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Couples Series #1: Debate Team – We’re Not in High School Anymore

This post marks the first in a short series on couples issues, inspired by Elizabeth Weil’s article in the NYT documenting her experience trying to improve her already good marriage. A quote to start:

We enrolled in a 16-hour, two-Saturday course called “Mastering the Mysteries of Love.” The classes teach students how to have “skilled conversations” or rather, I should say, how to stop having the let’s-see-who-rhetorically-wins skirmishes that were standard in our house.

Let’s see if this sounds familiar. Partner #1 opens a soon-to-be argument by saying something seemingly benign yet tinged with accusation. Maybe, “Could you stop loading the dishwasher so full?” Partner #2 takes issue with this statement and challenges (“What does it matter?”). Uh-oh. In this instant, both partners become experts on dishwasher-loading technique. They each mount arguments in their heads as to why they know exactly how to load the dishwasher. And why the opposing partner doesn’t. Sooner or later the argument moves from dishwasher-loading to communication and respect, and why neither partner knows how to do those correctly either.

I’m exaggerating a bit, but the idea is that often partners engage, like Elizabeth Weil and her husband, in rhetoric-based debates rather than mutually vulnerable discussion. They get spun out in the fact-finding, quote-quoting, philosophical/moral/ethical debates that lead to nowhere but exhaustion. It’s like junk food – you can’t stop eating it, but it just leaves you feeling sick and disappointed.

Many couples therapists suggest what Elizabeth Weil calls “forced empathy” – communicating not with facts and philosophy leading the charge, but with bared emotion and mutual vulnerability. Sue Johnson’s Emotionally Focused Therapy for couples is a great example of this type of approach – I use many of these elements in my own work with couples. Now, it takes a certain amount of safety in a relationship to access this type of vulnerability, but I find that more often than not couples are eager to learn to communicate in a different way than the “debate model.” It’s hard to shift styles of communicating, but once it happens it can be a great thing.

I’d be interested to hear thoughts or experiences with couples therapy, if anyone’s willing to share. If you’re interested in reading more about the Emotionally Focused approach, Sue Johnson’s book, Hold Me Tight, is a great resource to start with. Thanks for reading – look for Couples Series #2 soon!

Jeremy

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To Boldly Go Where Many Have Gone Before…

I just read a great article in the NYT (thanks, Kyle) that’s finally gotten me motivated to talk about couples. The article is essentially a first-person account of the author’s attempts to improve her marriage through books, workshops, and therapy. As a therapist with a special interest in couples work, this piece immediately grabbed my attention. So much, in fact, that I’ve decided to pick several excerpts and write a small series on couples work over the next week or two. Not exactly fresh territory, academically speaking, but definitely interesting and relevant  🙂

The series starts with Debate Team – We’re Not in High School Anymore. Check it out and keep watch for more in the coming days!

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The Bucket Runneth Over

Whew! I don’t know about some of you, but this time of year is always when things start to get a little crazy in my life. Traveling for the holidays, planning family get-togethers, dealing with daylight savings time (it gets dark at 4:30!), etc…it’s enough to stress out even the calmest of people. And this year is extra special – added traveling for a race this weekend and working at a university where students are freaking out over finals just ups the ante on craziness.

It’s no small coincidence that blog posts have been few and far between over the last couple of weeks. In fact, this is the longest I’ve gone between posts since starting the blog. This is unfortunate given that blogging has become one of my favorite things to do over the past few months. I found myself reflecting on the process of pushing aside enjoyable activities to attend to the stressful activities and decided to post on this very issue.

I know that we all have times when things get more stressful than others, but it’s important not to lose sight of the things that nourish us and give us positive energy. I use the “bucket” analogy with clients a lot. This is the idea that we have an energy store represented by water in a bucket. The bucket unfortunately has a cork in the bottom that can be yanked out during stressful times, allowing the water/energy to drain out. If we don’t turn on the faucet, so to speak, and fill the bucket back up, we end up with low energy and a “yuck” feeling.

I usually spend a fair amount of time talking with my clients about activities that help “turn the faucet on.” For me, I know that blogging, running, and socializing with friends can all help fill up my bucket. Having a good idea of these self-care strategies can help keep the energy from reaching critically low levels, preventing burnout and keeping meltdowns to a minimum. Sometimes I’ll even go so far as to have clients write out a “De-Stress Strategies” list to look at when they’re running on empty. So if you haven’t taken time to evaluate your balance of “faucet vs. cork,” now may be a good point to check in and make sure that you’re taking good care of yourself.

