Category: Blog

The Thousand-Armed Therapist

Posted on by Psychotherapy.net Team

A typical desire for most therapists (at least at some point in their training or career) is “to save people;” because let’s face it: the majority of us are in this business because we care a great deal about others. There comes a moment, however, when almost all therapists eventually learn that trying to save people is exhausting. Actually, even trying to help others gain small amounts of awareness on a daily basis can be difficult and draining. Therapists are not the only group of helpers who can become worn out attempting to expand the consciousness of others, though. Religions of the world have provided us with many illustrations of how wearying an altruistic path can be.

In Buddhism, for example, Bodhisattvas are those who have reached the ultimate state of enlightment, but have renounced that state out of compassion for the many who have not yet awakened. Bodhisattvas choose to put aside their own needs and patiently set out to help others. Throughout the world, perhaps the most venerated of all Bodhisattvas is Avalokiteshvara. Within his story are keys to how we, as therapists, can find incredible strength and inspiration for what we do every day.

Bodhisattva of Compassion
When Avalokiteshvara was in his last incarnation, he was no ordinary person. He had spent years in meditation, action, and reflection. He exuded a level of compassion toward all creatures unlike anything ever seen in the history of beings. In his final life, by his awakening, he transcended the perpetual cycles of birth and death, and was headed straightway for the ultimate realm of connection with the Divine.

Legend has it that in the final instant before he reached the entrance of Nirvana, another awakening occurred, and it was in that moment in which he halted his passage through the gates and swore a vow: He would not enter the ultimate realm until he had helped all beings achieve awakening. Now a spiritual Bodhisattva, he turned, sat arms outstretched in a meditative stance with his back to the ingress of paradise, and began to radiate a beam of compassion to every living being in every corner of the infinite universe.

His work was magnificent. The awesome task he undertook freed countless inhabitants from suffering in the deepest layers of Hell. Being after being benefitted from the overwhelming compassion of Avalokiteshvara until the entirety of Hell was freed from the everlasting cycles of birth and death. His work was complete. Suffering had ended.

Avalokiteshvara turned with a sense of relief that his hard work had paid off and his meaning fulfilled. Only the imaginary, non-being tempter Mara remained. Myriads of every kind of being had been awakened and the underworld of pain emptied—but as the great Bodhisattva glanced back, his moment of relief changed so rapidly into a moment of terror that what he saw and experienced would not only transform him, but all life as well. You see, when Avalokiteshvara looked back, he saw uncountable legions of new beings entering Hell. The thought that his work of countless eons was still inadequate to relieve the ever-occurring suffering of the world struck his very core, and he shattered into many pieces.

Suffering continued. While the darkest regions of Hell filled and expanded, Avalokiteshvara lay broken. But just as light can pierce even the darkest corners of the world, it was out of this darkness the great Buddha approached the fragmented Bodhisattva. Buddha put Avalokiteshvara back together—stronger this time than before. He gave him a thousand eyes and arms to see and reach the multitudes. Buddha stayed as guru until he taught Avalokiteshvara the final knowledge of meaning: that any why can overcome every how.

Reborn in the highest realm, remade from the ultimate reality, and prepared with a meaning that gave him more than Sisyphean strength, Avalokiteshvara rose from the darkness, outstretched his many arms, opened his many eyes, and emanated an ineffable compassion that could be seen and felt then, now, and always. To this day, it is likely that more prayers per second go to Avalokiteshvara than any other deity. Om mani padme hum (“The jewel is in the lotus”) is chanted repeatedly with great hope of eliciting the help and beautiful compassion of the divine, thousand-armed Bodhisattva.

Avalokiteshvara and Modern Therapists
As therapists, we might not be able to comprehend what it means to vow to save every living being, but we certainly have chosen a career path that leads us toward helping others. We might not know the exact pain that shattered Avalokiteshvara into countless pieces, but we can most likely all identify with the feeling of being shattered from believing that things were “supposed to be” one way in our lives, only to find out that they were not as we “expected” them to be. We might not know what it is like to have a thousand eyes and arms, but who among us has not wished to be able to help more than one person at a time?

The story of Avalokiteshvara can be an encouraging tale for every therapist who gets worn out from time to time. Whether the quest to help others achieve peace is laid out on a small scale or a grandiose one, the pursuit is the same. When we find ourselves shattered, lost, and overwhelmed, we can rely on each other. After all, even Avalokiteshvara had the Buddha for support. For each of us individually, we have no more than two eyes and two arms; collectively, however, we have more than a thousand eyes and arms. As a unit, we can rely on each other for strength and inspiration.

When we turn to resources like psychotherapy.net, professional organizations, and libraries, we are able to draw on the knowledge of our fellow practitioners. By the wisdom we gain in books and videos, we can approach our clients with the strength of a thousand outstretched arms of our colleagues, past and present. Through constant learning, experience, insight, and support, we can extend loving-kindness to meet our clients where they are, and help them expand their consciousness on their own paths to peace. In short, we can let the “why” for what we do overcome the seemingly insurmountable “how.”

