As a creature with the ability to proactively do so, we are awful at grieving. In this case though, I am not only referring to letting go of/transforming sorrow, I am referring to making any feeling that isn’t doing us service smaller… insofar as that’s possible. Shame, fear, anger, pain, and of course sadness are what I’d consider the fundamental candidates.
If therapists are purposed for anything I’d argue it’s this, and while not every therapist and not every method works for everyone, the clinician in question should both have a method and be able to articulate it clearly. Grieving is the term I use to describe making our “bad feelings” (something I actually don’t believe in… you might want to read my blog on the Utility of Sadness) smaller, if possible. We certainly have responsibility in helping people think “better”, behave “better”, but if we don’t have a method for reducing suffering in these ways that we can both articulate and employ in an empirical way, I’d question our usefulness as a discipline.
I am arguably already digressing. As I said above, we’re bad at grieving. Most of us are familiar with the microcosmic experience of this – when we say or do things that are unintended/not our best selves. Maybe we say or do things that are not as wise or compassionate or useful etc. as we would like. Maybe we have a response to something that isn’t what I like to refer to as “right sized”. Worse, we sometimes do something that is objectively unhealthy for us or others like being actively mean, selfish, manipulative/dishonest, drinking or drug use, eschewing self-care, poor boundaries, controlling behavior, symptoms of anxiety, isolating/ghosting, blaming, overeating, self-harming, mentally punishing ourselves and such. This happens on the macro scale as well and while I am going to quell my enthusiasm for addressing it at length, I’ll say we also seem to hold grudges, punish, and “act out” as nations, communities, organizations.
Another way of thinking about these “bad behaviors”, is to think of them as “neuroses” – ways individuals and groups behave that are at best barriers to grieving, and at worst perpetuate and/or create more suffering. A summary of this idea might be seen in the famous psychiatrist Carl Jung’s idea that, “All neurosis is a substitute for legitimate suffering.”
More directly, most unhealthy/“bad” behaviors that humans engage in might be seen as neuroses, and Carl seems to be intimating that “legitimate suffering” would reduce these behaviors. From here, it looks like to me like “legitimate suffering” is another way to say “grieving”. If so, how does one grieve?
Certainly worthy of a whole section of books on the subject, grieving is complicated. Methods employed by most therapists have four main parts:
Telling the story
Examining what we did to survive it
Talking about how the story affected the major areas of our life (family, friends, recreation, vocation, education, romantic relationships . . .)
How the story changed us as a person. To exaggerate to make the point: we were one person before something Really Difficult happened, and another person after it happened.
Different types of methods for the above can (and likely should) be employed for different people and different circumstances. Talk therapies of different types, thought experiments, working in a group, educating ourselves about the thing we are grieving, critical thinking/epistemology, writing, creative pursuits and more are some general methods.
It seems to me that something missing in a lot of schools of thought/therapy offices is that the four ideas above might lead to a fifth part of a treatment plan as issues may arise that require specific interventions. For example, someone might be referred to a survivors’ support group, a food and exercise plan might be needed, going directly to another person and dealing with a problem or circumstance/doing therapy with another person (or more), 12 step attendance, medications (though arguably much less often than we employ this tool), specialized methods of treatment are all examples of other treatment interventions needed where the first four may be insufficient.
All of these tools can be employed as ways of working through all kinds of emotions that are not just sorrow/sadness. The implication here is that if we feel better, we have the bandwidth to think and/or act better.
Though trying to make this missive blog-sized, I still find myself unable to resist giving some kind of a frame for the things I mean that we need to grieve, and why. In my sense of things, feelings are just physics. Meaning, they’re an unavoidable and ungovernable response to a stimulus. It’s not to say that just like healing a broken limb can’t happen over time, but it is to say that those experiences and feelings that we might need to grieve are not a choice. Grieving is what we can do after. These can be individual experiences, or groups of them. Of import, we can be right or wrong about them – we mistake feelings and interpretations of those feelings all the time. This is a topic worthy of it’s own book.
