? How’s recruiting going? Sometimes, these questions are geared toward acquiring information, while other times, they’re intended to start a conversation about something much deeper.

When Brian approached me that night, the fall chill still hanging in the air after a tough mid-season loss, I could tell the look on his face meant one of those heavy conversations was about to begin. “It’s just been really hard lately.”

Almost immediately, his eyes welled up with tears and Brian, the otherwise outspoken leader and all around tough-guy, opened up about his difficulty coping with the divorce of his parents. Things had not been alright for a while, and Brian was finding it difficult to manage the myriad of emotions that seemed to come and go without warning.

Brian opened up about expectations from coaches, parents and himself and how as a result, he was no longer having fun, wanted to quit the team and stop working out altogether. He even shared that he had previously considered taking his own life. We walked and talked for a while, and Brian shared his gratitude for having someone to listen to the painful feelings he was expressing, who saw him as a person rather than only as the blue-chip recruit the media made him out to be. Before we parted ways, Brian denied a current plan or intent to end his life, and agreed to stop by to see the school counselor on Monday.

Win or lose, the result of competition is often met with critique—from fellow athletes, coaches, and the public. Newspaper columns share stats and opinions about athletic performance, and interviews about last week’s performance are nitpicked until the next big news story hits. If the internal experience of the athlete is explored, it’s often approached from a mental performance perspective as opposed to one grounded in a genuine interest in their mental health and wellbeing.

The brutal nature of the win-loss column is characterized by attempts to tell the tale of the game, but numbers cannot always recount a personal best, or growth, or even effort. The numbers can’t tell the story of the internal battles and triumphs plaguing the minds of 1.7 million high school student-athletes nationwide.

While I may be somewhat qualified by virtue of my ongoing training in sports psychology and my years studying the complexity of optimal human performance and wellbeing, that talk with Brian could have been held by anyone with a genuine concern for who he was beneath the helmet and shoulder pads. All we did that night after a gutting loss to a cross-town rival was have a conversation. Person to person, and of course, I had the wherewithal to refer him to a professional counselor.

That night Brian had someone to talk to, and today he’s back out at practice trying to improve his skill in the game he loves, along with his mental health in the course of a painful family-life transition. We all know someone like Brian, whether that above-average skill is in sport, academics or the boardroom. They may not share their concerns with us, but those concerns may be impacting their life in a paramount way—unless we have those tough conversations.

When I think back to that conversation with Brian, I realize that the experience helped to shape the way I see the role of a sports psychologist working to improve either mental health or mental performance. It helped to deepen my belief that sometimes we need to take a step back from the game and slow down. We need to take a moment to check in with the student-athlete, who may be concerned about far more than the outcome of the next game or whether they will earn that free ride to college sports celebrity. Next time the question of, “Hey Coach, can we talk?” comes up, I’ll think back to Brian, even if the question is only about the game.  

What Am I Going to Do with all This Stuff?

Posted on by Psychotherapy.net Team

“I’ve always had trouble throwing things away. Magazines, newspapers, old clothes. What if I need them one day? I don’t want to risk throwing something out that might be valuable. The large piles of stuff in our house keep growing so it’s difficult to move around and sit or eat together as a family.”

“My husband is upset and embarrassed, and we get into horrible fights. I’m scared when he threatens to leave me. My children won’t invite friends over, and I feel guilty that the clutter makes them cry. But I get so anxious when I try to throw anything away. I don’t know what’s wrong with me, and I don’t know what to do.”

These statements are typical of clients with whom I have worked who suffer from what the DSM-5 calls Hoarding Disorder (300.5), a variant of Obsessive-Compulsive Disorder. Hoarding is a disorder that may be present on its own or as a symptom of another disorder. The other disorders most often associated with hoarding are obsessive-compulsive personality disorder (OCPD), obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and depression. Less frequently hoarding may also be associated with an eating disorder, pica (eating non-food materials), Prader-Willi syndrome (a genetic disorder), psychosis or dementia.

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

These clients have extreme difficulty parting with common everyday objects such as magazines, newspapers, used cups, household supplies, foodstuffs and various forms of waste material. They may also compulsively acquire and then accumulate other items and commodities including clothing, mechanical parts, toiletries, CDs, DVDs and toys. There really is no limit, and each hoarder and the objects they hoard are unique.
Hoarding is not the same as collecting, as collectors tend to look for specific items and often organize and display them in well-maintained settings. Collectors also express a sense of pride about their possessions, enthusiastically talk about them, feel satisfied when adding to their collection(s), and can budget their time and money.