Regardless of how many clients we may have helped along the way, as long as our doors remain open, there will always be new people who walk through them. No matter how strong our desire, we cannot save everyone, but that is because we cannot save anyone. All we can do is extend compassion to others, offer some insight along the way, and observe. We cannot live life nor even make a single choice for anyone but ourselves. What we can do, however, is continue to pursue the path of helping others. We can choose to not give up no matter how difficult that path turns out to be. We can turn to each other for support when we need it. In the end, we can choose to be thousand-armed therapists by recognizing the limits, possibilities, and realities of our own two arms.

Leave Your Degree at the Door, Dude

Posted on by Psychotherapy.net Team

The late 1960s and 1970s were exciting times for the fields of psychology and psychotherapy. Much of the enthusiasm was spawned by a body of landmark research. At the time experts postulated that humans had two distinct nervous systems: the voluntary and the involuntary. The voluntary nervous system allows you to brew your morning cup of Joe or take out the trash before you leave for work. The involuntary or autonomic nervous system controls your heart rate, blood pressure and the temperature of your baby toe. According to the existing theory, a human being could not control his or her involuntary or so-called autonomic processes. But all that was about to change.

Enter Neal E. Miller, a prominent psychologist and a past President of the American Psychological Association. By paralyzing animals, and hence knocking out voluntary responses, with curare (often dubbed South American dart poison) Miller demonstrated that involuntary or autonomic/automatic responses could indeed be controlled. And although later research would sometimes fail to replicate Dr. Miller's results, the implications for the human potential movement were staggering. If indeed Miller was correct, humans could do things to control their behavior that were heretofore considered impossible!

During this same era, the Menninger Foundation, a longstanding psychoanalytic foothold, located in Topeka, Kansas was doing some experiments that seemed to back up Miller's assertions. Subjects were asked to hold glass mercury thermometers and told to raise their hand temperatures. Not only did many subjects accomplish this, but as an added benefit, these same individuals often experienced relief from migraine headaches. When Miller was informed of this fact, folklore has it that he smiled and merely quipped: "I believe that in this respect men are as smart as rats."

Slowly but surely, thermometers and the like were replaced with sensitive electronic devices called biofeedback meters that gave subjects and clients the superior feedback necessary to make bodily changes at will.
With Menninger at least partially leading the charge, biofeedback seemed to be the coming thing in our field and I wanted to be on the cutting edge of the breakthrough. Luckily Menninger was offering brief biofeedback training sessions and as a graduate student I immediately applied.

I mean how fun would that be? I would get in my favorite car of all time and drive from St. Louis to Topeka—310 miles—to receive the best training of my life. The make and model of my favorite auto of all time are irrelevant to this discussion . . . okay, okay you twisted my arm . . . it was a 1965 Oldsmobile 442 and yes it was fast enough to get even the most conservative driver in a heap of trouble.
But as John Lennon once quipped, life is what happens when you are making other plans. Certainly, it proved true in my situation. I blew the clutch out on my 442 dream machine and thus an intercity bus transported me to the Mecca of biofeedback training.

The training was blow-away awesome and reached a zenith when at the end of the day's workshop we were given the exact temperature feedback monitor units Menninger was using to train clients to take home and experiment with. These biofeedback devices were manufactured in Lawrence, Kansas. Yes indeed, these gems were made in America and resembled a lunch box Larry Mondelo might have been toting in a classic Leave it to Beaver episode. In reality, the unit was a ultra sophisticated thermometer with 3 3/4 inch meter on the front. It would take a baseline, track the client's progress (or lack of it), and even had onboard calibration capabilities. We had the option of purchasing the units if we liked them and I did just that.

As for me, you won't find mine for sale on Ebay. After my brief training at Menninger I used this little gem to help hundreds and hundreds of clients with anxiety, habit control issues, and migraine headaches. It also came in handy for performing hypnosis and systematic desensitization; but that's a tale for another blog.

But here's where the story gets very interesting. On the night I took my unit home I had fairly good success raising the temperature of my hand. This practice was theoretically helpful in combating anxiety and once again helping those with migraine headaches.

As I was walking from my hotel to Menninger the next morning I spied a psychiatrist who was in my training class.

"Hey how's it going?" I asked.

"Not well. This biofeedback stuff is junk," he told me.

"What do you mean?"

"Well," the psychiatrist asked," were you able to make the temperature on your meter go up."

"I was," I proudly announced, "but I take it you could not."

"Right. My meter did nothing," lamented the psychiatrist.

"Look," I said trying to be nice. "It could be the biofeedback meter they gave you is defective."

