Category: Adolescents

The Instant Replay: Reliving a Critical Moment

Posted on by Psychotherapy.net Team

In doing psychotherapy, I sometimes feel like I am wandering with my client through a dense forest of brush and brambles, trying to find a pathway out. Often there is no clear direction or clue, and the way ahead may be difficult. However, there are also times when I have found it particularly helpful to ask my client to return with me to a salient event in his or her life and look at it once again in considerably more detail. This might involve, for example, reexamining a triggering experience or an incident that brought the client into therapy. I call this process of reexamining an earlier event—exactly as the client remembers it happening, moment by moment—the “instant replay.”

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You might do this when the client first brings up such an experience, but often it is best not to do so right away. The event may be too raw and painful when it first comes up in therapy; and additionally, you may not yet know enough about the client to grasp the full significance of this landmark in the larger terrain of his or her life. Consider the following case.

Beth, a fifteen-year-old, had been admitted to the hospital due to explosive outbursts, depression and suicidal ideation. Her anger toward her family seemed inexplicably intense, and her worst outbursts were directed toward her mother. For example, on the day she was admitted to the hospital, she had planned to run away, and when her mother found out and tried to stop her, Beth had threatened to “deck” her mother, had refused to return home and had threatened to jump out of the car when her mother tried to bring her back. When asked about her anger in family sessions with her mother—and sometimes in individual sessions as well—Beth would withdraw into a seemingly impervious and almost catatonic silence. When she did talk about her anger, Beth expressed feeling criticized, and stated a belief that everyone in her family blamed her for all the family’s problems, including the breakup of her mother’s marriage to her stepfather, and the fact that her biological father had stopped all contact with her. She was not convinced by attempts at reassurance that her mother and stepfather had had their own marital problems and that her biological father had stopped contact not only with her, but with other family members as well.

As time went on, another side of Beth began to emerge. Her mother revealed that at times, Beth had written letters expressing unbearable remorse about her behavior and a desperate wish to change. One letter, which was four-pages long, was entitled “The Unconditional You.” It described a story from a book Beth had read about a girl who was ungrateful and cruel toward her mother until she realized with shock that her mother still loved her unconditionally. The letter went on to express Beth’s belief that she and her mother were like the girl and mother in the story. Beth’s mother voiced exhausted confusion about letters like this and the fact that her daughter could still explode into rage toward her, even after writing them. Beth’s mother seemed to have difficulty accepting that her daughter could have such seemingly contradictory feelings.

At about this time, Beth opened up, first in group and then in individual therapy, about her history with her biological father. He and her mother had separated when Beth was very young, but he had continued to visit Beth, and had remained close with her until he moved to another state when she was 11. They had promised to write each other every week. They did so for a while, but a few months later he remarried and without explanation stopped responding to her letters. Beth’s behavior worsened after this.

The day after she told me about this, I found Beth crying in her room when I came to meet with her. She had spoken to her mother on the phone and was feeling hopeless about ever returning to her family. We talked about the phone call, and then I told her that her mother had showed me the letter about the story she had read. I said that I knew how badly she wanted unconditional love but that I believed that her mother couldn’t always give her this kind of love because her mother was dealing with her own problems.

At this point, the time seemed right to do an “instant replay” of the events that had brought Beth into the hospital. I reminded her of what had happened the day of her admission—how her mother had tried to stop her from leaving, how they had argued, and how she had exploded and eventually been taken to the hospital. I asked her to tell me what they had actually said to each other and we reviewed their argument, step-by-step and word-for-word. She described how her mother had attempted to talk her into returning home. Beth had refused, and after more attempts to persuade her, her mother had finally grown exasperated and said “You can just stay [away]! I’ve tried for seven years, and I give up!” That was the moment when Beth exploded and threatened her mother.

“It sounds like it really upset you when you mother said that. It really hurt you and made you angry.”

“Yes,” she said.

“It scares you when your mother says things like that.”

“Yeah.”

“Can you say why?”

“Because I’m afraid my mother is going to leave me like my dad did.”

This was the first time Beth had ever explicitly made a connection between her behavior toward her mother and her hurt about her father.

In the next few sessions, we clarified and extended this insight. Working individually with Beth, I pointed out that when she had felt hurt by some of her mother’s actions, the hurt had been supercharged by the past pain related to her biological father’s rejection. In parent work with Beth’s mother, I explained that Beth’s battle for distance was accompanied by a fear that she would lose her mother completely, leading her to do things that forced her mother to take greater parental control, while simultaneously pushing her mother away. And in family sessions, we explored together how Beth’s feelings about both of her parents had come to be focused on her mother. As Beth said to her mother in one of these sessions, “It’s easier to get mad at the parent who is there for you.”

Somewhere within us, painful memories are frozen in time. Unexpectedly, they may leap to life, opening old wounds. But under the right conditions, we can gain the upper hand over time—revisiting and re-running those painful experiences, freeze-framing the exact moments when we gave them power, and clearing a path to healing.
 

Judith Grisel on Addiction, Neuroscience and Choice

Posted on by rezendevknowfully.com

The Age of Neurophilia

Lawrence Rubin: Hi Dr. Grisel. I first became aware of you when Terry Gross interviewed you on her NPR show, Fresh Air, about your book, Never Enough. You mentioned that after that interview, they led you through a room where they store the hundreds of books they receive each week for consideration. I’m wondering, why did they pick yours from that pile?
Judith Grisel: Three things I guess. One is that we are really in a time in history where we’re very interested in the brain and in science. So, seventh graders appreciate things about the brain that we didn’t even know 30 years ago, and
I think there’s a neurophilia going on
I think there’s a neurophilia going on. Second, addiction is so widespread, practically everybody is touched by it. And third, I also think on my part, being at a liberal arts university and having to speak to students about complex ideas on a daily basis, I must be able to mine the minutiae of scientific inquiry and translate and explain its general principles in a way that people can understand.
LR: That reminds me of Stephen Hawking’s tiny volume, A Brief History of Time. Bringing it to the people, so to speak. What do you hope your slender volume will do that others haven’t in this conversation around the neuroscience of addiction?
JG: My hope is that the readers who aren’t scientists will learn about and be able to appreciate the core principles of brain adaptation—how it adapts to every single drug-related repeated experience that alters the way we feel. Seatbelts and sunscreen were not considered life-saving before the research taught us differently. Now, we understand the risks of not wearing seatbelts or using sunscreen, and both are seemingly simple, but most definitely life-saving practices. I want people to develop that kind of understanding about the brain’s adaptive capacity and drug use. My secondary hope is that scientists who read it will come closer to appreciating what it’s like to be an addict. My hope is that I was able to explain that in a way that made sense to both audiences.

Our Brain on Drugs

LR: You use this term, “neurophilia.” The folks who are going to read this interview may have some neuroscience interest, background or even training. Some may be neurophobic, but many, I suspect are armchair neuroscientists using trendy brain-based buzzwords, but who don’t know how to integrate the fruits of neuroscience into their psychotherapy. How can your book and your work around the neuroscience of addiction help neurophobic psychotherapists?
JG: Well, the first thing I would say—even though I’m not a therapist (and neuroscientists don’t understand it all that well, themselves) is that
there’s a difference between understanding the implications for people suffering with addictions and simply collecting piles of data
there’s a difference between understanding the implications for people suffering with addictions and simply collecting piles of data. I think that there’s definitely a place for all voices and insights to come together and try to work on this problem. It’s certainly not as if neuroscientists have made any great strides. So, that should alleviate some fear.

I also think that scientists like me who are working at a chemistry bench top or with laboratory mice, are looking at little trees or even particular leaves on particular trees. In contrast, I think clinicians are more trained to see the big picture—the psychological and social factors beyond the brain chemistry. I think we need a lot more communication and interaction between the neuroscientists and social scientists and the clinicians actually working day to day with addicts. 
LR: I interviewed Jose Rey, a psychopharmacologist, a while back and he spoke similarly of the importance of communication between disciplines, especially behavioral scientists like therapists. But you are both neuroscientists and I worry that our psychotherapist audience needs a bit of a primer—addiction neuroscience 101, if you will.
JG: I’d first define addiction, even though there is some controversy over that, and the definition changes quite frequently as anybody who looks at the DSM would know. I would say that there are five characteristics of addiction: Tolerance, dependence, craving, the drug use or the activity needs to be detrimental to the person and to their community, and denial. Those five things coming together are what I’m interested in understanding better. And the tolerance, dependence and craving are due to the brain’s adaptive capacity.

Any experience or drug that alters our neutral or baseline affective state—and this is a little different for each person, forces the brain to adapt to try to bring the chemistry in the brain, and associated behavior, back to that neutral baseline. Some people are naturally lighthearted and happy and some are naturally a little depressive and melancholy. Whatever their particular neutral is, it is the brain’s business to try to figure that out and return to its neutral position. The pathology arises when that neutral baseline is going up and down like wild all the time because of constant ingestion of drugs, because, in part, the brain is unable to sort what’s happening and do something about it.

I drink coffee every day, and what is going on in my brain is a good example. I am completely addicted to coffee. The only good news is it doesn’t cause any problems for me, so you can say maybe I’m not addicted; I’m just dependent. When I wake up in the morning, I am unable to really think or communicate until I get the coffee. I don’t wake up like my 16-year-old does, hopping out of bed and ready to go. I wake up like I’m in a coma. I get a big cup of coffee, and then I feel normal. That is true for every drug. If you take benzodiazepines regularly to deal with anxiety, your brain produces tension and anxiety so that now the benzos make you feel okay and without them you’re a wreck. The brain does something similar, but in the other direction with opiates.

Opiates affect our neutral or baseline affective state. They make us feel great. The brain makes us feel crappy to counteract that and bring us back to an affective neutral. When we take away the opiates, then we just feel bad and miserable. And that’s true for any drug: alcohol, stimulants, marijuana. I think, if I were
working with clients, I would want them to understand that their using has diminishing returns as the brain adapts
working with clients, I would want them to understand that their using has diminishing returns as the brain adapts. 
LR: The brain is always trying to pull the body and affect back to neutral?
JG: That’s right. It’s necessary for survival.
LR: Can you quickly run through the different classes of drugs and how they affect the brain and behavior differently?
JG: Let's start with the most complicated drug, which is also the smallest molecule—alcohol. Because it's so small and can go anywhere, it diffuses easily through membranes, and acts very promiscuously throughout the brain, including making us sedated, euphoric and less anxious.

At the other end of the spectrum are the stimulants; the class of drugs that includes methamphetamine, amphetamine, MDMA. They act in particular spots in the brain to enhance the amount of monoamines—dopamine, norepinephrine, and serotonin—in the synaptic spaces. By acting locally that way, they do two things. They make you more active behaviorally, so that's why they're stimulants, and they also make you euphoric, because dopamine works more directly in the mesolimbic system.

THC also acts all over the brain, like alcohol, but unlike stimulants it has a unique mechanism of action. THC mimics the endocannabinoids which can swim upstream across a synapse—it's a really unique pharmacology. The presynaptic cell sends a message to the postsynaptic cell, which on occasion makes these endocannabinoids tell the presynaptic cell, "What you just told me was really important." It can do that all over the brain, because we never know which circuits are going to be responsible for keeping track of important things. And when it does that with THC, then the whole brain thinks things are important, which is why Rice-A-Roni is delicious when you’re stoned.

And then there is LSD and the psychedelics—mescaline, peyote, and DMT, or the stuff in ayahuasca; and those four chemicals are unbelievably selective. They're agonists, so they mimic serotonin at the serotonin 2A receptor, and that action causes the serotonin filter to turn off. So, we can think of serotonin normally as kind of dampening or inhibiting most of the neural activity in the cortex. It's like a widespread filter. And when the filter comes off, things go wild. And so, there's it's kind of unfiltered cortical activation.

The benzodiazepines and the barbiturates are basically alcohol in a pill. The difference between benzos and barbiturates is that the barbiturates can be lethal, and the benzodiazepines cannot, although they both make a mean dependence.
LR: Is this new craze around cannabidiol (CBD) products potentially problematic, because they're touted as non-addictive and non-pharmacological, but useful for everything—like pharmacological duct tape, I guess.
JG: Placebos work for everything, though it's very hard to sort the science from the hype, and I think people are completely lost. On the other hand,
CBD is not dangerous, as far as we know, and if anything, it inhibits the effects of THC
CBD is not dangerous, as far as we know, and if anything, it inhibits the effects of THC, which has been linked to psychosis. There is also some evidence that CBD can inhibit psychosis. So, CBD is not addictive and it's an antagonist to THC. There is great evidence that CBD blocks certain seizures in children. I think overall that the evidence for THC is 10 times messier than for CBD. And one important way it's messy is that we can see that acutely, it helps somebody sleep or it helps anxiety. But because you develop tolerance, my strong prediction is that those returns are going to diminish with time and, in fact, the drug will create anxiety and insomnia, which is what regular users say. They cannot sleep without it. They cannot get through a day without it.

