Category: Addiction

Rewriting the Drinking Story: Four Pillars for Empowered Sobriety

Posted on by rezendevknowfully.com

“You really need to drink less.”

That’s what people kept telling me toward the end of my drinking career. The truth was I completely agreed but just didn’t know how. At age 26, I was diagnosed with Alcohol Use Disorder. Intuitively, I knew drinking was only the surface. The deeper questions—what’s underneath, and how do I address it?—eventually drove me to graduate training in Clinical Psychology.

Through both my own journey and my ongoing clinical work with clients, I began to notice a hidden loop and four forces that fueled drinking cycle:

  • Universal Needs: Alcohol often serves a purpose—to relax, connect, or have fun.
  • Learned Beliefs: People come to see alcohol as a shortcut to those needs.
  • Habit Loops: When alcohol ‘works,’ the brain reaches for it again.
  • Fixed Mindset: Stories like “I can’t have fun/relax/connect with others without drinking” keep clients stuck.

If the drinking cycle is fueled by more than drinking alone, breaking it requires more than “drink less.” Over time, I identified four pillars to help clients interrupt this loop and build an empowered alcohol-free life.

The Four Pillars

Pillar 1: Value Alignment

The first pillar is value alignment. I use value exploration to help a client tap into their intrinsic motivations, and replace behavior-based goals with emotion-based goals that allow them to bridge values and behaviors.

For example, working with a 67-year-old retiree and former lawyer, we uncovered that her core value was intellect. She noticed she drank more on evenings when she felt intellectually understimulated. We explored ways for her to feel more engaged and challenged. Instead of setting a goal around reducing her drinking time at night, we set an emotional goal: increasing the time she spent reading subjects that stimulated her mind.

Within weeks, she was 200 pages into The Satanic Verses and had rediscovered her passion for reading. As a side effect, she sometimes skipped her evening drink to stay sharp for her book.

Of course, not every client’s struggle is solved by picking up a good book, which leads us to the second pillar: Belief Reconstruction.   

Pillar 2: Belief Reconstruction

This pillar focuses on identifying, deconstructing, and reconstructing alcohol-related beliefs that fuel desire. At its core, this work helps clients become informed consumers through psychoeducation. In a culture that glorifies alcohol, many people have been sold on its exaggerated benefits while the harms remain obscured. One of my favorite “myth busters” is that while one drink creates a desirable buzz, additional drinks don’t actually make the experience better.

A successful entrepreneur in his early 30s shared that he enjoyed nights out on weekends, but struggled to keep his drinking within limits. Together, we uncovered the hidden beliefs: alcohol makes things more fun and if one beer feels good, five must feel better.

After guiding him to reflect on his own experience after the third drink, I introduced the science of alcohol’s biphasic effect: the first drink gives a brief buzz, but subsequent drinks bring diminishing returns as depressant effects take over. The result is an exhausting cycle of chasing the buzz, but never catching it.

He was struck by this realization. In the weeks that followed, he reported less urge for a third or fourth drink, becoming more mindful of how each one actually affected him—and recognizing that his experience confirmed the science.

While psychoeducation can shift expectations quickly, it alone is rarely enough for clients who rely on alcohol to cope. This leads to the third pillar: Skill Expansion.  

Pillar 3: Skill Expansion

The third pillar moves into behavior change. Informed by habit science and Dialectical Behavior Therapy (DBT) principles, I help clients see that breaking a well-worn drinking loop isn’t about simply removing alcohol, but about replacing it with empowering skills.

This work is highly individualized, based on the purpose alcohol serves in a client’s life. For example, I worked with a young woman in her 20s who used alcohol as “liquid courage” when confronting family members who treated her poorly. Together, we recognized alcohol was numbing her fear so she could set boundaries. What she truly needed wasn’t another drink, but stronger communication and assertiveness skills.

Skill expansion reframes alcohol as a signpost pointing to the abilities a client most needs to strengthen. Because mastering new skills takes time, this naturally leads to the final pillar: Mindset Upgrading.  

Pillar 4 Mindset Upgrading

The final pillar, mindset upgrading, is often overlooked. Many clients believe they should be able to quit overnight if their willpower is strong enough. When they struggle with cravings or slips, they quickly feel ashamed, assuming something is wrong with them. Subconsciously, they get stuck in self-defeating questions like, Why can’t I…?

One client in her late 20s, after quitting drinking, struggled to enjoy socializing without alcohol’s boost of confidence. She asked me, “What’s wrong with me? Why can’t I just make conversation like everyone else?”

What she didn’t realize was that thriving alcohol-free isn’t just not drinking, it’s about building new skills, which takes time and practice. To illustrate this, I shared the analogy of learning to ride a bicycle: falling after removing the training wheels is expected, not proof of failure. Similarly, slipping after removing alcohol is part of growth.

I encouraged her to shift from Why can’t I…? to How can I…? Instead of dwelling on limits, she began asking, How can I start conversations more easily? This reframing opened space for problem-solving and creativity. She even began experimenting with small talk tips as healthier ways to build her confidence.  

Sobriety as an Empowered Choice

Now, nearly six years into my own sobriety, I see it not as recovery but as discovery: a journey to reconnect with what truly matters, to become an informed consumer, to build confidence without alcohol’s crutch, and to embrace setbacks as growth opportunities.

My hope is that by mapping out these Four Pillars, I can continue to offer my clients a more concrete roadmap to outgrow drinking routines that no longer serve them, and to rediscover an empowered, alcohol-free life.

The Realm of Our Industry

Posted on by Psychotherapy.net Team

From The Grieving Therapist by Justine Mastin & Larisa Garski, published by North Atlantic Books, copyright © 2023 by Justine Mastin & Larisa Garski. Reprinted by permission of North Atlantic Books.

“In the beginning, we were all psychotherapists. And it was good.”

—Bruce Minor, Minnesota Member of the MFT Community

THE TIME HAS COME to face our industry and sit with the ways the therapy system in which we work helps us, hurts us, and holds us to a standard impossible to meet. Throughout this book we have touched on many issues facing our work; now we are looking specifically at the system in which we work. No longer a collection of individual practitioners who see each other as fellow members of a therapeutic federation, our industry (therapy) has become compartmentalized, industrialized, and controlled by third-party payers.

As you begin this leg of the journey, we invite you to pause and reflect on the mentors and experiences who supported you on your quest to become a therapist. We welcome you to reflect on mentors of both the past and the present, as well as those with whom you had a challenging or even fraught relationship. Even those mentors and supervisors who we experience as awful can teach us valuable lessons (though that does not exonerate them).

When it comes to mentors and supervisors, we, the authors, have had the best and the worst. For this chapter, we reflect on some of the greats from our local MFT community: Anne Ramage, PsyD, LMFT, our graduate school professor who taught us so much more than we ever realized there was to know about Carl Whitaker; and the collective of marriage and family therapists who have sustained the Minnesota field for decades, some of whom also became our supervisors and mentors: Ginny D’Angelo, LICSW, LMFT, Bruce Minor, LMFT, Briar Miller, LMFT, and Michelle Libi, LMFT.

You blink and end your repose to find that you’re alone. It feels as if you have awoken from a dream. You rise from your resting spot and begin to walk down the winding path toward the sound of a river. As you walk, you notice the crunch of twigs underfoot and hear distant birds. Is one of them the red-winged blackbird? Neither your bird friend nor the forest yeti are anywhere in sight. Perhaps you dreamed them.

You look up at the branches of a nearby tree and notice a small silver shape clinging to a twig. Pausing, you raise up onto your tiptoes and realize that this is a cocoon, perhaps belonging to a butterfly or a moth. You gaze at the cocoon for a moment longer, noticing it shake as the small creature inside struggles with its transformation. Change is such hard work, you muse, and resume the hike. As you walk you notice that you have many aches in your body. How long were you sitting in meditation? You stretch your neck from side to side as you continue to make your way down the mountainside.

As you breathe in, the air is fragrant with the scent of dried leaves and warm earth. You wonder at the way the seasons seem to have shifted around you on your travels. As you look around the forest bordering either side of the path, you notice hints of yellow and orange in many of the leaves. The wind shifts, blowing the undersides of the leaves up, causing them to shift and sway. It reminds you of a distant memory, but as you grasp for it, the memory skitters out of reach.

The path winds down the slope, and you lean slightly backward against the tug of inertia and gravity. The sun’s rays are just the right amount of warmth, offering a radiating blanket of heat against the cooler air temperature. You look down and slightly to your left, and you see a ribbon of blue snaking through the undergrowth far below: a river. It looks like a nice place to pause and rest. You estimate that you have at least another mile to walk down the mountain before you reach the riverbank. You walk down toward it.

Therapy’s Big Brother

Once upon a time, as Bruce Minor reminds us, we were all just psychotherapists. In the very, very beginning of our industry, there were just small- to medium-sized collectives of human beings throughout the American and European continents — composed mostly of wealthy men and a few audacious women — gathering together in an attempt to suss out the nature of the human mind and heart. From these meetings, the field of psychoanalysis was born.

While these early theorists and practitioners engaged in practices that we would gasp at today — Freud psychoanalyzing his daughter, Jung sleeping with several of his patients who then became therapists-in-training — their mistakes became the foundations upon which rules like “no dual relationships” were based.

These early therapists did not have insurance agencies or managed care with which to deal. But they also tended to focus on treating the bourgeoisie — the European upper middle class who could afford to pay for things like this newfangled “talking cure,” thanks to their monopoly on industry. Neither Jung, Adler, nor Freud himself (founding psychoanalysts all) had to consider whether high-quality psychotherapy happens in increments of forty-five, sixty, or ninety minutes. We bring you this abbreviated history lesson to remind us all that our present constructs have not always existed. Not only have they not always existed, but they might not actually be the most effective structure for treatment.

When family therapy was new, co-therapy and one-way mirrors with reflection teams were the standard of the day. When Justine tells graduate students about these once-standard training practices, they are in awe. “But how did that get paid for?!” they exclaim. The short answer is that decades ago, universities, particularly public universities, had more money in the humanities and social science departments.

Insurance once reimbursed for far more therapeutic services than they do now. Then Justine will often go on to tell her students about sitting in her own graduate school classroom at Hazelden Graduate School of Addiction Studies (now Hazelden Betty Ford) and hearing her professors talk about the changing landscape of drug and alcohol treatment.

Structured limitations are necessary for high-quality therapy (recall the example of sandtray therapy and the need for a literal box within which to put the sand, from chapter 2). Certainly, the case could be made that American psychoanalysis and drug treatment of the 1970s and 1980s was in need of a bit more clinical oversight. But the evolution that followed brings us to a dystopian present where third-party payers like insurance companies are dictating the terms and conditions of treatment. They’re also dictating the amount of money that the clinician receives for the work they do based solely on their licensure, rather than on the type of work they’re doing. These payouts are often inadequate at best and paltry at worst. Because of variable reimbursement rates, the amount of time and effort needed to handle billing issues, and the hoops clinicians need to navigate to get even the small amount of money they’re paid, private-practice clinicians are increasingly opting out of the insurance model. This causes frustration for would-be clients, and for other clinicians.

Licensure Drama

Have you ever had an issue with another clinician and thought, “Well, that’s just because they’re a Ph.D.; doctorate school sucks all of the fun out of you”? Or perhaps you’ve thought, “They don’t teach master’s-level clinicians anything about diagnostics.” Third-party payers and clinicians determine their reimbursement or compensation rates based on a number of factors, including education. Hierarchical thinking dictates that the more education and experience a person has, the more they should be valued.

The main way that we express or show value is through monetary compensation. However, this very quickly leads to confusion and resentment when master’s-level clinicians and doctoral-level clinicians are working at the same practice or agency, and are performing, at least on paper, the same job functions. Disparate training and licensure requirements can lead to differences in case conceptualizations, standards of care, and clinical interventions.

Certainly, these varied perspectives can be helpful if discussed and processed through open and honest clinical dialogue. But who has time for that? We don’t say this to minimize or undermine the value of care coordination. The reality, though, is that third-party payers don’t reimburse for care coordination. Contemporary clinicians are lucky if they can connect for five or ten minutes via phone either just before the beginning (seven a.m.) or just after the end (seven p.m.) of their clinical day. Thus, it’s no surprise that confusion and even infighting across licenses and education levels abound.

Justine recalls a question from a student about this infighting: “But who is actually above the others? There has to be a hierarchy, right?” Justine responded that while it may feel as though there is a hierarchy, the reality is that we’re a community with a variety of skills. We don’t need to fight among ourselves. She said that just because someone with a doctorate has more education than someone with a master’s degree, that doesn’t make them better than or above the master’s-level clinician. This is a social construct that we get to question and challenge, because it no longer serves us.

The tangible difference between master’s-level and doctoral-level clinicians lies in the area of assessment. Folks who complete doctoral programs are schooled in the practice of psychological assessment and usually graduate with the third party-payer reimbursable skill of psychological assessment.

With gravity on your side, you make it to the bottom of the mountain faster than anticipated. The sound of the river rings in your ears as you push through the bracken toward the riverbank. The grass along the shore is a deep green and only slightly prickly as you kneel down and bend over the water, cupping your hands to take a long, cool drink. Once you have quenched your thirst, you sit back on your heels and stare out across the blue water, leaning into the rays of the sun at your back. You notice a butterfly flapping its wings and landing on a nearby flower.

App Therapy Is the New In-Home Therapy

Newly-minted therapy graduates find themselves staring down the gauntlet of the licensure process, which usually entails several examinations, hours of supervision, and even more hours of direct client care. Depending upon the state where you live and the license you’re pursuing, you may find it very difficult to get a job that pays you money while you acquire hours you can count toward licensure.

Over the past few decades, the entry-level job for graduates in this predicament was in-home family therapy. Often considered the grunt work of the therapy industry, in-home family therapy requires practitioners to work long hours and drive long distances for very minimal pay. In 2014, when Larisa was working as an in-home clinician, she didn’t even make minimum wage, so she worked another job part time as an after-hours crisis counselor.

Today’s graduates have a new, additional option: they can become app therapists. Similar to other gig jobs like Uber Eats and Lyft, clinicians who work for therapy apps such as BetterHelp, TalkSpace, and Larkr are either populated by associate-licensed or fully licensed clinicians, and they work entirely through their company’s telehealth app interface. They tend to have very large caseloads (pitched to them as a “great opportunity to get your licensure hours”), minimal time with an assigned clinical supervisor, and demanding clinical expectations. Most therapy app jobs market their services to prospective clients with the promise of a readily available therapist, translating to the expectation that the therapist is available to the client at least via chat through most hours of the day and night.

