Category: Blog

Choice: My Lighthouse in a Wave of Disillusionment

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

At first, I felt like this:

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

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

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

Should Therapists Have Scales in their Offices?

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

When the Snow-Globe Shatters: A Counselor

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

Do We Really Know What We Look Like?

Posted on by Psychotherapy.net Team

We all think we know how we look, but do we really ‘know’? How can we? Certainly, we can see ourselves in the mirror, but do we really have a sense or knowledge of how others see us? We only have an idea based on what the mirror tells us and ultimately how we regard ourselves, the value we place on appearance, what our mood is and the feedback we receive from others. Is that objective?

How we perceive things changes from person to person. Have you ever found someone you regarded as attractive, only to ask someone else who comments, “Yeah, he or she is alright looking”? Well, how can that be if it is the same person? Yes, we all have different concepts of beauty, and the value we place on attractiveness determines how much attention we pay to our looks or those of others. The value that I place on attractiveness or brilliance would influence how I, and I alone, perceived that person. The same goes for ourselves.

I specialize in the treatment of people with Body Dysmorphic Disorder (BDD), which is a preoccupation with one or more nonexistent or slight defects or flaws in physical appearance. This preoccupation gives rise to compulsive behaviors that are performed in response to the appearance concerns that range from picking to plastic surgery. To the outsider, BDD may seem like a trivial concern and a matter of vanity, but it is really quite the opposite. The person feels disgust and shame regarding some aspect of his or her appearance and is often highly anxious about being seen and evaluated by others. About 40 percent end up homebound, they are hospitalized more often than schizophrenics, and 80 percent have suicidal ideation with 29 percent attempting suicide. It is a significant and serious disorder.

I was drawn to these clients because they are challenging and often misunderstood. They are perpetually wounded and cannot escape from their symptoms because they are of their own making and, after all, how do we escape our own bodies? Unfortunately for them peace does not come at the end of a surgeon’s blade, and this is where I come in trying to convince these clients to change the way they think about their body rather than the body part itself. Our goals are very different, and our first challenge is to agree upon a common goal.

I remember the day Jimmy, 22 years old, came to my office after trying to convince his parents to pay for surgery, angry that he was wasting his time with me. He sported a baseball cap with a hint of bangs showing partly below. He said he did not like the way his hairline looked, and that he wanted a second hair transplant, which his parents would not allow. In his sophomore year of college it had become impossible for him to sit in class or socialize and he had to finally had to take a protracted leave of absence. Jimmy thought that his forehead was too big and that his hair was receding. Nothing would convince him otherwise, so to hold onto my own receding credibility, I did not dare argue my perception with him. I said that I understood and that there was little I could do except ask him to try to think a bit differently about his appearance over the next few months, since his parents would not pay for another surgery.

My road ahead was not going to be easy, nor was his. He came in a few times a week, trying to align his purported values with the time he spent catering to them. Although he claimed that he did not value attractiveness as highly as education, family and friends, he soon realized that he spent more time on his appearance than anything else. We tried to set that straight. I took him out of the office without his hat and had him expose his hairline at the beauty counter of a nearby store. He had to sit with his anxiety, hair and forehead exposed in all the places he had avoided including the university cafeteria, the local bar and with friends. His anxiety and disgust decreased over time in all of these situations. After almost 6 months Jimmy was able to return to school, socialize with friends and eventually date. He had regained his life and had no need for surgery. At that point, he was able to recognize that the problem was not his hairline, but instead his beliefs about it, and the ways in which his preoccupation interfered with his life. He was back on track with a better sense of control. I believe that my CBT-oriented approach with Jimmy was useful; although I believe that it was equally important helping him reconnect with those experiences in his life that were of greater value than his hairline and appearance.

