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therapyThis blog presents a collection of short articles I have written that reflect my thoughts on a broad range of topics relevant to therapy. I hope it will serve as a resource for people wanting to start psychotherapy or for those who are simply interested in the process of psychotherapy. Whether you experience anxiety or depression, or struggle with codependency, or are facing the struggles of addiction and recovery, or are grappling with the effects of early abuse and trauma, you will find articles that speak to these issues. If you are interested in the role of spirituality in the therapeutic process, or wonder about whether the gender of your therapist matters, or feel that being diagnosed is dehumanizing, I have written articles that address these sometimes complex issues as well.
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Sitting With Emotions

We’re often overwhelmed by such feelings as sadness, anger, fear, depression, anxiety and even boredom. In modern society we have an abundance of ways to avoid these unpleasant feelings. Our phones and other devices offer easy escape into games, movies, videos, texts, emails, chats, and digital interactions with friends or strangers. Distraction can play a heavier role than passing a boring or anxious period of time; there are addictive ways of escaping, such as food, alcohol, drugs, gambling, and sex etc. Even our obsessive thinking can keep us from an awareness of deeper, more difficult emotions that lie underneath our spinning thoughts. The idea of being left alone with ourselves and our thoughts or feelings can even leave us feeling frantic.

People who have suffered from particularly painful events and situations often develop even more profound needs to get away from those memories or experiences. In cases of serious trauma, for example, people may have suffered emotional and/or physical pain that was literally intolerable and unbearable. The experiences may have been so overwhelming, disruptive, and fragmenting that they may have had to psychologically leave themselves to save themselves. Initially this is an adaptive phenomenon, but it can develop into a kind of reflexive habit that continues even when a threat is no longer present – another habit of escaping from unpleasant feelings.

Perhaps one of the most important aspects of psychotherapy is helping people sit with their own feelings and thoughts, whatever they may be. This is helpful not because there is virtue in the experience of suffering, but because it is often the only way to get through to the other side. As Winston Churchill said, if you’re going through hell, keep going. Therapy can serve as a container, a safe and non-judgmental place to make space for yourself. In therapy, you do not have to face these feelings and memories by yourself; therapy provides a sense of safety, and a sense that you are not alone. Your therapist can help you understand that your thoughts and feelings will pass, and that they needn’t be fragmenting and unbearable.

People are often afraid that if they let themselves feel their feelings, or let their thoughts go, they will become out of control. If I start crying I’ll never be able to stop. If I let myself feel all the anger I will hurt someone. If I let myself feel love, or feel gentle or vulnerable, I will be taken advantage of, or hurt. However, when people can let themselves relax and let their feelings be, they generally find that the difficulty of those feelings eventually leaves – not because they are indulged or pushed away, but because feeling states tend to be impermanent. Fighting with them keeps them present, and relaxing into them lets them pass through. Working with a therapist can help you sit with these overwhelming feelings so you can get through to the other side.

Developing the ability to notice and be with your experiences is neither about acting out your feelings, nor is it about repressing your feelings. Instead it is about maintaining an awareness of what you are feeling without having to do anything in response. It is about knowing that given space, feelings will pass.

buddhaThere is a wisdom to the approach of acceptance which goes back centuries, is outside the tradition of psychotherapy, and often has a spiritual bent. There are a number of techniques to becoming more focused on the present moment and learning how to be with the thoughts and feelings and perceptions that arise. Buddhist meditation, for example, aims at cultivating a calm awareness of whatever is happening; its aim is the development of a clarity of mind that neither grasps nor rejects. Other techniques that many find helpful include

  • Mindfulness meditation
  • Yoga
  • Transcendental meditation
  • Guided meditation
  • Mantra meditation
  • Qi gong
  • Tai chi

A more complete description of these various techniques can be found here at the Mayo Clinic website.

Developing the ability to notice and hold your experience allows you to become conscious and develop a sense of calmness. Of course at some point it is essential that we take action, but when the action is motivated by a frantic need to change things, or an experience of fear that leads us to run away from things, the outcome is most frequently counterproductive. What works best is to act from a grounded and open perspective that allows for a flexible and creative response.

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Psychotherapy and Medication

If you are suffering with emotional issues and are considering seeing a psychotherapist, you may also wonder about the use of medication.  Should you seek therapy alone, try medication alone, or would it be best to try both at the same time?  The answer to this question depends on a number of factors including your goal in seeking help, your feelings about the use of medication in general, and the nature of the problems you are struggling to resolve. Even your beliefs about what it means to be human are relevant.

If your goal is to shift your approach to life, understand and change destructive patterns, feel more connected to the world and integrated in yourself, and find a deeper sense of meaning, your first step might be to find a good psychotherapist  who can help you rework and resolve the underlying issues that lead to pain and suffering. While feeling better is crucial, and feeling bad may be what brings you to therapy, people are often also motivated by a desire to grow, to become more open, and to feel they are fulfilling their potential. Reducing your pain is critical, but you may want more from your life. In some cases, medication may help the therapy process, but medication alone will not address the basic issues.

If your primary desire is to make your pain and suffering go away as fast as possible, and you have little interest in working on deeper issues, your first step might be to visit a psychopharmacologist. A psychopharmacologist is a psychiatrist who specializes in the use of drugs to treat emotional states and psychiatric disorders. Depending on a host of factors, it is sometimes possible to reduce anxiety or depression and improve other difficult emotional reactions through the use of medication alone. Still, even the best medications are not a silver bullet. For example, research reported in The Journal of the American Medical Association in 2010 found that the effect of antidepressant medication on mild to moderate depression may be minimal when compared to a placebo, although when used to treat very severe depression, the effects of antidepressants over placebo are substantial.  Beyond the questions of efficacy, virtually all psychoactive medications have side effects, some of which may be severe and debilitating.

Medication may be useful in helping people feel well enough to begin the process of addressing deeper issues related to overwhelming inner conflict, the effects of serious trauma, and profound depression. For instance, people who feel so overwhelmed by anxiety they can’t even begin to focus on the reasons for their suffering, or so depressed they feel paralyzed and unable to begin to take any action, may not be able to start working productively in psychotherapy until these states begin to shift. Although medications may be helpful here, they are clearly not the essence of psychotherapy. To really address the confusion and pain in life, one needs to clarify and change what leads them to act and to feel the way they do. Some of these factors will be historical, and some will be related to current life circumstances; some may be conscious, and some may be unconscious.  Medication may help reduce the overwhelming symptoms that get in the way of doing the work of psychotherapy, but it does not substitute for going through the sometimes difficult struggle of becoming more at ease with who you are, and more of who you want to be.

It is also important to note that a person’s decision about the use of medication can reflect their personal perspectives on spirituality, philosophy, science, and what they believe to be meaningful in life. Do you think of yourself as a bundle of chemical receptors and physiological processes — that people are basically highly complicated machines? Or do you see your feelings and experience as basic to who you are as a whole person, transcending the physical state of your body and its biological processes? Perhaps you see the entire system interacting – chemistry and mind, biology and psychology. The idea that depression is a simple effect of a biochemical imbalance has become very popular in recent years, yet this point of view is far too simplistic and is frequently not supported by the evidence.

In seeking help for emotional problems, it is important to think about just what kind of help you really want, and what you hope to achieve. Think about your world view and what you find meaningful in life. Recognize that inner change is not equivalent to the immediate reduction of emotional pain. If your instinctive approach is for a quick fix, it may be worth thinking about the bigger picture. If you have a reflexive reaction against the use of medication, you may want to consider the possibility that medication may be an aid, though it’s not the solution. Whatever your feelings are, you should expect them to be listened to carefully and respected by whomever you ask for help. There are some situations in which the use of medication is advisable, such as when a person is in imminent danger of doing serious harm to themselves or someone else. Still, those offering help have the responsibility to listen closely to your concerns and to try their best to understand you and take your concerns into account.

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Female Therapist or Male Therapist?

When people are looking for a psychotherapist, they often wonder whether to choose a male therapist or a female therapist. For some people, choosing a therapist of the same sex seems the obvious thing to do. Others may simply assume that males work best with male therapists and females work best with female therapists, based on the idea that a therapist of the same sex is most likely to ‘get it.’ On the other hand, you might feel that a psychotherapist of the opposite sex would be the best choice based on your personal history with men or women. People who had abusive or untrustworthy parents of the same sex, or have in general found people of the same sex particularly anxiety-provoking or problematic to deal with, may assume that the best psychotherapist will be of the opposite sex.

In fact, the issue is quite complex, and the best choice for you might even be counter to your assumptions. In choosing a psychotherapist, the most critical factors are feeling safe, and feeling that you can be honest about what you think and feel. Regardless of their gender, you must feel your therapist is nonjudgmental, empathetic, direct, and professional. On this point, research shows that the relationship you develop with your therapist is the most important factor, regardless of the psychologist’s training, gender, theoretical orientation, age, and other factors.

To start with, therapists do not necessarily fit gender stereotypes. A dominant cultural stereotype is that women are more empathetic, understanding, emotional, nurturing, gentle, and intuitive, while men are more direct, intellectual, goal-directed, controlling, and out of touch with their emotions. These stereotypes often don’t hold for men and women in general, and they’re less likely to be true for psychotherapists. Research has shown repeatedly that there tends to be more variation within groups of all men or all women than there is between the two groups.

