Book Recommendation: Attached.

Prior to 1950, parents were told not to coddle their children for fear of making them soft. Sick children stayed in the hospital alone, allowed to see their parents only during visiting hours. The work of John Bowlby and Mary Ainsworth, the creators of attachment theory, changed America's approach to child raising. They discovered that children don't just need food, water, and warmth, they also need affection, love, and touch. When children don't get this, they development serious emotional and physical problems.

Bowlby and Ainsworth proposed that humans are endowed with an attachment system which propels them to connect with others, first with parents and later with romantic partners. The attachment system drives us to be close, and it freaks out when an attachment is threatened.

Ever have a partner fail to call you when they were supposed to and you started to get worried and develop theories ("Did they leave me?" "Did they get in an accident?" "Are they cheating?")? That is your attachment system being activated.

Attached. The New Science of Adult Attachment and How it Can Help You Find - and Keep Love is less a book about attachment theory and more a simple to use guide on how use the theory to, well, find and keep love. It is super readable, and I recommend it to pretty much everyone who wants to create a good relationship.

However, maybe you don't want to buy this book, and instead of a few hours, you only want to spend a few minutes learning about how attachment theory can help you. Awesome, because I am going to break it down right here in this blogpost.

Before I get to it, it is important to point out that attachment theory is backed up by reams of empirical research. Therefore, this is not an ordinary self-help relationship book. It is science, baby, and so is my distillation of the book's main points:

1. "Dependency is not a bad word." This was the biggest thing I learned from this book. According to the authors, everyone in a relationship is dependent on their partner. This is not a bad thing. It is the way evolution made us. 

Like toddlers who feel empowered to explore the world around them as long as they know mommy is there, adults who feel secure in their relationship are empowered to develop their individual selves. Hence, the "dependency paradox": people are better able to be an individual in the context of a good relationship.

This flies in the face of the belief in American culture that you should not have to depend on anyone else. As a therapist, I often here from clients that they fear asking for support from their partner because they believe this makes them weak. According to Levine and Heller, the opposite is true. Asking for what you need makes it more likely you will get it or realize that you are unable to get what you need from your current relationship.

2. There are happy relationships out there. You can have one.

3. There are four types of attachment systems: secure, anxious, avoidant, and disorganized (which the authors call anxious/avoidant and only mention briefly because it is rare.) Fifty percent of people are secure, twenty percent are anxious, twenty five percent are avoidant, and five percent are anxious/avoidant. Your type of attachment system is a product of how you were raised, your biology, and your experiences in other relationships.

Attachments are relatively stable but they can change. The authors provide a quiz to find out your own attachment type as well as one for figuring out your partner's type.

4. People with anxious attachment systems are afraid of being left more than others. They often don't speak up for what they need because they are afraid of being seen as clingy. Unfortunately, when they don't speak up for what they need, they don't get what they need, and then they actually do get clingy.

Calling your partner a million times, threatening to break up, trying to make your partner jealous - these are behaviors anxious people engage in when they feel threatened. The good news is when they feel safe, anxious people calm down and make good partners.

There are two big pieces of advice for anxious people: one don't get involved with avoidant people (more on this below) and two, communicate your needs. As an anxious person, you really need someone who is going to show up for you, otherwise your attachment system will go haywire. Therefore, be straight up about what you need to feel secure. Whatever anyone tells you, don't try to downplay your needs to try to win someone over. This strategy will backfire in the end.

If you are in a relationship with an anxious person, it is your job to make them feel secure. When you do, they will calm down. Don't try to wait for them to give you space and then give them the security they need. It works the other way around.

5. People with avoidant attachment systems fear having their independence taken away. When they don't get the space they need, they tend to put their partners down, to put up roadblocks to closeness, and to send mixed signals about what they want. According to Levine and Heller, avoidant folks are the roughest to be in relationship with, but they can learn to be close if they really want to and if they learn to communicate their space needs and these needs are met. 

People with an avoidant attachment system should not date anxious people, as anxious folks will have difficulty giving them the space they need. Avoidant people almost never date each other because, as the authors say, there is not enough glue to hold two avoidant people together.

