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Friday, August 21, 2015

Headspace and Mindfulness Revisited

The other day FD sighed, "You never blog about me anymore."

Mindful fishing

So I asked him (for a good offense is always the best defense), "Why do you bother wasting time fishing? You bring home nothing and the salmon at the store are bigger and better, and no worms are wasted."

I don't mention that the recent pic of a three-inch blue gill made me sad.

"It is relaxing," he says. "and allows me to spend some quality time with my grandsons and clear out my head."

So I wonder,
Might everything that holds our attention, that helps take our minds away from the stress and anxiety of every day life, be considered a mindfulness technique
I've heard people who downloaded the phone ap Headspace say that even five minutes a day, the minimum recommended dose of mindfulness meditation, is too hard to fit into their daily schedule. The process of mindful meditating is very easy if its essence is attending to one's breathing, becoming attentive to the five senses, and "watchful" of thoughts. Yet it feels like it should require some kind of warm up, maybe yoga clothes or something. A mat.

Not having gone farther than open Headspace, which calls for an email address immediately to continue, it might be presumptuous to recommend it. But my thinking is why not try it, at least until you have to plunk down the monthly fee, soon after the first ten days, pretty sure. I recommend it to those who like aps and have memory leftover on their phones, because a mindfulness ap has great potential as cognitive behavioral therapy. Of course you can  do it without a mat; almost anything can be thought of as mindful meditation with the right intent: walking, running, babysitting (maybe not when the baby is awake), shopping, gardening, whistling, even driving, although maybe driving isn't the best idea, unless you are being mindful of traffic. This is all about leaving judgments behind, losing the good/bad, sick/healthy, beautiful/ugly ways we look at almost everything.

Lose the labels, lose language if at all possible, and just live and experience life. No, that is not easy, but it has to be healing. That said, it probably won't make you rich, like they say on the radio in the Headspace interviews.

We can look at other behavioral applications that work, too, that also enable us to experience the moment to the fullest, do a comparative analysis. (They likely won't make you rich, either). Fishing, for example, is  a mindful sport. Because FD is relaxed merely reeling in a tangled bunch of string hanging from a pole, he can handle his thoughts, judge them less, because they don't upset him so much. He'll judge himself less, too.

There are other ways to get to this benign place. Once my nephew bought me a ticket to a new and trendy sensory experience, a pool, probably the size of a mikvah, encased in a soundproof, totally darkened room, designed to recall the womb, bring a soul back in time. He didn't know that I'm afraid of the dark, so he wasted $25.00, but I can see why he would think me a good candidate. Anything for nothingness. I think I still have the coupon somewhere.

So fishing works like that, and so does a sensory deprivation pool, probably, as does tennis and other sports, too!  How can anyone think about problems or anything else, when there is even a remote possibility of returning a ball well, perhaps even finding the racquet's sweet spot. It is all any tennis amateur cares about, really. Golfing is the same way, focus to connect well. (If only our focus to connect with people compared). And what is smacking a baseball, getting a hit or a home run, if not concentration upon the present, the speed of the ball, the arc of the pitch. Maybe all sports are mindfulness techniques, and maybe they are all recommended in the Headspace ap.

Therapists have always liked CBT because you don't need to change clothes, certainly, to work it. To counter a negative thought with rational thinking, for example, one might be in tuxedo. It is the same with mindfulness, which is probably best in comfortable clothes even in nothing at all, assuming we can lose our judgements, reservations. Who doesn't focus on the pounding of water on skin while in the shower?  Or the smell of soap, the steam? We can counter a negative thought in the shower, too, think how irrational it is to think we aren't as good as other people.

So why not put mindfulness into the CBT bucket, or shower, and put the CBT into mindfulness, even suggest the two can be one, if performed well, like most twos.

Wait, before we combine them (consider that done) a few more thoughts about meditation:

Mindfulness is marvelously adaptable, a flexible approach to feeling good, and it probably lowers blood pressure, but not cholesterol, because feeling good, a person who likes to eat is likely to just go for it, abandon a diet.

Also, we probably should mention at least one other meditative school, the Maharishi's meditation of the sixties, repeating a mantra, or even dharma, returning everything into white, as the Carly Simon song goes, to experiencing everything that is both inside and outside our selves. These are less flexible, compared to standing on the train on your way home from work and becoming mindful of your weight on your feet, or how fascinating it is that the brain does this job, balances you, not without help from a germy pole held tightly in your fist so you don't fall, a mindfulness exercise. Actually, the Maharishi wasn't a fool.

Long-time readers recall my reservations about mindfulness not so long ago. Someone suffering from severe anxiety had panic attacks at a mindfulness workshop. He asked me to give it the nod. Should he try it? Sure, go to the workshop. What have you got to lose? He suffered panic attacks at the first meeting and the instructor blamed him for doing it wrong.