"Ha. I don't think so," he responded. "I let my five year old son play with it and he was pegging the meter on super hot so easily I had to reset it several times for a higher temperature."

"Okay," I calmly responded. "I think I have an answer for you. You know too much. I mean look. Your five year old doesn't know squat about the nervous system. You tell your five year old that his hand is getting hot or to imagine that he is outside on a warm sunny day and presto . . . his hand temperature genuinely goes up. You, on the other hand are a medical doctor. Therefore, you know all these facts about the central nervous system versus the autonomic nervous system. You know the traditional theory forward and backward. You can tell me with great detail why a person should not be capable of raising his or her hand temperature. Too much traditional knowledge can be a dangerous thing."

"Al-right Rosenthal, maybe, just maybe, you are correct. So what in the heck should I do about it?"
"That's easy," I replied, "Just leave your degree at the door dude!"

"Hmm. Well what about you Rosenthal. Are you going to leave your degree at the door?"

"Not me." I said. My degrees are nonmedical and not focused on physiology. I might just know less about the nervous system than your five-year-old son. So, to put it bluntly, I'm good to go."

Just Peachy

Posted on by Psychotherapy.net Team

It's getting colder in the Northeast. I love it—mostly I do—except that I am colder than cold, colder than most folks. I feel it in my bones. My husband and I are Florida bound for vacation soon, and then, we think, to live. Not just yet. The kids need a bit more raising first.

So with the cold coming and the time being ripe, we take the kids (the same ones who still need a bit more raising, and two that are raised mostly) and we head to a peach tree orchard.
If you've never been, I cannot recommend it highly enough.

First, there was the utter joy of traipsing along a raggedy dirt road with nothing but corn fields and blue sky for the eyes to bump into. And the dragging—schlepping—our big container boxes at our sides, thumping and banging our thighs as we make our way to the orchard’s entrance.

And then, and I'm telling you—maybe it’s because I sit in my office for hour upon hour using all my ears (at least three, right?) to understand all the sorrows and stories, the doubts and the dreams, the longings and the fury and the unwillingness to be willing to be willing, and listening for all those “pesky little problems that lurk in the unconscious” (thank you Hedda Bolgar, may she rest in peace)—that upon entering that peach tree orchard, I felt like I had walked into paradise.

All of a sudden all my angst about drives and character and the complicated puzzle of the human heart and psyche dissolved under the shelter of hundreds of bumpy old peach trees.

Row upon row of overgrown knotty trunks with row upon row of green-turning-yellow leaves. No more sky, well, some peaking though here and there, and a hushed world of absolute peace. We stumbled endlessly under a canopy of fat fruit, inhaling some intoxicating mixture of smushed peaches underfoot and clear fresh farm air.

I was absolutely high from it.

And from the breather. From being reminded that there is a world outside, and a world inside that is not fraught with emotional suffering, warring spouses, mind bending grief, anger, abuse, rebellion, confusion. A world where all the simplicity has not been squeezed dry. A place where the only social media was the whispering of the trees and the glee of pulling fruit, each one prettier than the next. Even the bruised and battered ones were holding their own, smiling to me, it seemed, and saying, “Hey, we’re okay up here, even though we’re a bit dented and mushy, we’re holding our own.” This too gave me joy.

It reminded me that sometimes I get so immersed in the work of hearing and healing and sorting through the pain and the issues and the obstacles, that it’s just not as urgent as it sometimes feels. That sometimes it just is what it is. And it’s okay. It’s okay just to be there. We can’t—we don’t always have to—figure it all out.

And when it was time to walk out of the orchard with our full baskets we were full of something else that none of us could quite put into words.

Perhaps this:

That even though we can’t live in the orchard, the orchard can live in us, and that when we take the time to take time out, and go back to basics, there really is place where everything really is just peachy.

Dial-Up Connection

Posted on by Psychotherapy.net Team

Thirty-five years ago I got my first paid therapist job as a second-string telephone counselor for an enlightened radio station in Sydney, Australia. The radio station ran a daily one-hour program called “Kid’s Careline,” and my boss was the first string counselor who fielded on air calls from the radio audience. She was so brilliant at it that she kept three of us second stringers busy 9 to 5 fielding the calls that did not make it onto the air.

It was in this job that I began to learn about the unique power of telephone counseling. Stints of supervising and fielding crisis phone calls at Suicide Prevention and Parental Stress Services in Oakland enriched my learning. These experiences eventually culminated with me adding telephone counseling to my private practice, which I have done for the last 20 years.

I have an Intersubjective/Relational approach and specialize in working with individuals whose traumatic childhoods have burdened them with Complex PTSD. I am excited by my accumulating anecdotal evidence that significant attachment repair work can be done over the telephone. I have especially noticed this with clients whose trauma is so extensive that they are incapable of handling the anxiety of face-to-face work. Some of my clients have lived reclusive lives but sought me out because my website articles explain how their childhood traumas created their attachment disorders.