A therapist of the same sex may have had some experiences in common with you, but there is a risk of over-identification. It’s common to reflexively feel one understands another person’s experience “because we have been through the same thing,” but upon exploration this assumption may be very much off-base. This problem of unchecked assumptions reminds of an experience I had with a patient. I assumed he felt as irritated as I did with a loud banging pipe in my office.  In fact, upon exploration, he recalled feeling safer in his grandmother’s house than anywhere else in the world, and his grandmother’s home had banging pipes. Though I assumed the pipe was irritating him, I discovered that he actually found the sound reassuring and cozy. Also, it can be useful for a patient to have to clearly articulate the nature of their experiences to another person because it helps with integration, and helps them feel more grounded in knowing their own story. When therapists and patients assume they understand each other, it may seem less important to articulate feelings.

For people who have issues with the opposite sex but do not find these issues overwhelming, it may be particularly useful to work with a therapist of the opposite sex. Assuming you have a professional therapist who holds clear boundaries, it creates an opportunity to work on these issues as they come up between you and your therapist. In fact, it is possible that having a therapist of the opposite sex could be more helpful and produce insights that a therapist of the same sex couldn’t.

It may be important to consider the gender of a new therapist, but upon reflection, the issue can be complex. In situations where a person has had significant trauma, which may include sexual or physical abuse, a feeling of safety and security is essential and it may be important to choose a therapist who evokes the most trust and security – and this may be a therapist of the opposite sex of the abuser. On the other hand, selecting a therapist whose gender is likely to stir up some of the same feelings you are in therapy to deal with can be helpful. And finally, though it may be tempting to choose a therapist of the same sex out of a sense that they can best understand what it’s like for you, it may also be important not to choose a therapist who seems to automatically understand you, since this could get in the way of thoroughly exploring and articulating subtleties of experience that may be important to address.

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The Failure of Categories

Names have power. People who are sick tend to feel a kind of relief when their illness is named – ah, I have lupus; even though it’s a terrible diagnosis, there is relief in knowing. Having a name for the illness means others know what it is, perhaps how to treat it, and it means it’s “real,” in some way. It’s not uncommon for individuals to go from one doctor to another, to another, to another, in an effort to get a diagnosis for troubling symptoms.

Most psychologists and psychiatrists rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose emotional suffering. The DSM undergoes revision every few years, and those revisions reveal an important flaw in the concept of categorical labeling of emotional suffering. For example, homosexuality was categorized as a mental disorder in the DSM until 1986; political and cultural views clearly have an influence on the DSM categories.

psychotherapy catagoriesMore importantly, though, experience does not neatly fit into a category. If you tell me that you have been diagnosed with bipolar disorder, that communicates a list of potential criteria – mood swings, cycling, etc., but it does not tell me anything at all about your experience. I often hear therapists or counselors refer to people simply by a DSM category designation: “She’s an Axis II” (borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, etc.), or “He is a cluster B” (dramatic, emotional, or erratic) without any other description of the person as a human being.  Perhaps worse, I have heard people refer to themselves that way.

This diagnostic approach to understanding people has profound implications for treatment. Most broadly, it does not involve the therapist in really getting to know you. It interferes with understanding you as a whole person, ignoring the larger context of your life and experience. When someone focuses exclusively on diagnostic criteria – your ‘symptoms’ – you become nothing more than a pathological entity. You are not merely a bundle of symptoms. These diagnostic categories serve the pharmaceutical industry and the insurance industry, not you.

Therapists who take a humanistic approach, on the other hand, try to understand the patient’s reality, rather than trying to force the patient into their own reality. Humanistic therapy is more a process of discovery, in which the patient and therapist seek to understand the person as a whole, and to understand what works and what doesn’t work. No effort is made to necessarily fit you into the ‘norm,’ which can suppress radical and creative points of view; instead, the goal is for you to understand who you are, and to find your own way of being in the world that works well for you.

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Psychotherapy: Clinical Supervision and Training

therapist and patientClinical supervision is the primary training model for psychotherapists learning to be psychotherapists. Psychotherapists may be trained or supervised in the context of a particular theory, and trained to apply particular techniques based in that theory, but the best supervision is useful across techniques and will help a therapist gain competence regardless of his personal style or theoretical orientation. A clear exception occurs when the supervisor and therapist are invested in contradictory views of human nature and assumptions about the goals of psychotherapy: for example, if the supervisor sees the goal of psychotherapy as facilitating emotional integration and self-understanding, and the therapist sees the goal to be the control of behavior within the context of social norms.

Teaching new techniques may be helpful, but in fact the most difficult – and perhaps the most important– factors in successful psychotherapy are the subtleties around the relationship between a therapist and his patients. Therapy always takes place within the context of the relationship between patient and therapist, and the ways in which a therapist and patient experience each other are critical to understand. Issues of trust, empathy, and being direct are typically more important than theoretical orientation, or the application of techniques.

In any interaction between a therapist and patient, there are very powerful factors within both parties which affect the patient’s ability and motivation to change; these are broadly referred to as transference and countertransference.While they may be directly experienced and expressed, these factors are often unconscious and expressed inadvertently. Beyond this powerful dynamic, our assumptions and judgments always exist within a cultural context, so there will be blind spots around issues that are reflexively taken for granted by both therapist and patient.

A clinical supervisor’s primary task is to bring these factors into the therapist’s awareness. Issues for the therapist such as inadvertent guilt induction, reflexive negative judgments, people pleasing, modeling negative behavior, issues around personal boundaries, collusion with patients, and unconscious seduction can be present, and it is important to uncover and address these issues. To do this, the supervisor must be both a teacher and a kind of therapist to the therapist – not a therapist to the therapist regarding issues in general, but regarding the therapist’s mode of interaction with his patients. As in psychotherapy, supervision must be empathetic and non-judgmental as well as firm and direct. A supervisor’s interaction with the therapist provides a model for the therapist to interact with his patients. An effective supervisor will be an effective psychotherapist as well.

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Anxiety Plus Depression

anxious depressionPeople sometimes think that feeling anxious and feeling depressed are separate emotional states. While this is sometimes true, anxiety and depression often come together and can feel like components of an overall state. The idea that you seek psychotherapy for depression vs. psychotherapy for anxiety may be the result of using overly simplistic categories.

When describing depression, people often include emotions such as hopelessness, emptiness, and despair. Although depression may be described on a continuum from mild to severe, there are experiential themes that tend to exist across the spectrum. There is often a loss of interest in daily activities, and a loss of enthusiasm for things that brought pleasure or were fun in the past. There may be a pervasive feeling of sadness and/or a sense of emptiness, and the experience of the world as a whole is darker and gloomy. It can be hard to concentrate.

People who are depressed frequently have low energy levels and feel overwhelmed by performing day-to-day tasks and maintaining their personal relationships. Life may seem simply overwhelming and black, and there may be suicidal thoughts or behavior. Sleep is often disturbed: some depressed people feel like sleeping all the time, while others have trouble sleeping at all. Many people describe a day-night reversal, sleeping all day and being awake all night. There can be a constant sense of fatigue, at the same time one is unable to sleep. Depression is a dark and lonely struggle.

When describing anxiety, experiences of fear or panic come to the foreground, along with a general feeling in the body of agitation and restlessness. Even in normal social situations, this state leads to feeling anxious or threatened, and brings the anticipation of some misfortune. The experience of panic or anxiety may come in waves, without any obvious trigger in the moment. With panic or anxiety attacks, it’s common to get into an endless circle that builds on itself. There is something wrong, my heart is beating fast, and since my heart is beating fast there must really be something wrong, leading to your heart beating faster.  I am sweating and I feel flushed. I must be falling apart or going crazy. I’m hyperventilating and can’t even get my breath, Oh my god I’m dying! The anxiety escalates still more. Even without an anxious crisis like this, there may be a constant undertow of nagging worry or fear.

In fact, depression and anxiety frequently co-occur. In many cases, they may be seen as part of a single overall state of anxious depression or agitated depression. Though depression is often seen as a low energy state, this may not be true with agitated depression. A depressed person with low levels of energy may also experience considerable fear and agitation, or even terror. They may be having circular thoughts: I’m so depressed, I can’t function, I can’t sleep, I can’t take care of myself, I can barely move. I’m so paralyzed I will lose my job, lose my friends, have no money and wind up on the street. Without support from others or control of the things happening to me, my life will go downhill and I will wind up dead. These horrible thoughts alone are overwhelming, and the cycle starts again and can deepen.

There is considerable research documenting the relationship between depression and anxiety. For example, researchers found that anxiety began before or at the same time as depression in 37% of people, while depression began before or concurrently in 32% of people (Arch Gen Psychiatry 2007;64:651-660).  In other words, for approximately 1 in 3 people, anxiety and depression exist together and begin at the same time.

