What We Don’t Get Taught

Have been lucky enough to do some clinical supervision with Judy McGehee.  As I’ve mentioned before, she and some interns have been providing free services to their community for some time now.  Some concerns I’ve had with other venues of supervision have come up the last couple of times we’ve met.

Clinical supervision, like therapy, is different things to different people.  Many times it’s the opportunity to “present cases”, problem-solve clinical, legal, ethical issues and etc.  It’s also a place for us to have the opportunity to discuss or work out struggles we have as therapists- something that certainly should go on for our entire careers.

One of the things I like to do in supervision is talk about the issues that are not necessarily explicitly processed when we go to school.  There’s lots of these sorts of concerns…  how to deal with our own feelings as therapists.  Issues of responsibility- where ours are vs. where the clients’ responsibilities are, how much is “enough”, concerns when we’re sometimes working harder than the client is (or not).  Handling boundaries about parents endeavoring to influence issues discussed (or simply perspectives about them), concerns that arise in couples therapy or family therapy like one person in the “group” disclosing something that affects the others outside of the “group” proper.  How to handle when a client isn’t being honest about a problem or circumstance or behavior.  Determining how to handle “terminations”- planned discharges, “therapeutic discharges”, discharges against medical advice… sometimes when a child is “pulled” from treatment by a parent against the better judgment and suggestion of the therapist.  Speaking of, there is little discussion about how to handle referrals to other types of resources or therapists.  Specific methods to avoid (or deal with) “burnout”.  Very “nuts and bolts” concerns like documentation, treatment planning, dealing with insurance companies and such.  Fee setting.  What to do if a therapist runs into a client outside of the office or other milieu.  How to handle when a client is “stonewalling”. Handling clients that are self-medicating.  My personal favorite is specific goals and underlying philosophy of our methods as therapists.  There are many, many more.

It is of course really important to do case conference, have both group and individual forums for processing what is happening with specific clients or groups and the like.  I find it of great import too however, to discuss the above issues.  It is one thing to discuss a specific case, but I think it another to discuss what it is about that case that will come up (or has) repeatedly, in a principled manner.  Would argue too that discussing issues like responsibility, boundaries, terminations, referrals etc often lead to greater resolution with clients “in the room”, as well as provide a way of generalizing our knowledge and methods, thus making it a more organized and effective way of treating folk.

Am not suggesting that these things never occur.  It has definitely been my experience however, that most of the above ideas are not discussed in depth, if at all.  Certainly concerns of symptom ID and management, differential diagnosis, theoretical orientation and etc are of great import, but it is uncomfortable and counterintuitive to run into a circumstance that occurs frequently or that is a fundamental part of operating in our discipline (treatment planning, for example) that is largely omitted from our education.

More than anything else, I think I’m advocating for more of a focus on our underlying philosophy for employing the methods that we do as therapists.  I’m not simply trying to help someone (or their parents) improve failing grades, or get someone in a relationship to be more sensitive or attentive, or even to diminish “depression”.  What I hope to achieve in most (most) circumstances, is to:

1.  Insure safety and stability necessary to do “The Work”.  (absence of suicidality, abstinence from drugs, ETOH, or a behavior, have medical concerns be ruled out by a physician, insure that necessary resources to do the work are in place, etc)

2.  Identify “issues”- the events (relationships, circumstances, etc) or other causes that prompt us to feel mad, sad, afraid, ashamed, and/or hurt and/or “behave” in ways we struggle with.

3.  Process those issues in a way that diminishes, transforms, and/or (almost) eliminates them and subsequently behaviors, choicemaking, or perspectives that might contribute to these issues in an ongoing way.

4.  Provide a “body of material” (patient education, referral sources, resources etc) that enables the client to be able to do these things without the therapist.

5.  Insure that the client has sufficient resources (support groups, family, friends, etc) that support the work and use of that material in an ongoing way.

These are an oversimplification, but I think they go beyond simply “resolving a problem”, eliminating a behavior and etc.  Much of the inner workings of these ideas don’t get processed as much as I’d hope while we’re being educated about our discipline, but again, of course this philosophy likely exists in many of our “theoretical orientations”.  In my sense of things, the presence of such a philosophy doesn’t go far enough- we as individual therapists need to have a grasp of our own sense of these things to make them as effective as possible.