Complex PTSD survivors typically operate from a deep belief that “people are dangerous,” and feel less endangered on the phone because they know that they can escape in a second if necessary. Moreover, the phone seems to offer them enough protection, that they are able to drop into authentic and vulnerable relating quite quickly with me—often more quickly than new clients in face-to-face sessions. Once again, I believe this is because phone work offers them a greater sense of safety.

Telephone therapy can foster a uniquely rapid building of trust. In best case scenarios, as with in-person work, this eventually encourages some clients to look elsewhere for similarly trustworthy relationships. More than a few of my telephone clients have experienced enough relational repair within two years of weekly sessions to venture out successfully into the world of real live relating. Often this starts with participating in online support groups, and then expands into joining in-person groups.

I believe that part of the healing dynamic in phone work is that voice contact can be as soothing and brain-changing as the eye contact that seems so fundamental to forming attachments. I wonder, in fact, if voice contact is even more fundamental than eye contact, as the soothing sound of a mother’s voice may be laying down the framework for bonding long before the baby is born. Moreover, as most seasoned therapists know, voice tone, timbre and pitch carry a great deal of emotional communication. The client’s voice can tell us a great deal about her unexpressed distress. And our voice can carry our good will, compassion and, dare I say it, love to the client.

As I write this I flash back guiltily to my adolescence and my dog, Ginger. I once unconsciously experimented with teasing her with the tone of my voice. I soothingly and sweetly told her “You are a very, very bad dog Ginger!” and her dog smile lit up her face as her wagging tale oscillated furiously. Then I switched to an angry tone: “Good dog, Ginger, Good dog!” As I vituperated she fawned nervously and her tail disappeared between her legs. Now I flash on my mother lambasting me throughout my childhood: “Of course I love you!” and 60 years later, I feel my whole body contract and imagine my ears lowering like Ginger’s.

And now let me free associate further. I think of three different friends whose parents read to them as kids, and who still love to be read to. My parents, on the other hand, frequently spoke in tones of anger and disgust, and despite a great deal of attachment recovery, I still find little pleasure in being read to. My nine-year-old son, however, drinks it up like soda. When I come home and sit on the couch he often leans into me and croons: “Read to me, Daddy!,” and lucky man that I am, I still get to read to him for hours every week. We’re on our ninth Gordon Korman book this year. (Gordon Korman is a brilliant children’s author whose books are wise, funny and replete with emotional and relational intelligence.)

Coming back to the issue of therapy, I feel I now understand why traditional psychoanalysis works so well for some clients, despite the analyst sitting out of view behind the couch, and despite the criticism some attachment therapists express about it lacking the intimacy of eye contact.

Calisthenics in Front of the Fun House Mirror

Posted on by Psychotherapy.net Team

Sometimes my days bring to mind a funhouse mirror. I stretch, collapse, widen, or shrink depending on the clinical demands of the moment, fundamentally changing and fundamentally remaining the same, moment to moment and hour to hour.

Yesterday in my first session of the evening I was speaking with a young woman about the reasons for her recent spotty attendance. I fielded an interpretation that I know in every molecule of my being is correct, that she is trying to convince me of her essential badness and test if I will give up on her. She looked me dead in the eye and said “that is probably the stupidest thing I’ve ever heard in my life.” I had to laugh. I can’t in all honesty say I delight in being called stupid, but I do enjoy her feistiness. And I know I have spoken to a part of her, a part she thinks is stupid and vulnerable and wrong: she will show up next week.

In my next session, a client is debating having an extended family session that would include several out-of-town siblings, including a brother who happens to be a psychiatrist. I’m a little excited and more than a little intimidated by the prospect of this highly trained and reportedly difficult fellow professional in the session. My client is talking about who she would like to have present in the session, and I am feeling uncomfortable because I don’t know the answer. Partly I just don’t know, partly my own anticipatory anxieties are getting in the way, and partly I am feeling her anxiety. I feel myself stalling out, but then remember with a sense of relief that I don’t have to know the answer. How is it possible to forget this so many times? We explore her feelings, and the answer reveals itself.

The next session I’m feeling a bit tired, and I don’t know if it is because of the couple I’m about to see, or the time of day. Normally, it would be dinner time, and a handful of almonds and an apple weren’t the dinner my body had in mind. My body clock and the darkness outside are telling me it is time to settle in at home. So I’m not sure if it is my tiredness or my sense of the emptiness between these two, the complete absence of anything that to me feels like love, only the graying embers of duty and convenience, that makes me say “you are trying to live in a house without a roof.” He is sad, she is angry. They leave my office no closer than before. I feel like a dejected salesperson with a useless little pile of tools and skills they don’t want to buy.