Rethinking it now, of course anxious and depressed people (and who isn't) might likely to be even more anxious or sad in a group workshop, so many eyes in the room, so much new information to digest, instruction to execute. So we talk about that and much, much more at length in therapy, before shooing anyone off to a retreat, and suggest people are mindful of mindfulness training. Think of it as a weekend at a mental gym. Really want that?

But now, at least once a week, finding myself at that inevitable therapeutic impasse, because therapy is full of these, I'll bring up behaviors that define mindfulness as alternatives to whatever is holding us up, either negative thinking, ego-dystonic behavior, or emotional pain. These are the ABCs of CBT, cognitive behavioral therapy, fyi, affect, behavior and thought.

Because Aaron and Judith Beck got here first.

But they didn't say it quite this way.

A quick look at the basics (according to TherapyDoc who has read many books on the subject, if not opened the ap):

(1) attend to things inside, turn your attention to the rumbling of the stomach or heartburn, the feel of your socks on your feet (take 'em off if no one is around), whether or not you are hot or cold, how your breath feels inside your nose, the tiredness of your eyes, etc.

(2) attend to things outside of you, the ticking of a clock, the gurgling of an aquarium, the noise of the dishwasher or fan, the smells of cooking, the shadow of a lamp on the floor, the glow of the bulb inside the lamp, the different pieces of furniture in the room. Touch a person. Or if you are outside, watch the clouds in the sky for longer than a moment. Cloud-gazing is the original Rorschach test, so you can analyze what you see, what it says about you. It tells me that I really don't like giant ants.

(3) Keep on attending, watching, everywhere, all of the time. Be in the moment. If thoughts interrupt your discovery, watch them, too, even see them as words on a piece of paper, don't judge them or be upset about them, they are only thoughts, not real events, not happening right now. Sure, they may have happened, or might happen, but stay with what is outside of your brain, right now.

(4) Emulate others in the animal kingdom. Check out this bird, for example. No intention of letting anything bother him.
Nothing but mindful

(5) Emulate children. When they go to a rocky beach, they don't complain that it is too hot or too cold or there are too many people. They skip rocks on water, throw sand, consider what they can do with it, because there is so much! They search the earth and the sea just to see what they can find, right there in the moment, and this makes them happy.
Cloud-gazing mindful

Skipping stones-behavioral mindfulness
And they watch clouds, too.

They also play games.  Consider an adult version of freeze tag. Catch yourself thinking, doing or feeling something you don't like to feel, think, or do. Then freeze. In the game someone shouts freeze. So do that, shout freeze. 

Then take in all that sensory information we discussed in #2.

(6) Work your imagination. If you catch yourself thinking thoughts that feel mentally destructive, get creative, go to what you're going to make for dinner, what you might do in the evening or the next day, even think about what it would be like to take a vacation. Change your life story and make it into someone else's life story, more interesting, how you would see it in a movie, a romantic comedy. This can be hard, so let your mind wander to the places you know about, like what's in the fridge, what should be in the fridge, what music would be nice to hear, what you can do for someone else. Let these thoughts ascend, and the ones that upset you, deflate like lead balloons. See thoughts inside balloons that are losing their helium, coming down, down, down, until they are nothing but scrunched up pieces of blue, red, yellow and white rubber that might or might not have to be recycled.

Too much to ask? I hear that mats are only ten bucks.


There are many good books on mindfulness, try Buddha's Brain, by Hanson, and the mindfulness solution for pain, by Gardner-Nix,  (not that the book will necessarily take away your pain, but the idea is distracting).

the mindfulness solution for pain, by Gardner-Nix

Buddha's Brain, by Hanson

Friday, July 17, 2015

How to Save a Life (Part Three): Arguing with Suicide Intent

It is summer, and you wouldn't think people are too down, but maybe it hasn't been the best summer for everyone. Hopelessness doesn't always flip with the seasons.

A patient described panic symptoms, not knowing that she had suffered a panic attack. 
"But I told myself," she went on, "that everything will be all right. And it was!"
multiple meanings of spiraling BALANCE  

Therapists, friends-- we all say it with confidence: Everything will be all right.

The reply, "How, exactly, do you know?" is the tricky part. How do we know?

Emotions are temporary states, for one. We cannot stay in the same exact emotional headspace forever, wired as we are with homeostatic neurological and hormonal systems. Without therapy, we are changing all the time.

And therapy has improved exponentially in recent years.  Interventions are tested and have proven empirically effective. Change is so likely that when hopelessness spirals out of control and patients talk of suicide, therapists apply an adage,
Suicide is a permanent solution to a temporary problem.
There's so much else to do. But a body has to get there, has to get help.

There's a post on this blog (February 16, 2009) about a popular song, How to Save a Life by The Fray. The essay is long and winding, refers to the ballad, a lay-person's failed suicide intervention. The gist of the post (and one that follows, How to Save a Life, Part Two) is that when in doubt, when a friend talks about suicide, get him in for an evaluation, somehow, even a hospitalization, a visit to an ER with you. After that a primary therapist, and likely a psychiatrist, too, will shoulder the responsibility. As a friend you are a first responder, but not the last.