Treatment. Most forms of anxiety and depression improve with psychotherapy and counseling. In some cases, adding antidepressant medication therapy to psychotherapy is helpful in relieving the acute symptoms, while underlying problems that trigger or contribute to a person’s anxiety and depression are addressed in psychotherapy. (It’s notable that antidepressants are used for both anxiety therapy and depression therapy.) Antidepressant medication therapy is not always necessary; for some people whose ideas about or reactions to taking medication are negative, psychotherapy alone may be the best option. In cases where the symptoms are not life-threatening, a person’s feelings about the use of medication should be respected.

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Addiction to Drugs and Alcohol: Self-hatred, Cravings, and Therapy

If you have struggled with alcoholism or drug addiction, it’s likely that you have also struggled with feelings of self-loathing, self-contempt, and self-hatred. You probably found yourself doing things you wouldn’t normally do, and maybe even doing things you find abhorrent and believed you would never do. You may quickly go from looking at these behaviors to viewing yourself with moral condemnation. You might come to see yourself as worthless, bad, evil and unlovable. It all seems hopeless. With all your willpower, and all the self-hatred you feel for things you have done, you still can’t control your addiction. It seems the only way to make these unbearable feelings go away is to use again, but of course that only keeps the deadly cycle going. You want to stop but you feel you can’t stop. You feel trapped in your misery and self-hatred, with an increasing belief that things will never change.

These feelings of self-loathing are reinforced by society’s view of alcoholics and addicts, since people tend to see addiction as a personality flaw, a sign of weakness, or an example of immorality. People think nothing of going to an emergency room for a physical ailment, but if you (and others) think of addiction as sinful, and as your fault, of course the solution will be very different. Many people still believe that addicts need to be taught the “error of their ways” through punishment or religious indoctrination. This stigma can reinforce your negative view of yourself, and make it more difficult and frightening to ask for help or to get therapy.

The problem here has to do with how people conceive of drug and alcohol addiction.

Just what leads to addiction is a complex and highly-debated question. Some see addiction as a genetic or biochemical issue; others see it as a spiritual malady; some believe it is situational and reactive; and many see it as being due to historical psychological factors. In fact, addiction and alcoholism are multiply determined and include a number of interactive factors. The critical question in terms of helping people, at least early in their recovery, is not what caused it but what helps them change it. Once you take a substance into your body, it changes your biochemistry. At least from that point on, the addiction takes on a life of its own. One point of view is that the brain has been hijacked by the drug.

For most people, addiction involves feelings of overwhelming cravings, and a feeling of desperation that may be hard for you to comprehend if you are not addicted. The feelings can become so terrible that suicide can seem like an option, and it’s not uncommon for addicts either to actively or passively kill themselves. People often experience their craving as an intolerable state that will never end until they use, or die.

This experience can be so intense that addicts or alcoholics feel they can’t survive without using, while realizing that continuing to use can lead to death. This dilemma places much of their lives in the realm of survival, leading to an upended set of priorities that place the need for the substance above all other needs — more important than food or shelter, or connections to people they love. It is not that they become immoral, or now believe that doing bad things doesn’t matter; rather, the need for the drug or drink can supersede all other needs. This is why lying, cheating, and stealing often come with addiction. It is not that bad behaviors are not perceived as bad, but they become less important than stopping the intolerable feelings driven by the addiction.

Focusing on self-blame and self-condemnation doesn’t help; in fact, it can make matters worse and drive the addiction still more powerfully. This does not mean that you get a pass to indulge your addiction. You are still responsible for your actions, despite your addiction. However, it is important to understand why you behave the way you do – the addictive basis of your behavior – and not adopt a view of yourself as an inherently bad person beyond redemption, or without the ability to change.

Though part of the experience of addiction is a sense of despair and hopelessness, there are treatments that work. For people who feel lost and confused, it may be helpful to consult with a therapist who is familiar with the treatment of addiction. The best known and perhaps most effective group approaches are 12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and there are a number of studies which point to their efficacy. Still, different people benefit from different approaches, and there are a number of non 12-step treatments and therapy for addiction which have also been shown to be effective.

While this article primarily refers to substance addictions like drugs and alcohol, there are other things people may respond to with addictive-type behaviors including food, sex, emotional dependency, gambling, shopping, etc. Though these addictive-type behaviors are not based on an external substance (with the exception of food), they can shift one’s physiological state and produce the experience of a rush, the experience of cravings, and the experience of withdrawal. For some people the cravings involved are as potent as the cravings for drugs and alcohol, and can lead to similar compulsive behaviors. Just as with alcoholics and addicts there may be shame around seeking therapy. For more information on other addictive issues see the following links: CoDA, codependency, sex and love addiction, Al-Anon, ACOA, and the Caron Foundation.

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Finding the Best Therapist

the best therapyWhat kind of psychotherapy is the best, and why does psychotherapy work? If you are looking for a therapist, this may be a question you ask yourself, and it’s a question that academic researchers and insurance companies ask, too. Why does it work, and can we make it work faster and be less expensive? How does it work, and can we turn it into a workbook that you can fill out at home? What are the important factors associated with effective treatment, what therapeutic approach is best, what kind of professional is best?

Ultimately, of course, the answers to those questions are individual, and determined by factors that aren’t easily defined and measured. Although Cognitive Behavioral Therapy practitioners frequently claim that theirs is the most effective treatment, a number of studies (e.g., Consumer Reports, 1995; American Psychology, 1995; American Psychological Association Monitor, 2010) indicate that this is not true.

The Consumer Reports study was a large-scale, naturalistic survey of 4,100 people. The results of that study showed that

  • no specific type of psychotherapy is better than any other, for any disorder;
  • psychotherapy alone is equally as effective as medication plus psychotherapy;
  • long-term treatment is considerably better than short-term treatment;
  • psychologists, psychiatrists, and social workers are equally effective across the board, and all are better than marriage counselors and family physicians; and
  • patients whose length of therapy or choice of therapist is limited by insurance or managed care do worse than those who do not have to work with such managed-care restrictions.

A recent meta-analysis by Shedler revealed that psychodynamic psychotherapy, which focuses self-reflection and self-examination to get at the root of suffering, is at least as effective as symptom-oriented treatments like CBT or medication. In fact, the same study notes that psychodynamic psychotherapy was about three times more effective per treatment than the most popular antidepressant medication, and the benefits of psychodynamic psychotherapy persist and even grow larger over time. Another meta-analysis conducted in 2008 (“Person-Centered/Experiential Therapies Are Highly Effective,” Elliott & Freire) showed that relationship-focused therapies tend to produce large changes for patients, and that the gains are maintained over time.

It’s important to note that the quality of the relationship between patient and therapist was not captured in any of these research studies. Relationship is an elusive concept, and not easily defined or measured in any systematic, large-scale study. It includes how the therapist and patient feel about each other, and the various ways in which their personalities match. Psychotherapy is a two-person system, and over and above what gets talked about, and the psychotherapist’s theoretical orientation, the patient-therapist relationship may itself be the most potent therapeutic agent.

Despite the difficulties measuring such elusive factors as patient-therapist interaction, there has been some research which demonstrates the importance of the ‘fit’ or the ‘match’ between the psychotherapist and the patient in successful psychotherapy. For example, Pilkonis (1984) found that differences in outcomes are more often attributable to differences among therapists, and to interactive effects between specific patient characteristics and a specific way of doing therapy. In his book on psychotherapy (Contemporary Clinical Psychology, 2004) Plante states that “factors such as warmth, empathy, honesty, and interest on the part of the psychotherapist are important and even vital to treatment outcome.” Beutler’s (2006) review of the research indicates that at least when treating substance abuse, the match between treatment style and patient is important for both short- and long-term success. Beutler also found that treatment is enhanced when therapists develop a positive working alliance with their patients.

Overall, studies show that patients benefit substantially from psychotherapy. Further, the most important factor in successful therapy may be the ways in which a therapist and patient experience each other. This may be more important than theoretical orientation, or the specific techniques applied. The implication for choosing a therapist is that feelings of comfort and connection should be taken very seriously.

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Empathy is Not Enough

empathic therapyEmpathy can be seen as the matching of feelings or the matching of minds. It can reflect compassion, recognition and communion. It reflects an emotional understanding of another person’s feelings or problems. The ability to be empathetic can be a positive characteristic which brings people closer together.

In psychotherapy, empathy is critical. It allows the therapist to meet patients where they are, to enter their world and understand what it feels like to be them. Empathy is important in forming a bond and in starting a working alliance with a therapist. It leads to warmth, compassion, caring, and concern.

Patients need empathy. A therapist who has trouble being empathetic, whether for personal or theoretical reasons, is lacking something critical which will limit his work. When a therapist has an inability to make an emotional connection or feel empathetic, he or she will be overly detached, cold, and clinical. This provides little sense of safety, which is a prerequisite for any effective therapy to take place. A patient’s perceptions of the therapist as empathetic is necessary in helping the patient stay in treatment and feel comfortable enough to stick out the sometimes painful experiences that come up as therapy progresses.

Unfortunately, empathy alone may not be enough. While it can help a patient feel supported and understood, it does not necessarily promote change. Having a therapist with an empathetic stance may be necessary, but it is not always sufficient to help a person grow.

Take the example of someone who has had a difficult life for any number of reasons. These factors need to be recognized, appreciated, and understood. However, if in reacting to present-day problems the patient reflexively takes the stance that he is helpless, having little sense of his own role in his current distress and suffering, empathy alone may not be enough to help him change. If the therapist expresses nothing but warmth and empathy it may feel good to the patient but it can also support the problems rather than help resolve them.

