Success of Relationships

Was asked recently by a student, “How long do you think a couple should be together before they get married?”  There’s no way to give a full answer to this in a blog, but think it important, and would like to put out some fundamental ideas that I don’t think we can ignore.  Seems to me that this is not only about “knowing” when, or even the success of a romantic relationship- would suggest that some of these ideas are about all relationships.  What follows is my response:

Would offer that it’s not a question of how long.  The reason we think in terms of time, is because something is supposed to happen during that period, but we never say what it is!

Oversimplifying, first and foremost, my philosophy is that both persons should be self-supporting mentally, emotionally, physically, and “spiritually” (not necessarily religious, but not necessarily excluding it).  They should be able to see, and assess these things about one another.  It’s much deeper than it seems- mentally: responsible for one’s own critical thinking, memory, organization, prioritization, intellectual curiosity.  Emotionally: responsible not only for one’s own happiness, but one’s own sorrows and fears and shames and hurts as well (even if caused by others- this is really important).  Physically: responsible at least for food, clothing, shelter, medical care, diet/sleep/exercise.  “Spiritually”: responsible for one’s own connection to one or more communities, also for one’s own sense of place and purpose.  Short of that, the relationship becomes responsible for one or more of these things missing, and is diminished.

In more detail, any of these things absent weighs on the relationship.  One partner inevitably becomes resentful at having to “pick up the slack” for one or more of these things absent, or tries to get the other person to take up their responsibility, or withdraws, etc.  This shows up a lot for instance, in these examples:

One person bears on the other due to “insecurity”/low self esteem.  (emotional, “spiritual”)

One person struggles with providing their own needs for food/clothing/shelter/medical care etc.  (physical)

One person depends on the other as their sole source for community or purpose (sometimes, simply by providing community when the other doesn’t have it).  (“spiritual”)

One person expects or needs the other for reminders of appointments, choicemaking about how to spend money, interests about the world.  (mental)

Am sure everyone can come up with many more.

It takes varying amounts of time to know if someone is able to do these things, because it takes varying kinds of circumstances to have them come up.  Even discussed in a “principled” way as I’ve tried to above, there’s a lot of things to be considered.  When someone dies, does the person “deal” with it gracefully (grieves), or do they get intoxicated or treat others poorly?  When they get sick, do they have the means and do they do the work to do some of the effort to care for themselves?  Does this person avoid talking about feelings in general, or have a maladaptive way of dealing with them?  Do they have hobbies, interests, and do they occasionally get new ones?  Do they provide for themselves long-term?  Do they maintain relationships long-term?  How do they handle their successes?  These are all circumstances that often take a protracted amount of time to show up.

These things are also not simple for individuals.  As such, would argue that without having/knowing these things about ourselves, these qualities are difficult to identify in other people.  It takes a chunk of time, usually beyond adulthood, to really have a method and examination of knowing these things.

Clumsy Solutions

For many years now, I’ve noticed something that I think is pretty interesting.

We all have similar problems.  Problems of love, death, loss, fears, mistakes, power, our bodies, work, school, relationships, resources, abuse, abandonment, depression, addiction, self worth and the like.  In one way or another, most of these touch all of our lives.  Our responses to them too, seem common between us- we all have “bad” feelings and “good” feelings associated with these experiences.

It appears to me, that we also have solutions in common.  But what’s strange about it, are the solutions themselves.  If we just look at the “problems” (for shorthand purposes) we have in our lives, and our response or “reaction” to them (or as I’m calling them here, “solutions”, though we may not see them as such in the moment), the way we deal with them from this perspective is tragically ineffective.

Here’s what I mean, more specifically.  The way I see us (and of course, have done myself in many cases), is that we respond to perceived problems with (in no particular order):

  1. Avoidance, procrastination.
  2. Using our limited human intellect, and our limited human will, coupled together as a salve we cover everything with.
  3. Drugs, alcohol, food, spending, money, property, prestige, gambling, etc. ad nauseum.
  4. “Codependent” behaviors (oversimplifying: doing things for others that they can and should do for themselves, so that we don’t have to feel bad for one reason or another).
  5. Lying (or, in addict nomenclature, “manipulating”… insert tongue-in-cheek emoticon here), often, when telling the truth would be easier.
  6. Perfectionism.
  7. Control.
  8. Enduring untenable circumstances or relationships.
  9. Isolation.
  10. Ruminating.
  11. Reasoning with “unreasonable” people, or in circumstances that may not always be subject to such (there’s a large philosophical question here that can’t be addressed in a blog, hope the spirit of the thing comes through…).
  12. Self obsession.
  13. Being critical.
  14. Thoughts or attempts of suicide or related self harm.
  15. Worrying (the behavior… not to be confused with being afraid- as John Bradshaw once opined, “Worrying is like beating the drums to keep the evil spirits away.”).
  16. Pride or ego.
  17. Lashing out verbally or physically.
  18. Intellectualizing…

Et cetera.  This is clearly a truncated list, but am hoping most of us can see our most frequent responses here.  What I’m hoping to get across (at the risk of reiteration) is that these are our responses to perceived problems, and arguably, when observed, appear to be solutions that we employ to a whole host of life’s difficulties.