All to say though, while having a feeling may be a fact, we may not be having feelings that make sense all the time. Mostly I’m just talking about the obvious things like; breakups, loss of a job, loss of status, people saying/doing things that hurt or shame us, experiences that frighten us. They might be collections of these things, as humans have limited bandwidth (again, it’s just physics). We might need to grieve acts of nature (earthquakes, cyclones), loved ones having illnesses or behaviors/neuroses (mental/emotional illness, addiction) of their own. It’s reasonable to have any of the feelings I flagged above (mad, sad, afraid, ashamed, and/or hurt) in response to any of these kinds of experiences.
Were I to be further challenged on this to say exactly how it is that grieving “works” (and I would recommend asking your therapist this or if you are a clinician, asking yourself how you would articulate it), the actual mechanism that helps us feel “less bad” about a thing insofar as it is possible. I’d say this: it works based on “intimacy”, which I would say is one person having healthy feelings and responses to another persons’ feelings about theirlife.
I remember talking with another clinician after a group we had just run at an inpatient hospital, many years ago. I was 18 at the time. He was talking about some things that the group brought up for him that he was struggling with. What he shared moved me enough, that I started crying . . . and he started crying in response. He said to me, “I don’t think I have ever had anyone cry about ‘my stuff’ before.” We talked about how it made him “feel better”. I realized at that point how much value there was in that process, and have thought about it ever since.
As I mentioned though – the idea of intimacy helping the grieving process is pretty complicated. If someone else having healthy feelings/responses to my feelings about my life, there’s a lot of requirements. Requirements incidentally, that therapists are supposed to learn in school. That person has to have access to their own feelings. I have to have access to mine. They are hamstringing process if they have an unhealthy response, like shaming/diminishing me for having feelings. We have to have healthy boundaries. In my effort to make the illustration simple, it is easy to mistake that as easy or that the work ends there but as I offered earlier, it’s much more complicated than that and therapists should have great skill in these regards, and more.
Per usual, I have taken on something that is way too big for a blog post. It has been a long time since I put anything out, and our climate of individual suffering, diminishing our rights and one another, violence against one another and the Earth and more has long made me agonize about being helpful around these things. It is a hugely daunting task, and I have tried outside of doing therapy, outside of writing, to engage in other activities to be helpful or at the very least resist succumbing to these kinds of things myself. The awareness of that grief, makes these other types of grief so much more palpable.
A way of simplifying what I am getting at with this rumination is, suffering might reveal a lack of skill in grieving, that grieving might have features we can point at, and that skill in this way not only might make us feel better, it might make us think and behave better. We might do well to examine this skill level not only as individuals or communities, but as clinicians helping people.
When I ask most people about what gets us into therapy, the usual responses are; stress, depression, anxiety, relationship problems, drugs or alcohol, and a few others. In a more general way, I’d suggest there are three primary “issues” that get people into therapy; grief and loss, abandonment and neglect, and abuse of all kinds. There are certainly more reasons people cite in wanting to see a therapist, but in my experience, there is a fourth thing that prompts people to come in: perfectionism.
For many of us and many cultures, at first there seems to be little downside to perfectionism. In truth, some of the character assets that come with it drive many of the personal and cultural improvements we’ve made in all kinds of areas. Like many things though, it behooves us to look at the fine print. There is definitely a price for this way of behaving. It is sort of a softball to point at the usual and sundry – loss of time at home and in recreation, medical problems like heart attack and stroke, the aforementioned mental health treatment. These things are certainly caused by a constellation of problems, but if looked at a little differently, by looking at the symptoms of perfectionism and their subtlety, it might shed some light on perfectionism and its consequences.
Clients who self-identify perfectionism being a problem for them report a host of symptoms that are pretty easy to see are related to this issue. Here’s a few:
Rumination/obsessive thinking, replaying or imagining how we think some experiences should go
Imposition of high expectations on self or others
Sacrificing parts of ourselves/lives that we can’t afford to lose (time, sleep/rest/breaks, exercise, money . . .)