Individuals with hoarding disorder often experience severe distress at the thought of getting rid of their possessions. This results in their homes filling with clutter that disrupts their and others’ ability to use and, when severe, navigate living and working spaces. Individuals may engage in hoarding behavior for sentimental reasons. They not only feel, but deeply and intractably believe, that an item is unique, irreplaceable, or serves as a reminder of a cherished memory. Others attribute their hoarding behavior to instrumental reasons, clinging to the belief that one day these items will be useful. The psychological and physical burdens of hoarding may lead to unhealthy and dangerous living conditions, as hoarders are often reluctant to allow people into their homes to clear safe paths, remove contaminated or dirty items or to fix broken heating systems and appliances. Unlivable conditions such as these can lead to divorce, eviction, or loss of child custody.

Hoarding typically develops over the course of many years, sometimes beginning at a very young age and continuing throughout an individual’s life. Generally, in individuals living alone, the hoarding tends to develop more quickly and intensely than for those living with others. However, significant time must generally pass before the hoarder’s condition becomes very severe and impairing. It is the secretive and insidiously progressive exacerbation of the disorder that prevents those on the outside from immediately recognizing the hoarder’s issues and symptoms, and from facilitating the required intervention for the hoarder.

My work in hoarding arose through my interest in OCD, when a man once came to see me, reporting extreme concern for his children who didn’t have a bed to sleep on as the home was in disarray. The father was prominent in the community and was therefore expected to regularly invite guests to his home, which he was never able to do. Meeting the children was terribly sad as I learned firsthand about their isolation and the conditions in which they were living. My heart truly went out to the children and my memories of those interactions drove my future desire to treat and research hoarding. Upon meeting the wife who was the hoarder, it was evident that she was very socially presentable and an active member of the community. If you had met her outside of her home without knowledge of her home’s condition and clutter, you would’ve had no indication that she was a hoarder. This is very typical of most hoarders, and sadly perpetuates the hoarder’s resistance to treatment.

Many hoarders ultimately agree to seek therapy in order to avoid eviction or other negative consequences. When clinical intervention has been facilitated, which is often coordinated by those in the life of the hoarder, cognitive-behavioral therapy (CBT) has been demonstrated to have good efficacy. In such cases, it may be appropriate for the therapist to first specifically focus on helping the patient achieve greater insight into their personal situation, symptom severity, and necessity for change. Successful treatment is much more likely to be achieved and continued when the patient maintains awareness in these areas, and seriously engages in their intervention work.

Hoarders who are not determined to develop and exercise coping skills often don’t sufficiently engage in treatment to the point where they achieve long-lasting and sustainable progress, rendering them vulnerable to resuming their hoarding behavior. When CBT protocol intervention is appropriate, it focuses on four domains: information processing, emotional attachment to possessions, beliefs about possessions, and behavioral avoidance. The therapist will perform techniques such as cognitive restructuring and exposure therapy in order to challenge the patient’s beliefs about maintaining their possessions and the strong sentimental value placed on the hoarded belongings. Furthermore, the therapist will engage the patient in talking about commonly avoided and experienced situations related to hoarding that are intended to provoke anxiety, while allowing for the development of more adaptive coping techniques.

It is long and hard work to help the hoarder emotionally and cognitively disabuse themselves of their attachment to the things with which they’ve surrounded themselves, but quite rewarding to all impacted when the symptoms relent, and the stuff recedes from their lives.  

Where You

Posted on by Psychotherapy.net Team

Aimee (an amalgam of several of my patients), came into session, plopped onto the couch and said, “It happened again. Just like I knew it would.” Aimee was a 35-year old woman who came into therapy over a year ago, describing a series of failed relationships with men. She wanted to understand why it never worked out.

It can be a quandary for therapists to distinguish between outside, uncontrollable circumstances, and the patient’s participation in creating the opposite of what they consciously want. There are no absolutes. We have to understand each individual story and the patient’s unique psychology.