More striking to me is what’s absent from the list:

  1. Emotional availability, disclosure, and the like.
  2. Asking for help (having a “responsibility partner”, other similar ideas).
  3. Responsibility.
  4. Having “boundaries”.
  5. Kindness.
  6. Critical thinking skills.
  7. Service focus on others.
  8. Writing (and preferably, sharing that writing with one or more people).
  9. Art (painting, sculpture, music, performances, poetry, etc).
  10. Honesty.
  11. Support groups, 12-step meetings, or other types of community.
  12. Amends.
  13. Mindfulness.
  14. Meditation.
  15. Diet, exercise, natural healthy sleep.
  16. Being self supporting through one’s own contributions mentally, emotionally, physically and “spiritually” (for lack of a better term).
  17. Acceptance.
  18. Therapy, counseling, coaching.
  19. Community, relationships.
  20. Intimacy.
  21. “Non intervention”, being still.
  22. Forgiveness, “letting go”, and other similar solutions.
  23. Gratitude…

Seems I’m laboring the point here (hopefully in a continued effort to be helpful).  Have long looked at my own old behavior (though it still shows up sometimes!), and of course the behavior of others, and as I see “problems” come up, inevitably, I see the first set of responses above.  Often, repeatedly and perpetually for the same problem and/or new ones.  Have also observed that these responses almost inevitably make things worse, or create new problems.

While the second set of ideas don’t always “solve” things (sometimes, when honest, simply in the shadow of our own limited perspective), when practiced, my experience is that we all start to feel better about things, and certainly act better.  Very rarely, do I see the second set of  ideas create or perpetuate more problems.  Making a practice of replacing our first responses in the first section with the ideas in the second section, has been life changing for me, and lots of my clients.  If the theme rings any bells for anyone, would love to hear/see other ideas.

Advice for New Therapists… and Longtime Ones.

A week ago, my longtime friend Stan Smith MSW asked me to do some talks at USC.  The students were fantastic- they were really attentive, experienced, knew a lot of stuff, and so cool for me to see- were really into being of service in a climate that often doesn’t support our efforts.

The talks were focused on the idea of “legitimate suffering”, mostly.  It’s an idea stolen from Carl Jung, an idea near and dear to my heart for a bunch of reasons.  As I always do, we spent some time addressing questions that came up from students about doing The Work.

In both classes, the question came up, “What advice do you have for someone new in the field?”  This question mirrors too what a lot of our clients come in with.  I think the underlying theme of this for both mental health professionals and clients is, what do we do to give/get help?

It can be a complicated question, on both sides of the office/clinics etc.  As relates to depression, abuse, loss, addiction, anxiety, self esteem, relationships… whatever, if we intend to serve people suffering with it, we have a responsibility to an organized body of material that we think can be helpful.  My experience is that if it is used, it’s often helpful, when it’s not used, it is not.  Rarely is it simply not helpful at all.  The biggest mistake in my view, is simply not having a philosophy and principles for such things.  They should be agreeable both for client and caregiver, and of equal importance- they should be practical, empirical… things we can point at, that someone can do to improve the quality of their life, relationships, and decrease suffering from the things it is in our purview to treat.

We get some practical information as clinicians, some ideas framed by some “theoretical orientation” (Cognitive Behavioral Therapy, psychodynamics, Dialectical Behavioral Therapy, Jungian Psychoanalysis, etc).  Often though, it reaches what some patients need, but usually in the context of that orientation specifically.  It’s not to say that this information can’t be generalized, but it misses some of the fundamental aspects of what I think I’m being asked by a new clinician when they ask me what advice I have for someone new in the field.  This is talked about even less with “seasoned” or experienced clinicians.

More specifically, I think I’m being asked things like;

“How do I develop my style?”

“How do I provide great service?”

“How do I avoid burnout?”

“What can I do to develop my skills in an ongoing way?”

“How do I set and problem-solve boundary issues with clients?”