Self-Regulation

LR: When I teach abnormal psychology to my graduate students, I discuss addictions, eating disorders, gambling and even obsessive-compulsive disorders under the broad umbrella of disturbances of self-regulation. Our society seems so hellbent on opposing the body’s natural need to regulate itself into a neutral state.
JG: I first want to point out that this is a terrific example of what we were just saying—that we need both sides. We need the information that neuroscience provides at the molecular level but also the broader perspective that your observation implies. Your broad perspective suggests that all addictive disorders can fall under the umbrella of obsessive-compulsive disorders. Maybe obsessive-compulsive disorders, in turn, are under the umbrella of self-regulation. So, I really think it’s helpful because we’re focusing on some little, tiny detail and missing the big landscape.

I do want to say that we’re absolutely clear in neuroscience that everybody’s innate capacity for self-regulation is not the same. So, some people are fortunate with metabolism of monoamines, for instance, in a way that makes them a little more cautious and less impulsive. Impulsivity certainly counteracts self-regulation. So does frontal-lobe capacity. If you have a large frontal lobe, you’re better able to do it. I think community support and teaching can contribute to that, so I think everybody’s capable of it. I’m still working on it, myself. It’s not easy for me.

I’m somebody who tends toward extremes right away. I think, just to point out another big-picture view of this, it makes sense from an evolutionary perspective that some of us would be tending toward self-regulation and conscientiousness and careful thought and consideration before acting, and some of us would be more likely to swim to the other shore right away without even considering the implications—whether it’s good for the population—because you need both extremes. So, I think if everybody were reserved or everybody was impulsive, it would be detrimental for the whole group.

I do think in certain conditions, like the ones that you alluded to now of our current social institutions, we definitely value more highly the ability to pause, and you’ll do better if you’re not too impulsive, especially with all these drugs widely available. They are high potency and easy to administer. It’s not a good time and place for people who are poor at self-regulation, that’s for sure. 
LR: You say opiates are popular because they are the perfect antidote to suffering. Are we allergic to suffering in this society? We rush to mask it. We rush to medicate it. We rush to therapize it. What is it about suffering that is so abhorrent that it drives millions to drugs and other addictions?
JG: I really love that question. It’s really out of my expertise, so it’s going to be my opinion that I give here, and I can do that best from my own experience. I really did suffer for no good reason as a child. I think I was overly sensitive and tuned in to other people’s plights and confused by the values that seemed to be expressed around me. I don’t know, but I think if I had had an opportunity to talk about this kind of existential confusion, maybe I wouldn’t have found marijuana and alcohol such a sell.

It’s almost a knee-jerk reaction among otherwise sober, sane people to suppress and deny and minimize and escape any feelings of discomfort. Maybe I’m too heavy handed here, but as someone who couldn’t afford to do that anymore, I really think my suffering was the very thing that led to the not so much happy, as the well person.
I think it’s impossible to be well if you can’t face darkness
I think it’s impossible to be well if you can’t face darkness. We don’t have a lot of ways—I know I didn’t find any—to help people face the darkness. If you’re not taking medicinal alcohol, you’re taking medical marijuana. And if you’re not taking either of those, you’re taking prescriptions. If we look at the percentage of people in western societies who are medicating their existence, we are not talking about a physical malady, so much as a psychological malady. I think it’s hard to find people who are models for walking through it. I think that might be a dead end. I have gotten a lot of notes and letters from young people who say, “This is so hypocritical. My parents say, ‘Don’t smoke weed’, My parents say, ‘Don’t do this,’ but they do these things.” I even had a therapist the other day tell me, “Well, alcohol’s not really a drug.” I think that we’re all in denial, I guess. Not maybe you, but many of us. 
LR: Well, it seems that—and I know you’ve studied evolution—that an anesthetized and a medicated society does not build a stronger society.
JG: So true. If there was ever a time not to check out, maybe you could say this at any time, but I’m saying it now.
This is not the time to escape our reality.
This is not the time to escape our reality.

Choice Versus Addiction

LR: In the latter part of your book, you say the opposite of addiction is choice. Some would argue that’s a bit on the simplistic side; especially those who say it’s a disease.   
JG: I’ve gotten a fair amount of pushback about that. We were so bad at solving addiction and the NIH and NSF were funding all this research on addiction and Congress, probably about 15 or 20 years ago, said, “What’s wrong with you guys? Fix it.” At that time, we didn’t understand how the brain works. Like the “No Child Left Behind,” they thought if they made an edict, it would solve the problem.

So, scientists realized, “Well, we’re not going to fix it if our criterion is that people are well.” So, we’ve said, now, that you can minimize the harm—reduce the harm—and that’s partly strategic to say, “Look. We are being successful.” Suboxone is better than overdosing on fentanyl. I completely agree. So, I’m not dualistic about this; that you’re either clean or you’re not and too bad. I really think every single strategy should be employed.

I think we’re diminishing our potential by capitulating to this quasi-existence where we’re not really engaged with reality but we’re also not dying. So, I think short-term strategies are terrific, but I object to giving someone a prescription for a substitute drug and sending them on their way. The causes of their excessive use, I think, need to be looked at. For me, it was a really hard, multipronged effort on my part and on the part of a fair number of professionals before I was willing to take responsibility.

This may sound trite, but
in order to be free, you have to take responsibility
in order to be free, you have to take responsibility. I think, in some cases, people don’t want that. Initially, I sure didn’t want that. I’m so grateful for it today, because sometimes I have a really rough period or day and it does occur to me, “Oh, my gosh. I would just like a brief—” 
LR: Escape.
JG: Escape. I go to the movies or take a hot bath. That’s my option. I think that surviving that, awake, looking at the factors in me that contributed to that discontent, or those things I can’t control, I think that’s powerful.
LR: Can we get back to the notion of choice as a path away from addiction. The choice between addiction and what? What did you mean?
JG: What I meant comes from my experience. When I was using, occasionally I would think, "Mm, it's probably not a good idea to use today." Like, I was going to my grandfather's funeral or I was going to be traveling on a plane, or I had a final exam, or something pretty big, you know. So, the thought would come to my head, "I should not do this." And then I would compulsively steer right for it, recognizing for a moment that it was going to be bad. It was going to hurt, cost me, but I couldn't stop.
So, I think the obsession to use is still occasionally in my brain
So, I think the obsession to use is still occasionally in my brain. But what's different is I have some space now between the thought and the act. And I guess what I meant was that having that space is the opposite, because addicts often don't want to use but it’s just inevitable because they don’t have that space.
LR: So, it's a matter of expanding that space that's left if you confront the impulse, if you wait 5 seconds, although I know it's not as easy as counting to 10 to break an addiction.
JG: Are you kidding? No, I counted to 10 many, many times, and also walked around the block and, you know, chewed on spaghetti sticks and just kind of disconnect that habit part of my brain, the striatal part, which
by the time you become an addict, you might as well be a rat in a cage, because it's just press the bar, press the bar, press the bar
by the time you become an addict, you might as well be a rat in a cage, because it's just press the bar, press the bar, press the bar. Even if nothing is coming out.
LR: Like you said, helping build a tolerance to those spaces that feel like crap or those existential spaces where life doesn't have any meaning and life is still not going to have meaning after you stop using. It's how to deal with that lack of meaning.
JG: Yeah, or disappointment, which is a huge trigger for people like me, because disappointment is sort of low dopamine, you know? But I think that a therapist can have a great role here. Instead of trying to avoid the obsessions, to experience the obsessions with somebody who helps us get that distance would be useful. I remember it slowly dawning on me, wow, just because it occurs to me doesn't mean I have to do it, and that was a novel thought.
LR: Where do you land on the debate between those who advocate abstinence versus controlled use, and how can you help therapists understand that distinction?
JG:
I am not against drug use. I am really against addiction
I am not against drug use. I am really against addiction. I don’t think there’s good evidence that people who are addicted can manage a controlled use, ever. Sometimes, they grow out of it, if they’re young enough, so that can happen if they get stopped really early like before they’re 20. The way I think of controlled use is being on a perpetual diet at a holiday party. It’s just miserable because—and for me, it really would be. How can I control myself? There are all these tasty things. So, it’s just the cost—I think the goal should be freedom. I think that’s hard for most people like me to imagine if I was trying to manage my drug use. I’ve heard a million creative ways of doing it and they all look miserable.
LR: What about the difference between those who have a bone fide addiction and those who are midway down a punitive trajectory?
JG: I guess I would ask you a question about that. When I was in abnormal psychology—and this is in the ‘80s—I thought that my teacher told me that the understanding of pathology was qualitative. So, you’re either sick or you’re well, basically. I thought that seemed surprising, but it was a great relief because I was among the well, I thought, for most things. My understanding of the way it is now is that we see most disorders as spectra and at some point, normal functioning becomes pathological.

For addiction, I think that, at some point, the reward pathway—this mesolimbic dopamine pathway that mediates the pleasure we get from addictive drugs–becomes altered. For some people controlled, moderate use—making other things like your children’s wellbeing, for instance, more important than your getting high—those kinds of things become impossible. I guess I see that in my own life. What happened is all I really cared about was drugs. There was nothing—no consequence—that I wasn’t willing to pay. I basically gave it all away so I could have this momentary escape. I think that is so compelling for some of us, either at birth or as a result of experience or probably both, that it’s a point of no return. I think age might influence that. 

I’m really concerned for kids. We know 80 percent of substance abusers—people who have addictions—start before they’re 18. Using moderation or avoiding excessive use before their brain is done developing around 23 or 25 might be the way for them to avoid addiction. I think it’s possible, then, to grow out of it, if you can back away.
Maybe addictions that develop in adulthood might be neurologically different than the ones that come on early
Maybe addictions that develop in adulthood might be neurologically different than the ones that come on early.

Teens and Drugs

LR: That’s interesting because a lot of therapists in our audience work with adolescents who live in a very confusing world full of stress, contradictions, widespread drug availability and increasingly pro-marijuana legislation. What must these therapists understand?
JG: The one thing I didn’t understand was: since when do adolescents worry about death? Don’t they think they’re immune to it? Isn’t their ability to self-regulate naturally and appropriately diminished? Isn’t this the time in life when they’re supposed to be taking risks?

I just want to say to the psychotherapists working with adolescents that this seems to me to be incredibly important. For children growing up today, it is, as you say, unbelievably confusing and drugs are everywhere. You can smoke pot now in school right in your seat where you’re taking your math test with no one knowing it. I think that it’s a treacherous time to try to find yourself and a place for yourself in such a confusing world. I think that our future depends on these kids.
LR: How do we convey the information of neuroscience and addiction to adolescents without their eyes rolling back and them dismissing us? Do we do it through the parents? Do we do it through the therapists? Do we teach adolescents about neuroscience and about the vulnerabilities of their brain and their neurocircuitry?
JG: I think that the kids in my town are very interested in neuroscience and I think most kids are interested in information. One of the things that’s really had a big impact, surprisingly, because they don’t worry about their own death so much or their own mortality, is this idea of the transgenerational effects from epigenetics. There was pretty alarming data piling up and we don’t understand it so well.

We understand the mechanism but it just seems incredibly inconvenient that if an adolescent is exposed to a drug like marijuana or alcohol and then grows up normally—doesn’t get any more of the drug, the offspring of that adolescent partier are prone to anxiety and depression and higher self-administration of drugs of abuse. I have to wonder if the epidemic of anxiety and depression is in part due to what our parents were doing in the 60s and ‘70s. Talk about a complicated, systemic way of understanding suffering, so that you reap what you sow. Also, most of the blame has been on the mothers, on the women who, somehow, were crappy. In fact, we know that the pathway for the sperm through the epididymis is marked by these experiences. We have a mechanism for how this can happen. Fathers to sons and grandsons is clear in the lab. Another analogy for even younger people that I talk about—and I don’t know if this will impact them or not—but it’s almost like you have a bank.
You start out with a certain amount of money in your bank and that’s your affective state. When you use a drug to feel great, you’re withdrawing from that. It is always the case that you have to pay it back; quickly or slowly.
You start out with a certain amount of money in your bank and that’s your affective state. When you use a drug to feel great, you’re withdrawing from that. It is always the case that you have to pay it back; quickly or slowly. 

So, a hangover is a little payback of the great time you had last night but there is no influx of funds coming from any place else. They have to come from us, so that’s why, if you withdraw a little bit at a time and you put money in, maybe, by learning the kinds of self-regulation and purposeful nourishing of yourself and your goals, having a little treat every now and then isn’t going to cause bankruptcy. 
LR: So, parents of adolescents might benefit from a far less restrictive approach to substance use. It might be helpful for therapists to help parents of teenagers not get so crazy about occasional or small-dose usage, rather than talk to the parents about the importance of absolute abstinence.
JG: If we had a perfect world, I would say nobody would overdo it.

I think kids don’t listen to parents making rules so that’s not a great strategy because you cannot enforce this. They do what they do. I hesitate to say, “Help them do it at home,” or, “help them learn moderation,” because, really,
any time the brain gets a big enough taste of a drug to feel great, especially in adolescence, that’s likely to have a lasting impact in the opposite direction
any time the brain gets a big enough taste of a drug to feel great, especially in adolescence, that’s likely to have a lasting impact in the opposite direction.