I have a second wind for my final client, thankfully, because she is ferociously smart, and not a bit hesitant to call me out on any foolishness, inaccuracy, or inattention. I worry sometimes that the sheer intellectual pleasure of a conversation with her can be a distraction for me, diverting me from the emotional issues that she needs help with. Tonight we talk about lies, and the truth in lies. It is a conversation that seems to twist and skitter with a life of its own; I feel like we are both following this path together, uncertain of its destination. These are the sessions I like the best, when I feel fully engaged as both participant and observer.

By the end of the night, I feel good. It was a satisfying night; I feel like I did my work well. But I’m tired. Really tired. I think to myself, how can it be so tiring, just talking to people? Then I consider: in these four sessions I felt foolish, anxious, sad, excited, inadequate, engaged, uneasy, tired, impatient, admiring, relieved—and that’s just for starters. I have been stretched and twisted and pulled in many different directions. I have had my own feelings, I have had feelings in response to another’s, I have felt the feelings of others. I have seen myself reflected back in many shapes and forms: stupid and clumsy, idealized, frustrating and dangerous, for a beginning but by no means complete list. Odds are I haven’t identified or sorted half of the feelings or realities that have floated through my little office tonight. Four hours of emotional calisthenics in front of a fun house mirror. Oh right, that’s why I’m tired.

Technology and Psychotherapy

Posted on by Psychotherapy.net Team

A recent article on a study from the University of Zurich offered the headline, "Psychotherapy Via Internet as Good as If Not Better Than Face-To-Face Consultations." It does not surprise me when I think about many of my clients’ everyday lives in the Bay Area: technology tends to be seen for the most part as a fun, useful and normal part of life. It also makes sense when I think about the ways that technology, if wielded strategically, can sometimes make things simpler and more immediate. Grandkids and grandparents all over the world would agree (thanks Skype!), as would families with service members deployed in far-off countries.

Here's a quote from the article in Science Daily about the online psychotherapy study, "In the case of online therapy, the patients tended to use the therapy contacts and subsequent homework very intensively to progress personally. For instance, they indicated that they had re-read the correspondence with their therapist from time to time. ‘In the medium term, online psychotherapy even yields better results. Our study is evidence that psychotherapeutic services on the internet are an effective supplement to therapeutic care,’ concludes Maercker [one of the study’s authors].”

Skype therapy could improve outcomes while it lowered the barrier to accessing therapy. In one way of thinking about it, what was once a trip across town and a 2-hour commitment is now 50 minutes at one’s desk.

But I notice a conservatism and even a bit of prejudice against technology use among therapists: Skype, texting, online scheduling, and other things can be treated as if they are volatile substances when in fact they are more and more a part of everyday life, used by lots of people to great effect. Therapists can benefit from remembering the wisdom that often what seems unstable and jarring to an older generation is soon enough just “the telephone”—utterly banal and safe.

A few years ago a former Supervisor warned me against texting with clients about appointments and scheduling shifts. When I questioned him further, however, he admitted that email was ok for this, and that he emailed with clients about appointment times, though not clinical material. Most therapists under forty who I ask about texting with clients say it is the same thing—just a quicker form of email. I have even heard a client assert, “It’s rude to call someone on the phone now. You interrupt their day and make them say ‘how are you?’ Texting is more polite, faster, and doesn’t require needless formalities.”

I think that the obvious insight here, that technology changes and what seems outlandish today will soon be normal, can go one step further. What if therapists could harness the excitement and convenience of technology to improve our usefulness to clients and to improve our ability to help clients change their lives?

I've been thinking a lot about therapists and technology lately, as I have been part of a group testing out a new mood-tracking app called Senti. With Senti, users answer a few relevant questions about mood and emotion throughout the day and Senti keeps track of how they seem to be doing. The questions both track useful information (“Thursday tend to be a rough day for me”) and also function as a mini-intervention, just as if someone had texted you to say, "hey, put your feet on the floor, take a deep breath, and tell me how you're really feeling right now."

But when I described the app to another therapist she was skeptical. "It sounds great," she said, “but therapists are late adopters. You'll never get them to use it with clients." Similarly, The New York Times recently ran an article by therapist Lori Gottlieb with the headline, "What Brand is Your Therapist?" In it, she ponders whether therapy as we know it is a think of the past. "I hate to think that therapy is an outdated idea, too slow and too private to satisfy a population that has come to expect immediate responses and constant gratification."

I see people each day needing help coping with divorce, eating disorders, anxiety, depression, and other problems that cannot be repressed and forgotten and that need attention. There is a great need for inner work and for the relief of human suffering. Rather than thinking technology is a barrier to connection, we can ask what Darren Kuropatwa asks in his presentations about technology and learning: “What can I do now that I could not do before?”