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

Intimacy is scary. Letting someone see behind the walls we use in everyday life is scary. Sometimes people protect themselves by continuing to choose relationships that are destined to fail over and over–different bodies, same problems.
Aimee went on, “He gave me another excuse as to why he couldn’t see me this weekend. I knew he was blowing me off, so I asked him what was going on and he said, ‘I don’t think this is going anywhere. It’s the same sentence the last five guys have said to me. What’s wrong with me?” She buried her head in her hands.

Let’s face it, relationships are complicated. It’s hard to meet people who we want to be with, and who also want to be with us. Some parts of this we have no control over. What we do have control over is removing our own obstacles to finding the love, the commitment and the relationship we want.

Having seen this dynamic so many times in therapy, I decided to write a novel exploring this very theme. I began the story, as I do with all of my fiction writing, with a question. In this book called, Where You’ll Land, the question was: Can we choose who we love?

Alex Daily, my protagonist and a psychology graduate student, meets Will. The relationship is filled with passion but is quite tumultuous; the angst from both characters, as well as some of the secondary characters, forces them all to look at the obstacles that are in their respective ways.

As psychotherapists, we all know that we don’t see things about ourselves until we are ready. It can be a nail biter to sit with a patient, observe their conflict and self-sabotage, and know that the patient is in their own way, while also knowing they are not ready to garner the awareness that leads to change.

Timing of interpretive comments is vital for insight. We have to respect patients’ defenses and we can only guide them toward the awareness they are ready to have. Our job is often clearing out the weeds (defenses) so that the flowers can be seen, while watering the flowers (fostering innate strengths) so that the patient can grow into who they really are.

Toward the latter part of the book Alex has an insight, “She kept making the same mistake over and over until she realized that if she wanted a different ending, she had to have a different beginning.” This was also my client Aimee’s dilemma.

There is an irresistible draw toward the familiar, even when we say we want to change. If we hope for a different ending, sometimes we have to rework the beginning.

But where is the beginning? For Aimee, it began with not feeling her needs were met as a child. Whenever I explored how she didn’t feel taken care of in her relationships with the men she dated, she associated that to similar dynamics in her family. She’d choose men who reconfirmed that her needs were either too much or that she wasn’t good enough.

I redirected the session. “Maybe we can talk about what Jake wasn’t giving you throughout the relationship. What you don’t get from each of these men.”

“I feel like they could leave at any moment. I’m always anxious. I want someone who will be there.”

“Could you be confusing anxiety for attraction? Maybe the anxiety has to do with knowing they can’t meet your needs, the way you felt sometimes when you were younger.”

She contemplated. “That makes sense, intellectually. But it doesn’t feel that way. I can’t make myself be attracted to the guys I’m not attracted to.”

When it comes to feeling those emotional sparks – chemistry – understanding these conflicts is a dense conundrum. We have to create curiosity. We have to ask different questions.

“True. But I think we have to start asking what you’re actually attracted to, since you’re choosing men who make you feel on edge. How is that attractive?”

She flitted her hands around. “I – It’s not.”

“Let’s try looking at the anxiety as a sign that something’s wrong, not that something’s right.”

“OK,” she said.

We spent many sessions discussing how when there was anxiety, it was usually a sign that her needs were not being met. And we talked about her right to have needs and to allow someone who wanted to meet them, close.

I don’t believe we can control physical attraction entirely, but we can change some of what we are drawn to and we can control the decisions we make regarding who we allow ourselves to open our hearts to. If we are being open to people who continually disappoint and frustrate us, who perpetuate narratives from our life that are painful, then we need to ask why we are deciding to fall for the same type of relationship. And as therapists, we need to guide our patients to be curious about these questions. Because as Alex comes to understand in her story and as Aimee came to understand after a few more failed relationships:

Maybe we can’t decide who we fall for, but we can decide who we want to be with when we land. 

What Blocks Creativity

Posted on by Psychotherapy.net Team

Was our original creative project the wish to love and be loved by our mothers?

What happens if that creative project failed and your mother wasn’t able to acknowledge, respond to, and reciprocate your love?

I like Harold Searles’ writing. One of his papers, ‘The Patient as Therapist to His Analyst’ from Countertransference and Related Subjects (1979), deals specifically with Searles’ idea that the patient is unwell in relation to how their original therapeutic strivings (In Searles’ view, the wish to love our mothers) failed.

Searles’ paper came to mind recently in my work with trauma survivors.