So, I’m quite convinced that my brain is less sensitive to pleasure and reward, so that when I got married or had my daughter or any other kind of peak experiences, which were good, they might have been even better if I hadn’t dampened my sensitivity to that. While we know this to be the case, I agree with you, though, that coming down hard and fast is a waste of time.

It’s impractical. In general, I tried to bribe my children. I said, “If you can not get wasted until you’re 21, I’ll buy you a plane ticket anywhere.” That’s what I would like. I don’t think it worked but I do think they’ve, in some way, taken it to heart. I mean, we talk about it an awful lot. 
LR: I’ll bet you do.
JG: I put different pictures of the brain impacted by drugs in the book, by the way, because I think those pictures have an impact on kids. So, seeing how chronic pot smoking decreases the number of brain receptors that respond to pot, I think that might help.
LR: Well, there’s also the irony or maybe a paradox that—as you said in the beginning—teenagers are invincible. They see themselves as unbreakable. Unless they’ve had real adverse experiences with alcohol or pot, beyond a bad hangover the next morning, they haven’t been threatened with death. They don’t see their synapses deteriorating. They don’t see brain centers shrinking. So, at a point where the most damage can be done, they’re least amenable to contradictory information. It’s tough.
JG: I have heard, though, from dozens, maybe hundreds, of kids, 15, 16, 17, 18 who completely identify with the lost, empty feeling that they cannot get enough of a drug. If these kids can stop early, their brain is much more capable of restoring things than it would be if they wait ‘till their 30. So, on the other hand, just because they have an increased risk of developing addiction, they also have an increased aptitude for recovering. Maybe this is a unique opportunity for them to begin to understand that these drugs really are so potent and so widely used, that it really is a dead end.
LR: Are you suggesting that it may be more therapeutically useful to point out to adolescents how crappy they feel when they’re not using the drug because the brain is trying to adapt, than how crappy or perhaps stupid and self-destructive they were feeling and acting when they were using the drug?
JG: Absolutely.
LR: So, the real danger is in what their body is experiencing when it’s craving or when they’re doing ridiculous and/or destructive things to acquire the drug.
JG: For me and for many pot smokers, what that looks like is that everything is just completely boring and flat and uninteresting. I mean,
I remember not caring about anything unless I was stoned
I remember not caring about anything unless I was stoned. That is profoundly painful. It’s a big deal.
LR: So, it’s helping our young to build up resistance to feelings of loneliness. To existential pain. To sadness. To injustice. Giving them the skills not so much to battle addiction but to battle the natural response to the pains of life.
JG: I’m interested that you say battle it. I guess I wouldn’t expect that. Is it that we want them to battle the pains or do we want them to negotiate the pains?
LR: Negotiate.
JG: Yeah, and one way that’s helped me a lot is to realize it’s overwhelming if I look at everything. If I just pick something that’s important to me, one thing that’s important to me, and live my life to show that, then that’s enough. I don’t have to get overwhelmed by what’s going on in Yemen or what’s going on with the rising water—these are things that are beyond my scope, but I can do a little bit and that is, I think, maybe a message that’s lost to them right now. That there’s a place for each of us.
LR: I guess the irony, also, is that because they have increased cognitive ability and they can think about thinking and think beyond their skin, the problems of the world become their problems—they have to worry about everything at once. They’re not worrying about Yemen or Syria or rising tides or climate. They’re not doing their job, but it’s in taking on the world just because they can that they forget to take on themselves and what they can control.
JG: Then, you point out the incredible irony, which is that they’re aware of all of this, and how do they deal with it? They completely erase it all by getting high, and by becoming withdrawn into themselves and their own private mental state which is being further manipulated by the drugs they are using. It’s simply not functional or adaptive.
LR: It seems from what you’re saying is that the antidote to addiction is connection.
JG: I think so. Connection! I mean, this is probably, blatantly obvious, but requires another side. Others who need us. I don’t think we can do it outside of the support of wise people. Connecting to art. Connecting to our bodies. Connecting to the earth. Connecting to mentors.
LR: Therapists can play a very powerful role, there.
JG: Absolutely.

Loose Ends

LR: May we shift gears here for a bit because I have, and I know our readers have, so many more questions, like about the recent FDA approval of esketamine nasal spray for severe depression.
JG: Every new drug, when it comes out, has all kinds of promise and no side effects and that turns out to be true for a few months, until we get some data. I think
it’s absolutely clear that the existing pharmacological treatment we have for depression is largely useless
it’s absolutely clear that the existing pharmacological treatment we have for depression is largely useless, and if nothing else, is really benefiting drug companies.
LR: Thomas Szasz’s notion of “pharmacracy,” government and control by and for the pharmaceutical industry.
JG: I don’t think we have good pharmacological interventions, going back to what you said earlier. I think we are a society always looking for a quick fix. I’m not against this. What I like about this new drug is it’s finally a novel mechanism of action. It’s also not something you take every day. The chemical esketamine, though, is a little bit of a baloney because the drug that it’s copying, ketamine, is cheap and old. What do they have to do, because the patent’s out on that? They have to develop a fancy version on that, which is no more efficacious, but it’s going to earn a lot more money.

I think people are desperate for treatment for depression. There are so many people who are pleading, “Please, let me have brain surgery to alleviate my depression.” So, we clearly need something. I don’t think that it’s going to be a magic bullet, but maybe it’s good to see some movement in that area. 
LR: We may start seeing esketamine clinics and esketamine overdoses and illicit copies of esketamine. It will be helpful to some perhaps, but will the societal consequences be far worse?
JG: You know, it’s possible. It’s a dissociative anesthetic. It’s Special K, basically, which is abused.
LR: You mentioned that women metabolize alcohol and some drugs differently than men because of the greater distribution and density of fat, as opposed to muscle. I know you’re not a therapist and I’m not asking you to be one, but you have some really good insights and you’re raising a young person. Do we have to work differently in therapy with girls and women as opposed to men and boys?
JG: Oh, my gosh. That is worth an hour in itself. I think it’s critical. We basically did 96 percent of our research until the turn of the century on white males. They are not the default population, so it turns out—especially with drugs of abuse,but much more than anybody suspected—women respond differently. That’s evident in the clinic because
women progress toward addiction and to toxic side effects much more quickly than men
women progress toward addiction and to toxic side effects much more quickly than men.

Women need lower doses. I think the reasons for using are different. I suspect—and it’s borne out by some data that’s accumulating—women use drugs more to cope and men use more to get off—to enjoy it. Those are really two different things. I think for men anger and resentment are big precipitating factors. For women, anxiety and insecurity are the precipitating factors. 
LR: So, as you said earlier in the interview, we need to address the core issues that girls and women struggle with by virtue of being girls and women in a patriarchal society. Do you have any final thoughts you’d like to share with our readers?
JG: I think the conversation was really enriching for me because I think we are both interested in the same goals but from different perspectives. I think it’s important to have these conversations, these bridges between what I know and what you know and our shared experiences from these different sides. So, I think that was really pleasant and novel for me because everybody only wants to talk about the brain molecules, evading these big, important, systemic, and social and spiritual questions.
LR: Did I betray my roots? My psychosocial roots?
JG: I hope so.
LR: You really have some powerful insights and I think your wisdom goes beyond mice and the lab. I think it also transcends neural circuitry. I think you understand the bigger issues and I hope more neuroscientists recognize the importance of the psychosocial elements of addiction and disease. I did an interview with Allen Frances a while back. He, like you, thinks that we really need to create bridges between the scientists—the behavioral scientists and the neuroscientists.
JG: Can I tell you, lastly, why I think you don’t have to worry about that? The neuroscience is not yielding answers. So, it’s going to be the data itself or the lack of data—the lack of understanding, the lack of impact—that brings us back to the wider community—to these connections outside of ourselves. As I say in the book, we thought that the brain was acting like Oz behind the curtain.
Now, we realize, “Oh, the brain is just a way that the environment influences us.”
Now, we realize, “Oh, the brain is just a way that the environment influences us.” We are coming full circle, I think, and we will, eventually, get to the same place where we realize everything’s social, psychological and biological.
LR: So, what do you say to those psychotherapists out there who are addicted to neuroscience research and who have fallen in love with the brain and who are rabid neurophiliacs?
JG: I would say they don’t understand it. I guess they’re selling something but it’s not understanding. It’s not wisdom.
LR: So, psychotherapists need, as you said, to position themselves along the spectrum somewhere between the extremes of neurophilia and neurophobia?
JG: Absolutely.
LR: On that note, Judy, thank you so much for sharing your time, research and wisdom with our readers.
JG: Thank you.

Michael Gurian on Masculinity, Neuroscience and Psychotherapy

Posted on by Psychotherapy.net Team

Psychotherapy and the Brain

Lawrence Rubin: You are a prolific author and experienced clinician who's best known for your work at the intersection of gender and neuroscience. As you know, there's a fierce debate in both fields about the relative influence of genetics and culture on the experience and expression of gender. What does a psychotherapist need to know about both sides of this debate when it comes to working with boys and men?
Michael Gurian: As you know, my work focuses on nature, nurture and culture. So, I and my team work in all these areas. On the nature side, the brain differences are quite robust, and it's important for psychotherapists to consider this when working with male clients. In the psychotherapy profession, it’s, “come in, sit, talk for 50 minutes,” and that may be a beautiful match for the female brain in the aggregate, and in general a beautiful match for a brain that does words on both sides, that connects words to feelings and memories on both sides.

It's not as good a match for male clients, who only do words on the left, mainly the front left; who only connect words to memories, are sensorial, and who need more movement, more cerebellum involvement. So,

the male/female brain differences, I think, are one of the most important and underutilized parts of our profession
the male/female brain differences, I think, are one of the most important and underutilized parts of our profession. And when we do use them, when we do train people, like when I speak at psychotherapy conferences or do trainings with psychotherapists, their minds are blown when they see the brain scans.

And they say, “Oh. Okay. We'd better take this into account.” And they alter their practices and succeed more with boys and men. So, I would say that's a primary thing. And it doesn't negate LGBTQ clients. Those groups are set up ideologically by people as if they're in opposition, but they're not and their experiences are well-integrated into neuroscience. 

LR: So, you say that language is differentially represented in the brains of boys and girls, men and women. And for that reason, we must consider gender and age when planning our psychotherapeutic approach and techniques. It sounds like you're saying you just can't sit with boys and say, “Tell me about your childhood.” You advocate a peripatetic approach.
MG: The sit-and-talk method will work with about one out of five males darn well. It sure works with me because I like to sit and talk when I'm in therapy. But we've got to always remember that we also only have about one out of five males in general staying in therapy, boys or men. So, it can work with some, but no. We must expand and use peripatetic methods.
LR: I associate peripatetic with movement, perhaps taking a walk, maybe some sort of sports activity. What about the use of the different methods of art and play, music and dance—the expressive therapies? Do you find that boys and men, maybe more so boys, are amenable to these expressive, creative modalities?
MG: Yes, they're all within that range. Prior to writing Saving Our Sons, I wrote, How Do I Help Him?, which is a practitioner's guide for psychotherapists. And all those methods you listed are featured in that book because I have had success with all of them. They all come within the range of expressive modalities, and I have found that boys and men really like working with sand and art. I've even expanded it to looking at the use of video games in treatment. Graphics allows movement, so yes, all of those are great.

Video Games and Violence

LR: Do you have any clinical examples of using any of these movement-oriented modalities with a specific male client?
MG: I work with adolescents, puberty onward – 10, 11, 12. I worked with one such boy whose father fought over in the Middle East in Iraq, came back and was struggling with a lot of issues. The boy, therefore, was having issues as well. And we used video games including Halo, and we looked at what were the messages in Halo and what was Halo trying to do for soldiers. He really got into that. And at a certain point I was able to work with the whole family. The dad and the son, who was 13, had a session in which they were working through what the father had experienced in Iraq and his own PTSD using Halo.
LR: Over the history of media from radio through comics, television, movies, and now videogames, there's been a concern with the potential impact of violence and aggression on the development of boys, especially teens. On top of that is the notion of toxic masculinity. Doesn’t playing violent video games with an adolescent whose father is in the military just stoke the potential for aggression?
MG: I think you know from reading my other work that I have a different vision of male development. Let me preface it by saying that I always caution males and families about videogames. But videogames, even more than the violence in them, are fantasy and not as causal in my mind—
and there have not actually been causal links proven between violent video games and violent behavior
and there have not actually been causal links proven between violent video games and violent behavior.

And one of the ways we know that is we look at how violent the videogames are in Japan where there's very little violence. And so, we can do cross-cultural studies and try to really figure this out. For me, the bigger worry is how these games may desensitize kids to violence even though it hasn't been causally proven. The thing that worries me the most about videogames is the whole way that the dopamine system is getting messed up. That's harming male development even more.