Supply and Demand Psychotherapy

Posted on by Psychotherapy.net Team

I am a believer in psychotherapy. For close to three decades I had the privilege of working with clients as they transformed their lives in amazing ways. Nothing is more satisfying in life than hearing from a former client years later and learning about the wonderful ways their lives unfolded after our therapy was completed. As a psychotherapist, my entire focus was on the person sitting in the chair across from me. I rarely thought about the people who didn’t make it into my office. I didn’t focus on the waiting list or the people who were referred out. I was content and satisfied in providing effective therapy and a great therapeutic relationship to my clients.

When I became an administrator, whose primary clinical responsibilities were to oversee all of service delivery, my awareness of those who don’t make it into a therapist’s office was heightened. I worked in college and university mental health clinics, and the consequences for students who were made to wait were dire. If a student waited four weeks to get treatment for their depression, they were likely to lose their entire semester. If they failed classes in a particular semester, the entire trajectory of their lives could be altered. Their graduation prospects were in jeopardy, graduate and professional school could be out of reach, and job recruiters might very well may pass on them.

As an administrator, I found myself in the intolerable position of determining who would flourish and who would flounder based entirely on the date on which that student sought services. If a student arrived in late August, we rolled out the smorgasbord; group therapy, individual therapy, biofeedback, psychiatric consultation. Whatever they wanted we could provide. In contrast, if a student arrived in early October, they would get a quick triage and then be placed on a waitlist, sometimes for a month to 6 weeks.

Compounding the problem were the obvious differences between the people who came in August and those who waited a few weeks. Students who sought services in August were more likely to have been in therapy before. They were also more likely to come from higher socioeconomic groups-they were more often white. On the other hand, students who waited tended to be from lower SES families, first generation college students and “of color.” We were operating a system that provided advantages to the already privileged, and disadvantages to the already oppressed.

I could not continue to have our agency work this way. I had to find new ways to provide effective help to these young people on their way to adulthood. We needed to increase our capacity without sacrificing effectiveness, knowing we would never be able to hire our way out of our supply and demand problem. Our efforts to solve this problem lead to the creation of my company, Therapy Assistance Online (TAO). Problems of supply and demand are not unique to college counseling centers. Over 106 million people in the US live in federally designated underserved areas for mental health. About 56% of US counties have no licensed psychologists or licensed clinical social workers. We are unlikely to ever meet the mental health needs of the population through face-to-face individual psychotherapy. In digital and online tools and services we have the best hope for putting a dent in the problem.

Our software (TAO Connect, Inc.) is used in 120 college and university counseling centers and we’ve expanded into community mental health centers, employee assistance programs in the US and Australia, a Canadian Province, and two large provider groups. I am very proud to know that our software is helpful to ten times more people than I was able to treat with individual therapy. Recently, one of our university clinicians told me the story of a student whose anxiety disorder was so overwhelming that she had to leave school. She did not have insurance to cover any private therapist, so she worked with TAO’s online CBT for anxiety course. She was able to recover fully and returned to school, and had a great semester. She credited the TAO course with teaching mindfulness skills and learning to challenge her unhelpful thoughts.

As a field we need to explore, develop, research, and test digital and online tools, especially to populations at great risk. Too often mental health apps are developed by software engineers with little or no input from mental health practitioners. Our input is vital if effective tools are going to be developed consistent with what we know works. Practitioners in mental health need to be at the forefront of addressing these dire supply and demand problems and we need to lead in the development of effective tools. We can’t afford to concede our field to software engineers.
    

Trusting Her Voices: Trusting My Own

Posted on by Psychotherapy.net Team

There was something different about this seven-year-old who at such a tender age had already lost her father. And if that adversity was not enough, Christine was struggling to fit in and keep up. Yet, there was something about this lost and lonely girl, some palpable sense I had of her resilience. After a psychoeducational evaluation, carefully chosen recommendations, and consultation with her mother, it would be 15 years before I next saw this girl. She was now a woman who was, perhaps not unsurprisingly, still struggling to fit in and keep up, this time with a far-less accepting college crowd and the rigors of an academic curriculum that was really of little interest to her.