“What should I do to pass my licensing exams?”

“How do I set fees/schedules/obtain clients/deal with insurance companies/etc?”

“What can I do to get a job, and to stay busy in this as a career, when the economy is bad, insurance companies are difficult, agencies and hospitals are few, and there’s little funding available?”

“How do I deal with difficulties with specific clients, or colleagues?”

And etc.

As these are big questions to be tackled, and there’s certainly more, it’s better served to answer them in a book (or in school, but that happens little).  Sadly, there’s really only two practical guides for therapists that specifically address these kinds of considerations.  Finally getting to the point, here’s a truncated list of ideas that we discussed in these classes that I think might be helpful in some of these areas.

1.  Make sure you’ve endeavored to work through your own stuff. We’re already notorious for “going into the field to figure out ourselves and our own families”.  Get therapy.  Go to support groups or twelve step meetings.  Write, and share it with other people.  Have a meditative practice…

2. Focus on putting yourself out of a job, and the rest is easier- surviving, avoiding problems like job loss or getting referrals or whatever.  High quality patient care is the best way to do anything, as far as I’m concerned.

3.  Spend time mulling over what a high quality of attention is, and use that everywhere in your life.  Kids don’t just equate love and attention, they also feel the quality of that attention.  Same with our partners, and clients.  In our world, it’s one of our most-taxed commodities, and one of the greatest sources of creating or perpetuating problems.  It might be argued then, that it’s one of our most viable means of solutions.

4.  Read Sheldon Kopp- particularly “If You Meet the Buddha on the Road, Kill Him!” and “Back To One”. The former has the subtitle, “The Pilgrimage of Psychotherapy Patients”.  Would argue as much as it’s great for them, it’s better for us.  The latter is one of the two books I know about that are a practical guide for clinicians.  In it, he talks about a lot of the questions above- even how he deals with running into a patient in an elevator.

5.  Have principles you live your life by, and share ‘em with clients.  One of the things I tell my clients the first day is, I have a responsibility to try to be the healthiest person in their life.  For me, that comes from principles.  On a totally unrelated note, since many ask, this is also part of the source of the pet name “April 30th” for my practice.  It helps as an anchor to remind me of what those principles are.  It’s also a great means of putting me out of a job- if my clients leave with principles, they have methods of problem-solving, so that they don’t need to stay with me to solve them as they come up.  At least, until they get good at using those methods.

6.  Survive school. It’s a place to learn, not get straight A’s.  There’s nothing wrong with that in and of itself, except for the fact that many of us with self esteem/perfectionism problems of our own, this can become a terrible handicap.  School, in my opinion, is designed to expose us to what legislative and regulatory bodies see as the most fundamental body of material we, and they, have a responsibility to, that insures we provide service safely and ethically.  It therefore almost can’t be a place where we really learn how to put ourselves out of a job.  That, in part, is why I think our ongoing efforts are called a “practice”.  Doing school in a way that is unhealthy (feeds perfectionism, supports us trying to fix a flagging self esteem, etc) makes us less useful long-term.

7.  Remember why you got into the field in the first place.  This one elegant idea can get us out of a lot of emotional, ethical, and practical scrapes.  On a related note, I’ve seen some of us get so fearful of our ability to stay busy that we forget and/or compromise this idea, to the detriment of not only our clients, but in maintaining a base of people to care for.  If we operate in the spirit of helpfulness, my experience has been that we can more effectively stay in jobs and clients to take care of- more than any “marketing strategy”.

8.  Have a life outside of The Work. This is also a responsibility to our clients, I’d argue.  Nature seems to reward diversity in most every environment.  This is true too, in being a mental health provider.  It keeps us culturally aware, maintains our own health in different areas of our lives, and asks us to use skills we try to teach clients.  Hobbies, activities, intellectual curiosities, responsibilities, and of course relationships- but more on those below.

9.  Accept that the licensing exam is unlikely to make sense, in light of what you intended for the field. Referring back to #6, my experience with MSWs, PhDs, PsyDs, MAs/MSs and etc, few of us felt like the licensing exams really asked us to know what we thought we should when we took them.  This was true too, of my licensure as a Psychiatric Technician (all the way back in 1988 or so).  They help regulatory bodies insure that we are safe to work, and little else.