Let’s say a recurring theme for the person is feeling the world is always unfair. He feels his girlfriend is always critical or his boss always blames him. Simply being empathetic may lead him to feel understood and validated, but that doesn’t necessarily lead to change. At times, it may be important to challenge patients’ view of themselves and point out ways in which they have a part in bringing about the problems that lead them to suffer. At times it is important for a therapist to stand firm, even when the patient protests. Having another person stay grounded, firm, and steady without becoming punitive may be a new experience for the person, and just what is needed in order to grow. It can also give a person the space to express suppressed angry feelings with the therapist who is grounded and steady.

Patients who have been seriously traumatized may need a long period of empathetic support to provide a corrective emotional experience. There are people who must experience what they never had in order to go on in life — for example, people who grew up in a very abusive or cold environment. Beyond this, everyone needs to feel a baseline of care and support, just not at the expense of sometimes being challenged to change.

The problem is that a compulsion on the part of a therapist to be exclusively empathetic can reflect issues with the therapist’s boundaries and reflect his or her need to be overly involved. If the therapist always has to rush in and attempt to save a person from any and all distress, it can block a person’s growth. A therapist with his own boundary issues may be too concerned with being approved or liked by his patient, and find it overly important to see himself as a caring person. This is clearly being overly enmeshed and will sometimes even recreate what led to a person’s problems, and present yet another bad model.

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Psychotherapy in NYC

maxresdefaultThere is at least a kernel of truth in every cliché, whether we like that or not. One such cliché is that New Yorkers are all in therapy – in fact, it’s such a common cliché that it’s the hallmark of many Woody Allen movies, and a great many New Yorker cartoons. We laugh, whether we’re laughing at ‘them,’ or laughing at ourselves as New Yorkers. Still, it’s worth asking whether it’s true, and if it is, why?

In fact, a disproportionate number of people living in New York City struggle with emotional problems, compared with other areas of the country. You may have heard about the big Gallup poll that was conducted in 2010, ranking New York City very near the bottom on emotional health – 132nd out of 162 cities. That study included measures of happiness, worry, anger, and stress. The same year, more than 100,000 calls were placed to LifeNet, the city’s crisis hotline; more than a quarter of the callers were considered to have mood problems, and 15% were struggling with substance abuse. According to the New York City Public Health Survey, 14% of those completing the survey were given referrals for the treatment of depression alone.

Additionally, a disproportionate number of people in New York City seek psychotherapy, which is easy to find here. There are 4,478 licensed psychologists practicing in New York City. That’s one psychologist for every 1,868 people. Manhattan has more than twice as many psychologists as the rest of the boroughs combined. In comparison, Los Angeles has 4,143 licensed psychologists, which is one for every 2,380 people.

Many HMOs report statistics on mental health referrals of patients in their networks; when you examine regional and national statistics, it’s clear that the percentage of subscribers in rural America and smaller cities who seek psychotherapy referrals is significantly smaller when compared to Manhattan, which appears to be the point of highest concentration for psychotherapy referrals.

The natural question, then, is why do so many people living in New York City see psychotherapists? A number of possible explanations for this include that life in the city simply is more stressful, the city attracts more people who have emotional problems, and another explanation could relate to stigma and culture. And of course it is easier to find a therapist in New York City simply because there are so many therapists around.

Life in such a large and complex city may make it harder to form basic interpersonal connections. Lower levels of connection are intimately associated with an increase in alienation, despair, depression, anxiety and addiction. Although there are many great things about living here, it can be a difficult place. There are more opportunities for social interactions and relationships to go bad, and it’s harder to simply ignore them. It may be much easier in the suburbs to simply avoid the people or situations that produce conflict.

New York City might attract people who are already struggling with emotional problems, and hence are more likely to seek psychotherapy. People who feel alienated, out of place, and different often gravitate to New York City because of its reputation for tolerance and acceptance of differences, and its wealth of opportunities. These people may come to New York City hoping and expecting to find others who are similar – which can happen, certainly, but even that can take time.

Finally, it may be easier to feel OK about going to therapy in major metropolitan areas.  Although some degree of stigma still exists in certain circles, it is also true that in other circles it is valued. Not only do more people seek therapy in New York City, but those who do can find it easier to talk about it here, where it is more common. In smaller cities and rural America, considerable stigma continues to exist in regard to therapy; even those who choose therapy may be more likely to keep that fact private.

Of course, some people choose therapy because they see it as a means to increased personal growth and creativity. They may consider psychotherapy a form of self-enhancement rather than just a place to address problems. For various reasons, it is easy to imagine that more artistic and intellectual people choose to undergo psychotherapy. While this may be another cliché, there is also some truth to it.

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Experiential Psychotherapy

We understand this, even if we have to stop and make ourselves think about it: everything we know begins with our perception of it. The color of a car parked in the shade; the firmness of a peach at the market; the smell of dinner cooking; the mood of the man walking across the street – all these things we know as a function of our perception of them. We trust our perceptual systems so much that they are a relatively invisible part of the process. Equally true, if less obvious, is that even a physician’s or psychologist’s ostensibly objective knowledge of our internal physiological states – including neuropsychological events – is filtered by their perception of them.

Whether we can know anything outside the world as we experience it is an interesting philosophical question, but it has profound implications when we try to understand another person. This is particularly true in the context of psychotherapy and trying to help another person heal.

Much of modern day psychiatry, psychology, and psychological research operates under the illusion that physiology is primary. In fact, our experience is always primary, and this includes our experience of our physiology.

Though depression may have some relationship to fluctuating serotonin levels in your brain, depression is not your fluctuating serotonin levels. Depression is part of your experience. It is a mood that overcomes you or a shift in the way you experience the world. You may feel you cannot keep up with the world’s demands. Nothing matters. Both the world and your future feel grey.

Or consider anxiety: You can’t concentrate. You’re worried. You feel like you can’t stand still. You may feel dizzy, faint, sweaty, you feel the world has become far away. It can appear as though you are looking through the wrong end of a telescope. Though anxiety may have some relationship to changes in anxiety-specific neurotransmitters, anxiety is not changed neurotransmitters. It is an experience.

In both examples – depression and anxiety – your experience of these circumstances or events is at issue.

Psychotherapists must always start off trying to meet their patients on an experiential level. Failing to do so leads to objectification and dehumanization of the other person. Whether or not various psychological techniques are used, or physiological interventions such as medication are administered, a therapist’s primary task begins in finding access to the patient’s emotional state. The work of a therapist must involve the experience of the patient in all its nuance and complexity.

For the therapist who works within an experiential framework, a large part of the work must involve finding access to the experiences of his patients in himself. While being a warm and caring therapist may be important, it is relatively hollow in contrast to the therapist actually having a sense of how it feels to be you, how it feels to be experiencing the world as you do. A therapist must be comfortable sitting with feelings, both yours and his own, if he is to be helpful. The need to objectify patients and rely primarily on a conceptual or theoretical understanding of their problems, or a categorical diagnosis, often serves as a defense and blocks truly knowing the patient’s suffering and struggles.

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Advertising Psychotherapy: Attraction Not Promotion

Advertising typically presents an attempt at getting people to think, feel, or behave in a very particular way. Focus groups, market research organizations, and consumer psychologists operate with an explicit goal of figuring out how to make products and services appealing, frequently invoking an emotional response. This may mean creating a need or desire where neither was present, or getting people to ignore their own needs and desires and buy a product. The popular TV series Mad Men dramatizes this industry, depicting ad executives’ easy willingness to find new ways of promoting and selling cigarettes, even after they were discovered to cause cancer.

For psychologists, most advertising used to be considered unethical, and it still presents a dilemma for a psychotherapist who wants to work and maintain a practice. People seeking a therapist may be particularly vulnerable because they need help—and sometimes desperately so. If a therapist uses certain forms of self-promotion to convince prospective patients to choose him over others, he can be taking a position at odds with the actual work he needs to be doing, some of which involves helping people learn to listen to and trust themselves.

What can a therapist claim in an advertisement? Any promise, or implication of a promise, to help or cure is misleading because it is impossible to make a prediction without first getting to know the person in question. Testimonials and success stories are similarly misleading, because by its nature psychotherapy is highly individualized. Proclamations of success cannot be generalized. Additionally, the very meaning of success differs from person to person, and within any given context. Beyond this, a therapist who solicits testimonials from his or her patients may be exercising undue influence because of their relationship.

Other issues commonly presented in advertisements relate to claims about different therapeutic approaches. Claims that one approach is better than another seem fine if they are clearly presented as opinion, or as based on personal observations. Describing an approach such as CBT as “evidence-based” seems to imply that it is proven to be a superior treatment, and that treatments that do not include the phrase “evidence-based” are therefore less effective.  However, there is evidence for the efficacy of many types of therapy; using the buzzword “evidence-based” may not really mean anything in terms of efficacy. Therapy is certainly not a one-size-fits-all endeavor, even within very broad categories like phobia or depression or anxiety.