Saying “yes” when “no” might be better for us
Being critical of self or others in ways that have negative consequences
An “incongruent affect” (a clinical term) – the way we “look”, our facial expressions and the like, don’t match how we feel on the inside
“People-pleasing” – similar to #4 above, but subtly different
Lack of compassion/kindness for mistakes/foibles made by self and/or others
“Social engineering” or “the Jedi Mind Trick” – managing other people’s perceptions, thoughts, and feelings about us
Different types of negative “self-talk” – “How could I be so _____ (stupid, fat, ugly etc.)?”, “I should have/could have done more/better…” (there are TONS of examples)
“Punishing” oneself (staying later at work or activity, working more, sacrificing more, putting off things we’ve earned or deserve, sometimes physical or “verbal” self-talk punishment . . . ) for “not doing enough”, “not measuring up” and etc.
There are many more examples of symptoms of perfectionism. There are also more examples of the consequences than the ones listed above. Strange as it may seem, perfectionism can also show up as an unhealthy relationship with food, alcohol, drugs, sex, how we treat our partners and children (having high expectations, for instance), picking or staying with unhealthy friends/partners, depression, low self-worth, anxiety and more.
So, what to do? Many of the typical suggestions from therapists are helpful, but sometimes insufficient. Lots of these are intuitive, and can be done without paying somebody – there are plenty of resources available on the internet. They usually are ideas like:
Trying to remove the word “should” or “could” from discussion (including self-talk) about our abilities/behavior
“Being gentle with ourselves” (a strangely vague direction, I’d argue)
“Having healthier boundaries” (often ill-defined)
Using “positive affirmations”
There’s certainly more. What I would offer might be more concrete suggestions. This is an incomplete list due to the medium, and per usual, many of these are better utilized with the direction of a therapist on an ongoing basis. Here are some other ideas:
Learn to have (and survive) a “congruent affect” – how to gracefully and appropriately have your outsides match your insides
Get “peer review” – ask trusted friends to help with an objective sense of whether we are asking too much of ourselves, and the like
Make a list of the perfectionistic behaviors we engage in, and stop engaging in them. If that is difficult, would suggest using some of these ideas to help stop them. This is a great example of the kinds of things that might need more ongoing therapy to come up with specific strategies, as is the next item . . .
List quotes of our negative self-talk. These can be replaced with more “right size” ideas/statements, or counter ideas that both keep us from adding to the pile, but a way of starting to counter this self-criticism and other similar behavior.
Yet another really important method that would be better done with ongoing therapy, identification and processing of the issues/experiences that might have prompted us to suffer with this in the first place.
Learning what healthy boundaries are, and how to employ them
Replacing “punishing” ourselves, being hard on ourselves and the like with more compassionate/loving kinds of ideas. Every therapist on the planet (almost) suggests self-care/self love as a solution, but we are terrible at being specific about it. Will offer a quick “thought experiment”. Think of a person or thing you are pretty sure you are good at being compassionate/loving towards. Think about the principle that is involved in these ideas. Attention? Providing basic needs? Verbal affection/appreciation? Consistency/responsibility? There’s tons of examples, but whatever we come up with, if we add a little critical thinking skills/objectivity/guidance from a therapist, we can readily come up with some great ideas that we do for others, and learn how to apply those ideas to ourselves.
Learning how to handle the consequences of saying “no”, and methods of communicating it clearly/assertively
Learning “thought-stopping” techniques
Consider making __ (insert your age here) year-old mistakes
As I noted, while there are clearly more ideas that might be employed, I think this is a pretty good list. In some cases, this behavior might point to the ill-defined issue of “codependency”, but that is an idea better tackled for a blog (or book) of its own. It is hard for me to write about this and not make at least a mention of the idea of “humility”, another misunderstood and ill-defined term in some ways. However, humility, what I would suggest is a principle that helps us consider our awareness and relationship with our own individual human-ness, the quality of our human-ness, can also really help us have a “right-size” relationship with who/what we are. This seems to be a method too of diminishing perfectionism in a healthy way, but is beyond the scope of this blog as well.