Would say further that none of this is supported unless part of our own supervision is about dealing with our own experience both as a therapist, and a person outside of therapy.  My ability to problem-solve many of the issues “not discussed” above is diminished by not having the opportunity to explore these things as part of our own clinical supervision.  The largest of these things for me are the underlying treatment philosophy, and the effectiveness and grace that I deal with my own life- including my life as a therapist.

Shame, "Self-Esteem", and Buddhism

Been thinking a lot about how most of us, when we were kids, didn’t have a lot of compunction about playing with other kids, meeting new people we liked and such. Maybe when we were very little we might have been “shy”, but in this case I think we’re talking about caution, fearfulness, as opposed to lack of a sense of self esteem.

When I was a kid, it was easy for me to go down the street and ask about a kid there I thought was my age that I could play with, to try new things… I think because we’re actually born with a sense of self esteem or self worth, and that sense of worth gets taken away. That sense of our value, how we are connected to others, self esteem or self worth, gets replaced by shame- feeling “less than”, insufficient, unlovable, broken and defective as human beings.

This sense of self esteem is diminished or removed a lot of ways. Verbal abuse- actually being shamed by others, made fun of, called names, diminished for mistakes or lack of knowledge of a thing, literally being told one is somehow bad, not going to amount to anything, being compared against others, being yelled at or threatened.

Physical abuse. The predominant message a person gets when struck by another person out of anger, an effort to discipline, etc. is that they are somehow flawed. Being treated gently shows someone their worth. It takes effort… attention, patience, softness- the opposite of which takes little effort. Of course, this is often coupled with verbal abuse, sometimes sexual abuse.

Sexual abuse. When this happens to someone, they often get the message that this is their only value, their only utility as a person. It’s also extremely common, in order for the abuser to be able to continue the act, that they diminish the victim as a person. Taking away their power, their human-ness, their self worth, makes it easier to continue violating them. The act itself literally causes shame- it instills something in the person that they have to hide, something that makes them feel less human, separates them from others.

The media. There’s a lot of images in our society, a lot of messages that we get about our worth. Television, magazines, movies, other people, all bombard us with a message about what we “need” to do, have, look like. We are given the sense that unless we’re attached to some product, some lifestyle, some particular achievement, we are somehow not successful. This is not simply a message about how far we’ve gone in life, it’s a message about our being-ness, our human-ness.

We do a lot of work to “get” self esteem- take care of ourselves physically, our appearance, do esteemable acts, visualization, affirmations and etc. Those of us that have done these things often haven’t been able to maintain our self worth despite such efforts. These ideas help us feel better in the moment, but long term, we often still experience a deep sense of shame.

Some have said that a central idea in Buddhism is that at the center of each human being is the fear we don’t exist. This lends itself to the idea that we are constantly reaching outside of ourselves for things, naming and labeling them, attaching ourselves to them, trying to obtain them. In doing so, being attached to a thing (person, etc), we can fear less that we don’t exist. So we go about our lives in a way that diminishes our personhood, our being-ness, our selves being “enough” simply as we are.

The answer to this is not simply adding things to our lives, behaviors, personhood. Shame, low self worth and etc is something we have to give away. We have had experiences that diminished our self esteem- abuse, abandonment, exposure or humiliation, being diminished or demeaned verbally- those are the things that make us feel less of ourselves. Until we find a way to “let go” of those feelings, to give them away, to make space for our self esteem, we will be unable to experience it no matter how many “creative visualizations”, affirmations and etc. that we do.

Wanting to Stop

Have had several people in the last week ask me specific questions about wanting to stop (sometimes called “abstaining” or “cessation”) doing some “behavior”. Drinking, smoking, gambling, over/undereating (or not at all), self-harm behaviors (cutting, burning oneself etc), “codependent” behaviors, controlling behaviors, manipulating, even saying or thinking certain things and more. While some of these require more intense interventions (stopping alcohol or drug use for instance would require medical intervention), some other behaviors can be stopped or minimized by other means.

