We Should Be More Critical…

… in our thinking. While loath to say that in the current environment, and think we second-guess ourselves in unhealthy ways, am referring to a different type.

Whatever first brings my employers (clients) to my office- relationship problems, depression, anxiety, addiction, low self esteem, “stress”, anger etc…, I would argue that it’s really four things: they want to be happy, have a sense of self worth, have a relationship with another person, “succeed” in the environment/community around them. For all the Cognitive Behavioral Therapy, attachment theory, Dialectical Behavioral Therapy, Gestalt, existentialism, psychoanalysis, client-centered-solution-oriented-short-term-evidence-based-practices employed by the therapist or improvised efforts on the part of the client, critical thinking can go a long way toward the wants/issues above. Critical thinking is an organized set of principles, and tools, that should be used as ways of knowing and problem-solving things.

When confronted with a problem, we tend to throw “will” (some kind of effort that is nothing more than improvisation) and/or thinking at it. That thinking tends to show up without use of actual critical thinking skills. Worse, these efforts are usually based on a tacit approval of both the cause of, and solution to a problem. There is a term for this in both philosophy and psychology: naive realism. More simply, we tend to identify causes and solve problems based on whatever arrives in our consciousness, without examination. As a default we treat our anger as righteous, our hurts as immediate and “true”, etc., though experience tells us we are usually “wrong” as often as we are “right”. This is a very poor foundation upon which to build problem-solving methods of any kind, let alone imposition of will and intellect. There is a whole discipline of philosophy dedicated to how we actually know things called “epistemology”, to which we arguably owe credit for the tools below.

In addition to will and intellect, there’s clearly other means to solve problems- asking for help, being honest/taking a risk about something, not intervening at all (something that’s really difficult for a lot of us), compassion, waiting/being patient, making amends, setting a boundary, “softening up” (as opposed to resisting, building up defenses, etc), educating ourselves about the problem and more – but these rarely get to see the light of day when it comes to our sorrows because of naive realism. Some problems that arise in therapy stay unresolved too due to critical thinking errors that we call “cognitive distortions”. A different way to begin problem solving is to have the tools of critical thinking at our disposal.

Few of us are taught critical thinking skills “proper”. These are specific skills/principles, and there’s methods for their use. Unfortunately, we’re not really taught what they are – even if we’re encouraged to use them. Our schools, family constellations, churches, therapy offices may suggest them, but there’s little attention on giving them consistent names, defining them, or employing their use. Though addressing how to employ them is beyond one blog, as a start, I’ll offer some important/fundamental ones that are almost universally accepted in science and philosophy:

  1. Review and clarification of goals/”answers”/desired outcomes
  2. Defining relevant terms
  3. Asking “higher quality questions”
  4. Awareness of underlying emotions related to evidence and conclusions, application of the skills above (and more) to those emotions
  5. Skepticism
  6. Avoiding oversimplification or overgeneralization
  7. Identifying and “unpacking” assumptions or premises of assertions
  8. Consideration of types of evidence upon which conclusions are based
  9. Review and critique of conclusions from evidence
  10. Consideration of alternative interpretations of evidence
  11. “Peer review”

There’s more ideas, and more technical means of critical thinking thanks to philosophers, but won’t labor those here.  Here are a few examples of “cognitive distortions”:

1.  Absolutizing (sometimes called “all or nothing thinking”, this creates or perpetuates a lot of relationship conflicts by way of asserting something “never” and/or “always” happens)

2.  “Mind reading” or “fortune telling” (making assumptions about people’s thinking or future behavior)

3.  Emotional reasoning (“I feel __________ so it must be true.”, an example of naive realism – these show up for example as “righteous anger”, low self worth, fears, etc)

4.  Mental filter (“cherry picking” evidence- though 9 things were done correctly, one was done incorrectly, the incorrect item is what’s focused on)

5.  Catastrophizing

6.  Solipsism (seeing things only from one’s own perspective)

7.  Perfectionism (both with self, and others)

8.  Fudging on efforts to change now, in favor of believing plans to “do differently/better later”

9. False equivalence (seeing/arguing that two things are somehow equal, that are not)

10. “Ad hominem” arguments: because __________ (a specific person said it), it is incorrect . . . this works both ways – that because __________ (a specific person said it), it must be correct (often called “appeal or argument from authority“)

11. My favorite of late – mistaking an interpretation or inference for a fact

Again, there’s more of these too. Others might be added, though they’re not always thought of as critical thinking errors or cognitive distortions in therapy circles. Beliefs about the ability to change others (sometimes calling it “influence”), awareness of powerlessness over a situation but endeavoring to manage or control it anyway, doing the same thing more than once and expecting different results… all might be additional examples.