Larisa vividly recalls many of her lectures with Dr. Anne Ramage for a number of reasons, not the least of which is that Dr. Ramage is an excellent professor and an enigmatic speaker. Among all of Larisa’s memories of Dr. Ramage’s Carl Whitaker quotes and experiential roleplays, she recalls the professor advising time and again that “in-home jobs will be waiting for you as soon as you graduate. They’re tough. You need to be ready. But they’ll give you excellent experience in working with families.” Then Dr. Ramage discussed the MFT techniques from that particular lecture that might apply to in-home work, and she explained the basic safety strategies of which in-home clinicians needed to be aware.

When Larisa graduated, she did indeed take a job as an in-home family therapist. The night before her first day, she reviewed the strategies she had learned from Dr. Ramage:

1. Arrive five minutes early and look up the homes you’ll be visiting in advance so you can plan your parking strategy. Never schedule sessions late in the evening or after dark.

2. Be ready to set clear and consistent boundaries, and for those boundaries to be tested.

3. Pack a change of clothes and hand sanitizer.

4. Review your agency’s privacy policies.

5. When you enter someone’s home, assess for safety and your own exit strategy. Although it is rare that clients will ever mean you harm, things can and do get out of hand when you are in the family’s own space. You get to protect yourself first.

This survival guide doesn’t apply to folks who are working for therapy apps, but the need for both support and coping strategies is no less acute. If you’re working for a therapy app, we, the authors, offer you deep compassion and the following tips:

1. Plan an exit strategy. What does this mean? It means a human being can’t sustain years of work at the rate demanded by therapy apps. So, it’s essential for you to decide how long you can sustain working for a therapy app before you go the way of a younger Larisa and start losing your hair and developing insomnia.

2. Find a supervisor outside the therapy app. Yes, you will probably have to pay for this supervision, and that will likely cause financial stress. However, it is crucial for you to have a guide whose sole investment is in you and who exists outside the system in which you work, to help you regain perspective and hold boundaries around things like time management and availability.

3. Remember that any symptoms of burnout (i.e., signs of physical or emotional distress) you’re experiencing are likely the cause of moral injury — harm caused by the system in which you work — rather than any fault of your own (we’ll discuss these concepts in more detail in the next section of this chapter).

4. Manage your expectations for yourself. However, you envisioned your therapy experience, it likely did not involve a smartphone application called “Better-something.” You can’t do depth psychotherapy in this kind of context; what you can do is help your clients with basic coping strategies and compassionate presence — sometimes, but not all the time. You’re not required to have 24/7 availability, no matter what your company tells you. Not even standard laptops can run constantly forever; they need to rest and update.

5. Reach out to your community. When you work in an online environment, it can be difficult to get your emotional needs met. Please remember to engage with other living beings outside your work environment who understand some of what you’re going through and who can show up for you.

Burnout and Moral Injury

The Realm of Our Work has changed in ways that we never imagined over the course of the collective traumas of the 2020s. Suddenly the norm is to work in a virtual therapy room, and some clients expect to have regular access to their therapist via text messages and video chat services. This isn’t what we thought the field would look like.

When Justine imagined her future as a therapist, she saw herself engulfed in a scarf, with a teacup in hand, sitting across from her client in an overstuffed chair near a small fire in a fireplace, surrounded by books. She envisioned herself helping people and feeling filled up by the work, then returning home to a pleasant evening all to herself — overall a very calm and steady way of life.

This is not reality. For a time, she did have the tea and the overstuffed chair, but the rest of the fantasy was just that — a fantasy. Justine now works behind a computer and sits in a rolling chair; her view is full of microphones, a ring light, and multiple monitors. For her, the change in our industry has been the death of a dream. The death of any dream is an ambiguous loss that even therapists are not always good at recognizing and finding compassion and ritual to help them move through it.

Of course, parts of what Justine imagined the life of a therapist to be all those many years ago, before she ever entered the field, were simply inaccurate. Even before teletherapy and therapy apps took over the field, the life of a therapist was rarely calm and steady. It had moments and longer periods of such calm, but the nature of therapy is to work with volatile emotions. The emotional intensity inherent to the profession impacts even the most experienced and boundaried of therapists.

Larisa’s experience differed in that she had a logical view of what life in the field would be like. She felt like she had prepared herself emotionally for the trials of holding space for people and their emotions day in and day out. She believed that this preparation would act as a shield against any future catastrophe. The sadness came when she realized that no matter how prepared she had been, the situation was worse, and far more unpredictable, than she could have imagined. She was ready for the stresses of people’s everyday lives and even for their great despair and trauma, but she was unprepared for the collective trauma of our age stepping into the therapy room and into her own life. She was totally unprepared for how political leadership would fail her and everyone else in her country during this time of great collective need.

In her younger and more impressionable years, she believed that even though power is corrosive and toxic to politicians, when they were faced with clear and present disaster, they would channel their highest selves and work to help people. Now Larisa realizes that America’s representative government has devolved into rule by the wealthy elite who use their resources to buffer themselves from the pain and the needs of their constituents. Sometimes the despair she feels is crushing. Perhaps you can relate.

As we sit with the tragedies that have befallen our profession, it is no wonder that so many therapists struggle with burnout. Burnout can be defined from many perspectives. For the sake of brevity and clarity, we offer definitions of both individualized burnout and systemic burnout. Individualized burnout occurs when a person is so emotionally exhausted that they chronically struggle with depersonalization, which is emotional, physical, and cognitive numbness that makes the person unable to feel present in their own body or life.

Systemic burnout is also known as moral injury, which is when a person experiences symptoms through no fault of their own; rather, the symptoms result from harm caused by the system in which they work. Moral injury was first defined by psychiatrist Jonathan Shay as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.” Wendy Dean, Simon Talbot, and Austin Dean expanded upon this definition when they argued for clinician burnout to be redefined as moral injury:

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin [sic] of our working lives and our guiding principle when searching for the right course of action.

But as clinicians, we are increasingly forced to consider the demands of other stakeholders — the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security —before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.

The article quoted above speaks solely to the experience of medical doctors, but its implications are clear for the chronic systemic burnout faced by so many in helping professions, including (but not limited to) therapists, medical technicians, nurses, and case managers. Helping professionals are increasingly placed in a double bind; that is, they’re being placed in situations from which there is no escape, and they’re being asked to perform at least two mutually exclusive actions simultaneously. They’re being asked to care for clients but also to please many other stakeholders, all without the amount or quality of support that they need. Just like all double binds, this is an untenable situation that causes distress within the clinician.

We, the authors, appreciate the distinction between burnout and moral injury. The concept of moral injury takes the onus off the individual, because there’s not enough self-care in the world to account for a system that’s set up as a no-win situation. When larger systems talk about “burnout,” that terminology allows them to let themselves off the hook for the clinician’s pain. The system can then pass the problem back to the clinician as a personal failing, rather than a systemic one. The therapy field is currently crying out for systemic change. We cannot do everything and be everything to everyone. It is impossible, and it is destroying us.

The butterfly’s orange and black wings flutter back and forth as it buries its face in a Black-eyed Susan. You contemplate the effort that it took for this butterfly to metamorphose from a caterpillar. It went through a violent transformation in the cocoon to become this creature. It’s not a pretty process. The butterfly must flap and flap and flap its wings inside the cocoon to strengthen them. It can be a difficult struggle to watch, and an onlooker often wants to help the butterfly be free from its enclosure.

But if it’s released from the cocoon early, the butterfly won’t have the strength to fly and survive. It must struggle to become strong. As you stare at the butterfly, considering its beautiful wings, you start to breathe into your own bodily awareness. You notice the many places where you’re holding tension and feeling stiff and sore. Perhaps you have also been flapping your metaphorical wings, becoming something new.

Grieving Tools — The Pain Paradox

As you might remember from chapter 2, pain can be a pivotal part of the meaning-making process. When paired with reflection time, pain can help us learn about our core values and live a life in accordance with them.

Yet because we work in a field that values sacrifice and the pain that entails, therapists are also far more susceptible to what Freud would call the martyr complex, and what we refer to as hero/savior/sacrifice syndrome. The pain paradox explores the tension between pain as both catalyst for change and a state of prolonged suffering. Particularly in helping professions, suffering for our work is often framed as positive, meaningful, or altruistic. This harmful social construct can lead clinicians to stay in harmful jobs “for the sake of the clients” and sacrifice their own health in the process.

The pain paradox invites clinicians to question their social constructs around both pain and meaning-making. In the therapy room, the pain paradox is a tool that clinicians can use to help clients who are themselves engaging in harmful behaviors for the sake of “meaningful pain.” Let us explore how you can use the tool of the pain paradox as you navigate your personal struggles outside of session, and how to use this tool with clients inside the therapy space.

Client

Pain is not the enemy, nor is it to be avoided at all costs. Sometimes what brings clients to therapy is the erroneous idea that we, their therapist, can help them learn how to disengage with their feelings entirely because these feelings are causing them pain. Of course, the reality is that we can teach them distress tolerance skills to be present with their pain and their feelings so they can learn to listen to the important messages carried by their feelings.

However, clients can sometimes mistake pain for purpose. We see this frequently with our creative clients. So often the idea of the “crazy artist” takes hold of clients. Several of Justine’s clients were terrified of feeling better. They believed that their sickness and the distress it caused fueled their art. But the reality was that after going through treatment, these clients were all able to continue making amazing art, and in fact they did so with more frequency and focus. Another part of the process of working with these folks is helping them see that they’re full human beings who are more than just the art they craft.

Many fear that if they lose the art then they lose themselves and they no longer matter. However, in our experience, part of their healing journey entails exploring areas of their life outside of art. Eventually, they come to see their art as but an aspect or a planet within the vast cosmos of their lives.

Therapist

For many of us, the desire to make meaning from our own pain drew us to the field of psychotherapy. Most therapists have experienced some type of mental distress, whether it’s childhood trauma, an eating disorder, bullying, discrimination, or an abusive relationship with chemicals. For many of us, surviving this kind of pain was only the first phase of the healing process, with the second phase being meaning-making.

The pain paradox is a gentle invitation for therapists to carefully consider ways to cultivate meaning and joy outside the therapy field. Although our work as therapists is absolutely meaningful, it is also back-breakingly painful at times. If you don’t have other avenues or ways to make meaning and find purpose, you’ll find it even more challenging to take breaks from the field, regardless of how long such a break lasts, because you struggle to see the “you” outside the office. You need not try something life altering or huge. When Larisa was recovering from a severe case of moral injury, she began making playlists, an activity she had not engaged in since her college days. This small daily activity helped her to begin to reconnect with playful and creative energies outside her clinical and professional work.

The difficult message that Justine received was that her time as a direct-care therapist was coming to a close. After over a decade of work, and so many clients helped, she began to feel that her meaning-making was now to be found in the classroom, on the stage, and on the page. She experienced a great deal of pain as a therapist during the pandemic and the social justice uprising, but the pain invited her to consider where new meaning could form. The answer was that it was time to guide the next generation of clinicians and to hold the hands of those who are still in the trenches. As of this writing, Justine is currently working on the slow transition out of direct client care.

Due North: Self of the Therapist

One of the struggles inherent in walking the dialectic between the system and the individual is despair. In the case of moral injury, which is caused by a series of broken systems subjecting clinicians to harmful double binds, it can feel like there’s little or nothing for a therapist to do beyond retiring from the field. While this certainly is an option, we offer you another one: harm reduction and intentional activism.

As you may already know, the harm-reduction model of addiction recovery focuses on making small, actionable changes that mitigate abusing behaviors, rather than prescribing total sobriety. Our intention is to invite you as a clinician to assess the harm you’re currently facing in your career and how it’s affecting you. You can’t immediately change the systems in which you practice therapy, but you can make a concerted effort to mitigate the negative impact that these systems have upon you.

Some ways that you might limit the harm you experience include limiting the number of hours you work or the types of clients or clinical presentations with which you work. Perhaps you currently work in a place with an unreliable schedule, and that causes you distress; is it possible to have a more structured schedule? If you’re not being given time for breaks or lunch, is this a conversation you can have and a boundary you can set with your site supervisor? These can be small or large changes, but any change can go a long way to help mitigate the harm you’re experiencing.

Our Masturbation Machines

Posted on by Psychotherapy.net Team

Our Masturbation Machines

I went to greet Jacob in the waiting room. First impression? Kind.

He was in his early sixties, middleweight, face soft but handsome… aging well enough. He wore the standard-issue Silicon Valley uniform: khakis and a casual button-down shirt. He looked unremarkable. Not like someone with secrets.

As Jacob followed me through the short maze of hallways, I could feel his anxiety like waves rolling off my back. I remembered when I used to get anxious walking patients back to my office. Am I walking too fast? Am I swinging my hips? Does my ass look funny?

It seems so long ago now. I admit I’m a battle-hardened version of my former self, more stoic, possibly more indifferent. Was I a better doctor then, when I knew less and felt more?

We arrived at my office and I shut the door behind him. Gently, I offered him one of two identical, equal-in-height, two-feet-apart, green-cushioned, therapy-sanctioned chairs. He sat. So did I. His eyes took in the room.

My office is ten by fourteen feet, with two windows, a desk with a computer, a sideboard covered with books, and a low table between the chairs. The desk, the sideboard, and the low table are all made of matching reddish-brown wood. The desk is a hand-me-down from my former department chair. It’s cracked down the middle on the inside, where no one else can see it, an apt metaphor for the work I do.

On top of the desk are ten separate piles of paper, perfectly aligned, like an accordion. I am told this gives the appearance of organized efficiency.

The wall décor is a hodgepodge. The requisite diplomas, mostly unframed. Too lazy. A drawing of a cat I found in my neighbor’s garbage, which I took for the frame but kept for the cat. A multicolored tapestry of children playing in and around pagodas, a relic from my time teaching English in China in my twenties. The tapestry has a coffee stain, but it’s only visible if you know what you’re looking for, like a Rorschach.

On display is an assortment of knickknacks, mostly gifts from patients and students. There are books, poems, essays, artwork, postcards, holiday cards, letters, cartoons.

One patient, a gifted artist and musician, gave me a photograph he had taken of the Golden Gate Bridge overlain with his hand-drawn musical notes. He was no longer suicidal when he made it, yet it’s a mournful image, all grays and blacks. Another patient, a beautiful young woman embarrassed by wrinkles that only she saw and no amount of Botox could erase, gave me a clay water pitcher big enough to serve ten.

To the left of my computer, I keep a small print of Albrecht Dürer’s Melencolia 1. In the drawing, Melancholia, personified as a woman, sits in a room surrounded by the neglected tools of industry and time: a protractor, a scale, an hourglass, a hammer. Her starving dog, ribs protruding from his sunken frame, waits patiently and in vain for her to rouse herself.