Though we (therapists) are oft charged with the responsibility of helping clients stop these behaviors, we’re not always direct about how to help someone do so. There are real-world, practical means of helping us stop these kinds of behaviors. It should be noted though: in many cases, these are caused by unresolved emotions. It’s really important to note this, because no intervention we might suggest will work if there is a sufficient mental/emotional/”spiritual” and/or physical prompt to do so.  Or more simply and by way of example, if someone is suffering enough emotionally (or otherwise), no intervention will stop the behavior.  The feelings (even if physical) have to be transformed/diminished enough for the intervention to work.

These things in mind, here’s some ideas. Some of them are direct, some of them will take hold over time:

1.  Pay attention to how we feel.


2.  Ask ourselves, “Am I mad, sad, glad, afraid, ashamed, and/or hurt right now?  What ‘possible reality’ does this indicate?”

3.  Putting off the behavior.  For example, “I’ll _________ (smoke, drink, gamble, eat, etc…) an hour/day/week/month from now.” 
 
4.  Context.  This isn’t just a principle.  It can be practical.  Asking, “What am I supposed to be, or supposed to be intending to do right here, right now?”

5.  Service.  Finding a way to be of help to another person.

6.  12 step program attendance/participation.

7.  Saying the “Serenity Prayer“.  Even if not “prayerful” people, this can be a form of self-talk (the word “God” can also be removed).  For things we’re “powerless” over, “God, grant me the serenity to accept the things I cannot change, the courage to change the things, I can, and the wisdom to know the difference.” makes us mindful of principles and behaviors that can also help with abstinence.

8.  Speaking of praying (or doing self-talk)- praying for the obsession to have __________ (smoking, drinking, gambling, eating etc) be removed, helps.  “Please remove from me the obsession to stop _________.”

9.  If that is hard, praying/self-talking for the willingness to stop __________.

10.  Calling someone.  This, to me, is one of the most powerful tools.  Having someone who knows what we are working on that we can call when considering the behavior to: pull our covers (so to speak), have them talk us out of it, and/or “be” with us as we struggle with the feelings of letting go of the behavior can be pretty powerful.

11.  A different item from the above- calling that someone as a pre-emptive strike.  Meaning, calling them when we might be in a situation this will come up, before we go do the thing we have to do.

12.  Make a list of the times these things (smoking, drinking, gambling, etc) occur most frequently.  Take that list, and either apply the things above (and below) to those circumstances if you HAVE to be there for these instances, and or use the list to avoid those times entirely.

13.  Write a list of the negative consequences of the acting out behavior.  
14.  Maybe most important, is simply identifying the issues (even by making a list, which we will also do in a formalized way) that have prompted us to operate this way, and have an organized means of getting through these (which therapists are charged with the responsibility of).

15.  Based on that list of things/people/circumstances that get us in trouble, have a list of replacement behaviors.  For example, I know I shouldn’t be __________ (smoking, drinking, gambling, eating etc), so, I’m going to go to church/support group/call my friend/read this book/exercise/take a walk/write about it and more etc.

16.  Speaking of writing: when “tempted” to do the behavior, write about it.  That’s pretty common information from most therapists.  However, I think it doesn’t go far enough, unless you read this to your therapist and/or a loving friend and/or a sponsor (if one attends a 12-step program), priest, pastor, and etc.  Maybe more than one of these people.
17.  Putting a rubber band around our wrist, and giving it a gentle snap when considering doing the behavior.
18.  Making a “fund” for the behavior- putting a pre-determined amount of money in a jar when we do the behavior (or consider it maybe), and donating it to a charity or some related idea.
19. “Play the record through.” All the way through. Consider every step of what will happen, what it leads to, and its consequences.