Critical thinking though, can often be an antidote for cognitive distortions and a method for solving problems. Without principles or tools for doing so, we’re just burning calories (and few, at that). Or, as I often refer to clients “wasting cycles” (like a computer chip). A couple more examples: when feeling “low self esteem” (or as I prefer, “shame”) or anger, it might be helpful to “examine the evidence”. Are there current facts in hand, that are evidence I should feel “less than”? When ashamed or angry, many of us assume or treat their feelings in and of themselves as truth (like the “naive realism” mentioned above) … often finding out later there was little or no reason to do so. Many conflicts arise because a speaker or receiver make little (or no) effort to define or examine what they (or someone else) is trying to say, or because we have very different ways we’re defining a word or situation.

Regardless of what kinds of problems we’re assailed with, these critical thinking tools (and others) are very useful. It doesn’t seem to matter if these are problems of relationships with ourselves, relationships with others, or “Earthbound” problems (cars, money, weather, gadgets breaking…)- critical thinking tools are always necessary to employ, and are often quicker/more effective than our usual styles of solving problems.

There are quite a few fantastic resources for critical thinking, great people in our time that are doing important work in this way. Some of these people books are linked below.

The “industry standard” ideas and examples for philosophers is the “Delphi Report on Critical Thinking”

Daniel Dennett (Professor of Philosophy at the Center for Cognitive Studies at Tufts): a recent work, “Intuition Pumps and Other Tools for Critical Thinking”

Morgan D. Jones (former CIA analyst): “The Thinker’s Toolkit”

Christopher W. DiCarlo (Philosopher of Science and Ethics, Harvard and elsewhere): “How To Become A Really Good Pain in the Ass: A Critical Thinker’s Guide to Asking the Right Questions”

Peter Boghossian (Professor of Philosophy at Portland State University): part of the “Skepticism 101” resources at the Skeptics Society, Peter’s “Knowledge, Value, and Rationality” syllabus.

Winnie think

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…

Therapy, Counseling, Mental Health: Things That Put Me OUT of Work

My last piece of course is begging for a follow up.  If there’s semi-tangible things that put me in a job, there should be some things that will put me out of a job, so to speak.  Ideas, principles, behaviors that clients do that get them and keep them out of our offices, clinics, and hospitals.  Again, we as clinicians talk about them fairly often, but I rarely hear/see them showing up in discussions outside of our colleagues.  In all fairness, as with all professions, there’s arguably some things we don’t agree on or see a little differently, but if we’re really endeavoring to be socially responsible and progressively-minded about our responsibilities, I think we ought to be transparent about some of these things.

Should mention some of the spirit of where these ideas come from.  One day at a hospital I was hired to create dual diagnosis programs at, it dawned on me that there were a lot of suggestions that most clinicians of all types, gave to clients of all diagnoses/problems, in an effort to be helpful.  I created a beginning list of these as I saw them, and asked different psychiatrists, therapists, social workers, nurses, and recreational therapists to add/change/delete parts of the list.  After compiling 60 or 80 different items or so, we began using this as a resource tool for the clients.  The list below is some of those ideas, but am leaving some of them out for brevity’s sake.

They’re not really new.  Most of these appear not just in different forms of therapy, but some religion, philosophy/worldviews and the like as well.  It should also be said that they ought to be useful for most any problem- not a panacea, but consistent across categories of problems… depression and sadness, low self esteem and shame, anger, pain, grief and loss, abuse, “thought disorders”, affective disorders (depression, bipolar disorder, anxiety disorder, addictions, etc).

As with my last blog, would suggest that these might take deeper explanation and guidance, and hence, some of that work is beyond this medium.  That said though, I think that some of these ideas are extraordinarily useful (despite their age… ;-p  ), and can be applied a lot of places.  Some of these are simply ideas that I think “getting a handle on” and using them as a start for problem-solving is really helpful.  Not an exhaustive list, but as a start…