To the right of my computer, a five-inch clay angel with wings wrought from wire stretches her arms skyward. The word courage is engraved at her feet. She’s a gift from a colleague who was cleaning out her office. A leftover angel. I’ll take it.

I’m grateful for this room of my own. Here, I am suspended out of time, existing in a world of secrets and dreams. But the space is also tinged with sadness and longing. When my patients leave my care, professional boundaries forbid that I contact them.

As real as our relationships are inside my office, they cannot exist outside this space. If I see my patients at the grocery store, I’m hesitant even to say hello lest I declare myself a human being with needs of my own. What, me, eat?

Years ago when I was in my psychiatry residency training, I saw my psychotherapy supervisor outside his office for the first time. He emerged from a shop wearing a trench coat and an Indiana Jones–style fedora. He looked like he’d just stepped off the cover of a J. Peterman catalogue. The experience was jarring.

I’d shared many intimate details of my life with him, and he had counseled me as he would a patient. I had not thought of him as a hat person. To me, it suggested a preoccupation with personal appearance that was at odds with the idealized version I had of him. But most of all, it made me aware of how disconcerting it might be for my own patients to see me outside my office.

I turned to Jacob and began. “What can I help you with?”

Other beginnings I’ve evolved over time include: “Tell me why you’re here,” “What brings you in today,” and even “Start at the beginning, wherever that is for you.”

Jacob looked me over. “I am hoping,” he said in a thick Eastern European accent, “you would be a man.”

I knew then we would be talking about sex.

“Why?” I asked, feigning ignorance.

“Because it might be hard for you, a woman, to hear about my problems.”

“I can assure you I’ve heard almost everything there is to hear.”

“You see,” he stumbled, looking shyly at me, “I have the sex addiction.”

I nodded and settled into my chair. “Go on…”

Every patient is an unopened package, an unread novel, an unexplored land. A patient once described to me how rock-climbing feels: When he’s on the wall, nothing exists but infinite rock face juxtaposed against the finite decision of where next to put each finger and toe. Practicing psychotherapy is not unlike rock climbing. I immerse myself in story, the telling and retelling, and the rest falls away.

I’ve heard many variations on the tales of human suffering, but Jacob’s story shocked me. What disturbed me most was what it implied about the world we live in now, the world we’re leaving to our children.

Jacob started right in with a childhood memory. No preamble. Freud would have been proud.

“I masturbated first time when I was two or three years old,” he said. The memory was vivid for him. I could see it on his face.

“I am on the moon,” he continued, “but it is not really the moon. There is a person there like a God… and I have sexual experience which I don’t recognize…”

I took moon to mean something like the abyss, nowhere and everywhere simultaneously. But what of God? Aren’t we all yearning for something beyond ourselves?

As a young schoolboy, Jacob was a dreamer: buttons out of order, chalk on his hands and sleeves, the first to look out the window during lessons, and the last to leave the classroom for the day. He masturbated regularly by the time he was eight years old. Sometimes alone, sometimes with his best friend. They had not yet learned to be ashamed.

But after his First Communion, he was awakened to the idea of masturbation as a “mortal sin.” From then on, he only masturbated alone, and he visited the Catholic priest of his family’s local church every Friday to confess.

“I masturbate,” he whispered through the latticed opening of the confessional.

“How many times?” asked the priest.

“Every day.”

Pause. “Don’t do it again.”

Jacob stopped talking and looked at me. We shared a small smile of understanding. If such straightforward admonitions solved the problem, I would be out of a job.

Jacob the boy was determined to obey, to be “good,” and so he clenched his fists and didn’t touch himself there. But his resolve only ever lasted two or three days.

“That,” he said, “was the beginning of my double life.”

The term double life is as familiar to me as ST segment elevation is to the cardiologist, Stage IV is to the oncologist, and Hemoglobin A1C is to the endocrinologist. It refers to the addicted person’s secret engagement with drugs, alcohol, or other compulsive behaviors, hidden from view, even in some cases from their own.

Throughout his teens, Jacob returned from school, went to the attic, and masturbated to a drawing of the Greek goddess Aphrodite he had copied from a textbook and hidden between the wooden floorboards. He would later look on this period of his life as a time of innocence.

At eighteen he moved to live with his older sister in the city to study physics and engineering at the university there. His sister was gone much of the day working, and for the first time in his life, he was alone for long stretches. He was lonely.

“So I decided to make a machine…”

“A machine?” I asked, sitting up a little straighter.

“A masturbation machine.”

I hesitated. “I see. How did it work?”

Not unlike Jacob, we are at risk of titillating ourselves to death.

Seventy percent of world global deaths are attributable to modifiable behavioral risk factors like smoking, physical inactivity, and diet. The leading global risks for mortality are high blood pressure (13 percent), tobacco use (9 percent), high blood sugar (6 percent), physical inactivity (6 percent), and obesity (5 percent). In 2013, an estimated 2.1 billion adults were overweight, compared with 857 million in 1980. There are now more people worldwide, except in parts of sub-Saharan Africa and Asia, who are obese than who are underweight.

Rates of addiction are rising the world over. The disease burden attributed to alcohol and illicit drug addiction is 1.5 percent globally, and more than 5 percent in the United States. These data exclude tobacco consumption. Drug of choice varies by country. The US is dominated by illicit drugs, Russia and Eastern Europe by alcohol addiction.

Global deaths from addiction have risen in all age groups between 1990 and 2017, with more than half the deaths occurring in people younger than fifty years of age.

The poor and undereducated, especially those living in rich nations, are most susceptible to the problem of compulsive overconsumption. They have easy access to high-reward, high-potency, high-novelty drugs at the same time that they lack access to meaningful work, safe housing, quality education, affordable health care, and race and class equality before the law. This creates a dangerous nexus of addiction risk.

Princeton economists Anne Case and Angus Deaton have shown that middle-aged white Americans without a college degree are dying younger than their parents, grandparents, and great-grandparents. The top three leading causes of death in this group are drug overdoses, alcohol-related liver disease, and suicides. Case and Deaton have aptly called this phenomenon “deaths of despair.”

Our compulsive overconsumption risks not just our demise and death but also that of our planet.

The world’s natural resources are rapidly diminishing. Economists estimate that in 2040 the world’s natural capital (lands, forests, fisheries, fuels) will be 21 percent less in high-income countries and 17 percent less in poorer countries than today. Meanwhile, carbon emissions will grow by 7 percent in high-income countries and 44 percent in the rest of the world.

We are devouring ourselves.

***

From Dopamine Nation: Finding Balance in the Age of Consumption by Anna Lembke M.D., published by Dutton, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC. 

Truth and Fiction in Psychotherapy

Posted on by Psychotherapy.net Team

Arrhythmic Interventions

Sometimes with clients, I feel that I have gone on too long, offered several mixed if not confusing metaphors, used far too many words.

As confusion settles like snowflakes in the client’s eyes, drifting left to right, forming frosty banks of disinterest beneath the eaves of their lids, a sense of failure comes over me. It is a familiar, critical, internal voice that identifies my arrhythmic intervention as a product of inept clinical desperation, further proof of my sporadically undisciplined, ego-driven approach. Attempting to re-engage the client I often and fumblingly ask, “Does that make sense to you?”

This is intended to communicate that my preceding monologue was a humble offering for the client’s consideration, neither a pronouncement of truth nor an authoritative directive. I explicitly invite disagreement by disclosing therapeutic doubt as to the relevance of my intervention, graciously allowing space for the client to reject, accept, or reconstrue my thoughts to fit their own preferences. A leveling of the clinical playing field, I suppose. An empowerment of the client, particularly highlighting their interpretive role, calling them into a more active engagement in the dialogue.

But it is merely a closed, if not defensive question: it invites either a yes or no answer. What I justify as empowering of the client is actually highly restrictive. It fundamentally does not, regardless of my sound intentions, invite the client to reflect on their own thoughts and feelings. The query instead directs an assessment of my words and my performance as a therapist!

It is uncomfortably reminiscent of the stock illustration of common narcissism: “Enough about me! Let’s talk about you. What do you think of me?”

Perhaps when I respond negatively to my own clinical intervention, it’s because I recognize it as an unintended self-disclosure. Perhaps I am frustrated by the client’s perceived lack of progress, or they provoke in me uncomfortable personal associations. Or maybe there was an annoying itch on my left ankle. In asking the client to make sense of my words, I may be attempting to coerce them into helping me bury what I have inadvertently exposed about myself. Smoke and mirrors to distract from my embarrassment! A fiction masquerading as curiosity to distract us both from the truth about my outburst.

The Fallacy of Making Sense

Another problematic aspect of my question—“Does that make sense to you?”—is the importance it places on things making sense. But must every sentence in a therapeutic exchange be complete? No. Do the associations we make need to conform to a logical rubric? No. Must our emotions be reasonable and defensible? Of course not.

When I ask a client whether things “make sense,” I may be communicating that they should. In so doing I might exile from therapy parts of the person that are either currently or permanently outside of the logical realm. Such parts may contain important information about the problems faced, and they often are part of the solutions. Simple acceptance of unarticulated emotion, whether loss, pain, anger, or sadness, has so often marked the turning point in a client’s healing process. That such emotions may be illogical, in conflict with relevant facts, or appear baseless when judged cognitively, often serve as the underlying motivation for denial and repression.

When I over-value making sense within psychotherapy, I am suggesting that we are searching for a Truth. Not merely a true expression of the client’s experience but rather a Truth that will stand up to objective investigation. Something that stands the test of logic and reasoning, as some subjective experience does. For example, if I report that my wife hates me, and my wife explicitly confirms this impression, my felt experience is supported by objective evidence. In the case where my wife denies such hatred, psychotherapy teaches us that my experience of being hated by my wife is of equal or greater significance when it is disproven by factual inquiry as when it is supported. In the instance where my impression appears unsupported by the facts, further clinical work may reveal that I am suffering from paranoia, or it may reveal that my wife’s love is expressed in a manner easily understood by me as disinterest or hatred.

Therapy needs to be a space where we witness and accept the patient’s narrative, in whatever form they choose to offer it. For there are truths about sexual assaults that I have only come to understand when a client expressed themselves with a vague gesture, or another victim described watching their own rape from the ceiling of the room, or another interspersed details of the assault with seemingly unrelated and irrelevant trivia about their daily routines.

In Fiction Lies Truth

A central theme in the writings of Tim O’Brien, an acclaimed novelist and Vietnam veteran, is that a war story that is not fictionalized is not a true war story. Why? Because war is such a massively distorting human experience that telling of it in a rigidly accurate, factual manner is wholly distorting the truth about war. A war story without fiction is, by necessity, a lie:

In any war story, but especially a true one, it’s difficult to separate what happened from what seemed to happen. What seems to happen becomes its own happening and has to be told that way. The angles of vision are skewed. When a booby trap explodes, you close your eyes and duck and float outside yourself. When a guy dies…you look away and then look back for a moment and then look away again. The pictures get jumbled; you tend to miss a lot. And then afterward, when you go to tell about it, there is always that surreal seemingness, which makes the story seem untrue, but which in fact represents the hard and exact truth as it seemed.¹


When clients tell of traumatic events, exposing not just what happened but speaking of “its own happening,” I have experienced the raw power of their account and self-protectively withdrawn by responding with curiosity about what actually happened.

In his recent memoir, Dad’s Maybe Book, O’Brien instructs his two sons that maintaining humility about our own understanding and experience is an essential safeguard against arrogance and our own vulnerability to notions that there are truths we hold as self-evident. He argues that all such truths are subject to change and to cultural relativism. Better to say “maybe” than to believe you have a hold on Truth; better to say “it seems” rather than “it is.” In these times of “epidemic terror” and intolerance of ambiguity and uncertainty, O’Brien pleads: “I’m asking only that you remain human in your terror, that you preserve the gifts of decency and modesty, and that you do not permit arrogance to overwhelm the possibility that you may be wrong as often as you are right.”

One of the examples of a war story O’Brien tells in The Things They Carried is of a six-man patrol assigned to establish a listening-post in the mountains. They sat, camouflaged in almost complete silence and stillness for a week listening for enemy movements. After some time, they hear music, chit-chat, and what sounds like a cocktail party, with popping champagne and clinking glasses. The soldier telling O’Brien this story clarifies that the voices he and his comrades heard were not those of people but were voices arising from the mountain itself. “Follow me? The rock – it’s talking. And the fog, too, and the grass and the goddamn mongooses. Everything talks. The trees talk politics, the monkeys talk religion. The whole country. Vietnam. The place talks. It talks. Understand? Nam—it truly talks.”

Driven to their wits’ end, the patrol calls in air strikes and the mountain is bombarded throughout the night. When they return to base camp and a senior officer questions the basis for the airstrike, none of the men respond. “They just look at him for a while, sort of funny like, sort of amazed, and the whole war is right there in that stare. It says everything you can’t ever say. It says, man, you got wax in your ears. It says, poor bastard, you’ll never know – wrong frequency – you don’t even want to hear this. Then they salute the fucker and walk away, because certain stories you don’t ever tell.”

On the Wrong Frequency

How often am I as a therapist on the wrong frequency? Am I tuning in to analysis? Diagnosis? Cognition? Emotion? Is the client communicating in the equivalent of a dog-whistle? Is the lie telling me a truth? Is the truth masking what is not true but essential? It is not difficult to imagine clients who have saluted me and walked away thinking that I was a well-intentioned poor bastard who hadn’t heard them at all.

Earlier in my clinical career, a middle-aged man, Curtis, sought me out for my expertise in trauma. He complained that earlier therapists had been unable to impact his symptoms, including persistent intrusive memories of early childhood sexual trauma perpetrated by a family member. I had recently been trained in EMDR (Eye Movement Desensitization & Reprocessing) and was eager to utilize the approach with a case of complex trauma. After gathering a general history, forming an understanding of his current relationships, internal/external resources and supports, I was confident of a reasonable degree of rapport. We cautiously waded into an exploration of Curtis’s childhood relationships to both of his parents and how those dynamics, combined with family finances, regularly left him in the care of his perpetrator for most of each weekday through the years of his childhood.

Details of the sexual assaults were not remarkable to me. They were consistent with common incestuous, pedophilic behaviors. What struck me, however, were Curtis’s accounts. From session to session they seemed to become increasingly detailed, and the details sounded increasingly melodramatic. What I heard initially to be cold-blooded genital manipulation evolved into stories of emotional attachment, culminating in a seven-year-old’s feeling emotionally abandoned by his molester and proceeding to threaten her with exposing her deeds if she didn’t comply with his wishes. After several months, Curtis began disclosing memories of horrific, ritualistic abuse involving multiple members of their rural community.