Again, I want to reiterate that no amount of ideas to “stop” a behavior (that we do in our heads or outside of them, so to speak) will be sufficient without working through the attendant (and/or consequential) emotions that come with them.  Those are really strong reasons pointing to the idea of having a therapist that can help use these kinds of tools (and more), and walk through the related issues.  It’s important too that many types of concerns will require medical attention by a physician with experience with the specific problem.  Good luck with any of these efforts…

Post Script: It should be noted that the soul of such things is what Carl Jung would have called “illegitimate suffering”- meaning, we do these things as an alternative to simply feeling whatever we feel when we don’t do the behavior.  One of the things we do these over is feeling “bad” (about ourselves), broken, less than, “not enough” and the other variations on that theme.  Often, if we do the behavior we’re trying to stop, we feel those very things (“bad”, broken, etc).  As we often do the behavior to diminish or eradicate feeling those things, then we feel those very things for doing the behavior.  Simplifying: I feel “broken”, less-than, etc, I do a behavior to not feel that way, then feel “broken” (less-than, etc) for doing the behavior.  It sets up a vicious cycle, a repetitive cycle.  

Where I’m going with this is, if you happen to do the thing you’ve been trying to stop, “beating yourself up” for doing the behavior may be the very thing that prompts you to do it again.

You Can’t Heal What You Can’t Feel

We constantly “do” things- behaviors and thinking, that put distance between us and us, us and “others”, us and ‘god’ or the ‘universe’ as we MISunderstand s/he/them and/or it.  Food, sex, TV, gambling, relationships, rationalizing, avoiding, intellectualizing, alcohol, money, property, prestige, drugs, toys/devices (cell phones, computers, etc), fixing other people, “acting out” etc.  Overstating, when it comes to distance between us and us, we’re talking about putting distance between us and our emotional condition.  Simply using a lot of words (Lao Tzu has famously said, paraphrasing, that “many words lead one nowhere”) and even certain types of words can put distance between us and our feelings.

To simplify getting in touch with and processing our feelings about things, I encourage using what are sometimes referred to as the “Six Basic Feelings”.  These are mad, sad, glad, afraid, ashamed, and/or hurt.  Certainly, we can have one or more of them at any given time, even about the same issue.  I really resist other words if at all possible, for reasons too long to go into here.

If we’re engaged in the aforementioned behaviors, we are often mood-altering, and/or simply less or unable to be in touch with our emotional condition (and as a result, others and the rest of the “universe”).  If our feelings are indicators of possible realities, if these are altered or stunted, we may not have all the information about a given circumstance.  The idea we’re going for is to talk about them in a way that transforms them, and or helps us clarify different circumstances.

So, my suggestion to get in touch with and begin transforming these is this: know the things we do that are mood-altering, let go of those behaviors (a whole other note all together), and as our feelings come up, say the facts of the circumstance, and one or more of the six basic feelings.  For instance, “When my mom (or whoever) said/did/didn’t say/didn’t do __________, I felt __________.”  That’s all.  Trying to avoid inferences, interpretations, assessments, judgments, manipulation, controlling, etc., certainly avoiding behaviors we do that ignore or diminish our ability to be in touch with how we feel.

It’s been said too that we can’t heal what we can’t feel.  So the process I’m encouraging is identifying what we do to not feel, letting go of those so that we can feel all of our feelings (“all” meaning each one, in all circumstances, and with 100% of the intensity we’re experiencing them…), naming them simply, communicating them in a way that helps us stay in touch with/get help/transform them, then finding ways to live our lives gracefully through what comes up as we process them.  This is a process I encourage with therapists, relationships, as many places as is possible.

It’s really important to point out that I’m not advocating for this process to change anyone else’s behavior or perspective.  This is not an idea about right and wrong, certainly not about comparing the relevance of our feelings to others.  It’s simply a way of getting in touch with what we feel, so that we can change it.  We often say to one another that we should “let go” of things- but you can’t let go of feelings you don’t totally have.

Honoring What Is.

Laughing to myself a little now because, though I intended to write about honoring our feelings and “sense” (perception?) of things, was quickly reminded of how hard it is to know how we feel in the first place.