What if instead of a necessary evil, technology could facilitate a different kind of depth—the depth of a therapy that can be held by a client in their hand; where self-support, self-inquiry, and a therapist at the other end of the wi-fi connection make transformative work more possible? After all, there is nothing about Skype or about an email exchange that is inherently glib or false. What matters is the content and the material and the depth to which the client can face themselves, with the powerful support of another person trained to be of use. Whether the therapist is on Facetime or tweeting reminders to followers to pause and breathe when angry feelings erupt, what matters is that people get better and the world gets better. And for that project we need every tool we can get.

Talk is Cheap. Really.

Posted on by Psychotherapy.net Team

A few days ago, I read yet another article comparing the costs and effectiveness of psychotherapy and medication. While both have benefits, the article stated, medication is cheaper. Hmm. I wondered. My insurance company has a handy calculator that allows me to estimate the costs of various types of care, so I figured I’d check it out.

Well, as it turns out, generic antidepressants are pretty inexpensive—definitely cheaper than psychotherapy for insured and insurer. But let’s consider my modal client. You’ve all worked with someone very much like her. She is a midlife woman with trauma, a history of addiction and/or an eating disorder, and a lifetime collection of upwards of a dozen other psychiatric diagnoses. She occupies that portion of the diagnostic map variously labeled as bipolar, borderline, or PTSD. She has had several therapists and hospitalizations, and has had numerous trials of medications. She is rarely just taking an inexpensive generic antidepressant.

Suppose, like many, she found that a brand name antidepressant was more effective for her than the generic? Or that she had already tried just about everything and needed something “new”” Ahh. Let us ask the expense calculator. Twenty dollars for a month’s supply quickly jumps into the $150-200 per month range for a newer drug such as Pristiq, or even for a brand medication that has been around for decades such as Effexor. And suppose that little black rain cloud is still following her around? Suppose she needs a little dash of Abilify to amplify the effects of her antidepressant? Well, now we’re talking. Adding the lowest dose of this medication would add just under $700 per month (sometimes used similarly, Geodon is about half this cost, Seroquel less than a quarter). So now the cost of her medication is up to $800-850 per month. If we create a pharmaceutical cocktail that is far from uncommon by throwing in a mood stabilizer, or maybe a benzodiazepine or sleep medication (Ambien and Lunesta are impressive at over $200 per month), the price tag soars even higher.

Granted, assuming you are fortunate enough to have insurance, this is not the out-of-pocket cost. A client with insurance will pay a co-pay that is generally tiered, with generics and “preferred” medications costing less than brand products. Brand products can easily cost $50 per month, often more. So let’s see, with a brand antidepressant tweaked with Abilify we get $100 per month for the client, and, so the insurance company tells us, $750 ($850 minus co-pays) for the insurance company, or $1200 per year for the client, and a whopping $9,000 per year cost for the insurance company. If I were an insurance company and I were telling the truth about my costs, I’d really be thinking about talking up talk therapy.

Now let’s look at the costs of psychotherapy and imagine that a therapist might be paid by an insurer at a “reasonable and customary” rate of $100 for an individual session (and for many areas of the country, this would be a very sweet dream indeed). Say you see your client once weekly. Perhaps your client’s co-pay is $40 per session, or $160 per month. The insurance company pays a balance of $240. Say, though, just for kicks, the insurance company has set its rates just a tad lower. Suppose they set their R&C at $65 per session. Let’s give our client a $25 co-pay, leaving the insurer responsible for the $40 balance. Anybody seen this? Checked out Medicare rates lately? At 44 sessions a year (the number of annual visits I estimate for a weekly client, given illnesses, vacations, etc.) the $100 session costs the client $1760 per year; the insurer $2640. The $65 session costs the client $1100; the insurer $1760. Now return to Paragraph Four and review the annual costs of a newer or brand antidepressant and Abilify.

You will say, fairly, that I’m comparing an expensive medication option to a typical psychotherapy option. Yes, I am. But this happens every day in my practice—I am providing a typical psychotherapy protocol to clients on complex and expensive psychiatric medications. You will also say that no one would treat this modal client with only medication or only talk therapy, and you would probably be right. It should not be an either/or issue. We could wonder, however, for the sake of argument, which option offers your client or their insurer the most bang for their buck? Is it one year of Abilify for $8400, or one year of weekly individual sessions at $100 for $4400, or one year of individual sessions at $65 for $2860, or, heaven forfend, one year of twice weekly sessions for $8800 (at $100) or $5720 (at $65)?

Co-pays of course increase the cost of psychotherapy to the client. Twice weekly sessions for our $40 co-pay client add up to a hefty $320 per month. This reality is probably partly where we get the idea that therapy costs more. But in the total dollars that someone is paying—insured and/or insurer—it is not always quite so clear. If the total cost is roughly the same, how do we assess the relative value of 365 pills vs. 88 sessions of psychotherapy for a complex client? A year of Pristiq and Ambien or a year of psychotherapy? What is their relative potential for healing? How do we measure their respective long term effectiveness? How do we compare potential side effects? Who is benefitting from the argument that medication is cheaper than psychotherapy? Who funds outcome research for medications? Who funds outcome research for psychotherapy? Who is framing our discourse? Let’s talk about it.