In my private practice, I have worked with a number of people who have suffered early and sustained trauma. The psychotherapy often succeeds in helping these clients build up more of an understanding of what happened to them in their early life. It enables reflection and the construction of ideas and thinking that goes some way to explain what happened to them. It frequently throws light upon why they have been attached to self-destructive behaviours throughout their life.

In the psychotherapy, periods of self-limiting and self-destructive behaviour are explored and the client often becomes more relaxed and confident. They become better able to think and reflect on themselves and to collaborate constructively in the work. But when the session ends, they retreat, withdraw and often fail to build on what they have been doing in the therapy.

When we meet for the next session, they explain that they have not wanted to think between sessions about the work we were doing in case the work did not have its intended or hoped-for positive effects. Instead, they retreat or shut down.

One client, a particularly creative woman I will call Mo, had wide-ranging ideas and a number of projects that interested her that she would have liked to develop and work on. But, the pattern Mo was attached to was that she would go no further than to think briefly about her projects and then shelve them. Mo’s attitude toward her creativity contained a powerful repressive dynamic.

I came to think about this repressive dynamic, this limiting attitude to herself and her ideas as reflective of the failure of her first creative project—Mo’s wish to love and be loved by her mother. Mo’s relationship with her mother never developed into a loving reciprocal one. Her sense was that her mother may have been in a state of undiagnosed post-natal depression. It seems there were particular problems in Mo’s early home life. Partly as a result of this she was often left neglected and abandoned for long periods. Mo’s wish to love was met with anger, rejection, and resistance.

I came to understand this as part of the transference to the therapy and then began to see that it might be understood as describing the relationship Mo had with her own creativity. Though Mo could have very interesting ideas that captured her imagination in her sessions, she would later abandon them and leave them ignored, only to hesitantly pick them up again in the next session.

This led me to think about the way our creativity, not just our capacity to have an idea, but more particularly the possibility of following our ideas through, might be bound up with our original maternal relationships.

In psychotherapy, a client starts to develop a greater understanding of themselves and what they went through early in life. They become better able to reflect and to develop more benevolent and caring attitudes to themselves and others in the sessions. But outside of the therapy, they do not manage to sustain these attitudes. They return to a position in which they put themselves down at the expense of others and remain fixed to limited expression of creativity. The attitude they express to their own creative ideas contains thwarted, complicated and destructive impulses.

Have they transferred to their own creative selves, expressions of the sense of failure and disappointment they experienced in their original maternal relationship? Do they treat their creativity as an inferior object to abandon at will? My work with Mo has led me to think that a consequence of early trauma and abandonment may be reflected in the way people struggle to pursue their creative projects in later life.

Could this apply to your patients? Has their creativity become caught up in the pattern of their original creative failure(s)? Instead of writing their novels or memoirs or even other less lofty creative projects, do they continue to struggle with failed beginnings? Is the repressive early relational world that they experienced what they become destined to locate and repeat in their attitudes to you and their therapy?

Is it possible that through the shared creative therapeutic venture that you can both come to see the problems they experienced in their relationship with creativity as reflective of problems in their earliest relationships? Could you use that information or insight to help them change and improve their relationship with their creativity? 

Shame Part 4: I Deserve to Feel Bad, Because I am Bad

Posted on by Psychotherapy.net Team

In my previous blog posts, I discussed the difference between shame and guilt; both of which are painful, self-evaluative affects. Guilt involves the evaluation of a specific behavior and therefore, offers the opportunity for reparation. If Gary fails a test and feels guilty, he believes he can do things—like study harder—that will relieve some of his guilt. Even the thought that he is able to do something, alleviates some of the distress from his self-evaluation.

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

If Gary perceives himself to be a loser who can never do anything right, then he is experiencing shame. Although shame can be transient, there are people whose experience of shame (shame-proneness) is pervasive; meaning that at the very core of their sense of self is the feeling of being small, insignificant and/or bad.

In my most recent blog post in this series, I discussed how shame-proneness compromised empathy, causing conflict and turmoil in relationships. Another lasting and painful consequence of unresolved shame is shame-based depression.

Depression is at best, an umbrella concept, not easily understood or reducible to a diagnostic label. Just because people share symptoms does not mean the cause is the same. Think of all the different underlying reasons for a headache. If we are to hope for good psychotherapy outcomes, we need to understand the causes of the symptoms, not an easy endeavor with distress as broad as depression.