Interestingly, twenty five percent of people are avoidant, yet they make up a greater portion of the dating pool because they tend to be single more than other types.

6. People with secure attachment systems are comfortable with closeness, communicate directly, and are generally pretty mellow in relationship. They make for the most reliable partners, and if there is a drawback it is that their stability might seem a little boring at first.

Secure people will find it easiest to date other secure people, but they can help anxiously and avoidantly attached people move toward being secure. However, anxious and avoidant folks can push secure people away from security as well, so beware.

7. Ever been in a relationship where one partner is desperately trying to get close and the other is desperately trying to get space and both are miserable? You were likely stuck in what the authors call the anxious-avoidant trap. The best way to avoid this trap is for anxious and avoidant people not to get together. Not so easy because these two types are quite attracted to each other. The authors do give guidelines for dealing with the anxious-avoidant trap if you are caught in one.

8. Everyone should try to communicate directly about their needs. Secure people seem to have a knack for this while anxious and avoidant people have a harder time being straight up about what they want. Anxious people don't want to come across as too needy and often try to play it cool, until such time that they get hurt, and then they act out or get manipulative. Avoidant people often don't recognize their needs for space and instead start to feel less attracted to their partners instead of realizing what is going on inside.

The thing about communicating your needs is that it may not get you the result you want, but it will reveal the truth. Thus, if you want to get serious with someone pretty fast and are up front about this, you may scare away some potential mates, but in so doing you will be screening out folks who would probably make you unhappy.

The strength of this book is its clarity and readability. On the flip side there is some complexity left out. Though the authors note that attachment style is stable but plastic, but don't say much about how one changes type.

I also wonder about how different relationships bring out different tendencies in us even if we do have one basic type. I for one have found myself displaying traits of all three types at different points in the same relationship. Did I change my type several times? More likely, different aspects of myself came out in response to the relationship at different times. My point is that though there are three distinct types, I think that relationship can be more nuanced than the examples provided by the authors.

Sometimes the authors seem to imply that all you need to be happy is to find yourself someone secure. Though the book does not purport to be a complete relationship book, attachment style is only part (though a very important part) of a relationship. There are a host of other factors that go into choosing a partner including mutual interests, sexual compatibility, values, and religion/spirituality, to name just a few.

All in all though, I highly recommend this book. It will help you with romantic relationships, one of the most important parts of life. 

Peace Pilgrim

A decade ago, I was walking on the Appalachian Trail, and I came across a little book about a woman who called herself Peace Pilgrim. As I learned more about her, she has become one of my heroes. Each of my heroes exemplifies a different quality that I respect, and for me, Peace Pilgrim exemplifies faith.

I know the word "faith" has some religious implications that turn some people off. Let me explain. I don't necessarily mean faith in God, though Peace Pilgrim did believe in God. I mean faith in life, faith in other people, and perhaps most importantly, faith in oneself. 

I could use the words "trust" or "confidence" instead of faith, but I like faith because it packs more punch. To make bold changes to your life requires stepping out into the unknown, and this requires faith.

Peace Pilgrim, born Mildred Norman Ryder made a bolder change than most. At the age of 44, with only the clothes on her body and the possessions in her pocket, she left home on a pilgrimage, vowing to wander until mankind had learned the way of peace. She walked for peace for the next 28 years until her death. 

She walked until she was given shelter and fasted until she was given food. Most of the time, she was given both by people she met. She wore a sign on her shirt that said "Peace Pilgrim" and on the back read "Walking Coast to Coast for Peace". 

She walked 25,000 miles before she stopped counting. All told, she likely walked over 44,000 miles. She crisscrossed the US, east to west, seven times. She was the first woman to walk the entire Appalachian Trail in one season.

She did not approach people, but waited to be approached. She would then talk to people about peace - inner peace, peace between people, and peace between nations. Her message was simple and clear. Its central tenet was to "overcome evil with good, hatred with love and falsehood with truth." 

She was not affiliated with any religious or political organization. She laid out her ideas in a pamphlet she wrote called Steps to Inner Peace. You can read the pamphlet and more about her life here.