  • Knowing who we are and how we are is one of the most important things- and arguably the basis for dealing with a lot of our problems.
  • Have a “congruent affect” (affect is “feeling” or “emotion” in this context)… let your outsides match your insides.
  • Learn how to identify feelings, and share them with supportive/healthy people in ways that are easy to understand.  Might want to try using the “six basic feelings” of mad, sad, glad, afraid, ashamed, and/or hurt.
  • Don’t treat all feelings as facts.
  • Have “boundaries”.  Know where we each “start and stop” mentally, emotionally, “spiritually”, and physically.
  • Eat healthy, exercise, regulate sleep.
  • Remove thoughts/behaviors that put distance between us and us, us and others, or are used as simple distractions.
  • Being “right” is not necessarily more important than being loved.
  • We have to “have” something to “let go” of it.  This arguably applies to how we feel.
  • Is there another choice besides acceptance?
  • Mindfulness.
  • Using critical thinking.  Skepticism, defining terms, consideration of alternate interpretations, considering how an idea might not work/go wrong, resisting oversimplification/generalizing, comparing/contrasting with other people’s ideas…
  • Have a “resource group”… people with whom we exchange ideas, get support, do critical thinking with etc that have experience and/or education with the things we struggle with.
  • Treat happiness as an inside job.
  • Avoiding self-medicating with drugs, food, alcohol, shopping, gambling, sex, TV, etc.
  • Be self-supporting through our own contributions, mentally, emotionally, “spiritually”, and physically. (this particular item is a lot deeper than it may seem at first blush)
  • Don’t just read literature related to our problems and difficulties- actually try the ideas contained.
  • Give up comparing our insides with other people’s outsides.
  • Delay gratification.
  • Know and work on our “issues”.
  • Consider and act on “love” as a verb.
  • Get out of abusive relationships, maybe even relationships that are “potential” rather than “actual”.
  • Stop trying to control other people, places, and things.
  • Be of service.

Again, this is a painfully truncated list, some of the ideas are certainly arguable, and none are a substitute for working with a professional for learning how to do them if they are going to be useful.  My experience though, is that my clients who take up these things, with a pro, have a pretty common experience of feeling and behaving better themselves.  In some ways, it’s hard to imagine doing treatment without these things.  Of course, a lot of these are hard to do, but not impossible, and easier if made practical- things we can measure and point at.  Would love to hear ideas from other folk about things that they think are fairly indispensable, and might work for a lot of folk in a lot of different circumstances…

Therapy, Counseling, Mental Health: Some Things that Keep Us in Work

As I’ve said before, I try to work in the spirit that it’s my job to put me out of a job.  There’s some things I see pretty often though, that seem to be both counter intuitive and appear to keep me and my type in work.  My experience with therapists is that we often see these things, but rarely talk about them in a semi-organized way.  As much as loss, abuse, and abandonment cause depression, sadness, shame, low self esteem, anger, pain, addiction and etc, there are things we do that perpetuate our suffering in this way.  Some of these are survival or coping skills and thus necessary, but don’t really go very far to help someone get, and stay out of places like my office.  Here’s a list of some of those things off the top of my head:

  • Absence of critical thinking.
  • Responding to struggles by simply “staying busy” or just “trying harder”.  AKA, operating as a “human doing” instead of a human be-ing.
  • The kind of thinking that “Time heals all wounds…”, “It’s water under the bridge…”, “You’re just giving __________ power over you…”, “The past is in the past…”, “Just stay positive…”…
  • Using ideas and principles that got us suffering in the first place, to resolve that suffering.  Drugs, alcohol, isolation, shopping, food, gambling, etc.
  • Simply not knowing, and/or avoiding feelings.
  • Thinking and/or behaving as if the only answer to our suffering is for someone else to change or stop their behavior- even if their behavior was the cause.
  • Money, property, prestige.
  • Carrying the torch (or stick, if you will) of someone else shaming or diminishing/devaluing us.
  • For those that can and should, not being self supporting through one’s own contributions mentally, emotionally, physically (food, clothing, shelter…), and “spiritually”.
  • Perfectionism- both imposed on others, and ourselves.  Same is true for managing and controlling everything.
  • Going where the love “should be” in our lives, instead of going where the love is.
  • On a related note- staying in abusive or emotionally unavailable relationships.
  • This one is a little backwards from the context in the opening paragraph: took me a while to realize that I don’t have to do everything I think.
  • Blame.
  • Poor boundaries.  More specifically, not knowing where one person “stops” mentally, emotionally, physically, and/or “spiritually”, and another “starts”.
  • Operating as if our feelings are facts.
  • Euphemistic language.
  • Behaving or thinking as if we have to not be, or stop being afraid, before we can accomplish a task.
  • Same as the above, but instead of stop/not be afraid, that we have to be “motivated”.
  • Being an “island”.  Meaning, not having closeness with other folk, using ourselves as a sole resource for support or perspective or interpretation or encouragement, etc.
  • An inability or unwillingness to be “present”.
  • Can’t emphasize this one enough: not knowing who we are, and how we are.

Am guessing I’ll be adding to this list as time goes on.  The ideas above certainly warrant a deeper look/discussion to both understand and make them practical.  It appears to me that there’s a lot of fairly simple myths that might be dispelled that could help us all reduce chaos, and “increase the signal to noise ratio” in terms of our perspective and thinking.   The ideas above, I think, are a pretty great start at doing that.

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.

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.

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