For instance, I'm begging parents, “No videogames on school nights—only a couple hours on the weekends.” And I show them the scans and all the research about how this goes. And I show this to therapists too. I'm not a huge fan of video games. I also don't overreact to them. I try to use them. So, if it's a good link to something like for the kid with the dad who returned from war, there was useful language in Halo that I could use in therapy to help both father and son communicate better. I worked with that family to cut back on the videogames out of concern for his brain development even more than out of concern for violence. 

Toxic Masculinity

LR: In light of this particular discussion, can we circle back to toxic masculinity?
 
MG:  I don't do much with that. By focusing on toxic masculinity every ten years or so, our culture is recycling an anti-male movement. And we've done this for all the decades that I’ve been in the field, 30 years, and each one has some merit. None of us like bad men doing bad things. I was a victim of sexual abuse as a boy and I certainly am very clear on males who abuse and who rape. None of us want that.

The issue and the reason I don't use the concept of toxic masculinity much in my work is that it's based on a conceptual structure which we would never apply to females. We don't talk about femininity anymore and we don't talk about toxic femininity. Well, with males, what we do is we say, as the APA just said, “Well, you know, masculinity is the problem, especially traditional masculinity. And then it becomes toxic masculinity.” Well, masculinity is not a problem. And, in fact, masculinity is crucial for male development.

And masculinity does include, even though it's a culture construct, male/female brain difference. It includes the male development arc, which is different than the female development arc. It includes all the necessity for males of rites of passage. All these things that come under “masculine,” we simply should not condemn. And one of the primary ways we know that masculinity is crucial to male maturation is through father and absent father studies. So, we can directly link male disturbance, discomfort, difficulties later in life—and a lot of female issues as well—to lack of a father.

What the father transmits to the child is masculine development. So, I think the problem is with the word and what people think is masculine or isn't masculine. And then, of course, we add on “toxic masculinity” whenever we see a guy do a bad thing. And I think it's the wrong frame, and what it does is disallow what I think is the most necessary, which is to figure out what males and masculinity really are and to work with those.

By focusing on toxic masculinity every ten years or so, our culture is recycling an anti-male movement
For instance, there are more than 100 brain differences that all of us as psychotherapists have to integrate. If we're arguing about masculinity and toxic masculinity, we're not going to integrate those. We're going to be saying, “Well, guys should be crying like girls do. They should be talking about their feelings in the same way. Why can't they just sit down in my…” And then, “They shouldn't be stoic because stoic is toxic,” which, of course, has been disproven. Stoicism is not toxic. You know, on and on that goes.

I'm very vigilant about male behavior and male accountability. But I don't use that frame, and I think the APA used the wrong frame.
 

LR: You vociferously critiqued the new APA guidelines for working with men and boys based on it ignoring hard science and its stance, as you said, that masculinity is toxic. If you were to rewrite or be asked by the APA to write an addendum to these guidelines directly for therapists, what would that be and what do we really need to do in therapy with boys as we help them move toward mature male adulthood?
MG:  The good thing about the APA guidelines is that our profession has stepped up and said, “Okay. The world isn't a zero-sum world in which girls and women are victims and are struggling and boys or men have privilege and they're doing fine.” In fact, as all of us have been saying for decades, boys and men are behind girls and women. They're not doing fine. They need a lot of help, and they need help from our profession. We are in the trenches as a profession to help them.

as all of us have been saying for decades, boys and men are behind girls and women. They're not doing fine
I love that the APA did that—it is great and a long time coming. But once they go with a pure psycho-sociology approach in which they never mention the male brain—they just don't mention it—then we're back in the big problem. So, the rewrite for me would be, “Look at all the great stuff in these APA guidelines, but you're not going to change male lives, you're not going to save males, you're not going to help males heal by constantly talking to them about how bad masculinity, and that they shouldn’t be stoic, and shouldn't be aggressive.”

And males are simply not going to stay in our profession. And once they hear it—their wives drag them in, their moms drag them in for the first two or three sessions, they just keep hearing this stuff—they're going to find ways to leave. They're going to say that the therapist doesn't understand them. So, what we have to do is understand them. I would say rewrite the guidelines to spend more time now on understanding how important masculinity is to their development and their maturation, how to work with them based on the way the male brain is set up. 

Males Need a Nudge

LR: So, what does this mean for working with boys and men therapeutically?
MG: I gave one example about verbals. You talked about expressives. I'll give another example, which is aggression and a strategy that's a great with males. We're taught not to interrupt, to use our cognitive behavior strategies and to elicit from the client what's going on inside through a lot of listening—a little bit of guidance but a lot of listening.

Well, a lot of guys need us to interrupt them when they go off on tangents, and/or they need us to interrupt them and/or prompt them because they don't have access verbally to the feelings that we are asking them to access. A male brain can take an hour, two hours, a day, two days longer to access that thing we're trying to get them to access in our office. If we prompt them some, we can help them. We were really trained to work with females but weren't really trained to work with male brain.

And, in fact,

most or all of us were not given anything in grad school to prepare us to work with males in particular
most or all of us were not given anything in grad school to prepare us to work with males in particular. We came out of grad school thinking males and females are basically the same. Well, now what we do is we practice this strategy. And as they go tangential or as they are trying to figure out the feeling or the memory we're trying to get them to access, we prompt.

And so I will prompt and say, “Okay. So, it sounds like you're saying you got really angry right then,” or, “it sounds like you're saying that actually made you feel ashamed,” something like that, to help them. And then they say, “Yeah. Yeah, yeah.” Or they'll say, “No, no, no,” but then about 30 seconds later, they'll say, “Yeah, and then I felt really bad.” And so, the biggest thing we can do for males is to not see the 50 minutes as a pure listening environment or a mainly listening environment with the assumption that they'll get there themselves.

A lot of guys won't get there themselves. And if we don't prompt them, interrupt their tangents, get them back on track, they won't respect us as therapists. Guys are task-focused, and they want their mentor, who is their counselor now, to really help them. And they don't respect someone sitting there for 50 minutes, listening to them go off on tangents. They just don't respect that. 

LR: You are clearly a very passionate advocate for masculinity.
MG: Well, male development, because masculinity is such a charged word, you know? I'm an advocate for everyone understanding male development, and I do think our profession isn't as good at that as I wish.
LR: You say that because of the way boys and men are wired and then socialized, that they may need some prompting to develop a language around what we might call the anti-male feelings, such as vulnerability, fear, insecurity and weakness. Are we putting words in their mouths when we're pushing them to reflect on those feelings or incorporate those feeling words? Might that be a little too aggressive?
MG: I don't think so. Everyone should be case-by-case. We were talking about the brain spectrum and the one-in-five males, like myself, who can just come in and sit and talk. And then my therapist says a little something. Then I go off on a deep tangent. You know, there are a lot of guys who do that, and they don't need what I'm talking about here. But for the majority of guys, I would not say it's too aggressive. And what it will do is it will keep them in therapy.

I also use spatial and motor activities to get the right side of their brains working
I also use spatial and motor activities to get the right side of their brains working. I'll throw a ball back and forth and, as I talk, I'm squeezing the ball. Obviously, most of the talking should be going on with my client. I throw the ball to the client. That excites the right side of the brain, which is completely dormant when all we do is sit and talk. That can create more connectivity. So, then it's his turn. He's got the ball. More of his brain is already active.

He throws the ball back to me. He didn't quite get at it. I say, “I think what you're saying is you were really scared right there. Is that what you're saying?” I throw the ball back to him. About half the time, he'll say, "No. I wasn't scared," because that's a vulnerable feeling. “No. I wasn't scared.” But he'll process. We'll go back and forth.

By prompting him to try to understand that he was scared or for him to say, no, he wasn't scared, he will ultimately say something that's got emotionality to it and maybe he will link to a memory. And then we can get back to the root feelings like fear. We can get back to shame. It may be too aggressive for some clients. I'm case-by-case, for sure. But since we're talking in the aggregate, I think, for males, it keeps clients sitting in our chairs. 

Boys, Men and Depression

LR: On the heels of this discussion about boys, men and their feelings; what about toxic and unfettered masculinity, and the belief that if you don’t “tame” boys, they will go out and shoot up schools?
MG: Unfettered masculinity! Boys don't shoot up schools because of masculinity, right? They're mentally ill, depressed. I was asked to look at all the profiles of all the school shooters around 1998 to 2003. I'm going to speak in the aggregate because there's confidentiality there. Basically, all those guys were depressed.

The key element is, when males get depressed, they tend toward withdrawal and/or toward violence. The AMA has worked with this for 25 years. So, I don't bring masculinity and toxic masculinity into my practice. I'm not talking to my male clients about toxic masculinity. It's not my area.

Boys don't shoot up schools because of masculinity, right? They're mentally ill, depressed
If they're doing something that is wrong behavior—you know, adultery or some kind of violence—of course, I'm pointing that out and I'm working with that. They don't need a frame that says that it’s toxic masculinity. That's not really going to help them anyway. What they need is help with depression. They need help with understanding why they don't have the impulse control to not hit, what is chemically going on for them. That's what they need.

The masculinity/toxic masculinity thing is more a public frame that folks can use, and I believe to a great extent, to avoid what is going on inside male development. It avoids the depression. It avoids all these developmental issues males face by attaching it to a culture construct. So, no, I don't use it much in my practice. 

LR: Are we as a culture afraid of masculinity, and for that reason have vilified it and toxified it? Is there something about those characteristics of boys and men that you think are very positive that society and perhaps the APA is not comfortable accepting?
MG: Absolutely. We have a bunch of guys, and right now it's mainly white guys, who are at the top. They control a lot at the top. So, there's one set of optics that really helps push the concept that males inherently have privilege, especially white males. And that creates then a war—a gender war and a race war—because, of course, tens of millions of males and white males don't have privilege. They are depressed. They're struggling. They can't find jobs. So, we have that mythos and the optics that white males control everything and have everything.

we have that mythos and the optics that white males control everything and have everything
Then we've got the other set of optics, which is a bunch of bad guys who do bad things. Their numbers are not actually very high. If we look in the aggregate of males, it's not very high, but they're constantly reported. None of us like that behavior. And so, the academic universe said, “Come up with a concept.” And that concept was toxic masculinity.

And then we run with that when, in fact, the real life that's lived in the trenches is males of all colors who are struggling, in the aggregate. Absolutely more black and Latino males when we proportionalize that out. But we still have at least nine million white males right now who are without work and who've stopped looking for work and they're not even counted in the unemployment rolls. So, we've got the reality of that.

And then the reality with our male clients is that very few if any of them are becoming violent because of masculinity. They're becoming violent, again, because of mental illness, lack of impulse control, self-regulation—all of these things that are not cultural constructs but rather have to do with the way the brains work and issues that have arisen for them in their family systems
And then the reality with our male clients is that very few if any of them are becoming violent because of masculinity. They're becoming violent, again, because of mental illness, lack of impulse control, self-regulation—all of these things that are not cultural constructs but rather have to do with the way the brains work and issues that have arisen for them in their family systems. So, as you know, when I'm looking at violent clients, I'm looking for the three actual causes of male violence, none of which are masculinity.

The three actual causes are: 1) neurotoxins affecting cells in the brain, 2) trauma, and 3) under-attachment, especially in infancy, to a primary caregiver. Those three are proven causes of male violence, and those would be the ones that I would be trying to help them with. And in all these cases, they become depressed, and they tail toward withdrawal and/or violence. So, that's really what I work with.

For actual male clients in the trenches, I don't see a lot of gain by us spending a lot of time with cultural constructs that are not causal. Just like I wrote quite a bit in my books on girls, I don't spend a lot of time arguing that girls become anorexic or bulimic because they see images of thin women. That is not causal, right? That is something we've got to get them away from—we've got to get them to stop looking at those images of thin women. 

LR: So, it's not toxic masculinity that we need to worry about. It's addressing depression, the sense of powerlessness, and the brain's impact on their behavior—as you say, the neurotoxins.
MG: Oh, yeah, especially the male brain.
LR: What does the depressed brain look like in boys and men, what should therapists need to be aware of?
MG: Therapists may think of male aggression, even male anger as covering up fear, right? Therapists are often trained to see that as something to avoid or something that may show defect whereas I look for depression. It's not always there, but I know that aggression is one of the ways that the male brain masks depression.

aggression is one of the ways that the male brain masks depression
Guys are covert in their depression, and females are more overt. When covert, it hides under anger and aggression. It can also hide under substance abuse. One of the ways that covert depression manifests for males is through substance abuse—they're medicating depression. They may also be genetically predisposed to addiction , and so arises the need to medicate depression. 
LR: Has the male brain become predisposed to depression over the course of evolution?
MG: The reason it crosses cultures is that it comes in on the Y chromosome. In utero, the brains differentiate male and female, even including the whole gender spectrum. But they still differentiate male and female in utero. So, as these kids come out, yeah, we've got a much more fragile male brain than we realize.
LR: A fragile male brain! What does that mean?
MG: Both brains can be fragile, meaning that they can be vulnerable to neurotoxic effects and trauma. Social-emotional development is tougher for males, especially tougher if they don't have fathers—another Y chromosome in there helping them, and/or male role models throughout the lifespan, but especially ten to 20.