Eye-catching advertising may say little about a therapist or his approach. Although it may sound full of possibility, offering ‘whatever the customer wants’ can be a problem as well. Therapists tend to become most skilled in an approach that is consistent with how they understand human nature. Offering a potpourri of approaches may seem appealing, but they may not be well thought-through by the therapist. Different approaches can be based on contradictory assumptions for explaining and addressing emotions and behavior, and it may be hard to offer multiple approaches while maintaining a grounded posture—which is very important for a patient to experience from his or her therapist.

Of course, a therapist must be visible if he is to work. It’s also important for prospective patients to have some sense of a potential therapist, and in this way advertising can be beneficial. A therapist’s description of how he works can be important and helpful, even if it just offers a starting point for the patient to see who clicks, and for getting a sense of the potential connection. The nature of the connection may be the most important factor in successful therapy, and this is impossible to know without meeting in person. Perhaps the most reasonable thing a therapist can do is to state clearly how he thinks about therapy, how he thinks about emotional problems, and what his training and experience have been. To the degree that advertising and marketing are about increasing visibility, it can be beneficial to a prospective patient. Making oneself visible as a psychotherapist is ideally a process of attraction and not promotion.

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Expect the Unexpected: Living with Alcoholics and Dysfunctional Families

The statistics may not surprise you: in the United States, an estimated 14 million people are addicted to alcohol; more than half of all grownups know someone in their immediate families with an alcohol problem; and approximately 6.6 million minors currently live with an alcoholic parent. For those kids, life can be horrendous or at least extremely difficult. Perhaps there is incest. Perhaps when the father is drunk, he becomes violent, and hits or rapes his child or his wife. Perhaps when the mother is drunk, she becomes extremely vicious and unpredictable, and the safest thing is just to hide. Sometimes there is a more seductive violation of boundaries against the child, who is helpless to resist. Or maybe it doesn’t seem so bad, because he just drinks until he falls asleep in his chair most nights; she just becomes very happy and doesn’t really notice that the kids are there.

Even if they are not the direct recipients of violence, many children growing up with alcoholics witness violence directed at others in the home – the other parent, their siblings, and often, their pets. This environment of violence and unpredictability is both frightening and confusing. The child may identify with the other victims, or feel angry at not being protected by them. If the victimized parent seems weak, the confusion deepens because it’s hard to feel angry at them.

Even if the damage is not as obvious as sexual and physical abuse, verbal abuse and the consequences of neglect – physical or emotional abandonment – can be devastating on their own.

Kids in these families learn a lot of lessons: don’t tell; don’t have friends over; don’t air the family’s dirty laundry; keep a close watch for signs of an explosion; try not to be noticed; be ready to fix everything. Expect the unexpected. Life is chaotic and unpredictable, and people are likely to become violent or vicious at a moment’s notice.

Of course, these consequences are not limited to alcoholic homes – parents with other addictions, rage-aholics, emotionally disturbed or psychotic parents, or families characterized by other types of interpersonal dysfunction – all of these can produce the same constellation of long-term consequences:

  • symptoms of trauma
  • PTSD
  • a need for control
  • personal substance abuse
  • keeping oneself surrounded by crisis and chaos
  • guessing at what normal is
  • having difficulty in following a project through from beginning to end
  • lying, when it would be just as easy to tell the truth
  • judging themselves without mercy
  • difficulty having fun
  • taking themselves very seriously
  • having difficulty with intimate relationships
  • overreacting to changes over which they have no control
  • constantly seeking approval and affirmation
  • feeling that they are different from other people
  • tending to be either super responsible or super irresponsible
  • being extremely loyal, even in the face of evidence that loyalty is undeserved
  • tending to lock themselves into a course of action without giving serious consideration to alternative behaviors or possible consequences. This impulsivity leads to confusion, self-loathing, and loss of control of their environment. As a result, they spend tremendous amounts of time cleaning up the mess.

Most people will spot one or two items on that list that are characteristic of themselves, but for people who grew up with alcoholics, the list may be a little frightening because it is so descriptive. Maybe you always wondered why you are so hard on yourself, or why your relationships are so difficult, and never connected those things with growing up in an alcoholic household.

It can take a long time and a lot of work to learn to trust the world, and other people. To listen to your own voice, or even to trust your own sanity. Deep wounds need to be cleaned and healed, but healing and recovery is certainly possible. Psychotherapy can provide a safe, structured, and understanding environment for exploring these issues and addressing the symptoms. Many people find comfort and help from ACOoA (Adult Children of Alcoholics) groups, Al-Anon (families with alcoholics) groups, CoDA (Codependents Anonymous) groups, or other self-help or recovery organizations. In any case, if you are feeling the crippling effects of growing up in a dysfunctional family, it is important to seek help and support.

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Psychotherapy and Spirituality

People who find spirituality important often find that it can be helpful in conjunction with psychotherapy. Spirituality is not the same as religion; it is often seen as an essentially value-free experience and understanding of the world. Some religious individuals do connect their spirituality with their religious beliefs, while others are not comfortable with organized religion even though they are spiritual individuals. For many people, the important point about spirituality is the experience of connection to the world as a whole, to nature, to the universe or cosmos, and to themselves.

stars spirituality psychotherapyAlthough the practice of science and mathematics is often understood to be at odds with religion and spirituality, this need not be true. As Albert Einstein said, “The scientist’s religious feeling takes the form of a rapturous amazement at the harmony of natural law,” and as the mathematician Hardy (1940) said, “The mathematician’s patterns, like the painter’s or the poet’s, must be beautiful; the ideas, like the colors or the words, must fit together in a harmonious way.”

In terms of psychology and psychotherapy, Freud held the position that spiritual feelings are a neurotic regression to an infantile state in which one feels taken care of by an omnipotent father, and blanketed by a sense of connection and belonging to a mother. Freud tended to place a negative value judgment on spiritual experience. On the other hand, Jung saw spirituality as anything but neurotic; instead, he saw it as a deep and inherently human feeling of connection and transcendence. He understood it to serve a positive function for growth and healing, and as a positive way in which people give meaning to their lives.

Psychotherapists often work with people who feel an inner void, a sense of being isolated, disconnected, alienated, empty, and alone. Though many individuals do not see spirituality as a viable tool for addressing their issues, a therapist would be remiss if he were not open to the idea that some people do experience spirituality as an important part of healing. People often do come to experience a deeper connection between mind, body and soul through the process of psychotherapy.

There are various spiritual methods which may be helpful in reaching the therapeutic goals of clarity, insight, openness, self-acceptance, and inner growth. Ideas from Buddhist psychology such as mindfulness and meditation can be useful. Meditation can stand as a counterpoint to blindly pushing emotions away or becoming over-reactive to them. The ability to sit with one’s emotions can lead to a position of clarity and calm, and lead to insight into oneself and the world. Some people feel prayer gives them a sense of connection to something greater than themselves. For some, the simple experience of solitude, often in a natural setting, helps give a sense of being part of a larger world and connection to it. For others, being involved in a group experience such as shared interest groups, 12-Step recovery programs, or religious groups, helps address the experience of isolation, disconnectedness, alienation, and loneliness.

It is imperative that a therapist never push his views and values on the person he is working with. At the same time, it is also important to avoid coming from a detached, overly analytical, purely “scientific” position that does not recognize the possible value of spiritual growth for people who find meaning in this way.

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Trauma and Dissociation

It is a common experience to “space out,” and no doubt everyone does this occasionally. We space out, zone out, tune out. These unclear, confused, foggy, or somewhat disconnected states can be seen as one end of the dissociation spectrum, and may only mildly interfere with our sense of ourselves, and of the world.  When this experience becomes more extreme and leads a person into psychological or physical danger, psychotherapy is indicated. Dissociation can be seen as a disconnection from oneself, or a discontinuity of the experience of self, and it falls on a continuum from mild to severe. It often develops as a method for dealing with psychological or physical pain, and it may function as an escape from things that might otherwise be uncomfortable, overwhelming, unbearable, or that may even feel annihilating.

People who have suffered serious trauma at any time in their lives frequently dissociate. As one moves farther away from feeling like a whole person, grounded in the present moment, the experience of dissociation becomes more extreme. At this end of the spectrum, one’s actual perception of the world becomes more distant and more unreal. Things may look far away. It may seem like looking though the wrong end of a telescope, like watching the world on television or through a plate of glass. People in a dissociated state may feel like they are floating above themselves, seeing their body as an inanimate object, or as another person. They may look in a mirror and not recognize who they are looking at; they may have no experience of pain. The whole world may look foreign or unrecognizable, or it may seem to be disappearing. In the extreme, people describe everything as going white or totally blank. For some who dissociate, blackouts can be common. This type of experience can range from being unclear about what’s been going on for a period of time, to having no idea whatsoever (“losing time”). People may find themselves somewhere and have no idea how they got there, or talk to someone and realize that they have no idea what they have been saying.

Dissociation is not just related to experience in the external world, it is also fundamentally a disconnection from oneself. In the extreme, dissociated individuals may function and experience themselves as two or more selves with unique memory sets, distinctively different body states, and even with different names for each. Because there may not be communication between these self states, people can come to doubt their own sense of reality and question their sanity. They may not be sure whether something they remember really happened, or if they just dreamed it.