That’s all for now – happy holidays and full buckets to all  🙂

Jeremy

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Freud Wasn’t All Bad

I’ve been spending a lot of time over on Shrink Rap these days – they have some great stuff if you get a moment to check it out.  What drew me back again was a post that I read a few weeks back on transference and its role in the therapeutic relationship. Many approaches to therapy view transference as an important part of the process; others do not. It’s come a long way since Freud and the focus on erotic transference – now it may include the full range of client reactions to the therapist that reflect prior relationship experiences.

To acknowledge the existence of transference, I think you have to acknowledge the healing power of the therapeutic relationship as well. I mentioned this idea in the post on unconditional love. And I’m not just talking about the general lift in mood that comes from having someone listen empathically for an hour each week; while this is certainly important, I feel like there’s a lot of value in taking it to another level and purposefully using the relationship between therapist and client as a tool.

Dinah from Shrink Rap questions this approach. She says:

My sense is that for the average patient with a psychiatric problem, focusing on the therapeutic relationship in a major way probably does not make people better. I don’t usually do it, and people still seem to heal.

I agree with her thought that misdirected focus on transference can be narcissistic on the part of the therapist and unhelpful for the client. And I have certainly seen clients heal without relationship-heavy therapy. I’ve also had the experience of it being very powerful to use the therapeutic relationship as a live, “in-the-moment” experience of a client’s difficulties. An example that comes to mind is the fearful or anxious “people pleaser” client who gets walked all over. Before long the tendency to please will show up in the therapeutic relationship, maybe by scheduling at a time that’s not convenient for the client. I may say to a client, “I get the sense right now that you’re putting my needs ahead of your own, which sounds familiar. I’m aware that it makes me unsure of whether you’re being genuine, which keeps me from totally trusting you…and I bet others in your life might be reacting the same way. Let’s see what may be pulling you to do that.” By working with these issues in a (hopefully) safe therapeutic relationship, clients can have a healing experience that often can’t happen in unsafe “real world” relationships.

I’ll admit that I tend to view client issues as rooted in relationship, so it’s easy for me to sing the praises of relationhip-based interventions. That said, there’s some very interesting stuff (see work by Louis Cozolino, Daniel Siegel, and many others) coming out these days on the neurobiology of attachment, the impact of early relationship wounds on our developing brains, and the possibilities for healing them through a healthy relationship. At the risk of sounding like a psycho-geek, it’s kind of exciting 🙂

I’d be interested to hear from therapists and clients alike who’ve had experience with transference (and counter-transference) in therapy.

Happy early Thanksgiving,

Jeremy

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What’s in a Name?

Today’s post is all about labels. A big part of being a clinician is figuring out how much to use diagnostic labels in working with clients. Insurance companies say it’s absolutely necessary. Many mental health professionals say that you can’t treat an individual effectively without knowing their diagnosis. I tend to straddle the fence on this one – I’ll tell you why.

My inspiration for today’s post came from a post on Psychotherapy Brown Bag, an informative blog dealing with the application of research to clinical psychology, and the Time magazine article they cited (sorry for the link overload). Psychologists and other mental health professionals, like medical doctors, have a nice, thick book to guide us in making diagnoses. Ours is called the Diagnostic and Statistical Manual of Mental Disorders, and it’s currently on it’s fourth-and-a-half revision. The fifth revision, or DSM-V, is due out somewhere around 2012. Much of the discussion around the DSM-V centers on its shift from a categorical (all-or-nothing) system to more of a continuum model. In other words, instead of using concrete “you’re either depressed or you’re not” criteria, the DSM-V would allow for varying degrees of depression (or other issues).

But that’s not what I’m interested in today. I’m more interested in the use of labels, period – and how they impact the individuals who receive them. At times in my life, I’ve been relieved to get labeled. Often it’s been when I’m struggling with a medical issue of some sort and need someone to tell me that I’m not going to be sick forever. Another time it was comforting to have a physical therapist diagnose my knee pain and give me concrete strategies for helping it heal. But these were physical issues – discomfort that happened to me – rather than a mental health issue, which is much easier to interpret as coming from or caused by me. I’ve been very aware, during the times that I’ve used my insurance to see a therapist myself, of what diagnosis I would be given to justify continued treatment. Would it be Major Depression? Generalized Anxiety? Or the less “serious” Adjustment Disorder? Even though I cognitively know that there is always hope for change, the diagnosis carried a lot of meaning for me in terms of how “permanent” my symptoms were and what likelihood there was that I would feel better.