10.  Have relationships, first by working on how to be worthy of them, and make them matter.  So often, I have people ask me how I’ve not just survived, but been passionate about doing The Work since 1984.  That is a deep question, and really goes to how I deal with all of my feelings about all my life… hence, too big for a blog.  Having relationships though, is a huge part of that.  We all want love, fun, humor, depth, responsibility and etc, but my experience is that we often focus on getting these things more than we do being these things.  Being these things I think makes us more likely to have them in a way that has quality, and certainly, enables us to live more gracefully with living a life where we often have to wade through human suffering.  This does more to prevent “burnout” than any amount of exercise, hobbies, and etc (though I of course think these things are important too.

As per usual, this is a really truncated list, and certainly doesn’t address all of the relevant dynamics of these considerations.  They do though, reflect a lot of what I wish I had as a basic framework to operate from when going through a lot of getting to mental health, and working in it since 1984.  Sure gives me some parts of another book I feel a responsibility to work on…

What the Heck is “Euthymia”, and Why Should I Care?

Before getting into details, let’s make note of this: I’m altering the definition of the term as a way of creating a framework that allows us to look at something we don’t hear enough about in psychology and counseling- what is healthy!  We’re great at discussing “issues”, what’s “wrong”, what’s “unhealthy”, “mental illness” and etc, but we’re not so great at talking about the opposite!  Something to work toward, identification of what’s mentally, emotionally, and “spiritually” healthy, is a great way to change our feelings and our lives.

Oversimplifying, “euthymia” is a medical term, a term most often used in psychology, psychiatry, or philosophy to describe happiness or wellness.  Wikipedia separates out euthymia in terms of medicine, and philosophy.  In both, it is used to describe a “non depressed” mood, or “world perception” or “view” (Weltanschauung) as noted by the famous Greek philosopher Democritus.  Wordnik, a preferred website of librarians and info scientists for definitions of terms, defines euthymia as: “n. Philosophical cheerfulness and calm; the avoidance of disturbing passions, as inculcated by Democritus and Epicurus.”

As anyone who knows or has worked with me can imagine, I prefer the more global definition, the one hinted at in philosophy.  As promised, I’d offer that euthymia as a term might be most useful if looked at this way: an emotional response that is reasonable, adaptive, and of “right size” intensity, in response to one’s current circumstances.  In short, a healthy emotional response to one’s current circumstances.  Or (again, oversimplifying), a way of knowing that one has a healthy emotional response to the world.

Let’s start by thinking about what might be some indicators of an unhealthy response to the world, commonly understood by the medical and psychological communities.  Someone experiencing a “low grade” depression for an extended period of time might be diagnosed with “dysthymia”.  These symptoms being present, in absence of “psychosocial stressors” (AKA “problems” in life…), is arguably an indicator of something south of optimum health.  Without anything “bad” happening, to be “depressed” is regarded as unhealthy by most helping professions.  In a like way, being “sad” or “depressed” in a way that prevents us from doing things in our lives (work, play, relationships…) about something that happened say, 10 years ago is arguably not a healthy response to what is happening now.  To exaggerate to make the point, in schizophrenia (literally to be “split from reality”), this is an extreme version, the opposite of “euthymia”.  More specifically, if one is seeing things (having visual hallucinations, a common symptom of schizophrenia), I sometimes like to describe this as a response that’s not euthymic.

One of my goals as a therapist is for all of my clients… people who are depressed, anxious, have low self esteem, addicts, codependents, whoever- to have a reasonable, here and now response to their given circumstance.  If we behave for instance, based on old hurts to a current circumstance we tend to at best not be able to resolve either issue, at worst, make one or more of those issues more difficult.  Another way of saying this is that, if I experience a perceived sleight (someone makes fun of me, forgets a “small” responsibility to me, etc), but respond to that with isolation, threats, emotional blackmail, substance use or etc, this isn’t a “right size” response- it’s not euthymic.  Knowing that we are not having a “euthymic” response in this example, or as a way of problem solving, can help a lot in terms of dealing with our problems as right size, and might enable us to problem solve more effectively.  For someone suffering from anxiety, low self esteem, depression, addiction and more, this can be a great tool to start on the road of dealing with our current circumstance as it is.

Going back to some more painful considerations, I would suggest that in taking the example of the death or similar loss of a loved one or animal or etc, being sad is a euthymic response.  Just as our body has less than comfortable sensations in response to illness or injury- these are indicators of recovery from them.  Why don’t we see our relationship with our feelings in a similar light?  As an example of this, when we fall off a bike and skin our knee, most of us who know a little about science know that much of the reason it hurts is because of the inflammatory process- this is due to the healing and protective agents of our bodies (white blood cells to fight off infection, proteins to rebuild the part, fluids for transport of these materials and etc…) being sent to heal the injured part.  It hurts both as an indicator for us to know not to do that again, but as much, because it is healing.  Endlessly interesting to me, humans don’t see their non physical feelings, their emotions, in the same light.  We regard them as something terrible, something to be avoided.  It seems to me that we have them because they give us other information about our environment that we might not otherwise discern from our other senses, and a way of healing other aspects of our lives- hurts, shames, losses and etc.  It’s not to say that our feelings are all necessarily facts, but indicators of possible realities (more on this idea from my blog here).