Dissociation is frequently associated with post-traumatic stress disorder (PTSD). PTSD can result from surviving overwhelming and disorienting events such as war, sexual or physical abuse, or other forms of extreme victimization. People with PTSD experience flashbacks in which they experience an event from the past so vividly that they feel they are literally reliving that event. The terror and physical distress that was part of the original experience exist in the present moment, and the individual loses connection with his or her place in time. Not only is this profoundly disorienting, it can be dangerous if the individual responds to what seems to be happening. Dissociation born of trauma can represent the mind’s essential and impressive creativity: it serves to protect the traumatized individual from an experience that is too terrible to bear or experience. The individual “leaves,” and the experience is broken away from consciousness. These fragmented experiences may haunt the traumatized person, surfacing as strange half-remembered details, or nightmares, or inexplicable body states.

It is an important task of psychotherapy to help the traumatized individual integrate these disconnected aspects of self. Of course this is not an intellectual exercise; it may be easy to know the temporal facts from a purely rational perspective. It is the emotions that become confused in time and it is the emotions that need to be worked through and resolved. Quite understandably, addressing what once felt unbearable can be painful and daunting, and the work must not push too hard or the person is at risk of simply being retraumatized or finding themselves stuck, once again, in an overwhelming and intolerable place.

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Finding Meaning: Existential Psychotherapy

loneliness psychotherapyFor many people, the big questions are the most interesting: Why are we here? What meaning does my life have? What happens when I die? What is the purpose of my life, of any life? These are existential questions – questions pertaining to existence. They are the stuff of Philosophy 101 courses, they are the questions that might keep you awake at 2am, and they can be the questions you debate with friends and family.

For some people, these questions are not simply an intellectual exercise. Some answers to the questions (such as “life has no meaning“) can produce very deep despair, and depression. Sometimes the absence of an answer produces similar despair or depression. In these instances, therapeutic approaches such as cognitive behavioral therapy (CBT) will be of little or no comfort; the problem isn’t faulty thinking! The reality is that these questions don’t have answers; there is no back-of-the-book to look them up. You may not be able to know for certain what happens when you die, but you can wonder what the various answers might mean for living your life. These questions about meaning may be lifelong concerns, and your conclusions might change in any number of ways.

Existential despair, dread, anxiety, and depression can benefit from deep work with a therapist who takes an existential approach. Martin Buber, often identified as an existential philosopher, made two distinctions in ways of relating to other people: I-Thou, and I-It. The I-It relationship is characterized by one person interacting with an objectified other; some therapists may take this approach, if their interaction with their patient has the form of healthy person treating sick person. On the other hand, an I-Thou approach occurs when the therapist accepts the patient and acknowledges his or her portrayal as valid, stressing the mutual, holistic existence of two beings. Existential psychotherapists meet their patients where they are, and work through the very real struggles that stem from these mighty questions.

In contrast to the existential approach, and although professing to be nonjudgmental, the psychiatric and psychological establishments tend to be embedded in a proscribed vision of normalcy and socialization. One of the most obvious ways this is true is in the use of diagnostic nomenclature – but even setting that aside, there is a more subtle idea, in the view of many mental health professionals, about how people should or shouldn’t be, or what must be going on inside them. Unfortunately, these conceptions are not necessarily in keeping with what is accurate or best for a person, or what may help them develop a positive sense of themselves and their world. (These ideas tend to be culture-bound and/or have a basis in political or economic expedience. The most blatant examples of this may be seen in political regimes that hospitalize and label as mentally ill people expressing ideas which are contrary to the interests of the powers that be.)

This proscribed vision of normalcy interferes with creativity, deep personal growth, and points of view which might bring important and critical changes to the way the larger world functions. Although a therapist may have reasonable ideas of what turns out to be useful or positive for a patient, the final analysis must still be placed in the context of that individual’s experience. Further, the existential therapist must be able to understand and empathize with the patient’s experience of these difficult existential issues.

Ultimately, the existential approach to people and to treatment of their emotional struggles and discomfort is based on helping people find meaning in their lives, and avoids trying to apply external objective criteria and schemas. Victor Frankl, considered to be one of the early existential therapists, believed the striving to find a meaning in one’s life is the primary, most powerful motivating and driving force in humans. His approach was developed during and after his imprisonment in a Nazi concentration camp.

In fact, the struggle for all of us is to put our lives and life histories in a meaningful context. This may be primarily an unconscious emotional endeavor for some, but for others it may also be important to find an articulable structure or credo. Without a meaningful way of making sense of things, we are almost by definition left with a deep sense of emptiness and a feeling of an inner void. From there we are often left with nothing to do but despair and feel hopeless.

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The Anxiety Spiral

therapy anxiety spiralThere’s a reason people use a spiraling image to signify anxiety. The image is instantly recognizable, and even a little anxiety-provoking! Anxiety often operates as a kind of spiral of repetitive thoughts, turning on themselves. You start with a bit of anxiety about something, and your anxiety spreads and grows, and then you become extremely anxious about being so anxious. If you experience social anxiety, you may begin with an anxious thought that people are focused on you which leads you to become extremely focused on yourself, which produces still greater anxiety.

The experience of anxiety falls along a spectrum, or continuum. You may have a bit of difficulty concentrating; perhaps you’re restless; you may be worried and have repetitive thoughts; and/or you may feel an unpleasant self-consciousness. On the extreme end, you may have panic attacks, a feeling of impending doom, you may fear that you’re losing control or dying or ‘going crazy’; you may be dizzy and lightheaded, faint, sweaty, you may have difficulty breathing, you may have chest pain or heart palpitations. You may even experience depersonalization – the feeling that you have changed, and the world has become far away. It may seem like you are looking through the wrong end of a telescope.

Too much anxiety (and interestingly, too little anxiety) has a negative effect on performance, and researchers have discovered an inverted-U curve of anxiety. Without some anxiety, you can be sluggish and unmotivated, but with too much anxiety you have difficulty focusing and feel disorganized.  Performance goes down on both ends of the curve. The optimal level is in between, when you are energized enough to function yet not so agitated you can’t concentrate or get things done.

Anxiety is not just an emotion; it has obvious physiological components – sweatiness, dizziness, flushing, and difficulty breathing, for example. Anxiety is sometimes treated with beta blockers, which can reduce some of these symptoms by blocking the chemicals that cause them. Speakers, actors, and musicians who experience performance anxiety often experience some relief from beta blockers because they can reduce the extreme symptoms to a manageable level.

There are cognitive components of anxiety, too; if you’ve experienced anxiety, you probably understand the tyranny of repetitive thoughts, the kind of groove your mind falls into, where no matter how hard you try to think of other things that are less anxiety-provoking, or no matter how hard you try to stop focusing on the anxiety, you just can’t. You’re stuck, going around and around and around. Anxiety fear anxiety fear anxiety dread, stuck.

People attach anxiety to all kinds of things. Perhaps you experience anxiety when your mother is coming to your home. Perhaps you experience anxiety when it’s time to pay the bills and you may not have enough money. Perhaps work is anxiety-provoking.  Perhaps you feel anxious about driving in a car or getting in a plane. These are relatively concrete “causes,” issues that may be addressed by avoiding what triggers your anxiety. This is not to say that it’s a simple story: fix problem, eliminate anxiety; rather, the point is that anxiety often has an immediate referent.

Anxiety can also be existential; Kierkegaard talked about ontological anxiety related to questions about life itself. “Where am I going with my life?” “Is death the end of everything?” “Does my life have any meaning?” These are existential questions, and they may quite readily provoke deep anxiety. The issues may need to be addressed differently than those with a concrete ’cause,’ the consequences feel enormous and vast, and the questions are possibly unanswerable.

Anxious thoughts  and obsessions might also provide an illusory attempt at control. You may have been very worried about something in your life, and even though you know that worrying can’t help, hanging on to that worry gives you the feeling of doing something. Anxiety might also serve as a distraction from something underneath the issue you’re focusing on. Anxiety about going on a date may be a mask over your deep fear of being lonely for your whole life or your fear of extreme helplessness. Anxiety may be distracting you from a seemingly unbearable hurt, or fear, or anger. As unpleasant as the anxiety is, it’s more bearable than facing those deeper concerns which are rooted inside. Of course, you may not be consciously aware of those painful depths.

Real therapeutic work may involve working through the feelings which are under the experience of anxiety rather than working through the thoughts alone. Cognitive behavior therapy (CBT) may walk you through a process of identifying extreme thoughts, etc., but it doesn’t address the deeper issues which cannot be resolved with such concrete steps. For deeper resolution and integration to occur, one needs to confront, experience, and work through the issues underneath the anxiety. It’s important to note that anxiety and depression frequently occur together and they must be addressed together to resolve them both. Anxiety therapy and depression therapy are not separate endeavors.

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Depression: Struggling in the Dark

Although people may use the word lightly in their everyday speech – “I’m so depressed, there were no peaches at the market today” – there is nothing light about being depressed. The words people use to describe this bleak emotional state frequently invoke heaviness, weight, and darkness. In the extreme, depression may cause such profound suffering that suicide seems to provide the only relief.