I have learned a lot from her ideas about peace, but what inspires me most about Peace Pilgrim is the example she set. You might think that renouncing all your possessions and setting out on a lifetime pilgrimage for peace is crazy or perhaps fruitless. But you cannot argue with the fact that this woman had balls. This woman had conviction. This woman was living her life one hundred percent according to her values.

It is one thing to say, "the universe will provide". It is quite another to put this belief to the test and set out penniless with only your clothes and a "Peace Pilgrim" sign and just start walking. She braved weather, thirst and hunger, loneliness, dangerous people, and the possibility that maybe it wouldn't work out. This was a woman who had tremendous faith in God, in the goodness of others, and in her own abilities.

I can safely say that I will never undertake something so outlandish as Peace Pilgrim's pilgrimage. But in my own life, I have walked into the unknown in smaller ways. Sometimes at my own choosing - quitting my job and going into private practice. Sometimes not at my own choosing - the end of a relationship. 

Either way, I look to Peace Pilgrim to remind me to have faith. Faith that things will be ok, faith that my friends and family will be there to support me, faith in my own resilience, energy, strength, and abilities. 

Who are your heroes, and why are they your heroes? How do you keep the faith, especially when you are starting something new or life throws you a curveball?

All the fixin's

photo: by comedy_nose

I have been hesitant to write this post because it seems like trite advice you can find in any relationship self-help book, but I'm going ahead because it keeps coming up in my office. 

A woman has just told me about something difficult in her life.

Me: "Have you told your boyfriend/husband/partner about this?"

Woman: "I tried, but he doesn't get it. He tries to tell me how to fix the situation, but it only makes me feel worse."

(Note: To keep the language simple, and because guys are more often fixers that girls, I am making the guy the fixer in this post. Please note that any gender can try to fix, and any gender can just want to be heard.)

Guys, when your woman is upset, your go-to move should be to listen. Not fix. Get her. Understand. Convey that you understand. If you don't understand ask questions until you do. Don't fix. At least not until she feels understood.

Here is how you do this:

1. Get out of your head. Your head will try to find a problem and offer a solution. Do this by concentrating on your breathing and by putting as much of your attention on her - her words and her body language - as possible. 

2. Listen closely to what she says and what her body language is telling you. Get the feeling behind it. Is she sad, angry, overwhelmed? 

3. Let her know you get what she is saying and more importantly how she is feeling. Do this with words, (ie, "That sounds like your co-worker was really mean to you. No wonder you feel so hurt.")

4. If you don't get it, either the content of the story or the feeling, ask. Just say, "wait, there is a part I don't understand..." Or, "how did you feel when that happened?"). It is also good to ask, "Is there more?" to offer her a chance to get it all out. Make sure your questions are without an agenda beyond understanding.

5. If it is not obvious she feels understood, ask if she feels like you are getting it. Be patient. People don't always communicate clearly when they are upset. Also remember it's most important that you get how she feels.

6. If you really can't understand where she is coming from - and this is most likely to happen if she is upset with you - then do your best to let her have her experience. Just accept that she is feeling something you don't get right now, and give her space to have her feelings. Let her know that you are ok with how she feels.

Note: It is much harder to do this when she is upset at you for something, but that is when this skill is most important.

Women, if your man is not good at listening and getting you and instead he tries to fix the problem (and you are not looking for fixing), you can coach your man. Tell him you don't want him to fix the problem. Tell him just to listen and to try to understand you and your feelings. 

Be patient. Most guys are fixers by nature, especially guys who are problem solvers in their professional life, and they haven't had any training in just listening. Cut them some slack if they relapse and try to fix. Reiterate as kindly as you can that you just want him to listen.

Gooooooaaaaalllll!

I want to point you to the Advanced Riskology blog which helped influenced me to quit my job at a big hospital and strike out on my own. I've been thinking about this blog recently, specifically the 1% list on the blog. The 1% list is a list of goals that the blog's author, Tyler, wants to complete.