EMDR was having no significant impact on Curtis’s current levels of distress. In fact, there were signs that the clinical exposure to the increasingly disturbing memories were making things worse. His alcohol consumption was on the rise and seemed linked to increasing conflicts with his wife, who served as his principal support. To mitigate these negative secondary effects of the therapy I began to lessen the use of EMDR and increased identification of his drinking as a principal obstacle to healing from his past wounds.

Within a month of making this shift, Curtis withdrew from treatment with little comment or clarification. At the time I saw this as an indication that he wasn’t ready to confront his addiction, which was disabling him from processing the past traumas effectively.

In hindsight, and with my evolving perspective on truth and fiction, Curtis seems to have been in the same predicament as the soldiers in O’Brien’s account asked by their commanding officer to justify their ordering up an airborne attack based on their experience of talking rocks, grass, and fog. The soldiers opted to walk away from the commanding officer without a word. Curtis tried to communicate to me how his misshapen inner landscape was behaving. To his credit, he didn’t bother to salute when taking his leave.

Now, I imagine he knew I didn’t want to hear what he was telling me. This resistance led me to make a distorting effort to escape the truth via facts. I thought if we got the alcohol out of the picture we had a shot at finding out what really happened all those years ago.

Having since worked for close to ten years with victims of sexual abuse, I understood that the narrative often evolves over time. Difficult facts and experiences might be avoided in early sessions and disclosed later in the process. Conflicts in current relationships might reflect dynamics of the abuse. Adult memories of childhood events are most often fairly accurate as to the essence of an experience. Use of alcohol and drugs or other dangerous behaviors are adaptive means of survival, often difficult to abandon for less harmful comforts.

Now, ten years later, I have come to understand how crucial it is to believe the victim’s recounting, regardless of its form, and why it was difficult for me to fully accept Curtis’s narrative when I first began this work. The details of his account sounded like the climactic scene of a horror movie. I didn’t want to believe that such things actually occur in the basement of a neighbor’s house and that a half-dozen or more people could be complicit in such acts. My gut told me: Rosemary’s Baby was not only a fiction, it was, and is, impossible! Another part of me knew that the kind of nightmarish abuse Curtis described has happened before and, therefore, it remains uncomfortably possible that his memory may be partially or wholly accurate.

I fled to the problem of alcohol consumption.

I was fleeing from a combination of the client’s disturbing narrative and the failure of my interventions to make a dent in his very distressing symptoms. My flight was an abandonment of this client to his painful story, a story that he had bravely shown and invited me to enter.

Beyond Self-Protective Fictions

When Billow, an important voice in Relational Group Therapy, asks, “Where is fact, where is fable?” he is not only asking this about the client’s statements. His focus is on the therapist.
 

My self-disclosures give some idea of how I think and feel, how I think I think and feel, and how I would like others to believe I think and feel. Perhaps we need to put a Surgeon General’s Warning on all clinical contributions, certainly not just those intending self-disclosure: The analyst’s communications contain aspects of infantile as well as dissociated inner experience. Gross commissions and omissions are to be expected, involving conscious and unconscious censorship, relating to the analyst’s emotional, cognitive, and psycho-linguistic limitations, shame and guilt, fear of embarrassment, humiliation and ostracism, fear of the unknown, and fear of loss of livelihood…²


As a therapist, I have lots of reasons to generate fictions. We are trained to assume these human responses are regularly present throughout clinical work and to task ourselves with recognizing and utilizing them both in service of the client and of expanding the therapist’s own self-awareness. Richard Billow’s clinical warning label is not an identification of life-threatening effects of exposure to psychotherapy and its practitioners, it is a reminder that the truths being uncovered and the healing achieved in clinical interactions are inseparable from distortions by both the client and the therapist.

More recently, I was working with a client, Maureen, who was also an adult survivor of childhood incest. She courageously disclosed a series of traumatic childhood events over several sessions. We planned to proceed to processing these traumas utilizing EMDR. When the next session began, however, it was clear that the self-confidence evident in prior sessions was now absent. Maureen shared with me that the events we’d previously discussed had overwhelmed her during the week, and when I inquired as to the specific nature of the overwhelm, she explained that while she intellectually knew that these traumatic events were separated by significant periods of time, they’d been presenting as interconnected. Pieces of one event seemed spliced into the images of another. This not only condensed images but also magnified their emotional and psychological power. Maureen described feeling “shook,” out-of-control, and increasingly uncertain as to her experience and her memories.

With Maureen I was able to hear this distortion of her memories and her current experience of past events as essential points of focus for processing. In fact, I made the choice to explicitly communicate to Maureen that I heard this unification of her historically separate events, accompanied by numerous somatic expressions, to hold greater “truths” for our clinical work than the accuracy of her historical and chronological memory. She could see that all these terrible things, while having happened separately, had happened to her one and only body and brain. This communication had an immediate effect of relieving her emotional and physical tension. It also led directly to a discussion of how she could utilize the historical memory to reduce the sense of overwhelm that might resurface prior to our successful processing of the trauma. Unlike in my work with Curtis, I tuned into and remained on Maureen’s frequency, accepting her version of the truth as the Truth.

***


What O’Brien says about war stories is closely related to what Billow says about therapy. An exclusive focus on facts tends to obstruct recognition and development of appreciation for the truth of the human experience, whether that experience is a past traumatic event or a current meeting with the complexities of a clinical conversation. For the most important truths are always in the moment of the telling—not in the subject of the story. Therefore, the value of the telling is not located in its being verifiable. All effective communication, in fact, relies heavily on the honest, truthful aspects of our fictions.

¹O’Brien, T. (1990). The Things They Carried. Mariner Books; Houghton Mifflin Harcourt.

² Tzachi, S. (Ed.) (2021). Richard M. Billow’s Selected Papers on Psychoanalysis and Group Process. Routledge.

Confessions of a Student Counsellor

Posted on by Psychotherapy.net Team

Both Sides Now

At the time of this writing, I have one semester to go before completing my Master of Counselling degree, and I am sixty-five hours into the one hundred required hours of counselling contact hours of my student placement. I am still unsure as to who has received the lion’s share of therapy during these sixty-five hours, my clients or me?

This has not been my first exposure to the rudiments of counselling, however—I had some years of experience in addictions counselling and case management and no shortage of support work in various fields to ease me into the relative displacement of a professional counselling placement. At forty-seven years of age, I have undergone many transitions and life experiences.

Nevertheless, the Masters has been quite a proficient primer and prodder of the all-too-many things I didn’t (and still don’t) know about counselling practice, and of the myriad of things that I need to know in order to provide effective and ethical therapy for a range of concerns and to a broad demographic.

Having had experience in various counselling settings—and being quite familiar with both sides of the counsellor’s chair—together with the fact that I consider myself an avid collector of knowledge, particularly in this field, I still felt a strange cognitive dissonance of both excited preparedness and complete inadequacy to the task at hand at the commencement of my placement. But that was then. At sixty-five hours in, I am a worldly veteran!

The first thing that stood out to me about my placement experience was how pretty much every session turned into a countertransference case study from my ethics class, except that I was the subject. I knew about countertransference. I had studied it. Experienced it. Was consciously aware of it. Prepared, I thought. But I never really had that meta-cognition before that one develops, both while counselling and in the post-session self-flagellation…ahem, reflective practice.

Almost every session seemed like a mirroring of the personal life struggles I had faced, parallel processes of my current situations, relatables that were bone deep. The client I was sitting with was recounting the very relationship issues I had struggled with. Of course I was batting for him! My heart was filled with sympathy, my responses were, albeit textbook, empathetic, while my mind was firing off mostly Andrew-shaped responses ready for delivery. Often, I would catch myself before essentially counselling myself instead of my client. Sometimes I was too late and would realise, embarrassingly, later that day or week. More often than not, in supervision. Or because of past supervisions.

Or I could be sitting in front of the horrifying ghost of my mother-self. That is, this particularly triggering, discomforting, and disquieting quality that my mother possessed which I painfully one day realised I had inherited, now (mostly) exorcised out of me (thank you therapists circa 2000-2004, 2008-2009, 2012-2013 and 2020-2021; you know who you are). Noticing the life force draining from my being, I would sometimes sit across from the ghost-client in a sorrowful-seething state of frustration, compassion, bewilderment, intrigue, and hopelessness. I could swing between feeling annoyed and way out of my depths to such misguided compassion that I would feel the urge to take them home and care for them.

Going it Alone

Something I knew before but re-experienced in a fresh new light during my placement is that a significant part of learning to be a counsellor is essentially done alone. There is generally no direct supervision. There is no one in the room to monitor the minutiae of one’s work. There is no direct feedback loop. It is not as if your supervisor has a document to proofread. There is no material structure to assess for imperfections or to correct. No one is surveying clients at the end of sessions to establish trainee performance. No one is there to say, “Hmmm, maybe when you froze for a minute and a half with silence…” or “Perhaps Texas Hold ’em Poker isn’t the most appropriate game to play in a session with a six-year-old…” Of course, there are opportunities to be observed by colleagues and supervisors or to record sessions and review them. But this is limited in its scope and practicability. And daunting as hell! Or as daunting as having my own personal therapy sessions broadcast to the world, perhaps. Being utterly exposed. Vulnerable.

Sitting with clients who have just expressed something, there are a plethora of potential responses in any given moment of a therapy session. Sometimes they flow readily and easily. At other times they feel forced. And in some cases, when a response hasn’t felt right, an also potential plethora of self-reflective doubt and questioning can follow: “Did I say the right thing?”; “How am I going with this client? Doesn’t seem to be any progress being made”; “What is the correct intervention to use here?”; “They have been coming for three sessions now, why won’t they volunteer something… anything?!” Being left to one’s own devices (well, me to mine) can leave one unsure at times about particular interventions to use, ways of progressing through impasse, whether or not to refer, whether I am beyond my professional competence, and one’s capacity to be a counsellor, which can undermine self-trust and even self-worth.

And then at other times, when I am feeling in my flow, when I have recognised counselling greatness in myself—you know, when a client has expressed eternal gratitude or you witness a breakthrough or an insight emerges—then I can quite easily develop that very shiny, bulletproof sheen of self-satisfaction and self-congratulation, feeling like the king of the counselling castle! Either polarity can be both misguided and unhelpful to me, I have discovered, and, left alone with such musings, can be a potentially missed opportunity to see beyond my own perspectives and to develop my practice.

Thank goodness we are not completely alone during this, at times, trial by fire. Having practicing colleagues around is such a comforting and valuable scaffold of support. I am fortunate to be doing my placement in a medium-size clinic providing both psychology and counselling services, so there are usually at least a few others to talk to or debrief to if needed. I am aware, however, that others’ placements are more isolated and devoid of such support, and I have witnessed the emotional and psychological strain that this can take. I am very grateful to be developing in the kind of environment where I feel supported and not alone. Hmmmm, maybe there’s a market for a Tinder-like app for counsellors in isolation?

I think there is a limit, however, to how far collegial support can go. There are certainly limits to my own (and I am guessing other humans’) capacity to expose oneself in the workplace. Especially as an up-and-coming trainee counsellor, wanting to exude competence and confidence at every opportunity (I am willing to admit that could just be me, but I suspect not). Clinical supervision during my counselling placement has been a great support and I think the site of my most focussed learning during this Masters and certainly during my placement. I am fortunate to have both group and individual clinical supervision. They are both supportive, instructive and provide opportunities to develop and learn from others’ practice. I have found that it is in individual supervision, however, that I have the greatest opportunity to be vulnerable and to shed light on the more shadowy areas of my practice. It feels a bit safer than group supervision and I like its structure, containment, consistency, and predictability.

Maybe Not Completely

I am fortunate that I was paired with an external clinical supervisor by my university placement team whom I like and respect, but, most importantly, with whom I feel safe. Safe to say (almost) anything to. Safe to expose my insecurities and doubts to, to be able to tell them what I did and said in a session, for example, without any debilitating apprehension. They provide safety and security in calling me out when needed, ensuring I understand my limits and blind spots. Kind of like a parent’s love in providing firm and consistent boundaries to an overly exuberant child. They encourage me and validate me, sharing their own stumbles and falls. But the catch is, as I recognised a while ago, I must be willing to be vulnerable and uncomfortable and wrong, again and again, to gain the most from this. I must be willing to be a beginner again and again and again if I am to grow and develop as a person and as a therapist. But this is hard to do at times. For fear of judgement (self and other), feeling inadequate and for (the generally unfounded) fear of finding out that maybe I am not cut out for this profession. The most satisfying, albeit challenging, learning I have experienced during this placement, and the Masters too, has been exposing myself in supervision.

Like when I reluctantly discussed a client I had seen once whom I suspected to be beyond my scope of competence. Reluctant because I was personally and professionally very curious and they claimed they weren’t in a position to engage in costly treatment options and so I really wanted to keep working with them. And I suspected that if I spoke about them in supervision (and to my line manager) that they would advise referral. But I did. And it was right. And I referred. It was frustrating and challenging, but a great experience to have in the sandpit. And I incidentally had reflected to me my potential for a hero complex. Ouch! But yes, probably accurate. Or when I spoke about how I responded to an awkward situation with a child client and their mother, suspecting I didn’t handle it very well and wanting input. And then getting feedback that challenged as well as expanded me, reinforcing that I really do not know what I do not know as well as not knowing what I do know, too. These things can sting for a bit, but I am a better counsellor for it.

Just like when I have been in therapy myself, the more I am willing to be vulnerable and uncomfortable and reveal those shadowy parts of myself, so too in my counselling role (especially as a trainee), the more I allow this, the more space I make within myself to expand. I make the space for learning and growth and development and career and life satisfaction and ideally to be a more effective therapist and, of course, to do no harm.

***

I recall a brief conversation I had with a university lecturer this year, a seasoned counselling psychologist and academic. I was reflecting on the challenges of not knowing it all and bemoaning if I would ever feel competent as a counsellor. Their response was heartening to me, then and now. They related to this feeling, stating that they still occasionally felt this way. But they also knew that they are a damn good therapist and a valuable resource for their clients. Nice.

Successful Intervention with a Family Impacted by Treatment-Resistant BPD

Posted on by Psychotherapy.net Team

Borderline Personality Disorder (BPD) is one of the most difficult psychiatric disorders to treat, the main reason being that it affects the entire family. Thus, effective treatment requires working with as much of the family as possible in a coordinated effort. Multiple professionals are also often involved, which adds to the need for coordination of resources. Further adding to the complexity of intervening with families impacted by this disorder is the fact that there is usually significant resistance to the treatment by one or more parties.