If the above paragraph is any indicator, in many circumstances, having “bad” feelings might be the process of dealing with non physical difficulties.  Extreme (in terms of intensity) or maladaptive (not useful) responses to these create in turn more problems, and in some cases, diagnosable difficulties.  Having the idea of euthymia as a guidepost, it might give us a more tangible way of gauging our problem solving, behavior, and more.

Why Being a Therapist Is Better than Being a __________, at Least for Me.

When I was a kid and started thinking about what I was going to do as a “career”, I always knew I’d be a therapist or musician (as it turned out, was lucky enough to do both).  The reason is in part, growing up, I didn’t watch the usual TV shows- I was watching “The Twilight Zone”, “Kung Fu”, “Star Trek” (the original version), “M*A*S*H”.  What so intrigued me about the likes of Rod Serling, Kwai Chang Caine, James Tiberius Kirk and Benjamin “Hawkeye” Pierce was that they seemed to think there was “more” to the world, saw things others didn’t, and had deep passion.

In their wake, I tried to be “good” at lots of things.  Some of this came from feeling a deep sense of “not being enough”, and what still feels to me an unavoidable passion to do things That Matter.  The former almost killed me (as Sheldon Kopp said, “Why be perfect when you can be good enough?”), but the latter stays with me to this day… thankfully.

My first inpatient job while working on my Psychiatric Technician licensure (completed in 1988), I remember thinking how cool it was that all I needed to do my job was a black Bic medium point ball point pen, and my personhood.  In subsequent years, have come to a number of other awarenesses that have meant much to me.

It seems to me that it’s become a luxury for many of us to simply do what we would like to do, if we were to have our choice.  Many of us fall into what we do and begin to love it, maybe we do what our parents did, or simply honored a family business.  Lots of us do what we think we ought, or simply take on what feels best to serve and provide for our families.

All these are of course noble pursuits, but on the coattails of Rod Serling, Kwai Chang and Hawkeye, I have always felt compelled toward human service.  Famously, Lloyd Dobler (played by John Cusack in the film “Say Anything”) said, “I don’t want to sell anything, buy anything, or process anything as a career. I don’t want to sell anything bought or processed, or buy anything sold or processed, or process anything sold, bought, or processed, or repair anything sold, bought, or processed. You know, as a career, I don’t want to do that.”  Some of this points to why I’ve resisted other careers (and, Lloyd and I also turned to martial arts… a totally different story).

Many of us serve ourselves, but are still unsatisfied.  We work at jobs we are unhappy about, sometimes with people we are unhappy with, sometimes for things we don’t really need.  In some cases, these pursuits relieve others of resources that might be used otherwise- resources like money of course, time, and all too infrequently mentioned… our attention.  Some of these efforts are unsustainable, and environmentally unsound.

Not as if therapy, counseling, psychiatry and etc don’t have their defects that are creating some problems.  Overdiagnosis, starting with interventions like medication when arguably not called for and/or lesser interventions haven’t been endeavored, pathologizing and symptomatizing everything (often even the most understandable and euthymic kinds of feelings/emotional experience), passivity on the part of the clinician and more create big and often lifelong difficulties as well.

It’s hard though for me not to see a poor relationship with ourselves, others, our sense of worth, depression, addictions (and “codependency”), anxieties and fears, and maybe a couple more as being the soul (and result) of much human suffering.  That also creates in my view, the suffering of other creatures.  In the shadow of this, helping us through these concerns, and providing a framework for others to operate on in a like way are at this point, the most useful thing I can think of doing.  At least a thing that I’m good at.  ;-p  That’s a quip about my “musicianship”.

It is of great import to me that I have a small footprint on the planet.  Deeply concerned about where humans are going mentally, emotionally, physically and “spiritually”, I can scarcely think of a way to be more useful.  Therapy is a practical way of putting philosophy into use.

Something that matters to me a lot in light of some of the above is that it’s a great way to create something that can be easily passed on by others.  An organized, simple (but unfortunately not terribly easy…) and principled way of behaving in the world that can be shared can create great change of course.  Doing clinical supervision, teaching, giving tools to parents, or simply doing work with people who are in a place to impact others are my favorite areas of focus, and seem to be the most practical way of passing on what we’re capable of.