It seems to me that our society, certainly here in the US, is fraught with nudges for us to behave in a perfectionistic way. Though we all agree that our expectations of ourselves tends to be unhealthy, how it shows up in our lives is even more subtle than the messages we get this from in the first place – comparing our insides with the outsides of others, trauma, poverty, advertising blaring one-way communications with us about who we should be/what we need, and the like. The pain, shame, and anxiety this produces is intense, being a therapist in the room with many of my clients (and having struggled with this myself many times in my life).
One of my heroes, Sheldon Kopp has admonished, “Why be perfect, when you can be good enough?” in many of his books. My hope too, is to get us to consider that the only thing wrong with us is that we think there is something wrong with us, and give us more practical methods of changing our relationship with this on a daily basis.
… 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:
Review and clarification of goals/”answers”/desired outcomes
Defining relevant terms
Asking “higher quality questions”
Awareness of underlying emotions related to evidence and conclusions, application of the skills above (and more) to those emotions
Avoiding oversimplification or overgeneralization
Identifying and “unpacking” assumptions or premises of assertions
Consideration of types of evidence upon which conclusions are based
Review and critique of conclusions from evidence
Consideration of alternative interpretations of evidence
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)
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.
I was lucky enough to meet Sarah Wood through another intern I had done some work with, who had referred Sarah to me. She described Sarah as already being a therapist though needing to finish her hours and pass the tests, smart, ethical, with lots of integrity. All this and more turned out to be true. As of 6/25 of this year, Sarah got licensed!
In the past couple of years we’ve been working together, Sarah has seen what is arguably a full caseload in private practice, above the California average number of clients. She’s seen adults, adolescents, and children. She’s worked with individuals, couples, families, mixed demographic families, gay couples. She’s done grief and loss work, parenting issues, addictions/codependency/eating disorders, abuse, trauma, work with depression, and more. Days she’s not been in our office she’s been providing services for kids in schools, their parents, and the teachers who care for them.
It’s truly been a pleasure to work for Sarah. She cares deeply about her clients, has a fantastic “felt sense” of how to be helpful, and a great skillset to do The Work with them. Gratefully, looks like we’ll continue to get to work together in our office now that she’s licensed, and I would have been sad to see her go. That said, am happy to get to continue to recommend her services wholeheartedly. Congratulations, Sarah. Our community is really lucky to have you available.
Sarah maintains her office in Pasadena, has another in San Dimas, and has sliding scale services available. To learn more about Sarah and/or contact her for services, she can be found at : Sarahwoodtherapy.com/
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.
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):
Using our limited human intellect, and our limited human will, coupled together as a salve we cover everything with.
Drugs, alcohol, food, spending, money, property, prestige, gambling, etc. ad nauseum.
“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).
Lying (or, in addict nomenclature, “manipulating”… insert tongue-in-cheek emoticon here), often, when telling the truth would be easier.
Enduring untenable circumstances or relationships.
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…).
Thoughts or attempts of suicide or related self harm.
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.”).
Pride or ego.
Lashing out verbally or physically.
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:
Emotional availability, disclosure, and the like.
Asking for help (having a “responsibility partner”, other similar ideas).
Critical thinking skills.
Service focus on others.
Writing (and preferably, sharing that writing with one or more people).
Art (painting, sculpture, music, performances, poetry, etc).
Support groups, 12-step meetings, or other types of community.
Diet, exercise, natural healthy sleep.
Being self supporting through one’s own contributions mentally, emotionally, physically and “spiritually” (for lack of a better term).
Therapy, counseling, coaching.
“Non intervention”, being still.
Forgiveness, “letting go”, and other similar solutions.
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.
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?”
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…
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.
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.
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!
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.
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