Treating families impacted by BPD also requires specialized therapeutic skills. I have found that many techniques that are effective with other diagnostic groups are not only ineffective with BPD, but may actually make the disorder worse. This is why most of the families who present themselves to me have already been exposed to numerous therapists and treatment modalities by the time we meet, leaving them exhausted and disappointed. In many cases, large amounts of money and other resources have already been spent, also leaving them jaded and skeptical. These families are very often on the brink of their breaking point.

Am I expected to produce a Hail Mary, or am I just another soon-to-be-discarded and/or disappointing clinician in their minds? This is a very high-pressure situation for a clinician, and for this reason I suggest that colleagues only take on such situations if they have specialized skill in treating this disorder or other debilitating personality disorders. A full illustration of all of the specialized skills needed to work with these families is beyond the scope of this paper. For expediency, I will focus first on four tools that I have crafted and found to be highly useful in treating families impacted by this disorder. These tools are described below and will be illustrated in a case study that follows.

Useful Tools

Manage Expectations

This applies to the patient, the family, the other professionals, and yourself. Healing and growth are processes and not singular, disconnected events. All participants in the intervention should be told overtly that this process will take months, if not years, to reach an optimal outcome. I generally tell patients and their families, “Things will most likely get worse before they get better.” This prepares everyone for the inevitable resistance while creating a future milestone measured by increased cooperation.

Protect, Protect, Protect

You must protect the patient, the family, the process, and yourself. A key, and possibly the most disruptive, feature of BPD is the client’s lashing out at others when frustrated. Many families allow this behavior to provoke them into participating in disruptive behavior by shouting back or threatening. The therapist must provide some basic level of safety to the process and all who are involved in order to avoid disruption of the therapeutic work, often manifested by one or more parties’ walking out.

As a therapist in this situation, you are at very high risk for being triangulated into the family dysfunction, in which case this lashing out may be directed at you. Your chair should be the closest to the door, and you need to prepare to split up the group if you cannot deescalate conflicts with all present.

Modeling

You have to teach the family how to cope with disruptive behaviors such as lashing out, triangulation, codependency, and self-mutilation that are common with BPD and rare in other disorders. This is where the specialized skills come in. Each of these disruptive behaviors requires its own set of coping mechanisms. This is where conventional methods can backfire. For example, healthier families can share diverse opinions without the divisive effects of triangulation. In families with BPD, encouraging sharing of diverse opinions is likely to lead to further polarization and increased conflict, thereby worsening rather than improving the situation.

Starve, Do Not Feed, the Monster

The monster is the disorder, the BPD, not the sufferer. The family must bond together with the sufferer and the professional team to fight it. While traditional therapeutic methods encourage compromise and flexibility as solutions to conflict, these methods may feed the monster or make the disruptive and disturbing nature of the disorder worse in families with BPD. The emotional dysregulation caused by the BPD often escalates into rapid, impulsive acting out towards self and others. Introducing compromise, flexibility, or, worse, compliance, reinforces that lashing out will get at least some of what you want. This will increase the frequency and intensity of the lashing out. Conversely, withholding all possibility of acquiescence because of the lashing out starves the monster and sets the stage for the introduction of more socialized, and hence more successful, strategies. This is consistent with basic behavioral principles.

Case Study

The following is based on a real case, but with many details changed in order to protect identity.

Mary Zohn called me about her 19-year-old daughter, Rosa. She had been referred to me by her therapist because although her daughter was in treatment with a therapist, things were getting much worse at home and the family was in crisis. I agreed to meet with her and her husband Charlie for an intake.

The Zohns showed up at my office with two thick files that documented difficulties with Rosa since the beginning of high school. Since that time, Rosa had experienced steady deterioration despite multiple treatments with several different professionals. They explained that although she was intelligent, she had ongoing difficulty functioning in a school environment. She often missed classes and rarely completed assignments on time, if at all.

In her frustration with school, Rosa began engaging in other less productive and more self-damaging activities such as sexual promiscuity, substance abuse, and excessive computer video gaming. She began staying out late, and then overnight. Her room was dirty and her hygiene was regressing.

The Zohns began confronting her about her poor school performance and unhealthy habits. They tried to set limits. This was associated with screaming conflicts that ended up with her sometimes leaving for days at a time, and often included self-destructive behavior such as cutting and going days without food and water in protest. Her parents were becoming increasingly concerned about her health.

They were also becoming increasingly concerned about her influence on her younger sister. Rosa was the middle child of three girls. Her older sister, Wilma, did very well in school and had a good job. She was self-supporting and lived in her own apartment about an hour away from the family residence. The younger sister, Bertha, was in middle school and struggling with a learning disability and social issues at school. The Zohns were very concerned about how Rosa’s behavior would affect Bertha’s struggles.

Initial Interview

What precipitated their reaching out to me was that Rosa had been arrested with her boyfriend for possession and distribution of narcotics. Following are some excerpts from my initial interview with the Zohn’s:

Dr. Lobel: What is Rosa’s current legal status?

Mary: She is out on bail.

Dr. Lobel: What is she doing with her days?

Charlie: Supposedly she is in school.

Mary: She is enrolled in college but we think that she does not attend classes.

Charlie: She leaves every night pretending to go to school but she goes to see her boyfriend instead.

Dr. Lobel: How do you know that?

Charlie: Because she is getting incompletes in all of her classes and she doesn’t come home until 4 AM.

Dr. Lobel: How does she get to school?

Mary: She drives herself.

Dr. Lobel: She has a car?

Charlie: We got her a car so that she can go to school.

Dr. Lobel: But she is not going to school, right?

Mary: We don’t know for sure.

Charlie: Yes, we do. This is the 3rd semester I am paying for, and she hasn’t even earned two credits.

Dr. Lobel: So, you pay her tuition and buy her a car to go to school. She doesn’t go to school and you continue to pay her bills?

Mary: Are you suggesting that we should cut her off?

Charlie: I can’t do that to my daughter.

Dr. Lobel: You mean stop enabling her?

Charlie: What do you mean?

Dr. Lobel: Under the guise of paying for school you are enabling her to engage in unhealthy and illegal activities with her boyfriend.

Mary: We have discussed this before, but her therapist has recommended that we try not to stress her out; that we should give in to the small stuff so that she does not get dysregulated.

Dr. Lobel: How is that working for you?

Charlie: Not good.

The Zohns left the initial consultation a bit shaken by my recommendations. Up until this point, therapists had recommended walking on eggshells around their daughter by reasoning with her, trying to be flexible and forgiving, and overlooking Rosa’s outbursts and acting out.

Second Consultation

Three months later, the Zohns contacted me again. Rosa had been arrested. This time she had been driving while intoxicated and crashed. The car was totaled, and she was charged with driving under the influence (DUI). Fortunately, she was not significantly injured.

They came in for another consultation. They explained that they had come to realize that they were indeed enabling her, feeding her monster, and that they needed guidance. They didn’t know how to say no to her and follow through consistently. We agreed that we would meet with her together in order to help them to set up some healthier boundaries. Most notably, this included the plan that resources such as money and transportation would only be available for the pursuit of healthy activities.

I asked the Zohns whether they were on the same page regarding what was right for Rosa. They shared that they often argued about whether or not to be “strict” with her and how strict to be. I told them that they must be united in the setting and reinforcement of boundaries and that I would help them with this. They agreed. I suggested that I see Rosa individually before we again met as a family so that she would not feel ganged up on. They agreed, but she did not.

First Family Meeting

When the three arrived for our first session together, I asked Rosa to come in by herself for a few minutes, and she agreed. Here is an excerpt of our meeting.

Dr. Lobel: Do you know why your parents asked you to meet with me?

Rosa: They just want to control me. They irritate me constantly.

Dr. Lobel: How do they do this?

Rosa: They are constantly on my case. I don’t do anything right. They want me to be like Wilma. They have always favored her. I can’t be Wilma so I am a disappointment to them.

Dr. Lobel: In what way do they want you to be like Wilma?

Rosa: Smart, beautiful, and successful. That is not me.

Dr. Lobel: What do you think prevents you from being successful?

Rosa: Them. They nag me all the time and then I can’t concentrate on my studies.

Dr. Lobel: That’s why you don’t go to class?

Rosa: Yes. I get so upset I just want to get high. I would rather be with my boyfriend.

Dr. Lobel: What does your therapist suggest?

Rosa: She has tried to get them to back off, but they can’t stop themselves.

Dr. Lobel: What would you do if they were not bothering you?

Rosa: I would get a job.

Dr. Lobel: Have you ever had a job?

Rosa: Yes. Several.

Dr. Lobel: How did that go?

Rosa: I usually work for a while and then they start hassling me.

Dr. Lobel: At work?

Rosa: Yes.

Dr. Lobel: Out of the blue.

Rosa: They get all upset if I am late once or twice or if I call in sick.

Dr. Lobel: And then you get fired.

Rosa: Yes. But the reason I am late or sick is because of my parents!!

We brought the parents in. We all agreed that Rosa needed to take a leave from college while she resolved her legal issues and living situation and began to more directly address her mental health challenges. We then introduced the idea that Rosa’s access to resources, such as a car and money, would be contingent on her manifesting healthy behaviors. Her parents agreed to support healthy behaviors rather than unhealthy ones. Rosa began yelling at her parents and at me, stating that this was little more than additional control and would make things worse. She stormed out of the meeting. As she came in the car with her parents, we were confident that she would not be able to go far, so we finished the hour by offering suggestions as to how to respond to her agitation. We reviewed the “form before content” tool. This basically required that Rosa speak in civil tones, or the conversation would stop.

Dealing with Resistance from Rosa’s Therapist

The following Monday morning, I received a call from Rosa’s therapist, Ms. Hartman, who wanted to know what was going on in our meetings that was so upsetting to her patient. She expressed that Rosa was “triggered” by the meeting and it was making her sicker. I was expecting this call. Here is an excerpt of our conversation:

Dr. Lobel: What about our meeting did Rosa find triggering?

Ms. Hartman: She felt ganged up on.

Dr. Lobel: Which part made her feel ganged up on.

Ms. Hartman: You and her parents trying to control her.

Dr. Lobel: Did she give you any specifics?

Ms. Hartman: No. She just said that she was so triggered she had to leave.

Dr. Lobel: She appeared to get agitated as soon as I said that her parents would support healthy activities and not support unhealthy ones. Does this contradict what she told you?

Ms. Hartman: No.

Dr. Lobel: I imagine you must be working with Rosa on increasing her tolerance for frustration and difficult situations.

Ms. Hartman: Yes. I specialize in Dialectical Behavior Therapy (DBT). I think she also takes medication.

Dr. Lobel: We are trying to help Rosa take responsibility for her choices and behaviors and she is having difficulty tolerating it. Can you help her accept that she has to accept responsibility for herself while giving her the confidence that she can do so in a healthy way and grow from the experience?

Therapy Begins

Several meetings with the Zohns followed, in which we created a contract through which Rosa could benefit from all of the resources her parents had to offer if she used them for healthy pursuits. She got a job and prepared to resume her studies. She agreed to maintain sobriety. The sticking point was the parents not wanting her to be alone with her boyfriend, as they felt his influence corrupted her. We agreed that he could visit her at the family residence but that the Zohns refused to have their vehicle or their financial support to be used to spend time with him. She very reluctantly agreed.

I also inquired as to the status of her pharmacotherapy. She apparently had a psychiatrist who prescribed a combination of medications that included psychostimulants for attentional difficulties, a mood stabilizer, and an antidepressant. She refused to take the mood stabilizer and antidepressant but wanted to continue with the psychostimulants. The psychiatrist refused to treat her under these circumstances, so she was getting Vyvanse prescriptions from her pediatrician. I suggested that she consult with another psychiatrist, as I thought that the stimulant alone was adding to her emotional dysregulation. She saw a psychiatrist and agreed to work with her on a more therapeutic regimen.

Rosa seemed to stabilize for a few months and was moving forward on our plan, until, that is, when the testing began. Her parents noticed that she was not always at work when she said that she was at work. They suspected that she was seeing her boyfriend. They also found evidence in her bedroom that she was vaping marijuana again.

Mary and Charlie met with me to discuss their fear, apprehension, and guilt at holding to their boundaries. They feared confronting Rosa, which they knew they needed to do, and they feared for Rosa as well. They did confront Rosa, who denied everything. Then Rosa disappeared.

She went to work one day and did not return. The Zohns contacted her employer the next day, who confirmed that she had not shown up for work. They tried to contact her via cell phone, but she “ghosted” them (refused to answer). They were pretty sure that she was with her boyfriend, most likely using drugs and engaging in other unhealthy and risky behaviors.

I met with the parents a few times over the next few days. They were very frightened and questioned our plan. They contemplated texting her and allowing her to do whatever she wanted if she just returned home. I discouraged this and explained that this would be a major setback. I told them that she and her boyfriend did not have the resources to survive on their own and that she would have to return home eventually. She had nowhere else to go.

We began preparing for her return with the understanding that the Zohns’ home was not viable as a therapeutic environment for Rosa and that she was in need of inpatient treatment. I encouraged the Zohns to research options and prepare to have her admitted promptly when she returned.

It took about a month. Rosa missed one of her court appearances and was again arrested. She called from the police station. The Zohn were prepared and let her know her options. She had no choice but to agree.

She was admitted to an inpatient facility that specialized in BPD and substance abuse. She stayed for three months and then transitioned to a sober living residence near her parents. She stayed there for six months, during which time she got a job, resolved her legal issues and embraced sobriety with the help of a Twelve-Step Program and a good sponsor. She went from sober living to the university.

Conclusions

In this case, BPD had not only metastasized throughout the family, but also infected the professionals involved. Approaching Rosa’s treatment from an individual perspective was not successful, because her disorder caused her to manipulate her environment into a codependent mess that enabled her to stay sick and get sicker. The only way for her to recover was to assemble a team that included her entire family and all providers working together and consistently.

Intervening in a system impacted by BPD, as in this case, required specialized skills and the willingness to confront all aspects of the patient’s treatment, including enabling providers. This was often like stirring up a bee’s nest. Great care had to be taken to protect these providers by not making them feel negligent or naïve while at the same time engaging them in a consistent therapeutic process. It was critical to anticipate resistance, even by the professionals who attacked me for challenging them. I didn’t take it personally and haven’t, which has proven to be an effective tactic. I explained to them my process and expectations in non-accusatory terms and showed them their value in the coordinated healing process.

In looking back over the case, I knew I was going to be seen as a snake-oil salesman, met with skepticism and doubt. I had to effect a paradigm shift. I also expected things to get worse before they get better. And they did. I reminded myself that as a clinician. I had to stick with what I knew: with the treatment plan, with the best techniques at my disposal.