Depression occurs along a continuum. At a minimum, it is characterized by an inability to experience pleasure; lethargy, sadness, lack of motivation; feeling unengaged in life, disconnected, and uninterested in being involved with others. A depressed person may grapple with a general sense of meaninglessness, and perhaps despair. This emotional state may be mild, and even occasional. At the other extreme, the experience of depression can be deep and pervasive. Your body feels heavy, getting from one moment to the next feels burdened. Colors may not appear bright or distinct, and in severe cases, colors may not even be noticed. The world feels and looks gray. The future is not bright, but only contains more of the same unremittingly sad experience. Deep depression is a profoundly lonely state; nothing brings pleasure, the experiences that once may have produced pleasure are bled dry and now only remind you that nothing helps, that nothing matters. You watch other people living, and you feel even more isolated. You may trudge through your daily routine, managing to fulfill your obligations, or you may not be able to get out of bed. You may sleep all the time, or you may be unable to sleep. You may eat and eat and eat, or you may be unable to eat. The world simultaneously feels like too much, and not nearly enough. Some despair over the emptiness and meaningless of everything—life, experience, themselves, the world—and others no longer even have the ability to think about whether there is any meaning.

Depression can be a chronic state, beginning at a young age and lasting across the course of a lifetime. People sometimes say, when their depression is finally addressed, that they must always have been depressed, because they do not recall ever feeling relief. Some people live with mild depression for years, in a state just painful enough to affect their experience of life but not so painful that they withdraw from living. Others may develop depression and experience an ongoing increase in suffering leading to deep despair and thoughts of suicide. However pervasive depression may be for an individual, having people tell them to “snap out of it” or “just go out and do something fun” can indicate a lack of understanding, and often reflects the sense of helplessness and discomfort of the one offering the advice.

The bleak landscape of depression has been part of the human condition for centuries. The ancient Greeks believed that depression (which they called melancholia, or ‘black bile’) was due to an imbalance of one of the basic bodily fluids. By the 18th century, depression was believed to be caused by electrical and circulatory imbalances in one’s body. Some believed it was due to soul sickness. Psychologists in the 20th century developed theories relating it to deep mourning, to a kind of neurosis, and to existential emptiness. By the mid-20th century, theories of depression returned to the beginning, in a way, ascribing depression to an imbalance in bodily fluids/chemicals: this time, neurotransmitters. Today, some psychologists think depression is due to habits of thought.

Beliefs about the causes of depression are important, because they inform the way we think about helping people who suffer with depression. If the cause is seen as a chemical imbalance, the treatment is rebalancing those chemicals. If the cause is seen as unresolved mourning, the treatment must address those feelings of grief and loss.  If the cause is seen as a sense of meaningless and emptiness, then addressing the way the person makes meaning of his or her life is essential. Chemical causes need chemical treatment. Faulty habits of thought are relieved by training new ways of thinking.  A sense of isolation is addressed by feeling a connection.

A recent study that compared the usefulness and long-term effects of psychodynamic psychotherapy (which focuses on self-reflection and self-examination to get at the root of suffering), antidepressant medication, and Cognitive Behavioral Therapy for depression found that psychotherapy is as effective as CBT but considerably more long-lasting, and that psychotherapy is about three times as effective as medication in producing relief from depression.

From my perspective, one must always start from an understanding of the depressed person’s experience. Beginning the process by training you to think differently does not typically address the underlying issues that bring you to needing help. Beginning the process by prescribing an antidepressant medication may be useful for some and produce relief of your symptoms, and may help you enough to reemerge from the bleakest places, but medication alone is unlikely to address the factors that led you to such a state of suffering. Issues of loss, and pain, and meaning, cannot usually be resolved so simply. Finding a meaningful way of understanding your experiences may provide comfort even if the “causes” are ongoing, and therapy can help you understand your personal history and yourself, so you can develop your own sense of meaning within the context of your life.

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Codependency: Being Dependent on Others’ Dependency

codependency and therapyYou take care of others, you help, you go out of your way for them….but when do you cross the line from being a compassionate friend or partner or family member to being “codependent”? There may not be a simple test, or a clear marker, but if you consistently put someone else’s needs first, to the detriment of your own, you may be codependent with your friend or partner etc. This pattern may be an example of enabling—your behavior helps maintain someone else’s destructive or dependent behavior. A simple example of enabling might be your calling in sick for your husband, when he is too hungover to go to work.

Codependency may be a justification for allowing yourself to be mistreated based on your low self-esteem, your sense that you don’t deserve better. On one end of the continuum, codependency might mean remaining in a relationship that doesn’t support you or your personal growth, while on the extreme end, codependency might mean being unable to leave a relationship, even when you are being abused emotionally and/or physically.

Codependency really involves behaviors that go above and beyond normal care-taking behaviors, or the everyday kind of self-sacrificing that happens within relationships. Some examples that are common in people who struggle with codependency include:

  • Denial patterns, such as having difficulty identifying your feelings, or minimizing how you really feel;
  • Low self-esteem patterns, such as judging yourself harshly and believing you are never good enough, or feeling unable to ask others for help;
  • Compliance patterns, such as compromising your own values and integrity to avoid rejection, or staying in harmful situations for too long; and
  • Control patterns, which include believing that others are incapable of taking care of themselves, or needing to be needed in order to have a relationship with others.

For a more thorough exploration of these patterns, which include a wide range of behaviors not listed here, you might wish to read this webpage.

It is important to note that there are criticisms of the label “codependent.” For example, caring for an individual with an addiction is not necessarily synonymous with pathology. To name the caregiver as a codependent responsible for the endurance of their partner’s negative behaviors can pathologize caring behavior. You may only require assertiveness skills and the ability to place responsibility for negative behaviors on the other person. Also, when this idea is pathologized, the codependent person may swing from an extreme of excessive sacrifice to an extreme of excessive assertiveness or selfishness and an aversion to empathy, which is a positive human capacity. A healthy approach would be to develop a sense of balanced and healthy assertiveness, which still leaves room for caring and helping.

Tendencies and behaviors that can be identified as codependent frequently emerge from a childhood in a dysfunctional family; perhaps one or both parents were alcoholic or had some other profound problems, so these patterns have deep roots. For this reason, codependency may show up in a wide range of your relationships including work relationships and friendships. Some people find 12-step recovery groups such as Al-Anon/Alateen or Codependents Anonymous helpful, although some people do not. Therapy can be a useful tool to help you understand the complexities associated with these patterns, and to help you balance your own needs against those of others.

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Therapy and the 12 steps

People with addiction issues might hear this from a therapist: “Twelve-step programs are a good start, but only therapy will help you understand yourself and address deeper issues.” And they might hear this in the rooms: “Everything you need, you get by working the steps.”

12-steps therapyOf course, the truth is much more complex than either simple statement. For people who struggle with addiction-related issues, the integration of psychotherapy and the 12 steps is often the best approach; many of the elements of good therapy, and of 12-step programs, are similar or complementary. Undertaking the work of recovery can bring up a host of old patterns, ways of being in the world, and relationship dynamics that benefit from the more individualized and exploratory work of therapy; if your therapist understands the principles of 12-step programs, he or she can better understand your struggles and be supportive around an important part of your life. In this article, I will illustrate some ways in which therapy and 12-step programs are similar, and other ways in which the two approaches are complementary.


The first step – admitting that you are powerless over your addiction and that your life has become unmanageable – is also the critical beginning for therapy. You acknowledge that you have a problem and step outside of yourself to fully comprehend the destructive nature of the compulsions that undermine your life, conflict with your interests, and interfere with your ability to mature and to grow.

Step 2 (coming to believe that a Power greater than yourself can restore you to sanity) has a kind of analog in therapy. For change to occur in therapy, you come to trust your therapist and have faith that he or she can help you. You open up and believe that your therapist can be compassionate and caring, and that he has your best interests in mind.

Steps 4 and 5 are also similar to therapy in that they address self-exploration, self-disclosure, and confession. Step 4 involves making a searching and fearless moral inventory of yourself, and step 5 is admitting to God, yourself, and another person the exact nature of your wrongs. In a 12-step program, it is often your sponsor who listens to your inventory or your expression of secrets that you have hidden and feel shame about. Trust is an essential and necessary element in both relationships.

It is important to note that if you have experienced serious trauma, and early victimization, therapy with a professional is often the best place to talk about these experiences. Although doing a 12-step inventory focuses on your part in contributing to negative situations in your life, it can be destructive to look for “your part” in situations where you have in fact been victimized, and had no responsibility.

Working together

In other ways, therapy and the 12 steps are complementary. Your recovery community provides a sense of belonging in a group and of feeling accepted – fellowship, in program terms. Overcoming addiction requires that you develop a sober social network as an alternative to the people, places and things that trigger the addictive behaviors you are working so hard to set aside.

The 11th step encourages you to continue to take action and maintain a spiritual connection, to seek knowledge of what is good for you, and the power to carry that out. Therapy can support this effort. Therapy is also augmented by the 12th step, which exhorts addicts to carry the message to other addicts, and to practice these principles in all your affairs – to give back. Therapy does not offer a sense of community, and may have less focus on taking action; therapy will encourage you to understand yourself and integrate your insights throughout your own life. In this way, combining therapy with a recovery community provides you with a powerful and holistic approach to dealing with addiction issues.