I was immediately struck by how she was at the same time both young for her age and an old soul- isolated, enigmatic. In her “backpack of wonders,” as I silently called it, she had a number of amulets drawn from characters of popular culture; wore T-shirts advertising her fascination with or perhaps identification with popular teen icons, and soon revealed to me that she had learned to populate the empty rooms of her life with what she called her ‘All-Girls Group.’ “Voices in her head, damn!”, I thought to myself. Could I have so badly wanted to see that struggling child in the most benign light all those years ago, denying the possibility of early onset schizophrenia? A rising sense of panic muddled my thoughts. Critical, self-questioning voices.

What to do? Query her mother more deeply? Do a thorough psychological evaluation? Refer her immediately to a psychiatrist? Consider the possibility of hospitalization? These were the voices in my head, and while I did not ignore them, I addressed each of them, ruled out immediate danger, and opened myself to Christine’s inner world. In the process, I got to know Laura, a “real” young woman who chronicled her lifelong battle with cystic fibrosis in the book Breathing for a Living. I met Lisa, the take-no-prisoners character from Susanna Kaysen's Girl, Interrupted. And after being granted membership as the “only boy” in Christine’s exclusive private club, went to work with her, following her lead, suspending my voices, getting to know hers, and following her lead in trying to plot a therapeutic path for us and for her.

That phase of therapy ended abruptly following a surgical procedure for Christine and loss of the family dog, which I imagine were very destabilizing for her. I later found out that she had joined the Army. “Of all places to go… They will eat her alive.” When she arrived several years later to reconnect and reinitiate our work, I found out that Christine’s group had abandoned her to the military thinking it the wrong decision. But with some creative re-framing, she accepted the notion that her support team thought the Army would be an important test for her and that she had to go it alone.

And, as to be expected, Christine experienced considerable adversity during her short stay with Uncle Sam-a belligerent drill instructor, unaccepting platoon-mates, brutal physical rigors and loneliness Broken and alone, Christine hobbled back into her life and somehow her “girls” found her, flocked to her side, lifted her on their backs and marched her back to school…and life. Along the way, their numbers increased to include a few new select members, this time a few male figures- all strong, all supportive, all with stories of survival and resilience, just what she needed.

Christine finished her college degree, tried a few different jobs in the computer field, and as of this writing, was still searching for the very same things she was looking for when I first met her as a child. I see her whenever she calls, trust that she is never alone, and long since separated myself out from the voices in my head that did not trust the voices in hers. I don’t believe that Christine ever dis-trusted her voices – that was me, although I never showed it to her. I think I was only able to accept hers when I was finally able to subdue my own.
 

The One Thing a Therapist Should Never Say to a Client

Posted on by Psychotherapy.net Team

As a graduate student I was given the old stand-by assignment: seek out an accomplished therapist and interview him or her. Since my overwhelming desire in life was to become a private practice therapist myself, I didn't envision this as just an assignment, but rather an exciting adventure. I was going to put my whole heart and soul into it.

Since I wanted to pick a person of note, I spoke to a cadre of folks in the field, including my esteemed professors, and decided on a therapist I’ll call Mindy. She seemed to be a real therapist's therapist. A large private practice? You bet. A superb reputation? Affirmative. A mental health conference presenter? Check. She even ran workshops around the globe in remote countries I had never heard of. This was going to be great.

Mindy’s administrative assistant was kind enough to set me up with the necessary appointment and it was off to the races. Her office was in the high-rent district in a city about 130 miles away from my hometown in St. Louis, but I knew the long drive was well worth it. As the elevator to her office sped from floor to floor, I glanced in the mirror to check my hair a couple times. Okay, maybe it was more like a dozen or more times, but keep in mind I wanted to come off as a serious future professional. Maybe we would be working together in the same practice one day. Yes indeed, I had high hopes.

Mindy was dressed in a muumuu that made her look like she might be playing a part opposite Elvis the classic Blue Hawaii.

I had imagined I might see a couch or a rosewood desk with spit-shined brass handles, but that was hardly the case. She motioned for me to have a seat while she sat down in an antique rocking chair.
We were separated by an unusually large sheet of paper like one might use in a lecture for a flip chart. But the paper was on the floor. Hmm, what was that about?