I also knew that if this approach failed, there would probably not be another chance. Rosa would lose her only lifeline, and the family would all suffer. I reached the point of no return. I was fully committed and I had to see this case through, no matter what. I have treated families like this countless times over the years, but each case is different and each path its own.

If you are going to venture into this challenging treatment domain, conviction is critical, and still there will be no guarantees.

Caring for those Who Care for Our Pets

Posted on by Psychotherapy.net Team

Stresses on the Veterinarian

We can’t turn on the television or look at social media without seeing evidence of how the pet industry has grown exponentially over the years. We don’t just have pets anymore; we now are the proud parents (and grandparents) of “fur babies.” Rarely, however, do we think about the difficult side of having a fur baby. Yet veterinarians are on the front lines of managing the effects of this fur baby boom; and, as pets age or become ill, veterinarians have the difficult task of working with pet parents and providing the necessary care for their pets. This task, difficult on its own, is compounded when pet owners cannot afford or are astounded by and react intensely about their pets’ cost of care. Still other pet parents are unable or unwilling to accept their pet’s illness and insist on providing treatment, even when the treatment will not extend the animal’s life. Even with these tensions, veterinarians often develop an emotional connection with pet owners and their pets. The emotional connection adds a dimension of stress and emotional pain when pets become ill or must be euthanized. Being a veterinarian is far more than working with animals.

Then there are the kinds of stories that appall the public. In early 2020 in South Florida, it was reported that a local humane society euthanized 198 animals over a two-month period without first requesting any support from rescue groups. The story is certainly shocking, and the tragedy to the animals pulls hard on our heartstrings; yet we don’t consider the impact of situations like this on shelter veterinarians. For this group, the need to euthanize can be emotionally overwhelming, given the number of euthanasia procedures they must perform due to overpopulation.

A review of the literature suggests that there is some training to help veterinarians provide grief support services and resources to clients. Still, there is little available to veterinarians for their own work-related grief work. An example of the need for awareness in this area was noted when one of the authors’ dogs, Riley, had to be euthanized when medications to control his health issues were no longer effective. Riley had been a client at his vet’s practice for seven years, and the hospital staff was also affected by the need to euthanize him. While there is the need to maintain a professional stance in these cases, it is important to note that veterinarians and their staff may have strong feelings for their clients.

Over the last couple of years, we have come to see that, like others in the helping professions, veterinarians face a wide variety of stressors that contribute to issues related to their mental health. Because impairments manifest in varying degrees, it can be challenging to recognize one’s own or a colleague’s impairment, even in the best of times and with experience. This is of particular concern when we consider that this group of professionals is at higher than average risk for suicide.

According to reports from the CDC and other international studies of veterinary professionals, mental health issues amongst veterinarians can be attributed to multiple factors. Compassion fatigue, demands for euthanasia, challenges with workplace relationships, and the demands of supporting and educating pet parents on issues related to their pets all impact veterinary professionals’ mental health. The responsibilities of managing a veterinary practice and exceedingly high levels of veterinary school debt from tuition costs averaging $160,000-$329,000 add additional burdens to veterinarians’ already stressed and challenging careers. Given our current COVID-19 crisis, many veterinarians have been furloughed or laid off or are witnessing their colleagues being laid off, creating a new level of stress. In addition, veterinary office changes were required to help manage physical distancing during COVID-19, causing stress for both veterinarians and pet owners.

While client relationships are primary in veterinary medicine, veterinary practices are also production-based, meaning that the veterinarian must manage what is in the best interest of the pet/client and the need to produce to retain their position. This creates an ethical challenge. In addition, the level of rigor and oversight around medical documentation can vary, with some practices being flexible and accommodating about how documentation is kept and who can sign off on medical records. Some practices allow technicians to sign records for renewing prescriptions or completing medical notes; this can open opportunities for veterinary staff to illicitly take or prescribe medications.

When combining the immense stressors that contribute to depression and other mental health-related issues, a production-based work environment, lax or variable management of documentation, and workplace access to a wide variety of drugs, many of which are highly addictive, there is increased potential for veterinary professionals to become susceptible to drug misuse and addiction to cope with work stress. Dr. Jon Geller noted this danger in his 2016 article in DMV 360 and added that there are insufficient resources to address this concern, including insufficient drug testing in veterinary workplaces, few or inadequate drug control procedures, and limited access to or availability to employee assistance programs.

Veterinarians have access, often with limited oversight, to potentially addictive medications to help with depression, anxiety, and sleep management. While increased levels of scrutiny and oversight have limited opportunities for medical professionals working with human patients to access in-house drugs, this level of oversight has not been implemented in veterinary practices in the United States.

The importance of greater training around and support for prescription abuse for veterinarians is underscored in stories such as John Burke’s Pharmacy Times article (2019), which highlighted the implications of limited oversight in veterinary clinics. As Burke relays, as rates of addiction rise with the growing opioid crisis, there is an increasing need for veterinarians to receive training and support around prescription abuse. His article includes an account of a veterinarian who prescribed unnecessary opioid medications for pets she had placed under overnight observation; pet owners would fill the scripts and return the medications to the clinic for their pets, not knowing that the veterinarian was taking them for herself. This practice continued until a pharmacist learned that the drugs were being returned to the vet clinic for administration and reported it to the authorities.

Addressing the Need

Given these challenges, the increased attention to veterinary professionals’ mental health needs is both timely and necessary. Yet, according to the American Veterinary Medical Association, only 36 states and the District of Columbia have laws and regulations authorizing wellbeing programs for veterinary professionals. Once it is determined that a veterinarian is indeed heading in the direction of impairment, because of the taboo associated with “having” a mental health or substance use disorder, it is often difficult for colleagues to encourage the impaired professional to seek counseling. Seeking the right treatment is important to maintain professional competence. By developing interventions for veterinary professionals along the three levels of prevention (primary, secondary, and tertiary), mental health professionals can intentionally make connections with and offer support to veterinarians. These prevention services can include education, training, and support around mental health and substance use disorders that are focused specifically on the issues faced by veterinarians.

Primary Prevention Interventions

Veterinary training programs may serve as ideal grounds for implementation of primary prevention strategies, which aim to address prevention of mental health and substance use issues before they arise. In many ways, to address the needs of veterinarians, it just makes sense to meet their needs when these professionals are at their most energetic and idealistic—while they are students, before the stressors of the work really start to impact professionals’ mental health. Clinical training faculty; however, may not sufficiently focus on students’ mental health or stress the importance of self-care during training. And conversely, students in these high pressure training programs may be reluctant to admit to that they are struggling emotionally. In a school-based primary prevention intervention, mental health professionals might coordinate with veterinary programs to offer workshops or guest lectures during various points in students’ training to reduce the risk of mental health disorders and/or substance use disorders. Integration of mental health information should not be a one-time occurrence. Instead, this type of programming should be implemented from the initiation of coursework as a prevention strategy for students while they deal with the stress and pressure of training.

A primary prevention strategy also offers an opportunity to plant seeds for when the student is a professional working in the field. In this case, mental health professionals could provide services that educate educators and students in veterinary studies about mental health and substance use disorders as well as the factors that often affect these impairments. Such training should also help educators and students identify the potential signs and symptoms of the impairments. Moving beyond just providing factual information, mental health professionals could work collaboratively with veterinary education programs to develop prevention programs that address and mitigate risks for mental health and substance use disorders amongst students. These programs could include interventions to help students develop self-care strategies, connect students to resources in the community, and support the development of healthy relationships within students’ support networks.

Secondary Prevention Interventions

Secondary prevention strategies involve early detection of issues, usually through screening measures. One example of a secondary prevention intervention would be mental health providers’ working with veterinary professionals to help them recognize when they or their colleagues are impaired. In another intervention, mental health practitioners might help veterinary practices to set up regular mental health screenings of workers (i.e., for burnout, anxiety, or suicidal ideation) to help identify issues in their initial stages. Early detection and treatment are key. In this prevention level, mental health practitioners might provide support to veterinary professionals who were caught using or accessing drugs. Working with individuals at this stage is meant to “catch” the potential problem and prevent it from getting worse.

Mental health professionals can also provide mental health consultation services to help veterinarians develop and establish thorough clinic practice standards. These standards should include steps to obtain due process for individuals who may be impaired. In the case of a veterinarian experiencing opioid dependence, secondary prevention might include providing consultation to the veterinarian and staff to set up a modified work schedule so the veterinarian can return to their job without risk of accessing drugs. In addition to supporting veterinary professionals experiencing mental health or substance use issues, we need to keep in mind the colleagues who may be caught off guard when a veterinary professional seeks or is encouraged to seek help for drug use. Therefore, the services provided to veterinary staff may include counseling to those working with an impaired professional, including grief counseling.

Tertiary Prevention Interventions

Tertiary interventions are necessary when veterinary professionals relapse or have a drug addiction and need rehabilitation and ongoing support. This stage of prevention is meant to keep the situation from getting worse. Again, this stage requires the mental health professional to pull on actions from the previous two stages, ensuring the veterinary professional is safe, connecting them to resources in their community, and assisting them to develop a healthy support network. To further support the tertiary prevention efforts for this group of professionals, mental health practitioners can host support groups for participants to explore their mental health concerns and share strategies for living well. If veterinarian professionals are terminated from their positions, mental health practitioners can advocate for veterinary programs to retrain workers for new jobs when they have recovered as much as possible.

For mental health professionals to provide services to this specialized group, we need to understand that veterinarians and veterinary professionals face unique pressures. Not only are their workloads excessive and their hours long, but they also must face anxious and emotional clients and animals, often having to make life-or-death decisions about unwanted or sick animals. These stressors, along with other practice-related factors, contribute to the veterinary profession’s challenges of burnout and compassion fatigue, which are associated with mental health and substance use disorders, as well as suicide-related behavior.

Case Discussion

Melinda reluctantly came to counseling at her primary care doctor’s urging. Her mother had convinced her she needed help dealing with being overwhelmed, stressed, isolated, and anxious. She told Melinda to speak to the doctor about getting her anti-anxiety medication adjusted, given her stress and lack of sleep. Melinda has been on a low dose of an SSRI since graduating with her bachelor’s degree. She visited her doctor, explained what was going on, and he increased her medication. The doctor also asked her if she wanted something to help her sleep. Melinda became quiet and reluctantly admitted that she had borrowed some medication from the veterinary hospital where she worked to help with sleeping. It was at this time that her doctor told her she needed to seek help.

Melinda learned that the company she worked for offered financial support for those seeking counseling, but she was afraid of what people would say if they knew she needed help. Throughout her years in veterinary practice, she knew that people generally thought veterinarians played with puppies and kittens all day and did not think anyone outside of the profession would understand. She tried to forego counseling and try to resolve the issues herself but realized she wasn't managing well. In the past, Melinda would go to the gym five days a week to help manage her anxiety and stress. She noted that going to the gym always worked for her, but now she didn’t have time to do that. She also indicated that she was having trouble sleeping. All Melinda wanted to do when she got home from work was sleep. Sometimes she was too tired to cook and would pick up fast food on the drive home. Everyone at work thought Melinda was okay but tired due to long hours.

As a young adult, after working diligently to obtain her undergraduate degree and working at a local animal shelter, Melinda had finally been accepted to a veterinary school after three years of submitting applications. Her new friendships at school and enthusiasm for her career helped her manage the program's mental demands. She was concerned about additional student loans but did not consider the future impact of high-interest rates accruing during and after school. The program's high demands and extensive studying prevented any students from getting jobs during school to offset some of these costs. Melinda did her best to live within her means and focused on completing her degree.

Once she graduated, Melinda was selected for a 1-year rotating specialty internship and was excited for the opportunity to improve her clinical skills. Although internships have a low salary despite their highly demanding schedules and on-call hours, Melinda felt the experience would be important when looking for a full-time position. She deferred student loan payments and, upon completing her internship, obtained a small animal general practice position with a five days per week schedule. Melinda was excited about being out of school and moving forward in her career.

When student loan payments came due, Melinda began making payments. She was disheartened to see the amount of interest her loans had accrued but felt empowered to have her dream career and start planning her future. Due to the high cost of living where she lived and her debt-consciousness, she shared a two-bedroom apartment with a roommate.

“Melinda noted that she worked 55-60 hours per week on paper, but she stayed late at work after every shift catching up on phone calls and writing medical records”. Since generating revenue was a high priority in this practice, she picked up additional shifts and was now averaging 60–70-hour work weeks. She felt relieved as she saw the larger paychecks and ignored her exhaustion, telling herself it would pay off in the long run. Feeling pressure from both clients and hospital management, Melinda frequently agreed to squeeze in additional cases during the day, and it was not uncommon to skip lunch. She indicated that she was losing weight but didn't have time to eat. She was increasingly tired but saw opportunities to pick up additional shifts as a good opportunity to help pay off the student loans. She often didn't have enough energy to get to the gym at night, a key stress reliever during college and veterinary school, so she would periodically “find a medication” from the clinic to help her energy level.

Melinda was having trouble sleeping and would wake up thinking about cases. She would replay patient exams and lab results in her mind, worrying if she had missed something. Melinda noticed some cases where she had forgotten to finish typing a medical record, and clients were calling asking for lab results more frequently because she didn't have time to call them with results. When arriving at work, Melinda would often have numerous lab reports to review, refill requests to fulfill, and client calls to return about sick pets. She struggled to find time to get everything done. It was relatively easy to take medications from the clinic without being noticed, and she had been doing so for the last six months before seeking counseling. She began periodically taking a stimulant medication from the clinic to help her boost her energy and then a sedative to help her sleep at night.

Melinda reminisced about the first few years of her career, when she had mentorship, and wished she could go back to those days. She felt increasingly alone both at work and in her social life. When she wasn't in surgery, a large part of her day was spent seeing sick pets, trying to work within owners’ budgets for diagnostics and appropriate treatments without sacrificing quality of care, end of life consultations, and client education for wellness and preventative care. Relationships at work were good, but all the team members were under stress. Some long-term patients had recently been euthanized, which was adding to everyone's emotional strain.

Melinda said she had begun reducing shifts and trying to minimize the extra caseload but started to feel guilty when saying no to additional “fit ins” throughout the day. A client recently posted a review on Yelp berating her for being unable to fit a pet in on the same afternoon the owner called. Another screamed at her on the phone for wanting to charge for the laboratory testing to help figure out the cause of a pet's weight loss and accused her of not caring about animals. She was also worried about a tough case requiring many follow-up visits. The owner had started to have financial concerns, and Melinda was worried that without the continued follow-up to regulate the pet's disease, the pet might start to decline.