Belonging to a group may be something you never experienced before in a positive way.  Perhaps you were not supported by your family of origin, which is your first group experience. Twelve-step groups are cohesive, yet there is no leader, no authority figure telling you what to do; instead, other members offer suggestions, allowing you to take what you can use and leave the rest. By their nature, 12-step programs provide an accepting group experience. Being part of a non-judgmental group can have a number of positive effects for you. First of all, you are not judged, but importantly, you also learn how to react with compassion to others.

Twelve-step programs and psychotherapy are not mutually exclusive. Rather, they can reinforce each other and provide help for you as a whole person. While there is some overlap, and there are some differences between the two, the differences are not in conflict. In fact, they can provide synergy to promote your overall welfare spiritually, emotionally, socially, and physically.

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Trauma and Memory

trauma memory therapyMemory is a delicate thing. You might pass a woman on the sidewalk and her perfume brings a flood of memories of your mother. You might see an object and experience a full and complete recall of a memory, and say “I had completely forgotten about that!”As a Chinese proverb states, the palest ink is better than the best memory.

For people who have experienced a trauma, this issue of memory—and trusting memory—is particularly difficult, and carries an incredible weight and importance. When a traumatic event happens, the experience can be dissociated. In psychology and psychiatry, dissociation refers to a perceived detachment of the mind from the emotional state, or even from the body. Dissociation is characterized by a sense of the world as a dreamlike or unreal place and may be accompanied by poor memory of the specific events. The traumatized individual literally dis-associates himself or herself from the traumatizing event as it occurs, in an extraordinary feat of taking care of him- or herself.

When traumas occur repeatedly, as in chronic physical or sexual abuse, the experiences may be gathered together in the child’s mind and present a single memory that stands in for all the experiences. The recalled memory may not be “true” in terms of representing the very specific event it recalls, but it is true in terms of representing the full range of horrific experiences, many of which might not be recalled in their specificity.

Owning these memories is very difficult, and painful. When the events were happening in the past, people may have told you that they were not happening. If you told someone what was happening, they may not have believed you – perhaps because they could not tolerate knowing this truth themselves, or perhaps because they had their own reason to discount your story. Because the very nature of dissociation makes the memories feel unreal to you, it may be easy for you to doubt yourself, and wonder if you made them up. And finally, the memories may feel unreal because you cannot bear to acknowledge that they are real. You may even doubt your sanity at times.

therapyTherapy is sometimes described as peeling the onion. Early work removes the outer layers – you uncover what you can, you work with what is bearable, and then there is another layer. Another therapist I know describes therapy like a slinky spread out on the table; you go around the coil, and even though you find yourself back at the same place on the coil, you are farther along. Working with dissociated memories takes compassion, patience, and courage. The goal seems terrible – you know what happened to you and you believe it – but integrating the memories can relieve them of their ghostly, haunting nature, and heal the fractures.

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CBT and the Zeitgeist

Psychologists talk about the “zeitgeist” – a German word that means the spirit of the times. In the early part of the 20th century, the zeitgeist in psychology was inarguably Freudian; the ways people thought about human behavior, human motivation, the psyche, were all greatly influenced by Freud’s theories. B.F. Skinner’s behavioral theories were profoundly influential in the middle of the 20th century, and the cognitive revolution in psychology swept the field in the 1960s and beyond. Although many of these theories and perspectives were the work of experimental research psychologists, they were clearly influential among clinical psychologists as well. These days, clinical training for psychologists is often weighted toward Cognitive-Behavioral Therapy (CBT), which is a popular therapeutic approach to treating anxiety disorders, depression, and a wide range of issues that bring people to therapy.

What is CBT? CBT is an umbrella term encompassing a wide range of approaches, including Rational Emotive Behavior Therapy, Cognitive Therapy, Rational Behavior Therapy, Rational Living Therapy, Schema Focused Therapy, and Dialectical Behavior Therapy. According to the National Association of Cognitive Behavioral Therapists, these techniques share the following characteristics:

  • they are based on the idea that our THOUGHTS cause our feelings and behaviors;
  • they are brief in number — the average number of sessions is 16;
  • the relationship with the therapist is not the focus;
  • CBT is seen as a collaboration between the therapist and client;
  • CBT relies on a Socratic method, and is very structured and directive; and
  • homework is an important part of CBT.

It is easy to understand why this approach might be appealing to people seeking therapy. The idea that you might only need to see someone 16 times and your problems are fixed is undeniably appealing! However, it’s important to look more closely at these approaches, and evaluate them carefully.

APA Monitor, March 2010

APA Monitor, March 2010

In the March 2010 edition of the APA Monitor, the monthly professional magazine of the American Psychological Association, Dr. Jonathan Shedler reported the results of an important meta-analysis. Meta-analysis is a statistical technique that allows researchers to combine the results of a large number of studies in order to understand the degree to which an effect is important. Individual studies can be informative, but meta-analyses tell researchers just how large or important an effect is, regardless of how it was measured or reported in any individual article. Shedler wrote:

Psychodynamic psychotherapy, which focuses self-reflection and self-examination to get at the root of suffering, is at least as effective as symptom-oriented treatments like cognitive behavioral therapy or psychoactive medication, according to a January review of meta-analyses by Jonathan Shedler, PhD, a psychologist at the University of Colorado Denver School of Medicine (American Psychologist, Vol. 65, No. 2). According to one major meta-analysis, Shedler says, psychodynamic psychotherapy was about three times more effective per treatment than the most popular antidepressant medication. The benefits of psychodynamic psychotherapy seem to persist and even grow larger over time, he says.

Of course, other psychologists have reported similar criticisms of CBT; this wikipedia page offers a starting point if you want to investigate further. In my view, lasting change of an important type cannot come from such goal-directed, externally-driven exercises. CBT relies on a logical and linear system, and in my experience, people in fact act globally, and their actions represent the final common pathway that grows out of a combination of their drives, desires, needs, and  unconscious and conscious processes. True change arises from an appreciation of complexity. Lasting change involves integration of different aspects of your personality, of understanding why you do things, of unfolding and deepening your understanding of yourself. Effective work with a good therapist involves facilitating change, not directing it.

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Psychologists, Psychiatrists, and Social Workers

therapyWhat are the differences between psychologists, psychiatrists, and social workers? If you are considering psychotherapy, you may be wondering about this question. Although all three may do psychotherapy, their training is quite different, and this may have important implications for their approaches to working with you.

Psychologists: Licensed clinical psychologists must have either a PhD or a PsyD in clinical psychology, and have state licensing. Their formal education generally involves 4-7 years of training after a bachelor’s degree, including course work and practicums which focus almost exclusively on the theory and practices of psychotherapy, psychological assessment, and diagnosis. It also includes a one-year psychology internship (often at a hospital or clinic), along with writing a dissertation in a specific area of psychology. The PhD includes a greater focus on research than the PsyD, so psychologists with a PhD may be better trained to question assumptions and may be less likely to take things at face value. Both the PsyD and the PhD are doctorate level degrees.

Clinical psychologists consider concepts such as the unconscious, symbolic interpretation, thought, feelings, and behavior, and will use these concepts in conjunction with psychotherapy to address their patients’ issues and emotional suffering. In general, psychologists tend to focus on the inner world of their patients – their thoughts and feelings — although some may focus more on the link between thoughts and behavior.

Psychiatrists: Psychiatrists complete 4 years of medical school after the bachelor’s degree, and receive their MD. Medical school training is focused exclusively on basic skills in medicine. To become certified as a psychiatrist, a medical doctor must then complete a psychiatric residency, which is like an internship with practicum courses, after which they can be board certified to practice psychiatry. In general, psychiatrists prescribe medications, make diagnoses, and perform procedures such as electroconvulsive therapy (ECT), and some may also do psychotherapy. Many psychiatrists function as psychopharmacologists, with a primary focus on treating mental and emotional suffering with psychoactive medication. Unlike a psychologist, a psychiatrist is licensed to write prescriptions for medication, conduct physical examinations, and order and interpret laboratory tests. Since a psychiatrist’s basic training is in medicine and the treatment of illness or pathology, psychiatrists are more likely to depend on the medical model when helping patients with emotional difficulties.

Social Workers: Social workers are trained to address issues of social welfare and social change, and typically have a master’s degree in social work (MSW), which involves 2 years of graduate school after receiving a bachelor’s degree. Clinical social workers have further experience with direct practice with individuals, families, and groups. To be a Licensed Clinical Social Worker (LCSW), they are required to complete approximately 3 years of supervised work experience related to diagnosis, psychotherapy and assessment-based treatment planning and gain state certification. An LCSW can pursue further training focused on the theory and practice of psychotherapy and receive LMSW (Master Social Worker) and LMSW-AP (Advanced Practitioners) degrees. Social workers who hold these advanced degrees for the practice of psychotherapy generally have an orientation more like psychologists than psychiatrists.

As a psychologist, I believe the general approach taken by many psychologists to understanding and treating their patients often provides the greatest opportunity for insight, change, and growth. Ultimately, of course, it is the relationship that develops between a psychotherapist and patient that correlates best with a successful outcome, whatever the training or orientation of the psychotherapist.

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