Fray has the right idea.
Step One
You say, 'We need to talk.'
He walks away, you say, 'Sit down, it's just a talk.'
The purpose of the talk, even between friends, is to evaluate the situation. How bad is it? Poke around the topic especially, as the song suggests, at the end of the evening, when everyone else has gone home, but just one person is still awake, prowling around grumpily after the party. Sleepless.

It's just a talk.

See if you can get to something really important, suicidal intent. The plans actually follow the decision. So sniff out intent, that's how you know the answer to the question, How bad is it? Add to the list items about thoughts and plans. Invade the privacy, pass through social stop signs to check out sad friends. The refrain . . .
Where did I go wrong, I lost a friend. 
is simply too sad.

It isn't easy, prying like this. Mental health awareness advocates spend their days organizing suicide awareness walks,  prevention months, weeks and days, to teach us how to pry. These are opportunities to bring up the subject, good times for the talk, perfect segues into a difficult subject.

As are podcasts. There's one by Cheryl Hamilton, totally worth a listen.. Teaching a wilderness search and rescue class in New Haven Connecticut, with no training in it, she accidentally stumbles upon a young man intent upon jumping off a ledge to his death.  She tries to talk him down, and the results, the effect upon her, and perhaps upon him, too, startle them both.

The difference between where I'm at now and where I was in 2009 is that I'm a lot more confident in having the talk. You see, even being a therapist, this is a difficult discussion. You can't be too confident when you are dealing with hopelessness, can't be too smart, and should never get too lofty or too glib. So having more confidence could be bad, and can come back to bite you. But when you learn more about suicide, you do get more confident, and if you can keep it in check, will be more effective at this whole saving lives endeavor.

At some point after writing the How to Save a Life posts, I had a very sick patient who had been suicidal all her life, and it was one of those things where you want to punt to someone smarter, but the patient already likes you, so you can't. And you like her, too, and can never be too sure, when you suggest someone sees someone theoretically more qualified, that that person, the one to take over for you, really is.

So I dig in, embrace the therapy, and one day happen to be checking out the University of Illinois Bookstore online. I'm there to see what the professors are teaching in clinical social work methods these days. I find gold, a reading requirement for a class in treatment, a text by Shawn Christopher Shea. Dr. Shea is a pioneer in a new methodology, the CASE approach, Chronological Assessment of Suicide Events for mental health professionals.

Shea's text, The Practical Art of Suicide Assessment is technical, and for therapists, but could be for anyone. Rock star Kurt Cobain's story, for example, and his suicide note, make up almost an entire chapter.

Just a few take-aways for now on the reasons, or triggers for suicide, and a bit on intervention. It isn't like we can stop here, but if we know what really causes people to make the decision, we might be more able, if not so confident, in having the talk, and yes, punting for help if desired.

Start by forgetting the myth that suicide is always an act of a disturbed, depressed individual. (That myth is in one of these posts somewhere). Suicide is a decision, a way to solve a problem. It is about feeling cornered, or trapped in a painful dilemma. Note the language, painful dilemma, not depression. Sometimes people perk up and feel just fine after making the decision.

Step One, therefore, is the same, the talk, talking about the triggers, the dilemma. Then when that is fully fleshed out, when no more words from our sad friend are forthcoming, we might begin to wind the conversation around the rationale for it, for that decision, the pros and cons of suicide as an intervention. It isn't the most rational solution, although it might work. But it might not. Even in our death, our problems continue to affect others. And maybe people don't want to do that, hurt others, saddle other people, people they love, with their problems.

The triggers according to Dr. Shea:
Every therapist should have them memorized before stepping into their first job, but again, everyone else should know them, too.

1. External stressors: deaths, rejection, public humiliation (a big one), and serious illness;
2. Internal conflict: psychological impasses, unconscious conflicts, cognitive distortions and binds;
3. Neurobiological dysfunction: exogenous toxins such as alcohol and cocaine, endogenous (already there before situational stress), and pathophysiology, the biology of depression, for example, or other illnesses.

Once we have the triggers on the table, the words are, Build on that.

Again, just for today, let's just look at the first trigger, external stress, a loss, perhaps a death.

Ask about the impact of that loss, how did it really feel? How did it affect the present, life today, practically speaking? What will be missing now that things have changed, now that there is no job, or now that someone has passed away? Can the loss be replaced. Is that even possible? Is there a satisfactory substitution, if not a replacement? And finally, can the patient see that the pain will lessen eventually, even end?

The answers to these questions clarify the direction of a friend's (or patient's) strategies for coping. Because at the end of the day, suicide is just one way to cope. There are others.