Continued negativity from clients, the pressure to meet revenue goals set by the practice, self-care reduction, lack of personal space at home, worry about cases, and financial concerns drove Melinda to wonder if she made the right career choice. Given the high debt and interest rate on her student loan payments, she felt trapped in her current position, since a change for a lesser salary would make it impossible to make loan payments. After five years, she still had never taken time to travel, which had been something she had been hoping to do once she had a stable job. She realized she was not meeting her goals of meeting someone and starting a family. Melinda spoke to her manager and tried to reduce her hours down to four days a week; she then worried about the pay cut's impact on her finances. Melinda used some vacation days but felt she was not able to get her mind off work. She began to realize there wasn't much that she enjoyed in life anymore.

Primary Prevention: If we had been able to work with Melinda while she was still in her training program or as a new professional, primary prevention approaches would have focused on preventing or reducing the chances of acquiring a substance use disorder and/or mental health disorder. Prevention strategies at this level would likely include psychoeducation and skills development focused on awareness of the effects and potential consequences of SUDs and the importance of attending to wellness and mental health (e.g., stress management skills, self-esteem building, problem-solving, recognizing and building protective factors, recognizing risk factors). Given the stigma of seeking therapy Melinda seems to hold, we would work to destigmatize seeking mental health therapy, framing it as a source of support and one way to promote self-care, much like her time at the gym. We would make sure to provide connections to community and profession-specific resources that support veterinarians, such as state wellbeing programs for veterinary professionals. Considering the immense stress associated with student loans, having resource information about debt management training on hand would be another important prevention strategy to assist Melinda.

Secondary Prevention: Melinda is experiencing stress from work, the burden of a sizable student loan, and guilt (and possibly shame) for taking medication not prescribed to her from her place of work. From the perspective of secondary prevention, the focus is on harm reduction. Providing referrals to the resources identified in primary prevention would be appropriate in the secondary prevention process. Melinda will likely appreciate the information to help with her loans, but the referral alone is not enough to help her address her maladaptive behaviors. First, it is essential to assess for baseline severity of symptoms and coexisting mental health disorders. Given her reluctance to therapy, working with Melinda using motivational interviewing therapy might help her work through her ambivalence. Motivational therapies, such as motivational interviewing, encourage a client’s readiness for change and may help Melinda realize and voice her personal goals. To reduce harmful behaviors, for clients whose substance use is mild, CBT and social skills and other skills training (e.g., communication skills, stress management, problem-solving, and identification of the effects of the medication she’s taking without medical oversight) are reported effective. With addiction, a combination of motivational incentives/contingency management rewards and CBT appears to be an effective treatment intervention. Group counseling is especially effective in creating a support network. In addition to group counseling, there are profession-specific support networks available. One such group is Not One More Vet, which came about to prevent suicides among veterinarians. The last element of secondary prevention is to build in a relapse prevention plan into the client’s treatment plan.

Tertiary Prevention: Tertiary prevention would focus on relapse prevention and/or advanced substance abuse, the long-term effects of the abuse, and the impact of complications associated with SUDs. Relapse is common (and often part of the journey) in recovery. So, planning for relapse is an important part of any prevention plan. As a result, there are a number ways mental health practitioners can assist clients incorporate tertiary prevention approaches in their treatment. For Melinda, the following are just a few options. Focusing on relapse prevention, Melinda is encouraged to continue meeting with her therapist. However, the focus in therapy would be less on skill development and more on supporting her practice and implementation of her newly acquired (or reinforced) skills (e.g., stress management skills, self-esteem building, problem-solving, recognizing and building protective factors, recognizing risk factors) in her work setting and personal relationships. These skills are critical in her being able to deal with shifts and changes that happen in life, positive and negative. A related strategy would be to work with Melinda to identify and recognize the shifts and changes in her personal life or career that might negatively impact her sobriety and mental health and potentially open the door for relapse. Melinda’s continued involvement in her support group is also encouraged, so she can keep on learning healthy strategies from her peers.

In the case that Melinda’s substance use progresses and she opts to seek inpatient treatment, it is important for the practitioner to know of or to consult with colleagues about reputable rehabilitation programs. Helping the client research and select a rehabilitation program that best suits her needs fits in with tertiary prevention planning. Finally, should Melinda experience long-term medical or other disability effects of her substance use, she may need the support of a vocational rehabilitation counselor for assistance with employment support.

***

This brief article and case study propose making connections with and offering support to veterinarians and veterinary professionals from a prevention model perspective, engaging with them in training programs during their medical training and in the community. We propose not waiting for veterinarians to enter our practice for intervention, but rather reaching out proactively and identifying opportunities for providing psychoeducation, consultation, and advocacy.

Resources for Veterinarians and Mental Health Clinicians

State Wellbeing Programs for Veterinary Professionals
Debt Management Training
Not One More Vet

References

American Veterinary Medical Association. (n.d.) State wellbeing programs for veterinary professionals. https://www.avma.org/resources-tools/wellbeing

Geller, J. (2016, June 15). Dark shadows: Drug abuse and addiction in the veterinary workplace. DVM 360 Magazine. https://www.dvm360.com/view/dark-shadows-drug-abuse-and-addiction-veterinary-workplace 

Who’s Listening? Smartphones and Psychotherapy

Posted on by Psychotherapy.net Team

We both hear the buzz. I watch as he reaches over to the table to pick up one of his phones to see who the message is from. First, he checks his work phone, then his personal phone. I observe the tension in his face and try to hold on to the moment we just lost. It is 7:15 in the morning. He tries not to work during our sessions, but the financial overseas markets are already open, and his work expects him to be available. He does not mean to be disrespectful. I get more of his undivided attention than anyone else, but still I feel frustrated at being put on hold.

No-Smartphone Zone

The therapy hour is the patient’s and it is sacrosanct. In addition to the therapist’s training and expertise, what the patient is buying is fifty minutes of her undivided attention. In the not-so-distant past, the therapist used to receive her patient’s undivided attention as well. But no more. Smartphones have transformed the therapy hour, at least in my practice.

Therapy sessions are a laboratory for understanding human relationships. In addition to the patients’ individual needs, larger cultural trends are exposed in a therapist’s office. Personal devices have simultaneously enhanced and impaired human relationships. Helping our patients (as well as ourselves) adapt to the ever-changing world of technology is essential to functioning in our society. Examining patients’ relationships to their personal devices within therapy sessions sheds light on various ways technology is changing private and public lives.

Being unavailable for as little as an hour without fear of repercussion is no longer possible for many people. In the workplace, schools and within families, we are always expected to be available. Even patients with a standing weekly appointment, who are accustomed to the routine and sanctity of the therapy session, are often interrupted during a session with a non-emergency request. For a few people the consequence of being unreachable is truly unacceptable, but for most, having their smartphone on is merely a habit.

So why not simply have a policy that bans smartphones during therapy, as some of my colleagues do? I forbid anyone to smoke or use drugs during their sessions and I am comfortable enforcing those rules, so why don’t I enforce a rule about cellphone use? I imagine that some of my patients would balk at a prohibition on smartphones in my office. I also don’t want to spend the beginning of each session negotiating whether the potential need to be interrupted rises to the level of granting an override to my ban. But, perhaps more importantly, “I learn things about my patients as I witness their relationship with their phones”. At this point I have no official policy, but rather have incorporated my observations of how my patients use their smartphones into my general understanding of how they function in the larger world. Understanding how people relate to technology reveals important aspects of their values and personalities.

The smartphones—and yes, some people bring more than one—may be out in full view, or they may be stuffed into pockets, handbags or briefcases. On occasion, if they have been inadvertently left in the car, patients excuse themselves to retrieve the phone, “just in case.” It’s not just the phone ringing, but the ping of incoming texts, voicemails and emails that punctuates the session. Increasingly, people wear smartwatches that light up with each incoming text or email notification, adding to the distraction. People claim that they need to have their phones on in case of an emergency, but rarely does the interruption meet that bar. In fact, in over thirty years of practice, I have only twice had situations where a patient had an actual emergency which necessitated leaving the session early. This underscores that “technology has changed the social norms for what constitutes an emergency”. Prior to cell phones, people came to the therapy hour with less worry and distraction about being reachable. There was an implicit understanding that for fifty minutes the world could take care of itself without dire consequences.

GoPhone or StayPhone

Our relationship to our devices is embedded far deeper in our psyche than most of us would care to admit. Thinking of our phone as merely an appendage, like the car keys, denies its emotional connection. This is part of why people feel so unsettled if they can’t find their phone or if the phone is off. It is as though they’ve lost a part of themselves. A recent study in the Journal of Social and Clinical Psychology discussed how limiting social media access could decrease anxiety and depression. It is both the content of what we are seeing as well as the need to be incessantly looking that is impacting our mental health. The understanding that constant connectivity is hurting us is gaining traction, but that does not mean people can easily go cold turkey for an hour a week. Counterintuitively, by allowing smartphones to be out and visible during therapy sessions, some of my patients are calmer and more focused than they would be if left to wonder who might be trying to reach them for that hour.

During my work hours, both my landline and my own smartphone are silenced. Before cell phones existed, patients would occasionally ask me to turn on the ringer to my landline, so a babysitter or physician could reach them if needed. But at that time, the norm was that there was no need for interruption during the session and our time together was the central focus. The patient-therapist relationship was built on the communication that occurred between us in the office.

A colleague reports, “For those who peek at their phones throughout sessions, it feels like a compulsion—they can’t not look.” Some people glance at their devices during sessions to read incoming texts and missed calls throughout the session—as a form of multi-tasking—seemingly unaware of how such behavior disrupts the flow of conversation or limits the emotional depth of our connection. Patients have always had ways of side-tracking themselves during sessions, such as changing the topic, glancing out the window or playing with a tissue box, but the smartphone provides a far more powerful distraction. “Its addictive properties and prevailing social norms that permit having it on at all times contribute to using our smartphones as a psychological shield”.

He takes notes on his phone after their fights because he wants to make sure I hear “both sides.” He is a chemical engineer by training and committed to getting the facts right. He “walks on eggshells in their marriage,” scarred by her words and blind to his own rage. He reads his notes to me during each session, a practice he finds reassuring, confident that he has gotten the wording just right.

Sometimes patients use their phones in therapy to bolster their position on an issue. They want me to agree with their outrage over someone’s insensitive comments or their disgust with inappropriate pictures shared on dating apps. I wonder if people have ever thought about the possibility these photos could be shown to a therapist before posting them. Just as people no longer rely on their memory for phone numbers or directions, whole conversations are readily available to be shared. The story doesn’t unfold. Rather, the evidence is presented like a legal argument. Many of my colleagues have acknowledged the beneficial aspect of this—it allows for a truer glimpse into the patient’s behavior in the outside world. But it can also easily thrust the therapist into the role of judge, rather than allowing for a more nuanced dialogue. For example, at the end of reading a text exchange aloud, the patient may look up from the screen with a fervent expectation that I will be nodding in agreement. This feels entirely different from a story being told in the patient’s own words while maintaining eye contact with me. In an effort to highlight the patient’s reaction, rather than offering my response right away, I typically ask the patient to reflect on what he just read.

Occasionally, patients are genuinely confused about how to interpret a message. They search on the phone for a text or email and read it to me. “What did she mean by this text? Is she trying to break up with me?” “How could he think that was funny? He claims it was a joke.” “How long should I wait before texting back? I don’t want to appear too eager.” Integrating this ever-changing technology into our relationships requires that all of us write the instruction manual in real time. I am not the Ms. Manners of smartphone etiquette, but I think people are turning to their therapists for help in this regard because we are experts in relationships. On a recent episode of the podcast The Cut, “Bad Sex, Good Sex: Fiction That Makes Sense of How We Bone” (2019), one of the panelists reported that she brings her phone into her therapy sessions because she was explicitly looking for help from her therapist with how to interpret the text message exchanges on her dating app. No longer was she relying on her own experience, but rather she read the text exchange aloud looking for help with interpretation. She said, “All therapists need to get hip to this because it’s not just crazy assumptions anymore.” The fact that it is now “he said, she said” in black and white rather than one person’s recollection can add powerful information to the session. The panel went on to discuss how important it is for therapists to be knowledgeable about the varied ways emojis are used.

Therapists have a deeper understanding of our clients’ issues than an advice columnist. For example, someone who is conflict-avoidant would much rather send a text than make a phone call when there is tension in a relationship. As professionals, “being fluent in how smartphones and other forms of technology are used to foster social connections is critical to offering relevant assistance to our patients”.

By making us more reachable, smartphones have increased not only our ways of communicating (a simple “I’m sorry” text on the way to work can ease an early morning fight), but also the expectation that a recipient should respond ASAP. It can be excruciating to wait for a response and people often have a strong reaction to a real or perceived delay in response. Family members, friends and bosses text or email rather than waiting for an opportunity for face-to-face conversation. Sometimes, phones are used in this way to control the communication, pounding out a monologue and hitting send rather than welcoming a dialogue. Patients can use their smartphones as a verbal weapon when they impulsively bombard someone with a rant. Alternatively, being “ghosted” can erode one’s self-esteem. Learning how to interpret both the content and the timing of someone’s texting behavior is on par with learning a new dialect. All these new ways of communicating are significantly altering how relationships are formed and nurtured.

Commenting on the absence of my smartphone during our sessions, one of my college-age patients recently told me, “You’re the only person I talk to who actually looks at me the whole time.” This statement opened a discussion between us about her relationship to her own phone. As Cal Newport wrote in The New York Times (2019, January 25) earlier this year:

Under what I call the ‘constant companion mode,’ we now see our smartphones as always-on portals to information. Instead of improving activities that we found important before this technology existed, this model changes what we pay attention to in the first place—often in ways designed to benefit the stock price of attention-economy conglomerates, not our satisfaction and well-being.

Many of my patients have expressed a desire to spend less time on their phones but feel uncertain about what the consequences for their social life might be. As more people experiment with “Dry January,” could we imagine a social movement toward “Smartphone-free September” where we return to using our Smartphone only as a phone?