Before I could get my first question in which was something like "Did you know you wanted to become a therapist as a child?", she began firing questions at me.

I was way too timid at the time to ask this exalted expert what in the world was going on here, so I answered perhaps five or six questions. As I spoke, she would lean forward in her rocker and scribble something on the massive sheet of paper on the floor using a King Kong- sized marker.

Wait a moment. We weren't here to therapize me, or were we?

After just minutes, I tried to talk and she said, "Howard stop. I know exactly what your problem is."
Wait, I didn't know we were talking about my problems.

"I know you came here to interview me for your graduate class, but we need to deal with some much more important issues. You are just like me. You have severe anger problems and you are a quitter. Yes, a quitter. I am sorry to say you will never finish your master's degree. I'm going to set you up for a few sessions of individual as well as group psychotherapy. You still won't ever get your master's degree, but I can help you in other ways."

Had this merely been a bad dream we could have analyzed it, but it wasn't. I hadn't recalled saying anything even remotely related to anger and certainly nothing about giving up on graduate school. For gosh sakes, it was the number one thing in my life at the time.

Now fast forward to the present. I did an internet search and low and behold I discovered that Mindy never finished her degree. But wait. It gets even more interesting. Since she was attending a doctorate in psychology program where the master's was not conferred until you completed the doctorate, to this day she still possesses just a bachelor's degree in psychology. She was only allowed to practice back in the day when I saw here because licensing had not yet been enacted in our state.

So, what's the take home message? Well, I believe the behaviorist, hypnosis expert, and assertiveness training pioneer Andrew Salter (a famous therapist himself with just a bachelor's degree) nailed it when he gave the best definition I have ever heard of reaction formation: "You think you are looking out a window, but you are really looking in a mirror."

The worst thing a therapist can do? Well it is as simple as looking in a mirror while convincing yourself you are gazing out the window and making a pernicious statement about why the person sitting in front of the desk, or rocker will never be able to do something.

Oh, and by the way, Mindy, if you happen to be reading this blog and decide to email me to express your anger or discontent, just for the record, it's Dr. Rosenthal now.
 

The Modular View of the Mind

Posted on by Psychotherapy.net Team

My earlier blog post suggested that the human organism contains multiple selves in the same way that your cell phone contains multiple apps. I now want to link that metaphor to an actual therapeutic model known as Internal Family Systems that I have found useful in my clinical practice and then discuss its application with one of my clients.

IFS is predicated on a modular theory of the human mind. The human mind consists of modules (apps on a cell phone), discrete mental models that interact with each other to produce our experience of aliveness. You might consider the idea that we have mental models of parenting, careerism, friendship, family, as well as more philosophical mental models such as the meaning of life or our role and purpose in the universe. These mental models operate within discrete modules that are activated depending on the circumstance the individual encounters. One’s behavior (the manifesting of the “self”) hinges on the module that takes precedence within the human mind at any moment. The full range of our inner life reflects the complex interplay of these modules which is neither haphazard nor random. They function interactively and synergistically as a system. That’s why the IFS model uses systems theory—how parts interact to create the whole—to underpin the way psychotherapy is done. Human distress is often productively seen as the breakdown of a system—namely, the breakdown in the way modules within the psyche interact.