He calls it a 1% list because he says less than 1% of the world's population will complete the goals. On it are things like mountain climbing, running a marathon on every continent, and selling a business for $1,000,000. These are big, lofty, exciting goals.

My goals are more humble, but perhaps not easier to accomplish. They have to do with creating a life that feels sane, meaningful, and fun. I am more concerned with the day-to-day fabric of my life than with accomplishing something big.

Why goals? I have traditionally had a little resistance to goals. As a Myers Briggs (free test!) perceiving type, I have a disinclination to having regular, scheduled time commitments necessary to accomplishing goals.

When I think about signing up for guitar lessons, for example, I think, "yeah but what if there is something I would rather do on Thursday at 3 pm?"

Having a free schedule feels relaxing to me, but I have learned over time, doesn't make me happy. I end up with too much time on my hands, and tend not to enjoy the unstructured time as much as I thought I would.

In his book Happier, Harvard professor Tal Ben-Shahar writes that having a goal allows us to relax. It is, he writes, like having a destination on a journey. If you know where you are going, it is easier to enjoy the sights along the way. Without a destination, humans tend to worry about where they are going.

So, I am embracing goals. Writing down goals, whatever their size, makes it more likely you will accomplish them. So does sharing them with others. With that in mind, I would like to take stock of goals I have accomplished and those I have not in the six months since I quit my hospital job.

Goals I have accomplished:

• started this blog
• began work at Affiliated Psychologists, a group practice of therapists in Cupertino, CA
• started a private practice in Oakland, CA
• got hired to teach two classes to psych students at Argosy University in the fall
• exercised regularly 3x per week at least - gym, yoga, running, boxing 

Goals I have yet to accomplish (with deadlines which increase likelihood of completion:

• start guitar lessons (August 1, 2011)
• Visit local meditation groups and choose one to go to 1x/week. (September 1, 2011)
• create a website for my private practice (August 1, 2011)

Goal I want to add:

• Go on ten new hikes in the Bay Area (October 1, 2011)

So, it looks like I have been on track professionally, but I could boost my hobby/personal development activity.

What goals, humble or grand, do you have? Remember, sharing makes it more likely you will accomplish them, so by all means, share.

Talkin' bout suicide

I used to work at a hospital program for people at risk of psychiatric hospitalization. I worked with a lot of people who were at risk of suicide or who had made an actual attempt. Part of this work involved talking with clients' family members and educating them about talking about suicide with the client.

Hopefully you never have to have this kind of conversation with someone you love, but with an estimated 750,000 suicide attempts in the US each year, this kind of talk is more common than you might think. Because it is a taboo subject, people often struggle talking about suicide. I pass on what I know here in the attempt to help with these conversations.

If you take one thing away from this post it is this: if you are concerned that someone you care about may be suicidal, urge them to seek care from a therapist or psychiatrist. It is beyond your role to be assessing someone's suicidality.

I am offering these guidelines because I know that in reality people who are thinking about suicide do talk to family members and friends. But as a friend or family member, your goal should be to urge the person you are worried about to get professional help.  