I see the full range of reactions to diagnosis in my clinical work – it’s a very personal matter. Which brings me back to my fence-straddling. About half of my practice involves evaluating kids and adults for learning and attention issues; these individuals (or their parents) come to me looking for a diagnosis. And I gladly provide it. Usually these diagnoses mean relief for the individual, a name for something that’s been bothering them for so long or keeping them from doing their best at work or school. For my college students, it means accommodations in school and legitimate documentation for medication.

But the individuals in the other half of my practice are usually less excited about a diagnosis. Those that I see for individual or couples therapy are often just wanting to feel better, and I’ve found that it’s less helpful to label them when they’re not necessarily looking for it. Now don’t get me wrong – I’ve seen some clients benefit from knowing that their symptoms have a name. For instance, a lot of men that I work with are glad to finally hear that they meet criteria for depression – almost like naming what they’re up against makes it easier to work on. I wish that this was the case with everyone, but it’s not. Just the other day a client told me about the experience of receiving a Borderline Personality Disorder diagnosis from a previous therapist. This particular client felt pigeon-holed and hurt that their person hood was somehow summed up in this one set of diagnostic criteria. So I usually hold back with sharing my thoughts on diagnostic info unless clients explicitly ask for it.

Thoughts, comments, and experiences are welcome as always.

Jeremy

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Calm in the Storm

I had a nasty run yesterday morning. And not in the “nasty as an ironic way to say pleasant” sense. In breaking down the run, it wasn’t my energy level or the distance (often the culprits of a bad run) that made it so unbearable – it was the wind. For those readers in Colorado, you’ve likely experienced this type of wind before. A wind so intense that it was difficult to enjoy even when it was pushing me from behind, and enough to make me curse everything in existence while I was running straight into it. A nightmare to say the least.

If there’s any silver lining in this experience, it’s that I came out of it with the idea for this post. See, about halfway through the run, I suddenly noticed that my eyes weren’t stinging from twigs and dirt blowing into them. I was running very close to full speed, in a posture that didn’t have me bent double and twisted to protect myself from everything whirling through the air. I had no reason to be swearing (and immediately felt silly for doing so).

In that moment, one of my favorite concepts from mindfulness hit me in a rare moment of clarity – the idea that nothing is permanent. There are ebbs and flows to everything…nothing stays the same, all the time. I touched on this idea in the Comments section of an earlier post, placing it in the context of neurobiology and hope for change in our brains. But this experience was a little more direct for me; in that moment, the run shifted from a tedious chore to something a little more lively and dynamic. I recognized that the wind, contrary to my belief until that point, wasn’t constantly blowing hard and fast directly into my face. There were brief stretches where it let up, times when I could feel the sun more strongly or enjoy a little burst in speed. I started to shift my outlook on the run from one of frustration to one of recognizing and appreciating these small moments of relief.

This idea is so important in my personal and professional lives as well. Many times, I’ve talked with depressed clients who say they’re “always” depressed about how “always” is never true. There are inevitably going to be fluctuations in mood, however small they may be. Maybe it’s first thing in the morning, before things have a chance to go wrong. It might be a seemingly random compliment, or a good grade, or a better-than-average sandwich that gives a brief lift in mood. Whatever does it for you, it’s the ability to recognize these moments for what they are rather than let them pass by that’s important. It’s so easy to ignore or miss these times, letting them get swallowed by the dominant mood. But my experience has shown that there’s a lot of hope to be gained from being aware of these small fluctuations. Once you start tuning in to the possibility that depression (or anxiety, or relationship difficulties) isn’t permanent, things start opening up. The belief that there’s a chance to feel better can be incredibly powerful. In therapy I try to help my clients gain more moment-to-moment awareness so that they can recognize the small shifts rather than miss them. It’s not easy, but with a little practice it is certainly possible.

In this moment, I recognize that I want to write much more than I have time for, particularly around mindfulness. I’ve mentioned mindfulness several times in the blog and would like to do a more detailed post one day. Until then, here are a few topical resources:

Jeremy

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