That aside, the idea of “honoring” our feelings has come up a lot lately.  Am assuming we’re in a place to know how we feel to begin with.  Don’t run with this idea and think honoring our feelings is in conflict with my earlier suggestions that our feelings aren’t necessarily facts.  Paraphrasing one of my “heroes” (though he’d certainly admonish me for having any heroes in the first place, particularly him…), Sheldon Kopp has noted along with so many others (Tolstoy, Jung…) how curious it is that we spend so much time and energy actively not honoring our experience of things.  In favor of doing so we dismiss our feelings, compare our insides to others’ outsides, diminish the importance of our feelings (sometimes by comparing ours to what others have been through), distract ourselves (food, buying, drugs, sex, alcohol, TV…) and etc.

The consequences of not honoring our feelings are huge.  It can cause depression, acting angry (as opposed to being angry), addictions, irritability, not acting as the person we’d like to be, allowing people to violate our boundaries, is a huge factor in a lack of self esteem and more.  It can cause us to not trust our own eyes and ears when we maybe ought to.  It can keep us in relationships that are not healthy for us.

Honoring them is arguably as difficult as not honoring them.  It’s likely one of the primary reasons we don’t honor them.  For many of us, it’s not even an idea we’ve really considered.  Much could (and will, eventually) be written just about how to have our feelings in the first place.  Once we do have them though- honoring them and doing so gracefully is a very difficult challenge.

From my sense of things, “feelings” are called that for a reason.  It’s so tragic that we behave in a way that indicates we often think we ought to do everything possible with them besides simply having them.  They’re called feelings because we’re supposed to feel them.  They give us messages about our environment and allow us to heal.  Feeling them and not “folding, spindling, or mutilating” them is the first step.  Once we have them, giving them a name is useful- I always begin with encouraging mad, sad, glad, afraid, ashamed, and/or hurt.

Am also a huge fan of treating them gently once we have them and have named them, whether they “make sense” or not.  Not being gentle with them exacerbates them, or simply prompts us to change or otherwise avoid/ignore them.

Once having them, naming, and being gentle with them, we’ve begun to honor them.  If we know we have them, know what they are, and are experiencing them without trying to do something unkind with them (make other people see/think differently, harming ourselves, avoiding them with some of the behaviors above and more), we can process them based on what they are.  Crying when we’re sad or hurt, are pretty clear ways to honor our feelings.  Telling other people what is happening for us when we feel ashamed (some say “guilty”, or less than, broken, etc…) honors our experience.  Telling other people how we feel honors them.  Asking people to be with us when we’re scared or feel broken is a great way to honor our experience of things.  Being mad instead of acting mad (a subject for a whole other missive) is a way to honor it.

We don’t honor our feelings in relationships either.  We’re loyal to people that are disloyal to us.  We treat ourselves more poorly than other people often do, but when we do get treated poorly by others, we oft treat them more gently than we do ourselves, or ignore it wholesale.  Though we may get our feelings hurt about something, we keep it secret.  Sometimes we are sad or hurt or ashamed or angered by something, but keep it from the other person as not to hurt their feelings, but are often taking from them the chance to do or see something different.

Sort of wishing I hadn’t begun writing about this particular thing.  Honoring our feelings is dependent on so many things- not doing things to get in the way of feeling them, having simple names for them, having them gracefully, treating them gently, not thinking or communicating about them as facts, processing them.  So much might be written about any of those ideas.  It’s come up so often recently, and is such an important idea though, am compelled to put at least something out there about it.

Utility of Sadness

We do some *ahem* interesting things with sadness.

Often, people ask us how we are.  I think the real question is about how we feel, but we will oft answer “good” or “bad” or “not so good”.  All judgments about how we feel.  Most of us would argue that “sad” is a “bad” feeling.  If we can get past that, we may use another euphemism: “depressed”.  Our relationship to this thing is often not great.

When I left my office this morning (my second office at the Life Fitness Center, a group that provides a more holistic set of services), I was sad myself.  I’d spent several hours with people who were in horrible circumstances, and had already been suffering.  Mightily, and understandably, I might add.  When I got to the light, I noticed a gentleman, probably 7ish, walking through the crosswalk with his mom.  One of my licensures is in developmental disabilities and other related problems, and I noted his cerebral palsy right away.  They were holding hands, and though his body was having a hard time- his soul certainly wasn’t.  He appeared really happy.