When depression is shame-based, it is not only the symptoms that debilitate, but also the ingrained belief that the person does not deserve to feel better. Because fundamentally they feel bad, small, unimportant, the suffering feels congruent. Relief feels foreign and undeserved. If the shame basis of the depression is left unidentified, improvement will be a tortuous, uphill battle for both you and your patient.

Take Madeline (an amalgam of patients suffering from shame-based depression), for example. She’s a 39-year-old woman who came in for depression and reported a lifelong history of related symptoms. She described apathy, anhedonia, problems with motivation and concentration, appetite and sleep disturbances as well as feelings of worthlessness. As the therapy progressed over the first year, it became clear that Madeline experienced deep-rooted and chronic shame.

She regarded herself as unintelligent, unattractive and uninteresting. In response to these feelings, she developed grandiose aspirations to compensate for her supposed deficiencies that no one could ever live up to. Consequently, she experienced continuous and inevitable failures which confirmed and perpetuated her shame-narrative.

“I’ll never be intelligent. Everyone knows more than me,” she said, averting my gaze.

“Can you tell me more about that?”

“I need to read every single book on a particular topic before I’ll feel knowledgeable enough to have a conversation about it.”

“Does that seem a realistic endeavor?”

“I have to. It’s the only way I’ll feel smart enough,” she said flatly, fighting a frown.

“I worry that you are setting yourself up to fail by having expectations that are impossible to reach.”

“I never meet any of my goals, anyway.” She crossed her arms.

“You’ll never find a feeling of accomplishment or meaning if you keep setting insurmountable goals. I’d like to understand why you’re doing that. What would happen if we worked together to set realistic goals, things you can accomplish?”

“Well, then I might feel better.” She released a sarcastic laugh. “I wish that was a joke. I don’t feel like I deserve to feel better.”

“Tell me more about that.”

“No one ever supported me or any of my interests. I was told I wasn’t good enough. And it’s the truth, isn’t it? Look at my life. I’ve done nothing to be proud of. Failed at everything I ever tried or ever wanted.”

After I better understood her shame, I realized that despite our seemingly strong relationship, Madeline continually undermined the therapeutic process. Every time she started to feel better, she’d set these impossible standards, which ultimately confirmed her feelings of not being good enough, of being a failure. Of not deserving any relief.

Madeline knew nothing but her depression. She held onto it as if without it she would descend into an unfathomable void without it. When patients have a history of emotional abuse, as she did, where disparaging statements are woven through the fabric of their identity, the depression is often shame-based. And the treatment is extremely challenging. We have to help our patients to find ways to question, then challenge and finally close the book on their shame-narrative.

To some degree, all depressions contain an element of shame. But in Madeline’s case, it was pervasive, evolving more like a personality trait than a cluster of symptoms, making it harder to treat. Her shame caused her to perpetuate her own distress.

I combined humanistic, psychodynamic and cognitive-behavior therapy for Madeline. Psychodynamic, to help her understand how the shame evolved through her childhood experiences of emotional abuse; humanistic to focus on helping her identify and foster the many strengths she did have and to help her find meaningful pursuits where she could feel her endowments; cognitive-behavioral to help her with her thought distortions. I had her keep a journal of the false narratives. Every time she had an experience that disconfirmed them, I had her write it down. For example, she thought no one liked her and as a result, she was socially isolated. Every interaction where someone complimented her or showed interest in her, every time someone asked her for advice, she wrote it down. This was to reinforce different statements about who she was.

The more Madeline discovered her unique strengths and used them and felt them, the better she became at recognizing the falseness of her narratives. And the more she understood the distortions, the better she became at pursuing goals that were attainable.

I also did some psychoeducation in the second year of our treatment. I explained the shame and tried to help her understand her depression. Madeline had become curious and open and was able to introspect even in areas that were very painful.

Madeline developed an observing ego. She became more cognizant of her distortions and began to question their validity. In order to help patients recognize their shame, we need to listen closely to these narratives. We need to identify the shame. And then, we can adjust our therapeutic techniques to meet our client’s unique needs. We need to believe they deserve to get better and can get better, even when they are undermining every step of the process. But for the deepest and most lasting change to occur, they need to believe in a narrative free of shame.