Once I asked a patient who had lost someone a similar barrage of questions, including her belief in an afterlife. She did believe in it, and contrary to that helping her feel better (her friend being in a better place), the belief had solidified her desire to hand out together in Heaven. She didn't believe God punished those who put themselves out of pain by suicide. So we had to discuss that, see if there were other ways to be together, like rereading emails, attending to surviving family members.

This is cognitive behavioral therapy, or CBT. with its focus upon thoughts, triggers, the dilemma with the potential to culminate in a deadly decision. The goal is to find alternative solutions and to debunk the rationale for suicide.

We ask a few good questions of the patient: Will suicide actually work? Will it end the pain? Really, who knows? Will it solve the problem? It might create new ones, worse problems for other people. Debts might be someone else's debts, insurance likely won't pay out.

Is suicide ethical? If it causes pain for others, maybe not.

Besides suicide, what's a person to do? Here I'm talking to that person who has suicidal thoughts, intent, even plans. Stay alive, for one, to keep the discussion, the conversation going. Be open to being talked out of it. You might be bored with the topic, your problems, your reasons to end it all, saturate your interest. Strangely enough, you might get bored, but not everyone else is. Talk about the dilemma when you have that gift, the opportunity.

There really are people who are interested. Find them. These are your people. One of them will find a way for it to be all right.


Monday, July 06, 2015


The Kotel, Western Wall
It was a fast day yesterday, meaning no food or water from sunrise to sunset (we have 25-hour fasts, but this one, the 17th of Tammuz is considered a "minor" fast, less intense). FD and I woke up at 3:45 am to get in some breakfast before sunrise.

This helps tremendously, a pancake or two, a cup of coffee, a couple of preventive Advil. But when you're fasting until 9:15 pm on a summer day, you get more than a little thirsty.  I traditionally tease my children with a text, a reminder of the joke about the old Jewish guy on a train in Europe. He continuously bemoans aloud, "I'm so toisty," until someone finally listens to him. (There are variations, all with the same punchline.). It is my final text of the long day.

Anyway by 9:00 that day I'm at work, where people are often talking about food, and their diets, how cutting out certain foods, white flour or sugar especially, helps them lose a couple of pounds and improves their state of mind. Abstaining from anything is empowerment, imho, in moderation.

A Jewish fast is an empowerment opportunity of a different sort, however. It is thought that the Old Mighty (my grandfather's nickname for Her) is more accessible, a little closer on these set days, that She's really listening, hoping we'll connect sincerely, and more often. And when we fast, we're more likely to tune into that side of ourselves, the side that communes with a higher power, people say. I like to call this part of us our religious life. We have many lives, all tucked inside, and this can be one of them, or not.

When we're depressed it can go missing.

As it is also the Muslim month of Ramadan; Jews are not the only ones fasting this day. This has to be an interesting month, psychologically, for the cousins, and the world over their effort is both baffling and admired.

There are two summer fasts for Jews, one the 17th of Tammuz, then another, more compulsory, on the 9th of Av, three weeks apart. The fasts remind us not only of the destruction of the Holy Temples of Jerusalem by the Babylonians (586 BCE) and the Romans (59 CE), but also the many bloody initiatives of other nations intent upon destroying the Jewish people.
mass grave in Belson

Since the experience with Germany in World War II is so close to us, and because there are still survivors of the war, some of whom are still around to speak about it, and cinematic footage of them in dirty striped prisoner pajamas, blank-eyed living skeletons, and footage of the dead, too, ominous mountains of real skeletons, mass graves, thousands of confused, terrified men, women, and children shoved onto trains for days, no food, no water, no toilets, on their way to the ovens, and death marches, miles in the snow in those thin pajamas, sub-zero weather, those who stumble and fall, if they aren't already dead, shot on sight. The Holocaust reduced the population of Jews in Europe dramatically from almost 17 million to less than 11 million. But what is 6 million Jewish people, after all. What do Jews even contribute to society?

Oh, never mind. It wasn't my intention to go here. It is too sad. For a look at photos of the Holocaust, mountains of Jewish shoes and eye-glasses, maps of concentration camps, emaciated bodies, look at Shamash.org or better, visit a Holocaust memorial museum, like the Simon Wiesenthal Center's Museum of Tolerance  in person. Any Holocaust museum will do. Anytime.

Fasting, if you do it six times a year, for many years, is still likely to be dreaded each and every time. But it isn't really that bad, and those of us who wouldn't, couldn't, miss a fast, know it. The less spiritual can point to the benefits, purging the body of all the garbage we've eaten the week before. When the fast is over, if we don't eat too much in breaking it, if we keep dinner moderate and healthy, we feel great, assuming we haven't a "caffeine headache." (Hence the early wake up before dawn for coffee).

And even the next day, today, at the pool at 6:30 in the morning, when the body has adjusted to the cool water, the jump in serotonin in this therapydoc's brain is measurable, words for this post swimming in the brain with every stroke.