In the digital age, I don’t even have to use my pen or paper as often.  I get to impact people deeply, and most of what it takes is just me being as healthy a person as possible, and my time/being deeply present.  It’s also something I should be capable of doing for a long time.  I get to share and experience different people, cultures.  Many types of work are possible- use of humor, sharing resources, sharing experiences, teaching, problem-solving, processing, consulting and more.

Gratefully, all these years later, I could scarcely think of doing anything else, and still feel deeply committed to The Work.  The “how’s” and “why’s” of avoiding what some call “burnout” are an entirely different thing to write about.  Point is though, I’m so, so lucky I get to do something that I still feel so deeply passionate about, and doesn’t violate any of Lloyd’s principles.

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Clinical Supervision: A New Intern!

One of the better ways I think I can be of use to the community is by training other therapists and interns.  Have now hired and am doing clinical supervision with a new Marriage and Family Therapist Intern, Sarah Wood, MS, MFTI (#66300).

Am really happy about getting to do this.  With the Partners in Recovery program for interns sunsetting at the end of the last school semester, there’s been less opportunity to get to work with folk that way.  Am double excited about getting to do so with Sarah, because she’s already great at what she does, and really has a taste for The Work.

She comes on the recommendation of one of our last interns, Melissa Lamoureux, who was also at Partners in Recovery.  Sarah did her graduate work at the amazing program at Cal State Fullerton.  She’s done a lot of great work in the community already, specializing in therapy with children, trauma services for all ages, eating disorders/other addictions and more.

I feel like it’s a stroke of luck to get to work with her, am happy to get to recommend her services.  Please go by her website and learn more about Sarah at sarahwoodtherapy.com.  Welcome Sarah!

7400 Hours, Psychology, Clinical Supervision

About three years ago, my friend and colleague Judy McGehee LMFT (Partners in Recovery) began a supervision program for Marriage and Family Therapist interns (people that have completed their coursework for Masters degrees) and trainees (those who are about to complete Masters degree coursework).  Borne solely out of a desire to be helpful, and pass on the ability to provide effective human service, for fun and for free, Judy took on supervising 8 or so trainees and interns.  We were joined also by a visiting therapist, Ted Aaseland, Psy.D.  A little over two years ago I joined her in this endeavor, as I care deeply about passing on how to do “The Work”.

Over the course of those years, those interns provided services to the Glendora School District and elsewhere to children and adolescents for free.  Some of these turned into outpatient clients, individuals and families, also for free.  There were also public speaking engagements for adults and adolescents, professionals and non-professionals.  After all was said and done, over 7400 hours of free therapy (not including the speaking/community education efforts) were provided, all for free.

Interestingly and tragically, there are several stories that run in parallel with this one.  Before I get there though, it would be instructive to tell you a little about this process, both from the perspective of the licensed folk/interns/trainees, and from the folk we hope we were helpful to.

Will start with the experience of the trainees/interns/licensed folk.  Most universities require several hundred hours of internship/clinical experience for graduation.  The processing of these hours is supervised by a licensed therapist (who can be a supervisor, as regulated by the Board of Behavioral Sciences), and the student must pay for this process.  Most universities, in an uncomfortable wrenching of common sense, either don’t have someone to organize/and or set up/maintain these supervision placements, or they’re simply not updated for various reasons.  The student/trainee however, is still required to do this.  To add insult to injury, the trainee when in supervision, if they can find an agency, is rarely given a real experience of being supervised at their work.  It seems flabbergasting to consider this, yet it’s tragically true.

Similarly, interns (therapists just out of school) have to complete over 3000 hours of work with patients/clients, just to sit for the two licensing exams.  They have six years to complete this process, requiring continuing education to reset their chance to sit for the exams.  That means that they have to see clients, and that those hours also have to be supervised.  Related to both this issue and Judy’s (Ted’s, and mine) efforts, we were completely unable to get other clinicians to volunteer for either of these processes (for trainees or interns)- not even a couple of hours a month, let alone the minimal 2-4 hours a week.  In light of the complaints of most people we know not feeling like they received quality supervision, this is no small issue.

The second body of material that is really important here is the students and families.  There were of course the predictable experiences with clients who struggled with behavioral problems, substance use/addiction, depression, stress, bullying, pregnancy, self esteem, eating disorders, anxiety and the like.  It was also really common to have active suicidality, reports of abuse, the precursors of “thought disorders” (schizophrenia, and the like), violence, abandonment, PTSD, mood disorders (bipolar disorder and related problems) and more.  There was psychoeducation, crisis intervention, abuse reporting, ensuring of safety, documentation, creation and use of materials, referrals to resources, interfacing with administrators/Department of Children and Family Services/other clinicians/teachers/families and more, interviewing, showing up for IEP/planning meetings and more, and oh yeah… individual and family therapy.