Behind my wheel though, I was pretty sad.  For my clients this AM, and for him (though he was probably fine).  Most of the time when we get sad, we find some way to resist it.  We push it away with our minds, set our attention elsewhere, numb it with all kinds of different behaviors, even shame ourselves for having such feelings in the first place.

Would argue though, that my sadness, has great utility.  Not only is it the most effective way to heal my losses, it certainly makes me useful to other people.  Exactly how it heals grief and loss is not quite the gist of this missive, and takes time with a therapist/counselor/life coach to know how to do effectively and gracefully.  Am certain that my sadness today assisted me in being kind and present for my clients, and likely would keep me “softer” when dealing with folk like the gentleman in the crosswalk.

My hope is that I never lose this.  As long as I am sad about the suffering of humans, I have business doing the work that I do.  The point of this though is that this is true not just in terms of my relationship to my clients or other folk in the world, but all of us in relationship to ourselves and one another in general.  Honoring our sadness does more to “cure” “anxiety” (sorry for the consecutive quotes), relieve “depression”, and make us available for intimacy than most any other thing I can think of.

Reconciling ourselves with sadness, and finding some “grace” in how we live with it, if the above is true, surely presents some great reasons we should stop treating our sadness as something repugnant.

On a different note: as a reminder, Judy McGehee and I will be on the radio/live stream/podcasting at the link below tomorrow from 1130AM until noon on the “Project Get Well America” show with Dr. Mark.  The link for the show is here.

Feelings Aren’t Necessarily Facts.

Because it’s been coming up recently, and because it’s a fundamental principle of what I do in terms of therapy:

Feelings aren’t necessarily facts.  They are just indicators of possible realities.  Of course this doesn’t mean they’re not facts- but that’s beyond the scope of a blog.  They give us information about our environment that might not otherwise be discernable or supported by our other senses.  They do much more than this, but that too is too long for a blog.

Unless we have a relationship with our own emotional condition that is healthy, I’d argue that we will have a difficult time “seeing” things clearly (circumstances, other relationships, etc.), and making choices about how to handle things.  This is true even in absence of grief and loss, depression, relationship problems, abuse, addiction and etc., and is certainly made worse by the presence of these issues.

Processing feelings (emotions as some call them, or as I often do, e-motions), transforming them, reconciling with them, how to identify them and what to do about our sense of things in light of our feelings is of course what counseling, therapy, and life coaching are all about.  At least seeing this idea as a principle, even in absence of those things can help us tell real alarms from false ones, provide some simple relief in some circumstances, give us an opportunity to be kinder to ourselves, and an opportunity to be kinder to others and more..

Space.

So many of us are looking for self esteem, happiness, “God” (if one believes in such), good relationships and etc.  These ideas come up a lot in my work, from all kinds of people, all different kinds of age groups and backgrounds.  They’re understandable, and common efforts, much of what make our lives worth living.

We do a lot of… interesting… things to get these. We “socially engineer”, we try to bolster our sense of self with our egos, we do all the prescribed things that religions or spiritual traditions or philosophies (or therapists) encourage us to do to get a sense of “spirit” or “God”, we buy things, try to get him or her to be interested in us.  We use drugs, alcohol, money, property, prestige.  We even use a lot of methods we’ve gotten from other therapists or self-help books (or programs) to get these things as well.

More and more, I think that these things, if we’re to have them at all, are far less about “getting” them than they are about making space for them.  If we’ve been told all our lives that we’ll never amount to anything or have had things happen to us that have made us feel “less than” or broken or defective, no amount of the above ideas (and more) will be sufficient to bring us self esteem or happiness.  The ideas I’m suggesting about “God” or relationships etc are much the same- we have to make space for these things, that are usually occupied by some loss, hurt, anxieties and etc.

The how and why of this is beyond the scope of a blog, but it’s certainly an idea worth pondering.  Overstating, learning how to let go of hurts, losses, shame, ego- these will go much further in bringing us healthy relationships, a healthy relationship with ourselves, a sense of connectedness to “God” or others or the “universe”, than any amount of money or anything else will ever provide.

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