It is paradoxical that the anorexia of depression functions to increase depression, makes it worse, denies a good state of mind. The treatment is to increase appetite, and certainly, make sure the patient sleeps a solid six, at least, which is one of the benefits of medication. Sleep and food are healing.

So unless fasting is one of those things your doctor tells you to do before a procedure, or your clergyperson really recommends as a traditional way to connect to certain events and your Higher Power (assuming the pri-care has signed off on it), take all this talk of fasting from food and water for many hours at a time with a grain of salt.

Preferably on a no-yoke omelet, half a bagel on the side. With butter, thank you, and at least a quarter of a cantaloupe. They're in season it just so happens.


Tuesday, June 30, 2015

The Supreme Court, the Opposition, and the Gay Marriage Law

We have to talk about the Supreme Court decision making it a Constitutional right for gays and lesbians to marry in the United States of America. Less than 50 years ago the psychiatric community pathologized same-sex attraction, deemed it a disorder with a real DSM II code. That didn't last long.

Reporting the news, in the same breath, journalists quoted various self-identified groups of conservatives opposed to the decision. Googling "opposition to gay marriage," I found page after page after page of groups and individuals dead set against the right of same-sexed couples to marry. Many, if not most, because of a Bible prohibition.

Being one of a bible thumping tribe, the bible being the Torah, thank you, Orthodox the persuasion,
this booming opposition is a concern. There are so many commandments, and it is ridiculously difficult to keep the entire Torah, although that is the goal. (No idea what it means, by the way, to be Ultra-orthodox. Orthodox implies strict observance of Jewish law, or halach. All stripes of orthodox believe that Moses, a servant of the Old Mighty, passed the law along to the Jewish people. They were the only people who would take it, and they had to because God held a mountain over their heads, made them an offer they could not refuse.)

We could talk about all that for hours, but since it was 3500 years ago, and Moses isn't around to verify, we can only assume that he wouldn't lie to that crowd of three million who heard the Ten Commandments, ala Cecil B DeMille, as hail, fire, thunder, and lightning pounded them senseless, along with trumpet blasts, let's not forget, until they cried, "Stop! Tell it all to Moshe (Moses). We trust him. This fireworks display is too much!"

So God did just that, told it all to Moshe, and Moshe told it to those three million, who told it over to their children, who told it over to their children, who told their children, ad sterpes, until this very day.

And yes, we are still telling our children. And it is easy, because it is all written down, and sure enough, in one of the chapters there is a passage forbidding men from lying with other men. And that is why so many Judeo-Christian folks are still confused and intolerant of homosexuality. That is why there are so many opposition groups.

So, the strangest thing happened on my way to getting a PhD. I had asked for and been granted a year's leave of absence following the dreaded first-year comps. My family had a five-year plan to live and study holy things in Israel well before my decision to go back to school. Permission granted, the dean reneged about it being a year off. He wanted me to hook up with a social science professor as a research associate. That wasn't easy, but it happened, and I studied with one of the very best in Israel.

At the end of the year, packing to return home, stacks of academic articles about homosexuality made their way into my suitcases. All that literature, no matter what else might have been in the cards for me, determined my dissertation topic.  I just had to figure out how to make it something that would keep my interest in the coming years.

Being a family therapist, exploring variables in the parental acceptance of gays and lesbians did the trick. Now all I had to do was round up about 60 parents, interview and test them, and I'd be on my way to a PhD.

In 1998 most universities had not made the leap to allow researchers to look to the Internet to find subjects for study. It took some explaining at the time. At the end of the red tape (at a major mid-west state university), the Internet sample of parents most desirous to participate happened to be religious. Christians, many of them, had joined a movement called PFOX, Parents and Friends of Ex-gays, an arm of Project Exodus. Meeting together and talking about their issues, they came to the realization that hitting their kids over the head with theology wasn't working. Better to quit fighting, love them as is, and maybe someday they would give up on the lifestyle. Return to God.

PFOX is no longer around, except perhaps as a fringe group, but the entire Exodus movement, leave the lifestyle, come back to God, petered out, probably because the therapists who supported them had promised parents they could convert their children to heterosexuals (when they were ready) and couldn't. The practice of conversion therapies is and was at the time, unethical. Indeed, the major mental health organizations have all issued statements to that effect. Subjects endured shaming and humiliation from such therapies, treatments that undermined self-esteem and mental health in too many ways to count.

Meanwhile, before that hit the fan, I had managed to interview thirty-five parents who had participated in Exodus support groups. They described their own personal horrific emotional travels beginning when their child came out, or with the realization that their son or daughter would not be bringing home an opposite sex partner, this a traumatic experience for most. All dreams of grandchildren (this was fifteen years ago) dashed. Parents talked about their grief process and how they ultimately came around to accepting partners and friends, having barbeques and picnics in the kill them with love, or hate the sin, love the sinner world view. They stopped fighting, started loving, all the while hoping that their acceptance and love might change their child's predilection.