What the male brain tends to sacrifice is social-emotional. It'll retain things like spatial, but we don't have as many brain centers and connectivity. Females do that on both sides of the brain and are oxytocin-driven which is the so-called bonding chemical. If males don't have key relationships early on in life and are then impacted by neurotoxic effects too early, their brains tend to sacrifice social-emotional growth at the cortical level, and it then manifests behaviorally. 

Mentoring our Males

LR: Many boys grow up without male role models. Some are raised exclusively by their mothers or grandmothers while others are raised by lesbian or transgendered couples. Where do boys find mentors outside of male therapists and what does it mean for a boy to have a male role model or mentor?
MG: If their role models are bad males, obviously, we don't want them, but most men can provide good mentoring. Coaches can be mentors. Faith communities are systematically set up for mentoring. If kids are in school, we can become citizen scientists and watch them gravitate at five, at six, at seven, at eight to whoever is the male teacher. We also want to remember that female therapists and women are mentors too. This is not either/or. And gay couples can raise great kids.

Many boys grow up without male role models
I beg therapists to create academic systems that support more males so that they can become therapists. A lot of these guys who are raised by single moms and grandmas would benefit from a male therapist. As a profession, we have got to generate more male therapists to be these mentors and then generate more information to female therapists so they understand guys so that they can be mentors too. Again, it's not an either/or. You don't absolutely have to have a male therapist. At a certain point, you're going to need a one, but you don't absolutely have to have a one right now. A woman therapist could do it right now too if we train her in it. 
LR: It's an interesting irony, perhaps paradox, that a disproportionate number of clinicians, especially for boys and teens, are female. Does that mean that boys and men in therapy are being mentored by clinicians who may not be as adept around masculinity issues Are boys at risk by being treated predominantly by women?
MG: I love the women who are treating boys, but yeah, it's a systemic problem that started around 50 years ago, assuming and remembering that before between 30 and 50 years ago, most psychologists and psychiatrists were male.

But as we moved toward more verbal literacy and the notion of “use your words” that is practiced in both these professions, we set the profession up to be a verbal literacy platform without neuroscience to understand male/female brains differences. So, males are pulling out and pulling away in stages.

Fewer males than females move into our academy. They're not going to graduate school. They're not going to become therapists. And more males will become psychologists and psychiatrists, but far fewer become therapists. The males know that the academy is doing this—it's inchoate for them; it's unconscious. I don't think they've studied brain science, but they know, “Wow! Am I going into a profession where I'm going to be sitting there with a client for 50 minutes, trying to get this client to say stuff, knowing that for many clients, especially males, it won't work? And for me as a guy, I need to be a certain kind of guy to be able to sit eight hours a day, 50 minutes per hour, in that chair,” right?

So, I think that to some extent, we're losing them at the academy level. And then as they come out, we start losing the men as clients and as patients because there isn't academic training for most of the therapists, who are female, in understanding the male brain. And, we lose them in our therapeutic work with couples as it is generally the wife or the partner who brings the guy in, and it's clear the therapist doesn't know how to work with him. So, he pulls out of treatment as well. He's seen as a failure. So, from the academy to the therapy office, we are losing males because of systemically pervasive attrition. 

Which Therapy is Best?

LR: Have you found that there are therapeutic models that are more effective with boys and men? A client-centered approach, I consider a more-traditionally-feminine approach. It's about listening and reflecting feelings whereas a solution focused approach seems to fit more the male stereotype. “Let's

Digital Technology and Parenting:

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

Having the Hard Conversations in Sport

Posted on by Psychotherapy.net Team

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

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

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

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

“Hey coach, can we talk?”

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

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

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

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

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

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

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

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

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

Teaching Adolescents Mindfulness Using the Morita Therapy Concept

Posted on by Psychotherapy.net Team

Life presents us with many challenges; successes, failures, negative and positive experiences, and everything in between. Usually, when challenges occur, teens try to manage them on their own. As a marriage and family therapist who believes that we all possess the ability to overcome these challenges, helping my young clients to navigate them is particularly rewarding.

I practice and teach mindfulness including the Morita concept, which is about seeing and experiencing things as they are–in Japanese this is referred to as “ARUGAMAMA,” to accept things as they are. I am aware that the only way for me to find out how things will turn out is to begin taking on a challenge despite how anxious I may feel about it.

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Japanese psychiatrist, Masatake Morita stated that the reason why we may feel anxious or scared to take action is because we have a desire to do well. He framed this as “A desire for life.” If we can try not to be overly concerned about the outcome, we may not feel as hesitant to take on challenges. While the Morita concept teaches us to be mindful about our feelings, it does not ask us to forget what we set out to accomplish. We must realize that the process of achieving a goal often does not happen overnight and that the process may involve a series of mundane steps that we must constantly take. While we may not necessary to enjoy the process of meeting our goal, we must not forget there is important value in accomplishing what we set out to achieve.

I recently had several opportunities to discuss this topic with groups of Japanese high school students who were visiting the United States during the summer to learn how to mindfully take on a leadership role. I was asked by their program coordinator to present how I managed to live in the United States as a young Japanese woman and achieve success. I was also asked to share the same mindfulness techniques, including the Morita therapy concept, that I teach my clients when they face life's challenges.

During the discussion with these Japanese students, some realized that it is very natural to experience a spectrum of feelings as they go through life. They told me that they have more positive attitudes when taking small steps to achieve a goal rather than focusing on one big action. These students learned that life will continue regardless of how they felt in the process, and in fact, many of them already did take an action regardless of how they felt, in order to achieve their goals.

As part of my PowerPoint presentation, I discussed how my life was full of both failures and achievements. I was not aware of the Morita concept when I was a young student, so I gained the necessary life skills the hard way in order to persevere after failure. After my presentation, I asked these students to participate in a short activity to demonstrate how they could pull themselves together in a challenging situation that I created for them. As they struggled to figure out how to achieve their goals, they acknowledged their negative feelings, struggled, contemplated with their fellow students, came together to support each other and laughed when they were able to work through their challenges even though they did not feel empowered during the process. I was impressed with their ability to overcome how they were feeling by reminding themselves of their purpose. It was a powerful experience for me as well to witness the shift in their mindset and see how they were feeling at the end as well.

I thought it was ironic that my teaching of mindfulness, which is rooted in Japanese culture and specifically in Buddhist philosophy, to these young Japanese students was taking place in the United States. In other words, they came all the way to the United States to learn something from their own culture.

As they go through life, I sincerely hope these students remember the Morita concept when they face a challenge and can use it to help them in managing their response to their difficult feelings. After all, it is natural to feel bad when we must do something that we are not enthusiastic about, even though it is necessary in order to achieve a goal. Acknowledging all the feelings as they are, “ARUGAMAMA,” frees us from the need to fight them. We just must find a small action that we feel comfortable enough to take today, tomorrow and every day until we reach what we set out to accomplish.

For a small mindfulness activity suggestion, you may want to discuss the following with your teen clients:

  • Is it true that you must feel good in order to tackle our challenging or new tasks? Why?
  • Explore what your anxious feeling is trying to tell you? Why is it there?
  • Can you be worried about tomorrow and experience what’s present at the same time? How so?
  • How can you be mindful when you face challenges?
  • What is your goal or value in life and your current tasks? 

Working with Teens: The Good, the Bad and the Ugly

Posted on by Psychotherapy.net Team

“I never set out to work with teens.” For many years after I started my private practice, people would ask, “what is your specialty?” and I would demure. I thought it was pretentious to say I’m a “specialist.” I didn’t feel like a “specialist.” I also thought it would be boring if I specialized. I wanted to mix it up (a little ADHD?). But I soon found myself gravitating to adolescents and young adults, and them to me. Given my years of training in family therapy, it started to feel natural that I would work with this population, those not-quite-children but not-quite-adult people who most therapists feared. And then I had two teen girls of my own; one now 20. What better breeding ground for insight could there be, I thought. Boy, or should I say girl, was I wrong!

Girls Will Be Girls

A therapist can no more easily treat herself and her family than a doctor can heal herself. As far as I can tell, my own family problems stem back generations. Mark Wolynn’s recent book called, It Didn’t Start with You: How Inherited Family Trauma Shapes Who We Are and How to End the Cycle lends some credence to this assertion. Jewish-check, anxiety-check, narcissism-check, mental illness-check. And the list goes on!

“I sought to correct all that with my girls. Clearly, I overreached.” Not only did it not help to hold myself to exacting, unrealistic and perfectionistic standards; it was in fact, impossible. Fast forward to last weekend, my girls now 20 and 17, fistfighting (I kid you not) over a sweatshirt.

My sense of failure runs deep but I am thankful that I was blessed with pure luck with these two. My insights are largely useless. My husband, however, excels at mediation (he’s a lawyer after all), and he has filled in the missing pieces on numerous occasions. We make a good team. Nevertheless, my girls have taught me a number of key things:

1. Each kid is different.
2. They teach you.
3. The “0-60” phenomenon of the teen brain is alive and well.
4. Use humor.
5. Be strong. If you are emotionally weak, they will have no one to push against, leading to a failure to launch.
6. No matter the age and stage, be patient. As soon as you master it, it changes.

Mary and her Parents

There are some cases that make me feel like a complete idiot. Take the case of Mary. She never wanted to be there. My first tenet of teen therapy is that they have to own it. It’s their life. If I am doing all the work, something is wrong. It took me a long time to realize this one. It’s great to get them when they’re young enough to change but old enough to understand, which I’d put at 17– a beautiful age! Raring to go to college yet clinging at will to parents, kids this age are a pleasure to help. Change comes fast and furiously and if you’re lucky you’ll get hugs in there too! They go off bolstered by the therapy, and they don’t come back. On the other hand, if they are there against their will it’s a different story. We know this. No therapy is going to work by force.

Mary had a history of acting out and strict, somewhat eccentric parents who did not understand her difficulties (see “Far from the Tree” by Andrew Solomon). With this mismatch, things got off to a miserable start. She was returning from a multi-thousand-dollar wilderness program of questionable long-term repute. “Please fix her from here,” her parents dumped on me. And so I did, sort of. She continued awful acting out, rages, mood-swings, and long before I knew it there was a team of professionals all over the case. No problem. We continued to integrate her back to home. But the back-to-family part never happened. You see, the parents were the problem. This is hardly uncommon. Now they were avoiding me. They were done. I tried to explain to no avail that their participation would be key. More avoidance. So, we continued weekly until the girl simply said “this entire enterprise is futile. I give up.” What a sad case indeed when parents induce helplessness in their teens. Where will all her energy go, I wondered sadly. The case had fizzled out before my eyes. After questioning my abilities, I concluded that this was case was doomed from the start. Her only channel was anger and that wasn’t a channel I was on. Thankfully there was group therapy to warm the soul and I gladly referred her to the care of another clinician.

Group Therapy with Teens

Witness however, Cecilia. Her case was the best! Coming from a childhood of unspeakable trauma, she was rescued by a relative and set on another course. When she came to group therapy, she was literally an outcast from school, home and family. The group embraced her. She lit up each week. In my group there are no restrictions except on gossiping and phone use. I actually pretend that I am the most casual and chill person on earth so that they talk as freely as possible. It’s like when you’re driving your kids to the mall and they’re in the back seat, with no eye contact, finally telling you the most important thing they ever shared. That is my posture in the group. The more I lay back, the more they seem to talk. These kids have no other avenue to ask questions about sex, drugs, birth control, family, siblings, mental illness, physical issues, sexism, racism and relationships. They even accept academic support from me. I become like a big sister in the group, and it works. Cecilia grew to become her class president. She vented for a solid two years about her childhood. She was made to feel normal. She heard from other kids of all backgrounds. They all became “normal” together- normalized by the group process. Who doesn’t have a crazy mother/father/sibling/uncle/friend/teacher? My god, they were normal! Just the celebration of that became the group creed. We welcomed newcomers with near joy. Parents waiting outside would never have believed it. Their angst-filled, moody, belligerent offspring had finally shed their shells. I almost never told anyone my secret. Do you want to know the secret to teen group therapy? Pretend you’re not there, do not wince at disgusting revelations about sex, and by all means allow cursing of all stripes and colors.

As the “core group” began to solidify I worried if I was being effective and compulsively tried to “deepen” the conversation. As I began to relax, they were able to tell me that they liked the group just the way it was. Just talking, venting, sharing and taking turns. It soon became clear that my need to control and get it right and my own insecurities still plaguing me after all these years of experience were beside the point. The group had sustained itself. Nevertheless, the interventions I made aimed to reinforce the shared group values and purpose, the universal nature of the teenager experience and the shepherding of the inner self to the surface despite fear. I also increasingly pushed the more reticent members to link up their past with their present, thus gaining insight for the first time. Finally, I was “motherly” in that I could see from where I sat that life would ultimately deal them their share of traumas, yet I knew they could withstand it by holding that space for them, quieting down my own thoughts. By testing their judgment or lack thereof with their peers, they gained the self-knowledge to withstand pain rather than avoid it.