1. The best way to know if someone is suicidal is to ask. You can say something like, "I know you have been depressed for a while, and this may be a weird question, but have you been thinking of hurting yourself?" 
2. Sometimes friends or family are afraid to bring up the subject because they don't want to give someone an idea they have not already had. Don't worry about this; if someone is not thinking about suicide, your asking them will not make them suddenly think that killing themselves is a good idea. Bottom line: you do not increase someone's chance of suicide by asking them if they are thinking about suicide. 
3. Plans, means, and intent help determine risk. 
1. Plan: Has the person thought about how they would kill himself? A person with a plan is likely at greater risk than someone with no plan.
2. Means: Does the person have the means to carry out their plan? Someone who has the means to do so (i.e., "I would hang myself, and yes there is a rope in the garage") is likely at greater risk than someone who does not have the means, or has no plan to get the means. Note: If someone who is thinking about suicide has access to a gun, this greatly increases the chances that they will kill themselves.
3. Intent: Is the person actually planning on going through with it? When? Someone may have a plan and means but no intent: "If I killed myself, I would jump off the Golden Gate Bridge, but really I would never do this." Or they may be planning suicide but only if something they fear comes to pass "I will not kill myself unless my husband leaves." Obviously, someone who says they plan to kill himself in the near future is at extreme risk.
4. Certain risk factors can increase the chance someone will attempt suicide. Consider:
1. past attempt at suicide
2. people close to this person killed themselves or attempted suicide
3. drinking or drug problem
4. history of impulsive acts
5. hopelessness
6. history of abuse or trauma
7. isolation
5. Certain protective factors can decrease the chance someone will attempt suicide. Consider:
1. stated desire not to hurt friends and family by killing oneself
2. stated obligation to care for others (i.e., "I would like to kill myself, but I need to care for my children.") 
3. Religious beliefs against suicide
4. Person talks about future events they are looking forward to
5. Presence of family, friends, or mental health professionals who the person feels they can talk to and lean on
6. The phone number for the National Suicide Prevention Hotline is 800-273-8255. The hotline is open 24/7 Give this number to the person thinking about suicide. Call it yourself for support or advice if need be.
7. The emergency room or 911 is the right choice if someone is in immediate danger. If you are worried that someone is going to commit suicide in the near future take this person to the emergency room, or if they won't go, call 911. Having the police show up or going to the ER is a lot of drama, but far less than if someone kills herself. Err on the side of caution here. 
8. People who are suicidal are sometimes ambivalent about killing themselves. This can result in a person jumping from saying they are going to kill themselves to saying the reverse. The rule here is if the person you are talking to cannot convince you that they will be safe in the near future at least, take them to the ER or call 911.
9. People at risk of suicide need professional help. I am repeating myself here, but if someone is in a bad enough place to be thinking about suicide, they need to talk to a therapist or psychiatrist. Unless you are a mental health professional, you lack the training to be keeping this person safe. Urge them to get help. 

It's a process

I have this poster by the artist Nikki McClure in my office:

Despite its small size, clients comment on it more than any other piece of art in my office. To me, the word "process" has a dual meaning in the context of my office. One, people process or work through stuff in therapy. Two, therapy itself is a process.

The picture shows a process not unlike therapy. Pitting cherries, one cherry at a time. I imagine the hands belong to an old person who is patient and methodical.

It is a reminder to me that the work I do with clients and my own work in therapy is often this way. Big insights and dramatic breakthroughs do sometimes happen, but I find it is the change that comes bit by bit that often sticks.

For a long time, I looked for a cure for a part of my gut that gets tight. When I feel this way, it feels like the world is a scary place, and I would rather crawl back into bed. I have tried yoga, meditation, exercise, therapy, massage, and chiropractic to cure this problem. I imagined that I when I got rid of it, there would be no stopping me. I would be glowing with energy. I would be magnetic. I would accomplish twice what I normally do. 

What I realized was that hoping so hard this feeling would go away often makes it worse. It creates a split in me where one part of me hates another part.

I am learning to be more patient with my body. Now when I feel tight in my gut, I try to breathe with the sensation. I've found it important to breathe with the sensation - letting both my breath and the tightness be present - instead of breathing in an attempt to make it go away. I have also learned to expect ebbs and flows in my energy level. I would like to be high energy all the time, but that isn't how my life actually feels.

It has taken a number of years to learn to be more patient and gentle with myself. I have found that attitudes, especially attitudes about ourselves, change slowly. But it is this kind of change that actually makes a big difference in my life, actually makes me a happier person.

Do you agree? Have you found that change happens slowly or have you had more dramatic shifts that have stuck for you?

Breaking up is hard to do

I haven't written a post in a little while. I've tried, but I've either written diatribes against society or trite Buddhist wisdom.

It feels like I can only write with authenticity about one thing: the breakup of my long-term relationship. I haven't wanted to write about it because a. it is personal and b. I have qualms about talking about certain areas of my life given that clients may read this blog, but perhaps writing about it will help others who are going through something similar.

First, let me say that it sucks. It's just really painful and there does not seem to be any way around it.