God can do anything. Let go, let God. So many of us believe this. They defaulted to love is the answer.

But nobody talked about marriage.

I heard their stories, fascinated. The rest of my sample came from the other camp, PFLAG, Parents and Friends of Gays and Lesbians, and random people who saw fliers or had heard about the study. They, too, had difficulty initially, but never thought things would change with a loving, accepting relationship. They accepted with more of a grin and bear it, This is my kid, I love my kid. Often one parent accepted. Another did not.

And now? Now that it is a right to marry? Which parents will be going to the weddings? My guess is that most parents will go, but it will depend upon so many variables, like social support and willingness to differentiate as a marital team. One parent might go, the other stay home. People will do whatever works.

And those who object, but don't want to lose their child, might be telling like-minded friends that it takes a lot to make a marriage work. The divorce rate is above fifty percent. The odds are against them. Getting married and staying married are entirely different matters.

Maybe some will even add, "But if these kids can make it work, more power to them."


Monday, June 08, 2015

The Therapist Takes a Vacation and Blurting: Six ways therapists can recover from mistakes

We all do it once in awhile, say something we wish we could take back.
You may not even notice when your therapist does it, might not even get it, but she does.
Mount Kilimanjaro

You likely will notice! And when you do, might be tempted to confront, and you might just do that. But this is a hierarchical relationship, despite all our talk about Empowerment Therapy and Call me by my first name. We come to rely upon our therapists, don't get excited at the notion of arguing or challenging them. Well, some do.

Which is fine!

But we therapists know when it's a blurt, a wish I could'a taken that one back moment, either by the look on your face, or through the words that play later on in our heads. (Many of us do this, think about you when you're gone, try to capture answers by reviewing what happened in the room.)

If we think we've erred, and shouldn't have said what we've said, we have options, some more mature than others, some more therapeutic than others. Let's start with five of them.

(1) We can wait to see what happens. If the patient hasn't questioned us and didn't look confused or upset, we might totally get let it die.

(2) Alternatively, we might call the patient a few days after, ask if she's okay, suggest that some of what was discussed last visit might have been disturbing. If we're confronted here, we have the option of explaining ourselves. Best to have the explanation ready.

(3) We might do an honest assessment to determine what possessed us to say whatever it is we said. This might take a few days, but the explanation will likely be better, and more true, with a few days hindsight. At some point the data will come in handy.

(4) We can call a consultant and discuss what happened to get another spin on it, get it off our chests.

Whether we think it through ourselves or with a colleague, it is safe to say that we don't just blurt things. There are reasons for what comes out of our mouths, and these are systemic, not all about us. The patient is driving what happens, the therapist is the passenger, occasionally sharing directions.

(5) We can decide not to decide, to wait and see where the patient is next visit. We might bring it up then, at the right moment, explanation in hand.

Let's take a quick example.

A patient of means travels often, talks about his vacations as they affect his family dynamics, mostly. But there is always a reference to the beach, and to the food. The therapist is not of means and does not travel much, but one day has an opportunity to do so, go someplace exotic.

When she cancels for the week she'll be gone, the patient gingerly asks, "So where are you going?"

The therapist tells him, straight out. The patient seems uncomfortable.

This is not a good sign. It means that the tell is a blurt, a blooper; the discussion of the therapist's vacation not the best move.

Why? He could have grimaced because he realized he had to drive car pool the next day, or something else. We can't assume, that, however because of these four unspoken laws.

(a) There is an unspoken (covert) rule that it is okay for the patient to leave the therapist, naturally, whenever he wants. But it is not okay for us to leave them. This feels like abandonment, especially if the therapist is going far away. (When I took two weeks to go to Israel a few years ago, a patient did land in a hospital. Nothing to do with me being gone, she said. Of course.)

(b) Does anyone really need to be thinking of their therapist in any other context other than in that chair, facing someone else's chair, listening intently with concern? Probably not.

(c) The less we talk about ourselves, the more the person who is paying for the visit talks about themselves, which is how it should be. Yes, even as they are walking out the door, it is about them.

(d) If an absence must be discussed, and sometimes it should be, then it is the patient's feelings that matter, not the details of the therapist's time off. When the patient asks, "So, where are you going?" the more relevant response is, "What kind of stuff do you think is going to be coming up for you while I'm gone?" Then, "And how will you be coping with that."

So a blurt, any error in judgement, probably shouldn't be ignored. The patient will be talking about it with everyone else anyway, so direct communication is more than called for. But did the patient contribute to the blurt? Only in having presented a certain amount of information that triggered something, some off observation or comment, and that needs to be discussed, too, the patient's input.

Which brings us to number (6), if we're counting Six ways therapists can recover from mistakes .

A little speech can go a long way toward rekindling the therapeutic alliance. Make it relevant to what was said, and be sure to assess what it is about the patient that contributed to your impulse to share:

(6) Last week, after you left, I thought I detected a little discomfort on your end.