Teens and Divorce

Parents have often asked me what the best/worst age for a child to be at the time of divorce. There are many answers to this. First off, it depends not only on the age at divorce but rather on how the parents handle the divorce that really matters. Second, all ages suck, period, end of story. But divorce in the teen years royally sucks. Social/emotional development is significantly impacted. What the research says is not pretty: not only does the effect of divorce on teens have a huge impact for years, but also, it lasts forever and ever. The researcher Judith Wallerstein has asserted that unlike a parent’s death which has a beginning, middle and end, divorce just goes on and on. Once again, the teen brain, volatile as it is, is not prepared and will surely rebound with rage, defiance, profound risk behavior, testing limits and all the things you tried as a teen but on steroids (social media strikes again). So, buckle your seatbelts on this one and seek help early and often.

“One of my teen clients of divorce casually sent a nude photo to a boy in 10th grade”. The next day, it traveled around the school with the speed of rumor and she found herself in the hospital dealing with a new diagnosis- humiliation. With one parent working round the clock and the other nowhere to be found, she did what anyone in that situation would do, she went underground. The numbing, cutting and sheer embarrassment got worse. She started cutting school too. Each setback snowballed mercilessly. We had to get her back to herself. The therapy consisted of gradually starting her activities again, putting it behind her and structured-only phone use. To this day, she calls me every year on my birthday and says, “if it wasn’t for you, I’d be dead.” She is now a successful hairdresser hoping to open her very own shop. Her parents’ divorce was the hardest step from teen to adult, but she got by because she persisted, used her strengths and had a passion.

Older teens feel lost, insecure and socially stigmatized after divorce. The post-divorce financial uncertainty adds to the overall stress. College plans can change. One divorce created a situation with the parents telling their twins in my office, “surprise, we can no longer pay…” Plus, shuttling between two homes can be disorienting, to say the least (or in the case of my own parents’ divorce, jetting between two coasts). Parents often dwell on how and when to tell their children that they are getting divorced, rather than the aftermath. Just like birth plans, divorce plans go awry. Better to sort it out for the long-haul than have it scripted in the short.

I try to help the teens in therapy by “joining” with their rage. Damn straight your parents suck. They are the ones who should be here! Once I do that, and establish trust, rapport and confidentiality, it is easy to win their hearts and minds. I provide gentle support and strategies for coping and self-care while reminding parents that part of the confusion is normal teen angst. If parents make the common error of ascribing all behavior to the divorce, then guilt steps in and over-compensates in many forms including the of throwing money at the child, which rarely helps.

More times than not, my job is to mitigate confusion. You cannot believe what’s in these kids’ heads. For younger kids, they go right to the most concrete –will my room be pink at Mom’s house still? Can I have two stuffed animals-one for each house? If my parents separate, will I ever see dad again? Are my grandparents still going to be my grandparents? For teenagers and young adults, it can be far more morose, as it was for me with my own parents’ divorce. “Why why why?” is one refrain. The other is a lurking sense of doom some might call dysthymia. As soon as I labeled that for myself as an adult, I started to get help, including antidepressants. The clinicians’ definition of the word would be a “low-grade depression.” I call it, the lowering of expectations, always second-guessing myself. Demystifying the wild ideas kids and teens formulate goes a long way toward alleviating crippling anxiety and dread. It’s hard enough to grow up without constant stress in this world, let alone have your parents fighting all the time. One family was fighting so badly about the kids’ shoes at each house that I offered to go to Payless and buy them a second set of sneakers.

I now run a successful teen support group for kids between the ages of 13-19. I remember how my losses haunted me at that stage, but I never had the words to feel and let go–I was constantly grasping for meaning or truth that didn’t exist. I tortured myself to figure something out about my family. But all that I got in return were meaningless intellectual insights that couldn’t sustain me. Nevertheless, I did rebound. I got many degrees and certificates, had scores of talented friends and married the love of my life. Economic times have since hit us hard, but our fortitude is paramount. “I model this resilience to my patients through gentle wit, disclosing when necessary that I “get it.”” Then reminding them there is no one path; there is no perfect; there is only you, open to the ups and downs, or as my yoga teacher would say, “meeting each moment as a friend.”

It All Adds Up

A perfect case to illustrate when all cylinders are firing in teen therapy is Megan. This teen came in with what I call the “break up story.” Megan, like many other girls with whom I have worked, was a ruminator. So, the task is how to utilize all the teen’s strengths just to make it to another day. Why? The phone (you didn’t think I would forget the social media part, did you?). Because I was an “early adopter” of the internet age and even worked in the field of online production and community building in its heyday, I have always taken a favorable view of technology. That said, if my daughter doesn’t unwrap her phone from her head soon I’m going to throw it into the Hudson River. It is her permanent appendage. There is no doubt in my mind that she would benefit from a screen break. But instead of being that mom who limited screen time, I was actually the mom who was the first on the block to get the kids a phone. That did not make me popular among the neighborhood parents. I prefer to know where they are. On the other hand, I have friends who have their adult kids on “find my friends” which would literally put me in a full-time state of panic. There must be balance.

Megan started cutting in 9th grade because she already had a family history of poor emotional regulation combined with an awkward style and no real avenues for getting her feelings straight. Her father was absent and alcoholic. Her mother was a determined and high functioning administrator who was always on the brink of a breakdown, and who could blame her? Therefore, Megan was accustomed to caretaking not care-receiving, which she desperately needed. In therapy, she was able to use her intellect and motivation for good. I encouraged her to think of things in a less catastrophic/dramatic, black and white and exaggerated way. “My boyfriend friended his ex on Twitter” she would say. “So what!” I would chime. “I’m stalking him. I see he’s online at 3am. I saw him with her. She liked his status.” It goes on. Yes, this goes to his character of questionable trustworthiness. But does it REALLY matter? Growing up in the 70’s and 80’s has made me a bit cynical to what real love is (memories of Kramer versus Kramer dance through my brain). I try to get them from point A- everything matters, to point B- nothing matters. “The therapeutic technique most attuned to this might be called Freud-light”. What is getting in your way of allowing this process to work? What is coming up as a trigger/resistance? What can we work through/process/vent/feel/release/analyze or simply let go of to move forward? Nevertheless, the point is the phone doesn’t matter! What matters is can he be at the right place at the right time, can he talk and communicate, can you be friends first and foremost, do you even know him, can he get off his phone…? Megan started putting herself first. She got into the college of her choice. A big girl with body-image issues, she bought herself the shiniest red prom dress I have ever seen and danced right through to morning!

What’s my Theory?

Lest you think that I’m just flying by the seat of my pants, there is plenty of theory to support my approaches. I rely on several methods and philosophies, yet I’m not married to one. I lean toward mind/body (Van Der Kolk, Levine), existential, person-centered (Rogers) and family systems (Haley, Minuchin, Bowen), and group (Yalom.) Much of my work is based on the idea that anyone can relieve anxiety by allowing it to flow through you. Just like going to the gym, anxiety is a habit of mind that if practiced will be reinforced. It’s the faulty circuit of fight or flight. It’s the mammalian brain. The goal (CBT and DBT) is to allow yourself to practice a better way of coping. A way with ease and equanimity; a way with kindness and support. A middle way, a way that allows you to press the pause button while you cool off. Getting flooded by one’s emotions is useless, so learning CBT (“I’m a mess and everything is a mess” to “I made a mistake; humans make mistakes and learn from them” makes good sense.” With DBT, “let me calm down for a second–getting worked up is totally unproductive. I’m just going to breathe and let it pass,” you will most likely get results. What I have not done more of until recent years is appreciate the role of trauma in that it can completely derail or retard the above process to the point of paralysis.

Lessons Learned

Therapists may turn away from working with teens because of their volatility and the resultant risks involved in their care. They flake out of appointments, come late, walk out, don’t return calls, and show up high and hungover. Their parents are often difficult, defensive and in denial. Sessions have to be coordinated with who can drive when, a logistical nightmare from volleyball to work to therapy and back all after a parent has put in a full day’s work. In short, it’s a pain in the butt. Nevertheless, teens are fast learners, quick to laugh out loud, they can cry their hearts out one week and the next week show up like nothing happened. They leave you with all the debris while they move on. My kids started doing this in daycare. Sobbing when I left, then an hour later, having the time of their lives. You simply can’t take it all personally. This takes a concentrated effort on the part of you, the therapist and mom, to feel as deeply and sensitively as they do, and then drop the whole damn thing. Only time can teach you that.

What it has taken me my whole adult life to learn is that there is no absolute answer. There is no one truth. There is no lasting stability. There is only you, open to the shattering of reality, embracing the change; knowing that change is the only constant. My history of loss/resilience/loss makes my therapy genuine. My genuine interest in teens, my blessed gifts from my parents, and my profound belief in being curious is what helps the therapy. It’s the turbulence, the roller-coaster, the deep pain and sorrow, and even the helpless confusion that instructs me how to remain flexible, less anxious, more prepared and physically more resilient (Yoga!). I still crave stability, but I have learned to create it for myself both inside and outside of the therapy office.

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. 

Teen Heroes with Feet of Clay: The Dilemma of a Pop-Culture Psychotherapist

Posted on by Psychotherapy.net Team

Recently scanning the Internet, I was dismayed although sadly not particularly surprised by the glaring headline which read “Demi Lovato rushed to hospital for possible overdose.” My first response was “damn, poor kid!”

The next flurry of thoughts closely paralleled my own varied life roles. The father in me remembered my kids’ shock upon learning that this same celebrity, former Disney actor/singer used to cut herself. The pop-culture author in me reflected on the writing I’ve done around superheroes who are often deeply flawed characters. Finally, the teen therapist in me wondered once again how to bring the stories of popular culture icons like Demi Lovato into the therapy room. As examples of the challenges and pitfalls of high achievement and celebrity? As cautionary tales to those who would model their lives and mold their dreams in the images of superstars? Or simply as examples of people more alike than different from them, who struggle to regulate anxiety, depression and the accompanying demons by using, cutting and killing themselves.

Heroes abound in popular culture, exceeded only by those who have fallen hard and as such are in no short supply. As I watch the 2018 Tour de France, I remember Lance Armstrong’s substance-enhanced fall from grace. As I read more deeply into the life of Demi Lovato, I think about Justin Bieber’s near-death automobile escapades, Britney Spears’ seemingly unending brush with the dark side and the terrible fate that Heath Ledger, aka the Joker met; not to mention the myriad music legends whose lives were cut short by their own hands- Kurt Cobain, Whitney Houston, Michael Jackson and the artist who will forever be known as Prince.

Just today, a soon-to-be twenty-year-old asked me (in my professorial role) a poignant question about adolescent identity formation. A question she would like to have asked her developmental psychology professor, I believe she was reflecting on her own journey to personality coherence on the road to adulthood. We concluded together that there are many influences that shape who we are and who we become during our formative years, not the least among which are popular culture figures both great and small, evolved and base, and those who succeed and ultimately who fail…terribly.

In his book, Breaking through to Teens: Psychotherapy for the New Adolescence, Ron Taffel encourages all those who work with teens to be familiar with popular culture and its many and often strange inhabitants. He challenges clinicians to regularly assess their PCIQ, or popular culture IQ. As a therapist who specializes with children and teens, I couldn’t agree more strongly. I worked with a troubled seven-year-old who had been alternately diagnosed with ADHD, oppositional defiant disorder and conduct disturbance. He taught me about the struggles Japanese anime character Naruto faced, and in so doing provided me key insights to helping him. And it was the tortured relationship between Darth Vader and Luke Skywalker that assisted me in my work with a depressed and alienated adopted pre-teen. Each of these pop-culture characters, regardless of their fictional origins, struggled in very real ways.

So, the next time you have the opportunity of working with a child or teen who identifies with a figure of popular culture–whether fictional or non, elevated or fallen; be prepared to explore the meaning of that identification, whether positive or negative. And be prepared, as I have learned, to sit patiently at the intersection of that client’s and their hero’s relationship in order to gain a deeper understanding of your young client as they wrestle to make sense of themselves, the world around them and the characters within it. Lessons abound.  

Lynn Ponton on the Challenges and Joys of Working with Teens

Posted on by rezendevknowfully.com

A Delicate Balance

Rachel Zoffness: Lynn Ponton, you are a practicing psychiatrist and psychoanalyst who has been working with teens for over thirty years, and are author of the books, The Romance of Risk: Why Teenagers Do the Things They Do and The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls. Let’s start with some of the salient issues that come up when you’re working with children and teenagers. I find that confidentiality when working with kids and teens is often a tricky subject because teenagers have rights as clients and they want to maintain their privacy, which is critical to the alliance. But at the same time parents want to know what’s going on with their children. How do you maintain this delicate balance?
Lynn Ponton: I think it begins with the first session, and even before, when you talk with the parents on the phone—you have to alert them about how you run your therapy practice and your work with kids. I almost always say that I try to encourage privacy with the teens so that they feel open to talk with me, and I will tell their child during the first session that I’m going to try to keep things confidential, but that there will be some exceptions, and I let parents know that right away on the phone. In general, I meet the teen with the parents before I even start and I alert everybody to the parameters and the boundaries around confidentiality.
RZ: So that both the teenager and the parent are on the same page and know exactly where you stand.
LP: Exactly. The kinds of things I would need to share with parents, which I’m clear about right from that first session, would be drug use that was risky or risky behavior that would result in serious self-harm. And sometimes other things—abuse when it’s disclosed has to be shared with the parents for a variety of reasons, and because I’m a mandated reporter.