And now for a closer analysis of this pain and how I am dealing with it:

Feeling: Self-blame

Every time I feel sad, there is a feeling that if I had done things differently then I would not be feeling sad right now. My general theory is that loss is inevitable, but we humans have an immensely hard time accepting this as part of life so we try to assign blame, hoping to feel more sense of control. 

Some people like to blame others. In keeping with my humble nature, I prefer to blame myself. I think about various points in the relationship where, if I had acted differently, we would still be together. I imagine going back in time and tapping myself on the shoulder and telling this version of me what I know now.  

Action: Stop it!

As much as I can, I try to short circuit this thinking. It is just not helpful and leaves me feeling worse. Also it is unrealistic: a. I can't go back in time. b. Even if I could, would this have saved things? I don't really know. It was a complicated situation and my fantasy of going back in time makes it much simpler than it actually was.

So, I just try to pull my mind out of this loop. Not always successfully. Sometimes I end up wallowing, but I try.

Feeling: Sadness

As I said, the self-blame tends to set in over a feeling of sadness. Sad because I miss her. I just do.

I think about times we had fun together or I think how it would be if she were with me in the moment. It's like I am reaching out with my mind and heart, but she is not there. Even though it hurts, there is something soft about this feeling, something tender.

Action: Feel it! 

When I actually let myself feel sad, and maybe cry it out a little, I usually feel better. This is often easier with another person - my therapist, my friend, my mom - than alone. I don't know why but it feels harder for me to get to a sad place when I am alone. 

For people who tend to spend a ton of time crying and feeling sad, I don't recommend staying in that place indefinitely. If this is you, you might need distraction. But if you are like me and getting to a sad spot can be hard, then I think it is good medicine to stay there for a little and let your heart be sad.

Feeling: Emptiness (depression)

This one sucks. It feels like there was a tube that supplied color to my life and now there is nothing on the end of that tube. My life feels like it is in black and white. 

I don't feel excited about anything, and there is the impulse to zone out, watch tv without really watching, even stare at the wall. My body feels heavy, and without energy.

For me, sadness has a feeling of movement to it, but this emptiness, this lack of feeling, feels heavy and stuck, like a stagnant pool of water.

Action: Keep doing my life!

I assume that time will heal things, and the color will return in time. I also find that when I actually do the things I am not excited about - exercise, hang out with friends, work - that I feel better at least during the activity. So, I continue to exercise, take walks, work, write (a little), meditate and see friends.

Action: Rest!

More than normal, I am allowing myself to spend time in bed, nap, and watch movies on my computer. I think you have to be careful with this one because too much bed time can exacerbate depression, but shit, I am going through something hard, and now and again, I let myself take it easy.

Feeling: Fear of suffocation

Ok, I know this may sound strange, but there have been several times when I have realized that a part of me is afraid I won't be able to breathe. It has happened during meditation and also when I wake up from a dream. It is like there is this fear that I will be stuck somewhere, somewhere I can't get out of, somewhere where I can't breathe but I don't die.

I have noticed that several times when I have woken up from a dream, I am a little afraid to go back to sleep for fear that I will get stuck in the dream world. I don't really know what this has to do with my break-up, but I think somewhere in me is the fear of dying and the sense that my relationship was a buffer against this fear. Like, ok here I am alone in the world and destined to one day die, but at least I have this loving person to hold onto, and now I am all alone.

Action: Be curious!

Even though this fear is terrifying, I am actually really curious about it because I sense there is something big here. So whenever it pops up, usually only briefly and on the edge of awareness, I actually try to feel into it more, so I can better understand what it is.

Action: Take a deep breath

Self-explanatory.

Feeling: Jealousy

"What is she doing right now? Is she with someone else? What is she doing with them?"

This one comes on fast and hard, the images of her with someone else flying through my mind and my stomach tightening into a knot. It's a burning feeling, like I have swallowed a red hot lead ball, and I don't know how to throw it up.

Then my thinking mind kicks in - in a bad way. "What day is it? Tuesday. Shit, she doesn't have her daughter on Tuesday. She could be on a date. With who? There is that guy she mentioned being friends with a few weeks ago..." And so on.

Action: Get to the bottom of it!