The interns (and will give a little credit to us as well) braved all of these issues and more.  All for free.  Seven thousand, four hundred hours of it, and the attendant signing off of supervision hours.

We met weekly for all this time, as individuals and as a group, to meet the requirements for the relevant university, and for the Board of Behavioral Sciences.  We met in between to take care of paperwork.  To problem-solve.  To handle questions.  We met for lunches, at each others’ homes, in restaurants, in parking lots.  We celebrated birthdays, mourned losses, processed issues, checked one anothers’ heads.  There was a lot of happiness, crying, efforts to glean resource support to continue the work, discovery.

There’s certainly more to be said, and obviously, more work to be done.  Though this cycle of supervision is over, we still have a lot of passion and ideas for what might be next.  The whole point of writing this though, is simply to honor the work of Michael Cardenas, Eryka Gayoso, Elva Cortez, Jessica Wilson, Jeffrey Craig, Melissa Lamoureux MS, Ted Aaselund Psy.D, and most of all, Judy McGehee LMFT.  Thanks so much for making all this matter, and letting me participate.

Difficulties, Diagnoses, the DSM.

In a New York Times Op-Ed piece from today, one of the leads on the DSM-IV (the “Diagnostic and Statistical Manual”, the current edition of an industry standard tool for mental health, primer here) task force wrote about the upcoming changes in the DSM-V (likely to be released in early 2013).  Summarizing, Allen was suggesting in part, “…after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription.”, and that the American Psychiatric Association was  arguably no longer in a place to be singularly in charge of the meting out of diagnoses, calling it a “monopoly” (offering that an agency akin to the FDA or National Institute on Mental Health might be examples of ways to provide oversight in the efforts to insure some science around diagnosing emotional and mental problems).

Am with Allen on quite a bit of this.  What comes to me often too, is that we have equally large fish to fry with the DSM and the profession than just the pathologizing and monopolizing he suggests.  We have been over-diagnosing ADHD (attention deficit hyperactivity disorder) and bipolar disorder, among others.  Our differential diagnosis (rationalizing one diagnosis vs another) has also been resulting in much harm to people by way of treating issues unneeded, and/or incorrectly.  We are also arguably guilty as a discipline of using interventions that are more “intrusive” than necessary (for instance, medicating a problem before efforts at traditional talk therapy and/or other interventions have yet to be tried).

It seems to me that in reviewing the DSM, we are more currently in need of insuring the accuracy and value of our diagnoses, in terms of insuring that those so suffering are treated more appropriately.  We do know ways to treat depression, anxiety, addictions, bipolar disorders and etc.  We do have means of helping people through grief/loss, communication problems, abuse, suffering with stress and etc.  As the saying goes though, the “cure” (a dubious word to begin with) is only as good as the diagnosis, and with the numbers of the diagnosed only increasing in the US year after year, either our diagnosing or treatment (or maybe a bit of both) are not faring as well as they might.

A quick aside here- not all of the missed treatment opportunities are about the above issues.  Some of them are due to the influence of Big Pharma (an intense imposition by the pharmaceutical industry), access and funding of mental health treatment, the insurance industry and more.

Specifically related to the DSM though, my hope is that we’d simply be better at a lot of the material we already have.  Adding diagnoses, or simply separating them into finer and finer constellations of symptoms seems both unnecessary and unhelpful, philosophically speaking.  Part of what I’m getting at above is that I think we have some good ideas about how to help many ills- I just wish we spent more time treating them, and less time diagnosing new ones.

PTSD, Euphemisms, and George Carlin

The famous American standup philosopher George Carlin has a fantastic piece about euphemisms.  Paraphrasing and simplifying, he offers that he’s against euphemistic language.  Part of what I’m with him on is that euphemisms tend to conceal the truth.

May 5th, there was this article in the Washington Post indicating that there are a group of psychiatrists hoping to change the term “Post Traumatic Stress Disorder” (AKA “PTSD”) in the upcoming DSM-V (the “Diagnostic and Statistical Manual, 5th Edition”, the industry standard for all things psychiatric diagnosis… quick primer on my website here) to “Post Traumatic Stress Injury“.  The change, they hope, will make it easier for people, particularly military personnel, to more readily seek help.  They are citing that the term PTSD has a stigma attached to it.