It’s often hard for a teenager to tell their parents these things directly, so I’ll offer to meet with them and their parents and we’ll work together to help them disclose this material. Collaboration with the young person assures them that even if they do tell me something, it’s not going to be reported over the telephone to their parents. They’re not going to find out about it by surprise. Instead, we’re going to collaborate together as a team to make sure that parents know this.

Of course there are times when this doesn’t always work perfectly. Having worked with kids for more than 35 years, there have been exceptions where I’ve found out quickly that a teenager is suicidal and I have to let the parents know. Maybe we have to work toward a hospitalization period or something like that, but I try as much as I can to have the teenager be part of this process and be involved with it.

Cutting

RZ: You mentioned a very hot button and interesting topic, cutting, which to me seems to have become almost a contagious and trendy behavior among teenagers. What’s your thought about that?
LP: Well, self-mutilation in all of its forms is something that therapists have to learn to feel comfortable with working with teenagers. It’s a big part of our work to connect with them, to know about it, to seem comfortable with it and not put off by it when we hear about it in a session. I first saw it about 30 years ago and wrote a paper on it in the ‘80s, which talked about self-mutilation as a communication. As you point out, it’s a contagious risk-taking behavior. In a group of teenagers, one will do it and the others will copy. They’ll think, “I’ll try it and see what I can learn from it.” That’s how that process really starts. In the ‘80s there were big concerns about self-mutilation because of sharing of implements and a lack of understanding around HIV risk, so we had to be very careful about that until we better understood it.

I think it’s often scariest for parents. So how do you work with teens around the cutting for parents? How do you help a teenager who is cutting really find other ways to cope with some of their feelings and to develop identity in a healthier way? In general I try to educate teens about cutting. I often employ them to get involved in it, to look online, look up articles about cutting. We’ll have conversations about it so that it’s really an educational process with them.

Some teens don’t want to engage in that process.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it.
They may tell you they’re cutting, but they don’t want to learn about it, they want to do it. This is something private that they’re going to do to help themselves feel better, so I’ll respect that, but I’ll still engage in conversations with them about it. I want to make sure that if they are cutting that it is safe in other ways. There’s significant risk of scarring, of infection—there’s a whole lot of risks that are associated with it.

Many teens cut because they say they feel better afterwards. A number of papers point to the beta endorphin release with cutting—the focus then becomes the physical cut and not the emotional pain that they’re feeling. So it accomplishes a lot for teenagers, but it is an unhealthy coping strategy and risk-taking behavior that you have to work with teens to limit. There are many different ways to do that.
RZ: The way you talk about cutting, it sounds like it might serve an important function for the teenagers who are doing it. What would you say to people who say that it’s just an attention-seeking strategy?
LP: Your question is well placed because I think a lot of times therapists who work with teenagers are faced either by teachers or parents or even other therapists who say, “I don’t want to work with those teens. They’re engaged in a lot of attention-seeking behaviors. How do you handle that?”

I think many behaviors in life are attention-seeking, and often we’re seeking greater attention from ourselves, that we pay attention to our own pain. Teens usually cut because they’re in pain and they don’t necessarily understand their own emotional pain but when they cut, it allows them to at least understand that it’s a painful thing that they’re dealing with. So, yes, it is attention-seeking, and adults will often be drawn in to it. Teachers at school are shocked when they find out about it and they’re worried other kids will cut.

But I think there are a lot of other factors that play in to cutting besides seeking attention. I’m also interested in questions about molestation with cutting. Were they ever hurt? Did they ever suffer abuse? Are they using that in the context of cutting? Has it become very ingrained, so it’s a behavior that they use as a coping strategy that they may have done thousands of times and they find themselves unable to stop? How does it fit in with their family?

Does their family know much about it?
There are many, many reasons why young people cut, and attention-seeking is only one of them.
One of the cases that I worked on for a long time, a girl cut because her father was a surgeon. He talked about cutting all the time, a different kind of cutting, but she imitated him in a kind of identification with her father. It took a long time to unravel, as it wasn’t obvious at the beginning of her treatment. There are many, many reasons why young people cut, and attention-seeking is only one of them. And it’s not often the major one. You have to address the complexity of the behavior and also the feelings that go with them.

Five Perspectives

RZ: I think some professionals are concerned that giving too much time and attention to cutting might be positively reinforcing. So it seems to me that as a clinician addressing it you want to find a balance between over-reacting and under-reacting.
LP: I think that’s more of a strict cognitive behavioral model way of looking at it, and it gets to the question of models and how they affect our work. Cutting is a behavior, but it’s attached to many other perspectives that we look at when we’re engaged in therapy. I try to look at things from at least five perspectives.

One is the more dynamic-relational, where you engage and are looking at aspects of the relationship—how it affects you, the parents, the cutting behavior, all of that. How disclosure plays a role in that. Attachment. Therapeutic alliance. Then there’s the behavioral model. A lot of therapists don’t use that model, but I think it helps to focus on the behavior. I often have kids keep a timesheet or a workbook on their cutting behavior and have them draw their feelings at the time that they’re cutting in addition to recording the number of times they cut. It’s a kind of cutting journal that we look at from a behavioral perspective. We also look at their thoughts that are occurring at the time that they’re cutting, so we can target really negative thoughts.

Then there is the family system. Cutting is usually very much connected with parents in some way or another—they’re worried about the parent’s reactions; they’re worried about feelings they have that they feel the parents can’t help them with. A lot of our kids have trouble with self-soothing, so they’ll cut to self-soothe. The parents might like to learn how to help soothe their teen, or help their teen gain self-soothing mechanisms, but they don’t even know the cutting is going on so they can’t focus on that area with them. Or they, themselves, may be unable to self-soothe and not know that it’s an important skill that you need for raising teenagers.

Carl Whitaker always said, "You lose the parents, you lose the family, you lose the case."
And then there’s the aspect of meaning for the teenager. What does cutting mean to them? Do they think about suicide? Some cutting is related to suicide. Self-harm that is related to suicide is very important to pay attention to, not just for our board tests but in our office with our kids.

Lastly there’s the biological perspective. With some kids that I work with, they carry biological conditions which may lead to increased cutting behavior. Prader-Willi Syndrome is one of those that has some increased cutting and self-harm. You want to be thinking about underlying conditions that might contribute to this behavior.

All of those things are going through my mind, so I’m not thinking, “if I pay attention to this behavior I will reinforce it.” Instead I’m working on all of these levels if I can. I didn’t start with this in the first year or two of being a therapist working with kids, but the longer I’ve worked with kids, the more I’ve been able to see the complexity of so-called simple behaviors.
RZ: I really appreciate that more systemic approach to working with families because when you work with children and teenagers you’re never just working with a child. You’re always working with the family and the larger system.
LP: One of my greatest teachers was Carl Whittaker, a well-known family therapist I worked with as a young medical student therapist in Wisconsin. He always said, “you lose the parents, you lose the family, you lose the case, Lynn.” I kept that in mind and it’s really helped me with all of these cases.

Manualized Treatments

RZ: Apropos of what you just said, I was trained in manualized treatments and I do see a use for them. But a lot of therapists think they’re mumbo jumbo and that they don’t address and can’t respond to the spontaneity of what happens in treatment face to face with clients. How would you make a case for manualized treatments, if at all, or what would you say to people who don’t believe in them?
LP: Well, there are now manualized treatments in dynamic relational work. There are over 400 manualized treatments that I know of in working with children and adolescents from a behavioral modality. Family therapy, too, has manualized treatments. I don’t think there are any in the more existential perspective, because it kind of runs counter to manualization. In biological therapies they have always had manualized treatments for how you evaluate symptoms and work with things.

When I work with young therapists—and I supervise a lot of residents, fellows, psychologists, psychiatrists who are at all stages of training—I really encourage them to pick one or two manualized treatments and really learn them—go away for a day or a weekend, learn the strategy, practice it, and try to become familiar with it. Even if you’re going to be a strict psychoanalyst or family therapist, I think they’re valuable because they teach you how to focus on specific things, how to evaluate. Often manualized treatments have an evaluative component built in, so you have to look at your actions and evaluate how they’re working at the end. That’s a very important part of all therapy.
RZ: Measuring one’s progress?
LP: Exactly. That’s the key, I think, in mastering some of our work. Now, which ones would I recommend? I think one of the best ones to know about is the basic cognitive behavioral therapy approach as developed by Aaron Beck at Pennsylvania. He was my supervisor when I trained there as a resident, and it’s a very successful modality to use. It helps us understand the impact of negative thinking. Another supervisor of mine was Joe Weiss, who worked on Control Mastery theory—which is about negative thoughts and ideas and the power of unconscious beliefs. I admire Marsha Linehan a great deal and the Dialectical Behavioral Therapy model. I’ve had some wonderful conversations with her about her work with adolescents and I think she really grasps what it’s like to work with high-risk adolescents. I would encourage almost anyone to look at her book on working with high-risk adolescents. It’s a wonderful model and it adds much to the work we do with young people. A third area that I think people should look into is trauma. We work so much with trauma as child and adolescent therapists. There is a trauma focused interview that we can do with kids that I use all the time. It’s very useful in diagnosis and at looking at symptom category.

I think learning a little bit about any one of these models helps any child and adolescent therapist function in a more complete way.
RZ: So it sounds like what you would advocate for is an understanding and knowledge of these manualized treatments because it gives you, as a clinician, more tools in your tool belt to pull out for individual clients as they come to you with their individual differences.
LP: It’s one of the reasons the tool belt concept is helpful. But it also makes you feel more comfortable as a therapist, knowing that you have some grasp of these different ideas. Knowing that you’re not following one dogma, but are open to new ideas, because I think ultimately as therapists we end up constructing our own way of working. The theories that we use to support our work, the collection of tasks and techniques that we define and use—these form the basis of our work . It’s very valuable to look at other people’s constructions, integrate them into our own work and say, “hey, this is useful for me. It works with these patients. I can really take this and run with it.” I mentioned five perspectives that I’ve accrued over maybe 35, 40 years of work, but I anticipate over the next 40 years there are going to be others that will greatly benefit our work as child and adolescent therapists.
RZ: There are therapists and other mental health practitioners who would say that defining yourself as eclectic dilutes your work. Do you believe that that’s true? How do you define your theoretical orientation when asked?
LP: I remember that same question from 35 years ago in residency. I think having multiple perspectives strengthens our work, and there are multiple perspectives within each of these theories, so it’s not like people who belong to one model are necessarily doing some ossified therapy that was created by some individual or group of individuals. In my work, I want to stay open and patients open me up.

One reason I like adolescent work, even though I feel like I’m getting older, is that it keeps me young. It keeps me open to new ideas. My patients actually taught me how to text on my cell phone; my patients are coded in by their first name so that they can call me and have a relationship with me.
My patients actually taught me how to text on my cell phone.
I remember one of my other supervisors, Hilda Brook, who worked a lot with eating disorders, was working with teens into her 70s and early 80s in a wheelchair, and she had greater facility with them than even I have today in my 60s. We can continue to grow in our work with teens if we stay young in other ways.

Texting

RZ: You bring up a very important and hot button issue when working with teenagers, which is texting. And I think doing therapy with teenagers and kids today is a whole new world because teenagers and kids are used to communicating through their technology. What are the upsides and downsides of deciding to be a clinician who texts with your clients as you are?
LP: I think it’s important to be aware of some of the legal parameters around texting. Many of us work with large organizations, and it’s important to be aware of HIPAA regulations and such. HIPAA doesn’t regulate all therapists, only certain therapists who are involved with electronic billing, which you might be if you work in a large institution and you bill electronically. In that case you are HIPAA regulated and with regard to texting, HIPAA states that you cannot be sending clinical decisions through a texting modality or an unsupervised modality. You have to have some regulations around it.

When I worked at UCSF for 35 years, I was in a large system that was HIPAA regulated. My texts, which I did with teenagers for 10 years during that period, dealt with scheduling, and if they texted me about an issue that I was clinically concerned about, I’d have them come in so that we could then talk about it and then work on it in person.

But the texting connection I think is very, very important with teens and therapists. Not all therapists can do it for a variety of reasons. Not everyone feels comfortable with it and not all teens have phones. I’ve done a lot of work with homeless teens, who usually don’t have phones, so you have to figure out other ways to communicate with them.