IFS envisions a tripartite system. That system consists of the Manager, the Exiles, and the Firefighter. The Manager module is the most familiar, for it is that version of the self that tries to exert control. When we say to ourselves, hey, let’s keep it together, we are trying to activate the managerial self. When we present our best selves to the public, we are giving priority to the managerial self (the managerial self is a kind of public-relations self). The Manager is the module in the psyche that promotes order and combats chaos and disorder. The Manager module vigilantly stands guard against the Exile module which contains the unwanted aspects of ourselves (the pain, the shame, the trauma that accumulates over the course of a life). When the managerial module fails to quell the upsurge of the exiles sequestered in the exile module, the “self” behaves in maladaptive ways. We often call that falling apart, or having a meltdown, or losing our cool. Enter the Firefighter module. This module is allied with the Manager module since it, too, exists to keep the exiles sequestered within the human psyche. The firefighters are aroused into action when the managerial self finds itself unable to quell the upsurge of the exiles. You could look upon a person who resorts to alcohol or drugs to numb the pain of trauma as one who has unleashed the firefighters upon the escaping exiles. The managerial self would prefer to shepherd the exiles (the pain of the trauma) back into the recesses of consciousness; but when it cannot do so, the firefighters spring into action, which is experienced as the irresistible urge to get high. Firefighters aren’t concerned with what’s optimal. Firefighters douse the fire.

It is the interplay of these three modules that inform an IFS practitioner. But I want to be clear that the IFS tripartite system isn’t the sum total of the modular view of the mind. Quite the contrary. It is the specific therapeutic application of it. The modular view of the mind is better understood as a philosophical model of the human organism, where the notion of the unitary “Self” is seen as an illusion. The upshot is that suffering arises from a disharmony among the various modules within the psyche, a kind of fragmentation of the mind. Mental and emotional health—equanimity, inner peace, self-command—reflects psychic integration. The healthy person is an integrated person (a person with integrity).

The therapeutic project of achieving integration is collaborative, non-pathologizing, and above all, ongoing. It was quite useful for me in working with Phil, a client struggling with alcohol abuse, who came to me because his estranged wife gave him an ultimatum—therapy or divorce. He said his wife thinks he needs “anger management lessons.” He admitted sometimes going “semi-postal” –a characterization that alarmed me but that he shrugged off as flippant—and wanted to “fix that, you know.” I didn’t “know,” which is why the first session explored Phil’s motivation with the hope that the Managerial-self could fully explain what “fix[ing] that” would look like. The second and third sessions brought to light the subtleties in his Managerial module. What sorts of perceived chaos was Phil seeking to avert? What kind of inner monologue preceded and followed an outburst? Why is his managerial self so ineffectual? The fourth session attempted an exploration of Phil’s exiles, but he disavowed having any (“I’ve never been abused.” “Seen bad things but not like I’ve been to war or anything like that.”). The fourth session; however, was far from a bust. He offhandedly admitted that whiskey with a dab of Coke help him “cool out.” He said he only goes “semi-postal” when he hasn’t had a drink in the last twenty-four hours.

“Ah, there’s his Firefighter module in action,” I thought.

Once we got beyond the Managerial module, things got interesting. Anger-management therapy transmogrified into substance-abuse counseling, which ultimately turned into something quite dramatic. That story, too involved for this blog, will be presented soon as a full-length article.

Stay tuned!

Finding Playfulness in the Seriousness

Posted on by Psychotherapy.net Team

I have recently seen videos of social experiments that encouraged adults to find time to play. In one such video, a hopscotch board was drawn on a city street and over the course of the next ten hours of the 1,058 people who walked by, only 129 stopped, if but momentarily, to engage in the playful distraction.

In another video, a man and his friends set up a large ball pit in an urban space to see if adults would take a moment for themselves. He asked people walking by if they were too busy to have fun. Immediate responses focused on the need to return to work – all work, no play. However, several people decided to seize the moment to dive in. A man wearing a perfectly pressed suit threw his briefcase into the pit moments before jumping in. The joy that exuded from those playful moments was priceless.

I am a play therapist, so am fortunate to play for a living. Through play therapy, children can externalize, process, master their struggles and tame inner demons through a variety of expressive mediums. Sessions transform from battles to caring for babies, playing sports, building worlds in the sand, making and eating full course meals, watching puppet shows, drawing, painting, blowing bubbles, and much more. With play, the possibilities are only limited by one’s imagination. It is truly a privilege to see the healing power of play first hand and to make time to experience play myself.