I thought about what I said, that I'm going to climb Mount Kilimanjaro, thought about it a good deal. I tried to figure out why the impulsive share. So much information about my travel!. You might think it natural, after all, you travel a lot, and surely that contributed. But it didn't feel right to me, and I'm sorry. We should have just talked about how you'll be handling things while I'm gone.

Fact is, I hardly tell anyone about trips, certainly not patients. You share quite a bit about your travels, so maybe that had something to do with it, but I think there's more.

It is this wonderful quality you have that makes people want to share with you. It's true, you know, that a lot of people probably want to talk to you about all kinds of things.* So don't change.

But from here on in, I probably will.


Only say this if it is probably true. It does happen to be true about many, many people, and most of them don't even know it.

Thursday, May 28, 2015

CBT and Song: I'll See You in My Dreams

It is no secret that when a therapist goes to a conference and learns something new, or merely signs up for a continuing education course online and actually applies herself, learns the material before taking the test, she'll probably talk about the new intervention or theory for at least a week or two. All patients are unknowing guinea pigs. Beware.

But sometimes we come upon something on our own, a random strategy that helps us with our depression or anxiety, and having successfully applied it, we know that it works for at least one case study. If it lifts our dopamine or serotonin, changes the way we feel, why wouldn't it help at least a few others?

Not to tell all, but I had a bad day, and I felt really badly, and I couldn't shake it, obsessed about what had happened far too long. This can happen to anyone and probably does, but knowing that time heals (most of the time) didn't help at all. Neither did any of my tried and true CBT interventions.

Talking to FD and my friends, which usually helps SO much, only helped a little. No emotional energy left to write (not wanting to revisit the material, that's for sure), I was frustrated and out of steam. Then, out of nowhere, I remembered something.

Maybe the writers of Blythe Danner's I'll See You in My Dreams remembered it, too.
I'll See You in My Dreams

The movie is all about Ms. Danner, and if you've been missing her, you won't in this film, she is all of it. This is about aging and loss, and that's as far as we'll go with the spoilers, except to say that at some point she is discussing her first career as a singer with the pool guy.

Yes, there's a pool guy, and yes, very handsome (Martin Star).

He asks her, "When did you stop singing?"

She doesn't know.

That's all you'll get about this film for today.

So here's the thing about singing. It does change the way you feel, as does listening, but it is active, not passive,like listening tends to be. It focuses the mind with several senses, not only one, especially if you try to sing well, by ordering the lips to work in a certain way, the chest to breathe deeply, to hold then release the breath, the words, with exactitude.

To say that song is an avenue of expression is redundant, but if it is, why don't we sing more often? We're fearful of being heard, obviously, and being laughed at, as if anyone really cares or would. Like sport, where spectating is the next best thing, we listen to and admire Adelle, Renee, so many others. We sing along and cry, perhaps, transcend our realities, dissociate from what is troubling us. That is what it is, really, when we're engaged like that, dissociating from problems. We all have them, and creating something new, when we do something creative, such as sing or sing along, puts us totally, consciously in charge. Except when we hit a wrong note. But we're not Adelle, not Renee, not even, dare we say it, Barbra. So sure, there will be a wrong note or more.

So there I am, can't remember exactly where, probably in the car where they say most people sing, no, in a parking lot looking for the car, and I'm actively searching for a song to lift me up, and I remember Barbra's Smile, everyone's favorite, and I begin to sing and it lifts my spirits some, but not nearly enough. In fact, the song makes me a little worse, because it is about feeling sad and how smiling makes us feel better (believe it or not this is true). But a person has to really work at smiling when it doesn't feel natural, when the feeling isn't there.

This is a do it thing, however, and if you do force your face into a smile and hold it, this, too, can produce a little change in the brain, enough of one that many depressed people who go to work and have to smile because they won't sell something if they don't, or people will ask too many questions if they don't, will report that their days, while faking it, can feel pretty good.

So smiling is an excellent cognitive behavioral exercise, and Barbra's song is spot-on.

But it's sad!

I switched to happy songs, literally peppy tunes, which helped enormously. Zippity Do Dah and High Hopes--Oops There Goes Another Rubber Tree Plant, and a few slow ones (Where is Love, Oliver) some of my all time favorite songs.

And yes, I have been suggesting to patients that they do this, find happy songs. Although crying feels good, and surely, we can't help it, we have to cry, it is irrepressible; but if it is at all possible, if we can get out of our sadness, pull ourselves out of that dark place, lift our own spirits without waiting for the Lexipro to kick in, then there's no better feeling, no better facial expression, than a smile.

Because at some point, as the queen of Broadway croons, What's the use of crying?


Oh, just a few.


Wednesday, May 20, 2015

Child Sexual Assault: A Different Paradigm

May is Mental Health Awareness Month, and what better way to promote that than to discuss a successful therapy. Thanks to the American Psychological Association's Annual Mental Health Blog Day (today, May 20for keeping us current.
APA Mental Health Day

APA Mental Health Day

Onto the case study.