While it arguably does, “Post Traumatic Stress Injury” might also be an equally unhelpful euphemism.  Non-military personnel frequently get the symptoms of PTSD as well.  Victims of crimes, violence, sexual abuse and more often have sufficient symptoms to justify being diagnosed with the disorder (Wiki here, for a quick look).

My concern about this is not simply haggling the diagnosis.  In all candor, the tome (the DSM) is a convention (with some real science too, but arguably still a convention)- a means of shorthand for mental health professionals to communicate.  My interest in the book is mostly about how it helps us guide treatment, and obtain treatment from the relevant funding sources.

Back to Carlin, he specifically addresses PTSD.  He takes us through the historical context- that the problem began with our recognition of the symptoms post war.  A condition we used to refer to as “shellshock” gave way to “battle fatigue”, then “operational exhaustion” (probably the grossest evasion of the depth of the severity of the symptoms of the problem), eventually leading to the current “PTSD”- arguably in light of the awareness that lots of things besides war can cause the aforementioned symptoms above.

We need a shorthand.  This will be the 6th shorthand (if we count “combat stress”) we’ve endeavored to come up with.  What we need more though, is an honest representation (and advocacy of awareness) of the consequences of these horrific events.  I’m less worried as a professional about whether or not someone suffering needs help than I am about whether we can actually get them access to it- and our evasion of these truths, often through our language, prevents us from getting legislation, funding, and other resources necessary that we can serve all victims of trauma in the ways that they need and deserve most.  Sadly, my experience of the last 28 years (at this point) has led me to feel that how we communicate about these problems has led largely to desensitization, in part, due to a euphemistic way of communicating such problems.

On a related note, often, a lot of the language in my discipline serves the individuals and the discipline itself, rather than the sufferer.  Pharmaceutical companies are served, occasionally a “new” theorist is served in terms of marketing their ideas, insurance companies are served, but rarely is it people that are suffering who are served.  It’s a source of consternation for me, both personally and professionally.

Some might say I need to come up with a more accurate term.  Maybe I should, but it’s not really the part of this that I’m invested in.  It takes longer to talk about someone suffering flashbacks, avoiding situations and experiences, fears, hypervigilance, poor regulation of their feelings, struggling with being overwhelmed by sadness or shame, having their ability to function in their responsibilities and relationships diminished (and much more), and explain what these things are to people, specifically.  But seeing how these folk are so suffering, it’s clear that doing so is worth it.  Taking the time to live with these words and feelings means much not just in terms of understanding the suffering, but honoring it.  If we’re truly going to care for people who are suffering, it will take at least that.

From the “Something That Came Up Today” Department… More on “Stopping”

Truth, it comes up a lot.

We’re all trying to “give up” some stuff, trying to stop doing some things, but often have difficulty doing it.  Aside from a blog I wrote about this a while ago, we might want to think of such things as surrender instead of “quitting”, stopping, etc… but I digress.  We endeavor to stop drinking, overeating, eating poorly, isolating, perfectionism, controlling things, spending, video games, TV, and a host of other things.  Sometimes we’re trying to avoid things that are actually good for us- exercise, going to a support group, going on a job interview, self care and the like.  Most of the time we point at a lack of insight, “willpower”, or related ideas.  For dozens of years, people have been going on *wince* Dr. Phil, Oprah, Donahue (I don’t watch too much TV- who do we have now?), and others asking why people can’t stop __________.

There’s an interesting colloquialism in 12-step programs that addresses this.  Some say that “what makes people drink is sobriety”.  Whatever one feels about 12-step programs, this is a pretty elegant, and deep idea when applied to alcohol or drugs or other things we might want to give up.  Consider it this way- what if our inability to stop something (or start something) is not the difficulty in stopping or starting, presence or absence of “willpower”, but the difficulty of how we will feel if we do?

Try this thought experiment.  How would an alcoholic feel if they stopped drinking?  Someone that stopped “obsessing” over __________?  A person obsessed with control feel if they stopped controlling things?  Someone that stopped overeating?  It’s intuitive to say that these folk might be “relieved”, but I’d argue that’s a superficial look.  I think these persons (and other people with other issues) would feel pain, fear, sadness, even shame and anger.

What I’m getting at (simply) is this: if we have trouble surrendering something, it’s more likely that is difficult because of how it would feel to do so.  More difficult than the effort or organization or “insight” about what we need to give something up.  If that’s the case, it points to why much deeper “work” is more often necessary than simply will-ing our way into stopping something.

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