But the bulk of teens out there today do have access to texting and they will communicate that way, often just to check in with you. They may just want to know you’re there and I think that sets up a relationship with them. I don’t always respond to those texts, but they know that I’m receiving and reading them.

But let’s say you’re not HIPAA regulated, so you can put anything on text. I would still say if you’ve got a big clinical concern with a teen—let’s say they text you, “I’m cutting, I think it’s out of control, I’m feeling really anxious”—I’m going to call them immediately rather than text, and most likely try to get them in to see me if I can. So it’s not that I’m sending long texts back and forth about that type of behavior. I’m really using it as a way to communicate to stay in touch.

Other ways that teens will keep me informed, they’ll often text me, “Saw an article you should be reading, doc,” or “thought you’d like this.” Those things are important because it is a reciprocal relationship. I’m largely involved in educating young people, but they help me a lot, too, and I get a lot from them.
RZ: For therapists in private or group practice who don’t work for large organizations, is there a downside to texting? For example, what if you lose your phone?
LP: I think that gets back to just have their first name, maybe an initial afterwards, but no way that they could really be identified. And if they’re very sensitive texts you can also erase them, although we all know that things are out in the cloud forever. So be aware that that information is out there.

This is also one of the things that you should discuss in the first session. I often discuss with my patients my availability, how they can get a hold of me, so they know that I will have their first name on the cell phone, and their phone number, and that I’m fairly easily accessible. I believe one of the reasons I’ve been so successful with teenagers and their parents is because I have very good accessibility. I take my cell phone all over the world when I travel. I do have somebody on call to cover, but I’m available in that way. But let’s say that cell phone is lost, and I’ve never lost my cell phone, though I fear it all the time, Rachel. I’m looking around for it and I worry about memory loss and loss of cell phone. But if it’s lost I think you have to alert the patients, especially those that you’re texting with, that there is a risk and the cell phone was lost. Most of them are not that concerned about it because their whole name is not out there. There’s not a lot of information out there. But I think it’s important to do that. But I also know from forensic cases that you can actually remove data from a distance off of a cell phone, which might actually be required if you work for a university or large organization.

Sexting

RZ: Technology and internet use seems to be a primary source of conflict between parents and kids. Do you see this a lot in your practice? And how do you go about addressing it both with the parents and with the children?
LP: Very young kids, 9, 10, 11, 12 are using the internet or videogames or other media for large periods of time, and parents are often seeing symptoms—kids are struggling with school, their concentration is impaired, and they’re not engaged in other activities or relationships.
Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
I think that that’s a very important area to be aware of. Parents need education around the signs to be looking out for when kids are struggling. We need to think about their media profiles, how much time are they on TV, how much time they are playing videogames, how much time are they on internet, and what different modalities they’re involved with.

When families come in, I’ll have both the kid and the parents keep a journal and write their feelings down about what’s happening when there’s a confrontation at home regarding this behavior. And all of that comes back into the session. I often will use the family modality to meet at that point and we’ll talk about what’s going on in that type of interaction.

The other area that comes up frequently with teenagers is sexting—texting sexual material. During the past five years I would estimate I’ve had 50 teenagers referred to me who have been involved in sexting activities.

In general, the girls are involved in sexting pictures, nude photos of themselves that have caused some great difficulty. These are often selfies where the girls will hold the camera out in front of themselves, often in their bedroom or bathroom, sometimes partially clothed, sometimes not, and then they’ll text the photo to a friend or friends, and then it gets texted everywhere. That type of interaction is very important to pay attention to and I’ll generally work with the teenage girl alone and talk with her about what happened. The feelings around sexual development are very private and tender, and it’s deeply shocking that this is suddenly exposed to a large group of people. I work with the family around this behavior, too, and sometimes will meet with parents alone to help them understand why this behavior might have taken place.

I would say a smaller number of the sexting cases, roughly 20%, are boys texting nude photos of themselves, but they’re mostly texting nude photos of girls. There are also laws involved with this and I’ve been involved with the FBI and other law enforcement officials around how to handle these cases. There’s awareness in high schools now that they have to report these cases when they discover that boys are texting sexual photos of girls. Some boys are being prosecuted for texting sexual photos and parents of boys are very concerned about this.
RZ: How do you handle those cases when they come in?
LP: First be aware of the legal ramifications. Second, encourage them to get legal advice, because we as therapists can’t provide all of that. Third, I often will meet with the boy individually and try to get a sense of what happened and work with them around that. Many boys are shocked that this has happened. They may have thought they were doing what the other guys at school were doing, that it was cool, they were getting more status. But I’ve also seen boys who’ve had long-standing problems and the texting of the sexual photos is connected to other sexual difficulties that they’ve been struggling with. They may have been molested. They may have molested another person. So to be aware of that, to be open to hearing about that is very important.

Parents of boys are often very angry about this process. They feel that the boy is at a disadvantage because though he sexted the photos, it was the girl who originally sent the photos out so it should be her responsibility. Helping the parents see that we have to take a deeper look at what’s going on with their son under these circumstances is really, really important and not easy to do. You have to stay open to their feelings about their boys being scapegoated, but at the same time point out this is something we have to pay attention to.

The intersection of online work and sexuality is really a key area to focus on, to get as much help as you can as a therapist. Sometimes if I have a question, even today I’ll go to another therapist that I think has more expertise in this area and get supervision.
RZ: Are there particular resources for therapists who want to learn more about how they can be better clinicians when addressing something like sexting?
LP: Yes. I’m not going to toot my own horn about this, but I’ve written an article that’s online about sexting and working with clinicians that I think is very helpful. It has a literature review of a couple of cases and ten guidelines for parents and therapists around this area. There are not recent and current books because it’s a fairly new topic, but I think it’s something we’re going to see more of in textbooks and articles. A lot of young psychologists’ dissertations have been done on sexting, and those are valuable if you can get a copy and read them.

Learn to Like Kids

RZ: What advice do you have for beginning clinicians treating kids and teens?
LP: The most important thing about doing this work is that you have to be knowledgeable about your own childhood and adolescence. You have to have thought about it, its impact on your own development, the issues that you might bring to the work, questions and preconceptions about it, etc. I encourage almost all therapists to have their own experience in therapy and to explore some of these issues.

Second, what helps the most in this work is really loving children and adolescents. Having a strong love for that age group or working toward it. Let’s say you don’t love it, you’re kind of afraid of it, maybe you’re going to work toward a passion in that area. You’re going to learn why you’re afraid of that age group and you’re going to try it out and get supervision with somebody who is really very good at it. It is a group that is fun to work with, is very challenging, and can really be a growth opportunity for you as a therapist. But I’d say try to develop a passion for it. Learn to like kids. Learn a lot about child and adolescent development. I think either being a parent or playing a role with your nieces and your nephews and other kids is really important.

Third, you’ve got to be able to work with parents. When I was younger and starting out one of my mistakes was that I thought I knew what it was like to be a parent long before I was a parent, and I was often angry with how parents treated kids. By now I’ve gone through decades, I’ve had my own kids and I see it differently. I see myself as a valuable resource to parents and I have great empathy for them.

Sometimes I have to do very difficult things with parents.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby.
Once I had to climb through a glass window when a young mother was holding her new baby and was psychotic and trying to do something to the baby. The police were there and there was obviously a lot involved with this, but we had to save the baby and rip the baby out of the mother’s arms. So there are things that you often have to do in this work that are not very easy with parents and I think I’ve learned how to do those with concern and empathy as I’ve grown older and become an older therapist. But at the beginning I would say stay open to the work with parents. Keep your eyes open. Realize you don’t know everything.

Fourth, Don’t just accept a dogma. Try to integrate and construct your own idea of how to do the work. I talked earlier about the five perspectives I use but think about those that work best for you, yourself, as a therapist, and with the patients you’re working with.

Lastly I’d focus on the first session and developing a good alliance with kids relatively quickly. That first session is really important—how you connect to your passion, staying open, not being judgmental. Watching tapes of other therapists do first sessions can be really helpful, or being in a study group where you share information about your sessions with kids. Or even observing preschool teachers, who are often very good with kids, welcome kids into the classroom, integrate them, and get them playing and involved in activities. All of that adds to our abilities in that area.
RZ: What do you think has helped you become a better clinician?
LP: Years of experience have helped a lot. Reading widely has helped a lot. Having my own children has helped a lot. I have four—two step sons and two daughters—and I’ve learned from all of them. It’s not been easy.

Supervising younger therapists has also been really helpful, because I’ve listened to their problems and I really try to figure out what they’re going through, which keeps me more in touch with what it’s like to start this work. This is not easy work. There’s a lot to learn. We make a lot of mistakes in it, but we do a lot of good.

Maybe the last thing I’d say about it is I’ve been so impressed over all the years of working with adolescents how many return. They bring their own kids back for treatment. That keeps me in it more than anything—having the kids come back with their own children, and seeing that they’ve shared things I said to them. This is not everybody, of course, because I’ve had over the course of my career two adolescents who killed themselves. I’ve gone through a lot of difficult experiences, as have my patients, but I am impressed with this type of work and how much we can help kids if we stick with it.

It’s wonderful work that makes you feel very good about your life’s work at the end of it. I don’t see myself at the end of it, but I have talked with others, like James Anthony, a role model of mine who was a wonderful child therapist who worked with Anna Freud. When I was a very young student I had the opportunity of working with him in London. He loved the work and he still continues to teach me things—and he’s in his late ‘90s. He talks about having patients come back and treating the grandchildren of the children he saw. That is an amazing thing. It’s a chance to be very connected with others in life really.

Suicide

RZ: It sounds incredibly powerful to have had such a positive impact on someone as a teenager that they want to bring their own teenagers to you once they have had children. It also sounds incredibly powerful to have lost an adolescent client to suicide and I’m wondering if you feel comfortable talking about that a little bit.
LP: It’s a reason that a lot of therapists seek out supervision.
RZ: It’s admittedly my worst fear.
LP: I think it is for all of us. It’s not just the legal aspects of it. We all carry liability insurance and we’re worried about that part of it—but it’s also just the connection. I will say that I really remember these patients and their treatment very, very well because of going through this and thinking about it a lot. The first was a young man who killed himself when I was the director of the adolescent unit at UCSF.
RZ: How old was he?
LP: He was 19 and he had very severe bipolar disorder. He stopped his medicines when I went on vacation and then went into the woods and shot himself. I had arranged for somebody to cover me during this period of time. It was a short vacation, but still enough for this to happen. I’ve thought about it a great deal, of course. It’s changed the way I take vacations. I still take them, but I’m very alert, thinking about coverage and concern about these teenagers and children when I leave.

I spent several months working with his family. They had anticipated it more than I had and that surprised me. I went to the service and worked with them in a collaborative mode, which I did not charge them for, and they were very grateful. I’ve stayed in touch with them in some ways, though that happened I’d say roughly about 30 years ago now.

The other suicide was about 20 years ago and was a patient I’d worked with for years. She had a chronic psychotic condition. She was a very bright young woman and I had spent a lot of time with her. She had promised me that she would not harm herself until she was 30 years old, and then she killed herself not long after her 30th birthday. So she stayed alive working with me for years I think to try to get better, and we tried everything. Family therapy, medications—and it was clear that she was going to be living with a chronic psychotic illness that was incredibly painful for her.

I still think about her all the time. I think she helped me in many ways to understand that sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
Sometimes we work with individuals who are suffering so much that from their perspective, their life is really not worth living.
We can discuss that with them, we can work to help them, many different things can be done, but there are limits to the work that we do. She left me a number of drawings she drew and painted. I think a lot about her family. I worked in much the same way that I described with the earlier boy. I met with her family and had contact with them for a long period of time. I still think about her all the time.
RZ: I bet. I think this is particularly important to talk about for young therapists who are, as you mentioned before, maybe put off entirely by cutting because they’re so scared of it, or don’t want to work with suicidal clients because they’re so afraid of losing a patient. It’s really valuable for me as a young therapist to hear you talk about having gone through this worst fear with a couple of your clients and not only did you get through it, but it made you a stronger clinician ultimately.
LP: I think ultimately it did. Of course, a big part of this was questioning what I had done with them and if I had made the right decisions.
RZ: Of course.
LP: Had I done something wrong?
RZ: That’s natural.
LP: I think any therapist who has had a patient suicide question their work. Families question their interactions with their children after suicide. We all think about it. I work with many teenagers, especially here in the Bay Area, who have had friends suicide, and the young teens question what they could have done to help their friend. It’s not only us as a group of therapists who question ourselves, but it’s really the world that comes forward to question itself around suicides.
RZ: It seems like that’s the first question people ask friends, family, and therapists alike: What could I have done? Could I have done something different or better? And I think that is a real challenge.
LP: It’s natural and appropriate to ask those questions and explore them, but it’s also important to really understand that there are limits in life to what we can do. It’s important in this line of work to talk about this aspect of it.
RZ: That’s a very realistic and compassionate perspective. Thank you for your time and for your wisdom.
LP: And thank you for your good questions, Rachel.