Some deep breaths help me calm the crazy-making thoughts and feelings. From this place I ask myself what is beneath this and I find fear first and then loss. 

The fear is like an alarm bell signaling grave danger: "Woman about to go with other man! Woman about to go with other man! Act now to prevent loss of woman!" 

But the truth is we've already broken up. I've already lost her. I do my best to tell the alarm bell to calm down, the thing I am afraid of happening has, in a way, already happened.

I am also afraid that her being with someone else means she doesn't love me anymore. I remind myself that just as I will always have a place in my heart for her, I believe she will always have a place in her heart for me. I find this comforting.

That's when I get to the loss that has already happened. She is gone. 

 

If, or should I say when she goes with someone else, it will mark another stage in this loss, making it more final. This is inevitable. When I can calm down about it, I realize I am more sad than anything else.(see sadness above).

So what feelings have you dealt with when you broke up with someone, and how did you get through it?

The comfort of the cage

The other day I was running around Lake Merritt in Oakland. It was sunny, the sky was, well, sky blue with no clouds. The light was glimmering off the waves and a cormorant flew low over the water. My Oakland peoples were out running and walking their dogs. It was Springtime and life was in the air.

But I didn't care. I was worried, and I kept thinking about whether she was going to call. I would only feel better if she called. Or should I call her? Should I be honest and upfront about my needs because that is who I am, honest and upfront? Or should I play it smart, let her come to me, knowing that this strategy is probably more effective?

All of a sudden, I got pulled out of this tizzy of thinking and I realized where I was. I saw the water shining, I heard the rhythm of my footsteps, I smiled at a guy running in the opposite direction. I felt a part of this day, connected to the lake and the sun and the other people. I felt alive!

And then I remembered I was worried, and just as suddenly, I was back in my anxious little head, worrying and strategizing. As unpleasant as it was, it was as if a part of me actually preferred the worried thinking to the freedom of letting go.

This part of me said, "hey, yeah I know you are digging on the scene and and the sun and the lake and just being and all, but you have a life to worry about, so get back to worrying, bitch". And like a good bitch, I obeyed, worrying my little head off the rest of the run.

This is what I call the comfort of the cage: when we actually choose a crappy state of mind over a more free state of mind because somehow feeling good is scary and feeling bad is safe.

In my experience, there are three reasons we do this:

1. We are scared to not think about our lives. We feel like something bad will happen if we are not worrying, planning, analyzing. "Can't let go into the moment, because then the house of cards might topple". This is what happened to me when I was running around the lake.

2. Feeling good is scary because we might lose it and feel bad again, so instead of dealing with this fear, we decide to just get it over with and feel bad again. This happens a lot with people who are starting to get better from depression. They are so scared of falling back into depression that they can't enjoy the new, good feelings and end up exactly where they don't want to be - depressed again. It's like flying feels really good, but shit, I might crash, so I better go ahead and just land the plane.

3. We find ourselves feeling really good, and then part of our brain wants to figure out exactly how we got here, so instead of just enjoying, we start thinking again, and dammit, the good feeling is gone. This one happens to me sometimes during meditation. It's hard for me to enjoy the new scenery, I want to go back and create a map.

In each of these instances there is the underlying sense that uncertainty is unbearable, and we actually prefer unpleasant states of mind that we are familiar with to the uncharted terrain of being more alive to the moment.

I don't know of any foolproof tricks to stay in the moment. I just keep reminding myself to let go, that it is ok to get out of my head and enjoy what life has to offer. Maybe one day, I will no longer be my mind's bitch.

What about you? How do you get out of your head and let yourself be in the moment?

Note: You can now subscribe to get new blog posts by email, that way you don't actually have to visit the blog. Just put your email address in where it says Join Our Mailing List. Hopefully this goes without saying, but I would never, ever sell or give your email address to someone else or use it for anything other than mailing you new blog posts.

 

A Happy Relationship with Alcohol

Drinking too much will mess up your life. It will rot your liver, hurt your self esteem, get in the way of your relationship, destroy friendships, even cost you your job if the problem goes too far. 