Clocked

Posted on by Psychotherapy.net Team

I once took an informal survey of clinicians to find out a) where in their office they keep their clocks and b) how they ended their sessions. I found out we are a crafty lot indeed. Clever too.
Some of us keep a big round clock somewhere behind where the client sits, so it can be seen either directly or with peripheral vision at all times. Some of us rely on our wrist watches. Some of us sport large analogues and others digital, depending on our vision. This enables seemingly nonchalant glancing at the time without being too obvious. And some of us try to glance at the watches of our patients if they are wearing one.

Others have clocks that are in the direct line of vision of the patient, and others have a clock (some digital and some analogue) that can be seen easily by both patient and therapist.

Some of us have patients who lie down on the couch, thus giving us carte blanche to not only look at the time as many times as we’d like, but stare at it the whole session. (Not that many of us do that.)
Some of us admit to looking at the clock not just for time keeping, but as an action of sorts. And we might be well served to study why, at any given point in a session, we are prompted to check the time. What feeling are we avoiding? What feeling are we having? What is or is not happening in the session that prompts us to look at the clock? And moreover, do we feel glad if there is a lot of session time remaining, or disappointed?

You are just keeping time, you say.

Not so fast.

I am always interested in what prompts my clients to check the time in session. When they check their watch (or my clock, which is irritatingly difficult for both me and them to see) I ask “too much time left or too little?” Some folks shrug. Others give credence to the question and we explore it a bit. What are they not saying with words that they said by checking the time? (Why have I not, in all my years in practice, gotten a better clock, I don’t yet want to understand.)

And then there’s how we end our sessions. My own analyst simply gets up from her chair. I could be right in the middle of the most amazing insight, the most painful memory, and all the sudden she is lurking somewhere in my peripheral vision. Her clock is not where I can see it, nor do I wear a watch. And I lie down on the couch for my sessions, so if she did not make herself visible in this way, I would just keep talking.

By the way, I dislike this practice. For a while, she switched, at my behest, to saying some version of “well, it’s that time now.” Subtle? Gentle? Not so much. But what are the options? Some of us say, “It’s time to stop.” Or “Our time is up now.” Other possibilities: “We have to stop.” “The session is over.” Or “Time to wrap up for now.” Or “We will have to pick right up with this next time” or “Okay, then,” accompanied by a nod of sorts. Some of us start fidgeting in our chairs, reach for our appointment books, or make an obvious glance at the clock (wherever it happens to be).

One colleague friend of mine who has been practicing for many years tells me that even though she herself does a good bit of clock watching, when she sees her own therapist checking the time she feels wounded. She assumes that her therapist is anxious to end the session and get rid of her. They’ve unpacked it of course, and agree that it’s quite similar to her experiencing her mother as always having been in a hurry to rush off somewhere, leaving her to her own devices. And no matter how her therapist ends the session she always seems to feel a rush of rejection.

I suppose I’m given to wondering how much it matters really. How we keep time and how we close our hours. But I think there is meaning to it. Like everything else we do in session, how we run things can leave a quiet emotional hand print, and it may be good to study it a bit. All in good time of course.

The Power of Custom in Psychotherapy

Posted on by Psychotherapy.net Team

It’s the kind of telephone call that every therapist gets and every therapist hates to get.

“I’m sorry to disappoint you on such short notice, but I can’t come in today.”

It was a patient who had come only once before, the week prior, and though he was articulate about what troubled him, one could discern that he was deeply conflicted about whether he even wanted help at all to solve his problems or even ease his difficulties. So it was no surprise to me when he attempted to cancel.

But here he was, live on the phone, the morning of his appointment, his words saying one thing, I’m not coming—but his voice full of conflict and ambivalence. One could sense the pulse of life in him, fragile and quivering.

Patients cancel with painfully short notice or sometimes with no notice at all. That is the way of the world. It’s a loss for them, for you, a loss of money and time. Most often there is little to be done. You put the receiver down and regrettably, you write them off. People will be people, you tell yourself. But every once in a while, you get a feeling that someone who ordinarily might cancel, ought to be encouraged, encouraged that is to keep the appointment. Was this one of those people, I wondered.

“Is there anything keeping you from making your appointment today?” I asked.

“Well, it’s just that as I explained last week, I wasn’t sure if I wanted to come at all…”

“Yes, you are in conflict, that’s true. But you know it is customary, usual and customary that is, to keep appointments unless they were canceled with 24 hours notice. You’re aware of that custom, aren’t you?"

“Hmm…it’s a custom? I suppose it is,” he said haltingly, sparingly. Okay, I will keep the appointment.” And so it was.