Early in my training as a psychologist, a supervisor taught me that he waited 24 hours before returning a phone call from a prospective new patient. He explained that he wanted to “set the stage with realistic expectations about his availability.” I have continued that practice, but recently I have begun to wonder if the wait for a call back feels different to potential patients in this day and age. Do they just “swipe left” and move on to the next therapist’s profile? It is also interesting to see how long a week between sessions feels to different patients. The timing of sessions is always part of the treatment protocol, but in a landscape that is more 24/7 than ever and with so much instant connectivity, waiting a week to continue a conversation is no longer representative of how most relationships function. Increasingly, and counterintuitively, because we will sometimes communicate between sessions, I find I have to remind patients about what happened in past sessions to keep the thread of our in-session work alive. This is a change from earlier in my practice when our time together week to week was more demarcated. Now people are “in touch” with such frequency that it can be harder to hold onto what was said in the session as opposed to all the noise in between. To combat this, I encourage patients to organize their day in such a way that they have time after each session to quietly contemplate our work rather than squeezing it in between all the other parts of their lives. Sometimes “I explicitly encourage someone to not reflexively check their phone the moment the session ends, but rather give themselves time for reflection”. By delaying the inevitable distraction created by reentry into their busy lives, patients can make much better use of their therapy sessions. Ironically, this suggestion is undermined by using the smartphone as a calendar. As soon as patients turn on their phone to make an appointment, they are greeted with all the missed communications of the last hour. Consequently, the session ends abruptly even before the person has left my office.

Worth a Thousand Words

Her son is worried that he is getting fat. She is worried that her own body image issues are scarring her child. She reaches for her phone and offers to show me photos of her family. Her eyes reveal the fear she feels anticipating I will judge her as a bad parent.

With the introduction of photos on phones, I feel that I’ve graduated from radio to television in my sessions. Patients may hand me their phone to look at photos during a session. At times this can involve an awkward dance as we negotiate how to be physically next to each other. Do I get up from my chair or do they come over from the couch to me as I am introduced to the family? Because I usually hear the details of someone’s personality long before I see a photo of them, I often draw my own picture of the person’s appearance, sometimes finding out how wrong I was when I see their image. For example, a tyrannical father may have been only a few inches taller than my patient, but his forceful behavior had me visualizing him as much larger.

There have been occasions when I’ve asked to see an image of someone, such as after the death of a parent, as a way of feeling closer to my patient. Patients sometimes solicit my reaction to the photos they share, but in my role as therapist I always try to reflect to the patient that their opinion is the one that matters. It can be illuminating, though, to see the discrepancy between someone’s self-report and an actual image.

Sharing photos from major life events of my patients can also foster joyous connections with them. In many instances the result of our work was critical to the realization of a wedding day, a baby or a graduation. Prior to smartphones, patients might have brought photos with them to a session in a planned way to share these significant events, but now there can be the spontaneous sharing of a child’s first steps or the photo of a new home.

The availability of photos and videos on phones has also increased how much of my patients’ lives I can share virtually. I have heard musical performances, comedy routines and graduation speeches. I now have greater access to the full scope of my patients’ lives as they send me updates through texts or emails. In addition, the exchange of podcasts and articles to supplement the therapy hour can be beneficial, just as book recommendations have been. But this necessitates that I manage patients’ expectations about my availability between sessions. Sometimes people want me to read or listen to information as a way of getting to know them, rather than relying on the work we do together during the therapy hour. Potentially this can speed up the connection we have together, but there are other times when it feels like resistance to actual therapy.

Incidental Eavesdropping

In an effort to contain how my patients reach me between sessions, I am judicious about sharing my email address or cell phone number. Historically, all these ways of interacting would be considered “grist for the mill” in a therapy relationship. To an extent they still are, but I think it is important to monitor how effective the access to technology is for improving or hurting therapy relationships. An article in Forbes.com, “Sleepwalking Towards Artificial Intimacy: How Psychotherapy is Failing the Future” by Essig, Turkle, and Isaacs Russell (2018, June 7), articulates the slippery slope therapists are on when their behavior contributes to the notion that human interaction can be replaced by technology. From scheduling appointments to responding to patients’ requests with our own text messages, we are succumbing to the ease of using technology and missing the fuller exchange possible in a phone call or face-to-face meeting. When therapists’ behavior reflects social norms regarding technology rather than challenge it, the authors conclude, they are failing their patients.

She reads the text thread on her daughter’s account from her own phone as she tells me about how worried she is that her daughter will be expelled from boarding school.

Recently, one of my patients was complaining that her daughter, who is enrolled at an expensive private high school, was on her device during class time. The mother, my patient, is able to track her daughter’s use of her phone clandestinely. She saw that her daughter did not use her phone during lunch or free periods, when presumably she was having face-to-face contact with friends. When my patient questioned the school about their policy for the use of personal devices, they stated that they choose not to police students’ phones but rather to teach students how to police themselves. Ironically, the mother and I had this conversation while her own phone was lighting up with text messages to her from her daughter and she was paying me for my time. When I pointed out the contradiction between her unhappiness that her daughter was not paying attention in class and her own choice to be on her phone during our sessions, she grew quiet. She was so concerned about being available to her daughter at all times, she had failed to see how she was modeling exactly the behavior she does not respect.

I listen as he talks to his wife. I am a silent observer to one side of the conversation. I can see his facial expression and body language. I hear the frustration in his voice despite the polite language he uses. I wonder if she realizes how close he is to leaving her.

Once, a patient who was going through a nasty divorce continued his phone call with his wife for the first five minutes of our session. He was on his phone as he entered my office and, without acknowledging my presence, continued the conversation. I had heard him describe his frustration and hurt, but to actually hear the anger in his voice and see the veins in his neck throbbing as he shouted at her brought his pain vividly into the session. We are all privy to overhearing phone conversations with little regard for privacy as we go about our day, but hearing snippets of conversations can reveal aspects of patients’ personalities that otherwise might have stayed hidden far longer.

The Newest Addiction

Increasingly, the very topic of addiction to smartphones is the presenting problem in therapy. Patients are looking for help to manage their addiction to the use of the device and/or the content on the device. Hours are spent on pornography, dating apps and/or social media. People spend time chasing down news stories, only to find themselves more depressed than ever. In these cases, a discussion about the presence of personal devices during the therapy hour is essential. Some of my colleagues have a basket in their office with the expectation that patients turn off their phones and drop them in the basket. One colleague, who works primarily with adolescents, told me, “This (dropping phones in baskets) is so routine for them—at school, friends’ parties—they never question this expectation. My adult patients are much more likely to balk at the request with protests of needing to be available “in case of an emergency.”

Patients complain of partners who take their phone to bed and are text messaging with someone else or looking at the Facebook posts of friends as they lie there feeling ignored. Or they engage in parallel play, side by side, watching their own TV show or film. Single patients will talk about the hours they lose to being on their smartphones. It is easier to play another game of Candy Crush than meet a stranger for a date. “Feeling connected to the world virtually makes staying home feel less isolating, but it rarely touches their deep loneliness”.

Even though she knows “it’s crazy” she reflexively checks to make sure her phone is off before talking about her mother. She is terrified that her mother might hear what she is saying.

There are those patients who religiously turn off their phones and direct their full attention to our work from the beginning of each session. I have yet to find a way to predict this behavior by age, gender, profession or presenting problem. I’ve talked to other therapists and they say the same thing. Some patients eventually adopt this stance on their own. As the work gets deeper and our relationship closer, they invest more thoughtfully in our time together by turning off their phones, whereas in the beginning of treatment they may not have been as ready to do that. Some express relief to be away from their devices for an hour and to focus on themselves. Sometimes, when I observe a patient nervously looking at her phone, I may ask her if that is really how she wants to spend our time together. Turning off the phone can be an assertive act and contribute to enhanced self-esteem. It may also generalize outside the therapy office, giving people permission to ask others to turn off their phones for the purpose of decreasing interruptions or staying focused in a face-to-face conversation. Much like the transition from allowing people to smoke everywhere to limiting smoking to designated spaces, I find people are starting to long for a social change where they feel more empowered to ask people to turn off their phones. The quality of the conversation we have during therapy can become a benchmark for the kind of conversation people want to have with other people in their lives. Just as I encourage patients to meet someone for a first date at a coffee shop rather than a place where alcohol is served, discussing how to limit smartphone use before engaging in a difficult conversation seems critical to increasing the likelihood for a successful interaction.

She asks me to slow down as she types my words into her phone. She tells me that she reads them between sessions to remind herself that she has a right to exist.

A Place on the Couch

Smartphones are not the enemy of psychotherapy. In fact, therapy can illuminate how technology is changing the social fabric of society, especially relationships. Psychopharmacology was once seen as a threat to “talk therapy,” but it is now clear that they complement each other. Technology expands the possibility for people to receive treatment in remote areas where there may not be many providers. Through the introduction of Skype, FaceTime and other applications which allow for both visual and verbal communication, patients can have sessions during extended periods of being away. Recently, insurance companies have started to reimburse for teletherapy, thus making it easier for potential patients to find a provider. Although I still prefer to meet with people in person, there have been instances when, because of technology, I was able to continue working with someone, such as when a patient studied abroad for a semester, despite a geographic separation.

Linda Rodriguez McRobbie of the Boston Globe (2019, January 31), reported on a relatively new development- apps that deliver therapy without a therapist; the therapist in your pocket. People use their smartphones to establish meditation practices, exercise routines and various other self-help functions. Cognitive-behavior therapy principles are available to download as an alternative to actually engaging in therapy. Our reliance on our smartphones to fulfill our needs, even going so far as replacing human interactions, is troubling. Perhaps the best example of how seductive a relationship to a smartphone can become is revealed in the 2013 Spike Jonze movie, Her, (where the main character falls in love with his phone and takes it on dates).

Adapting to change is a hallmark of therapy. Therapists are in a unique position to experience as well as reflect on how human connections are floundering or flourishing by the presence of technology in our lives. “When technology enhances our connections, relationships blossom, but when technology becomes an overwhelming focus of our lives, relationships suffer”. The therapy hour can serve as a reprieve from being available, a training ground for practicing a phone-free hour. Ironically, I, of course, have my smartphone silenced and out of sight throughout every session. The person in front of me deserves my full attention and my behavior models that it is still possible to be unavailable to the larger world for an hour.

As I struggle with the reality that technology is omnipresent and ever-changing, I also continue to believe in the power of human connection. One of the benefits of a psychotherapy relationship is its consistency. Every week I show up at the same time ready to listen to the deepest thoughts and feelings my patients choose to share. Together, through our connection, I explore the needs and desires expressed by them to support their change and growth. This is my life’s work and it is enormously gratifying. I have adapted to changes in the field of psychology over the years, yet the heart of my work has remained my ability to establish a positive relationship with each patient.

Recently, a former long-term patient celebrated a milestone birthday. She called my office phone, the landline I have had for over 30 years, grateful to know I was still there. She wanted me to know that despite all odds—she was a newly sober alcoholic at the age of 35 when we first met—she had made it to the age of 70. When I returned her call to offer her my congratulations, she updated me about where she was living and her family members. Then she wistfully asked if I have FaceTime, so we could talk one more time, “in person.”

References

(2019, January 22). Bad Sex, Good Sex, Fiction That Makes Sense of How We Bone. The Cut Podcast. Podcast retrieved from
https://gimletmedia.com/shows/the-cut-on-tuesdays.

Essig, T., Turkle, S., Russell, G.I.. (2018, June 7). Sleepwalking Towards Artificial Intimacy: How Psychotherapy is Failing the Future. Forbes. Article retrieved from http://forbes.com.

McRobbie, L.R.. (2019, January 31). Apps can Put Therapy in the Palm of Your Hand. But What Happens When They Go Haywire?. The Boston Globe. Article retrieved from http://bostonglobe.com.

Newport, C. (2019, January 25). Steve Jobs Never Wanted Us to Use Our iPhones Like This. The New York Times. Article retrieved from http://nytimes.com.
 

Addiction: What Glory in the High Recidivism Rate?

Posted on by Psychotherapy.net Team

When I began my career as a psychotherapist, I was sure I would focus on addiction recovery. After graduate school, I ran into an amazing professor and took a year of courses with her on dual diagnosis. Thirty-six years sober, she was my guide to a world I hoped I would never enter personally, but would focus on professionally.

I proceeded to work at a number of drug and alcohol rehab clinics, from tony Malibu in-patient programs to down-and-dirty outpatient clinics for people fresh from prison or the streets. I was a “newbie,” one of the few working in these organizations that did not have prior addiction as one of my credentials. I talked my way into the jobs by stating that I could offer an alternative to the way people had been living. I had learned how to talk the talk, from AA to NA to no A’s at all. But I learned that as hard as I worked and as connected as I felt to clients, I was never going to lower that +70% recidivism rate reported by the National Center on Addiction and Substance Abuse. Success stories were rare. Those who emerged from a facility often found their way back in. I treated a 20-year old woman in her 10th rehab program. When asked the first thing she would do when she had completed this stint, she stated she would escape from her home and go straight to her dealer for ‘H.’

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

In private practice I continued working in addiction recovery. There was the shopping addict whose addiction not only emptied her pocketbook, but also derailed her marriage. I like to think out of the box, so we made a deal: she could shop till she dropped on Saturday, Saturday night she could try on her bounty, but on Sunday she had to return all of her purchases. This was monitored by mandatory photos sent of the purchases and returns. It became such a tiring process for this client that she eventually gave it up. When she needed something for a special event, she had to call me for permission. When she “graduated” from therapy, it was with a growing bank-account, sadly a divorce, but an understanding of her addiction and the knowledge that she could never go back to that behavior again. You might be saying, oh a shopping addiction is not as life-threatening as drugs or alcohol, but in another way it is. The depression precipitated by being broke and now divorced was mentally debilitating. Take gambling addiction. All you need to do is read former Good Morning America anchor Spencer Christian’s book, You Bet Your Life, about the thirty years of shame he hid and the near ruin he continuously faced, to know that addiction in almost any form is a health threat.

I also began to understand that giving up one addiction often leads to another. Why do you think that during AA breaks, so many people are outside smoking? The hole that created the addiction in the first place needs to be filled. So why not with something healthy? I began to find those “hole-fillers” for my clients. Exercise became the most successful. Hangovers and the day-after partying like a rock star are not feel good moments. Getting your health back, your body back, a clear mind—that became the goal.

One client was a law school student. After two years of Taco Tuesdays, Thirsty Thursdays, Freaky Fridays, Saturated Saturdays—and oh well, Sunday too, she was a full-blown black-out drunk; failing out of law school, sabotaging friendships, avoiding her family. When she came to work with me, eschewing AA, she had to come three times a week. She also had to pick a physical activity; her go-to instead of drinking. It was a long year. It became a long second-year of maintenance and on the anniversary of the completion of year two, her official graduation from therapy, I had baked a cake and had sparkling cider ready. She walked in, and to my shock, was followed by her parents, 2 sisters and her soon-to-be fiancé. There were hugs. There were tears. She was carrying a large wrapped photo.

I looked and said, “What a great picture of you and your Mom.”

“Susan,” she grabbed me. “That is me when I started seeing you and me now. I am sober and 60 lbs. lighter and a rockin’ marathoner.”

Did I move the needle on the overall recidivism rate? Probably not, but small successes are what makes this profession worth practicing.  

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.