I would guess a vast majority of adults believe that play is primarily reserved for children. Life is stressful and there are a plethora of serious tasks and obligations that we must save our energy for instead of goofing off and spending time playing. Many of us are inundated with a full caseload, meetings, case management, consultation groups or supervision, continuing education, family obligations, and other side projects. We simply do not have time to stop and play hopscotch or jump in the ball pit. It does not mean that we do not want to; there is just not enough time in the day.

Being a psychotherapist is an immensely rewarding, and at times challenging and emotionally draining job. Being a container for so many hurting humans takes its toll on mind and body. We need self-care more than we allow for ourselves. We need to remember that we cannot give so much to so many and very little to ourselves. We must be gentle with ourselves and find time to rest, relax, and replenish.

When was the last time you allowed yourself to be completely immersed in your imagination and fully experience that moment? How can you make more time for playful self-care? When an obligation needs to be removed from our schedules, why is self-care is often the first to go? Because we convince ourselves that we cannot possibly sacrifice anything else on our schedule. As the Zen proverb states, “You should sit in meditation for twenty minutes every day – unless you’re too busy. Then you should sit for an hour.” This gentle self-care reminder is applicable to time spent playing as well. Foster more moments of joy, laughter, happiness and the liberation play can bring in your lives. The next time we contemplate if we have time in our day to playfully tend to our minds and bodies because we are too jam-packed, we must remind ourselves that these are the moments that we need these experiences the most.
 

Why the Therapist

Posted on by Psychotherapy.net Team

My family, like any other, has its ups and downs, especially now as we are free-falling somewhere in the middle of Monica McGoldrick’s stage of ‘launching children and moving on’. I’m not exactly sure if our children just aren't on the same launch schedule as my wife and I, or if we have simply failed to supply them with sufficient psychological propellant for their tanks.

In any event, a recent episode in our family’s unfolding narrative culminated with my wife, a social worker by training, texting our seed-sowing, soon-to-be 20-year-old ‘emerging-adult’ daughter a poignant, incisive and heartfelt text. Fearful that her venturing forth would leave family and friends behind, it read simply, “it’s much easier to ignore people and cut them off, than working at repairing relationships.”

Brilliant, I thought. My wife was quite proud, and I of her, for providing our child with yet another foundation stone in the launch pad from which she could eventually free herself from the massive gravitational pull of planet parent (not sure of why the intergalactic metaphors here, but it probably has something to do with encounters with alien life forms- our young-adult children).

We both eagerly awaited our daughter’s response, certain that it would be replete with affection and gratitude for sound advice. What my wife got back was, “Is that a dad quote?!” REALLY, is that a dad quote?!?! Was this a not-so-cryptic attempt to marginalize and diminish my wife? A backhanded insult at me for offering yet another of my unsolicited and perhaps patronizing pieces of parenting?

Mind you, I am a PhD clinical psychologist, with ABPP certification in child and adolescent psychology and a registered play therapist-supervisor. I have street cred with kids, teens and families. People pay me cash money, and those whose lives I have touched seem grateful, at least many of them do.

Which finally brings us around to the mixed metaphor title of this blog post. Parenting is rocky on any planet. And to paraphrase the great Sylvester Stallone from his movie Rocky Balboa, “life ain’t all sunshine and rainbows…it’s a mean and nasty place, and will drop you to your knees.”

So, getting back to the idea of therapists offering advice to their not-so-receptive children. The proverb says, that ‘the cobbler’s children always need new shoes,’ a popular example of the notion of vocational irony. A deep inspection finds this saying has several implications. If the cobbler was really good at his job, his kids wouldn’t need to go barefoot. Or perhaps it means that the cobbler is so busy cobbling for others, that his own children go without. But did anyone ever stop to think that the cobbler’s kids just don’t want to wear their father’s cobbled creations? Maybe the kicks (teen slang for shoes, I am told) are cooler in the cobblery down the street. Or maybe they would rather make their own shoes!

And maybe psychotherapists everywhere, especially those that dare to work with teens and their families, can take a lesson from this humble cobbler of young psyches. Keep your cobbling separate from your parenting, or you might end up with holes in the soles of your relationships.