This is about Ziv Koren, who at the age of six became the sexual obsession and conquest of her uncle, remained an extension of him for ten years. As in the case of many pedofiles, entirely possessive, the abuse blocked Ziv's social and psychological development. Her identity remained in no-man's land as did her sense of self, even after the abuse had stopped.

She had six years of unsuccessful therapy (Ziv suffered addictions and a plethora of disorders), until she met Dr. Rachel Lev-Wiesel, a professor and childhood sexual assault specialist at the University of Haifa, in Israel. Dr. Lev-Wiesel is director of the Graduate School of Creative Arts Therapies. (For another synopsis of their work together, click here).

Rachel asked Ziv to draw her feelings, her experiences, and this became the vehicle for communication, a process of externalizing pain and telling the story. The doctor and patient published a book together, a near complete transcript of what happens, psychologically, when a perpetrator steals a child's body and mind. It is a picture book. Ziv's art tells the story. When when it is finished, we are treated to the therapist's contribution to mental health, a gift that will change the way many will perceive and approach the treatment of child sexual abuse for years to come, a new paradigm, new ways of seeing this inhumanity. She refines her research in a mere twenty pages.
When Time Stood Still by Rachel Lev-Wiesel and Ziv Koren

Nowhere, not in any of the data bases I've scoured for the latest treatments of sexual assault and pedophilia, have I read the word, "soul". If I did, it was in passing, perhaps soul-less behavior, assault; not a core construct for therapeutic intervention.

But of course this is about stealing a soul.

Rachel Lev-Wiesel, has no issue using the word and discussing the existential experience of assault victims who lose their identity to their perpetrators, and dissociate from their bodies, the bodies that betrayed them. Citing numerous studies on dissociation, she reiterates what most therapists already know. Dissociation is a process that enables sexually abused children to survive abuse. The conscious mind detaches, disconnects from reality, the thoughts, memories, feelings, and acts in the here and now. The onslaught of pain is avoided as reality is put in its place, far away. The soul, or self, or mind, consciousness, whatever you want to call it, is entirely separate from the body, from the event. Identity confusion has to follow, will take years to coalesce, healthy relationships difficult to maintain.

Paradigms about what happens to us during any emotionally upsetting, memorable, traumatic event are referred to traumagenic, and they are not new. At the core of psychological injury, Finkelhor and Brown (1985) categorized four dynamics: traumatic sexualization, betrayal, stigmatization and powerlessness, all associated with victimization, characterizations that have helped those of us in the helping professions to work successfully with survivors. Dr. Lev-Wiesel builds on this theoretical framework, and mental health professionals should be listening.

We need more words, easier words, to work with in treatment.

Those last twenty pages of When Time Stood Still deliver, and the first 147, Ziv's story and art, move us as if we are there, doing the treatment, feeling the pain and the progress. It is an art therapy, and for those of us who haven't ever tried this treatment modality, certainly worthy of considering when words simply don't mean enough. Ziv Koren's drawings are the heart of the book. The pictures aren't pretty, but the art is what art should be, the great communicator. The verbal therapy is via email, a discussion of pictures, and we have the transcription.

Dr. Lev-Wiesel's theoretical framework, however, tells it all. Here is where the concept of a soul's homelessness resides. She explains that most of us see our homes as shelter, safe, predictable places, points of departure and return. The body is similar in that it is the shelter of the soul. The soul is loosely defined, and we might substitute sense of self, other words, but if the body is the soul's private space, and it is invaded, unprotected, that sense of safety is corrupted, ruined.

We all have strong reactions to breaches in personal space. In the case of sexual assault, especially chronic, prolonged sexual assault like incest, the body is no longer safe. It becomes a prison.

What's a soul to do? There are options, Dr. Lev-Wiesel teaches us. (1) Identify with the aggressor (take his identity), (2) split off with dissociation, become oblivious to the body and its needs, and (3) retaliate with punishment for betrayal. This we're all familiar with, self-injurious behavior, substance abuse, eating disorders, promiscuity, addiction to sadomasochism, neglect of hygiene, depression, etc.

No, not new to those of us who work with victims. When the body fails to protect, when it has caved to coercion, an act of self-preservation, it becomes repulsive, contaminated, worthy of self-abuse, self-punishment.

And soul's homelessness is only the first of five exquisitely conceived traumagenic constructs.  Over time we will revisit the others, captured in time, the present and future become reflections of the past; re-enactment of abuse, or time cycling; the betrayal entrapment; and entrapped in a distorted intimacy.

Valuable stuff for not only therapists, but victims and survivors as well. A new appreciation of art, one we won't get in Art History 101.

I'm Blogging for Mental Health 2015.There is much to be positive about this May, Mental Health Month.


More on Ziv Koren's art and her therapy, click here.

Ziv Koren's art

Ziv Koren's art