What is it about customs that seem to excite less resistance while “laws” and commandments appear to excite more resistance?

From my own experience it would seem that "customs" act in some sense seem to lubricate the traumatized psyche to negotiate the torturous demands of id and superego while "laws" further tighten an already overloaded, cramped psyche.

***
In my neighborhood of Orthodox Jews there are many families with young children. One mother once came to me a couple of years ago. “My 8-year-old daughter, she refuses to take a bath or shower, even on Fridays before the Sabbath.”

“What do you tell her?” I ask.

“I tell her that she has to do it; that she smells or will smell very badly and no one will want to be near her or even come to play with her.”

“And what is her response?”

“It seems to make her even more stubborn. She won’t do it. She says she doesn’t care. She just won’t.”

“Consider telling her that it is the custom in Passaic, New Jersey that girls take a bath before the Sabbath—emphasize that she doesn’t have to, but that is the custom. Say this and no more.”
The mother followed through with the suggestion and reported back to me with pleasure and satisfaction: “My daughter said, ‘if it’s the custom, then I will do it’ and she went into the bath just like that.”

The Ones That Get Away

Posted on by Psychotherapy.net Team

On sunny days, the koi rise to the surface of the pond. Occasionally a particularly interesting one rises through the murk, and for a few moments it is clearly visible in all its mottled, sun-dappled glory, fins lazily stroking the water, eyes unblinkingly assessing my shadow before it propels itself back into the depths.

That is the image that comes to mind when I think of Cassie. She contacted me initially through an email, sending me a clear, carefully composed assessment of her situation that ran to several lengthy paragraphs. She said she could not maintain relationships. She could go to work, but otherwise was almost unable to function. She had no close friends or family. She became dissociative and unbearably anxious whenever she tried to talk to anyone about changing her life. Beneath her insightful description of herself there was a barely muted, desperate plea for help. I was hooked, and I responded carefully, aware already that any hint of impatience or intrusion would send her back to the bottom of the pond. I offered an appointment time, and she accepted in just a few words: already I was becoming real, and real made her wary.

In my waiting room on the day of our first appointment I found an elfin, fair-skinned woman with a dancer’s grace and a mass of auburn curls piled loosely on her head, stray tendrils curling over her cheeks and forehead, a scatter of freckles on her nose, tight jeans, black boots, green sweater. She was as carefully composed as her prose. She was well spoken and seemingly calm in the session, except for the constant trembling of her slender, pale hands. I tried to negotiate an impossibly fine line between keeping the session safe (she had warned me that she could not talk about her experience of abuse without dissociating) and getting some kind of rough history and initial therapeutic conversation going. I suspect part of her would have preferred to just sit silently and observe me, getting used to me and my office, my odds and ends, my clothing, my books, my body language.

In fact, it was soon clear that she wanted me to divine her needs and tolerances as a mother would—a fantasy mother, the one she never had. She wanted me to guess when she was tired, hungry, overstimulated, playful. When I didn’t get it exactly right, she was irritated and frightened. Like an infant, she could only protest–no, no, no!–when I inevitably got it wrong, but she could not or would not give me further direction. If I tried to offer her something concrete like specific coping skills, for example, her quick and analytic mind rejected my suggestions as facile and superficial. When I tried to offer her something nurturing and digestible like a supportive comment, my shadow inevitably fell on her, and she flinched away, diving deep.

We managed two or three sessions before I went too far, discovering something she did and didn’t want me to know about her secret world. She admitted she had been binging and purging most nights for years.

Immediately it was as if I were a thief who had invaded her home, intent on stealing her treasures, in spite of my reassurance that I could not take her eating disorder from her against her will. She fled from the session and wrote me an email saying she would not return. I wrote her back, leaving the door as wide open as I could. It worked after a fashion: a few months later she returned, but again we lasted only two or three sessions before I got too close and received another emailed goodbye.

Starved and unentitled, it is her pattern to reach out and snatch hungrily, wanting and needing “too much”—an impossible attunement. Her “greediness” is then followed by feelings of regret and shame, exposure and humiliation. She punishes and protects herself by retreating from contact. Binge, purge, restrict. For her, food and relationship are interlocking metaphors for each other. I imagine a sort of psychic double helix that twists around and replicates itself wherever fear and longing converge.

We are in another pause now. Maybe she has burrowed in the mud for a season, maybe she will never return. If I am honest, I am a little impatient, a little frustrated. She has given me a shorter glimpse, a smaller fraction than I am usually granted as a therapist, and I want more, even knowing as I do that getting Cassie in the office regularly will only be a small part of the challenges we are likely to face. Though I am prone to self doubt, I do not dwell on my possible failures with her. She knows I’ve done my best; I know she wishes for the courage to come back. There are no magic words or techniques or interpretations for coaxing her. I just remember her, and hope for her to return to the surface.