Nothing new here.

Recently though, a friend told me a reason I never thought of for making sure I keep my relationship with alcohol healthy: If drinking becomes a problem, I may have to stop drinking. That would suck, because alcohol is fun and part of my sane lifestyle. Hell, I’m on a plane right now enjoying a Jack on the rocks. The alcohol makes my space invading neighbor’s elbows more tolerable and keeps the reality that a few inches below my feet is 37,000 feet of air pleasantly fuzzy.

As you can probably attest, alcohol has a great variety of uses including lowering inhibition, decreasing awkwardness, and increasing fun. It enhances meals, improves conversation, and makes cooking more enjoyable. Plus, mixing drinks can be a creative and tasty art.

But if you drink too much, you sacrifice all this. When you realize you have a problem, you will have to cut down. Then, you will no longer have license to get drunk. See, if your drinking is under control, every once in a while, in the right situation, with the right people, its fine to get a little ripped. But once you have a problem, you loose the right to get drunk. Now you probably shouldn’t have more than two, because well, you know what happens once you start down that road…

And if things get really bad, you will have to give up drinking all together, and forever. You will have to dance, go on first dates, attend weddings, reunions, and family functions completely sober. And then even if you have one drink, you will have relapsed. You will feel bad about yourself and have to go acknowledge what happened at a meeting.

You don’t want this. You want to be able to drink and have it be a good thing not a bad thing. So, keep it under control. Find other ways to cope with stress, so alcohol is not your go to stress reliever. Don’t drink every day. Make alcohol an addition to fun times, not the point of fun times. For college-aged readers: don’t funnel, shot gun, use a beer bong, or engage in drinking games – this is dumb. Only get drunk once in a while and then in circumstances where you are with people who won’t take advantage of you and where you don’t have to drive.

With a little maintenance, you can enjoy a lifetime of happy times with your good pal, booze.

How did that make you feel?

"How did that make you feel?" is such a cliched therapy phrase that I try to avoid asking anybody this question.

On the other hand, "how do you feel right now?" is often therapeutic gold.

I was halfway through a first session with a woman in her mid thirties. As a therapist, I am trying to do a lot in that first hour: understand who this client is, identify why they are coming to therapy now, rule out any emergency conditions, and above all, establish rapport. The session started well, but when I began asking her more questions about her marriage, the vibe changed. It was almost as if we were arguing a little bit, me curious about her marriage, her not wanting to go there.

"It's not my marriage, I've been sad for years before this."

I tried to explain how relationship dynamics can reveal how people relate to others in general, then I backed off. I was getting heady, a bad sign. I remembered one of my favorite therapist acronyms - WAIT - Why Am I Talking? 

"Ok. You've been sad for years..." I said. Neither of us was sure where to go next.

"How do you feel right now?" I said.

"I feel anxious. I hate feeling this way."

"What happens if you let yourself just feel anxious without trying to push it away?"

She didn't want to do this, but I convinced her to try it for 30 seconds.

"Now I feel sad."

"How is that?"

"It's better than feeling anxious. I feel calmer."

The whole vibe in the room had also changed. I felt calmer, less frenetic. I felt like my energy had come down from my head and into my body. The rest of the session flowed with a natural rhythm.

Feelings can sit on top of other feelings. They call this primary (underneath) and secondary (sitting on top) emotions. Particularly when someone is anxious, there is often another feeling underneath. Even though the primary emotion is probably something difficult, it almost always feels better when it has a chance to breathe in a safe environment.

This is something I practice myself when I feel all jumbled up inside. I find a quiet place and let whatever it is I feel just be there for a while without pushing it away and without trying to figure it out with my head. Usually, in time, the mud settles and I can see a little more clearly what is actually going on inside me. This doesn't "fix" the problem, but seeing clearly is often the first step to fixing something.

Anxiety and Evolution

Crap, I am anxious all the time, and so are most people I know. 

What gives? 

The conventional reason is that there are evolutionary advantages to being anxious. Essentially, the argument runs that our ancestors who were worried were more likely to gather nuts for the winter, watch out for predators, and avoid the annual Caveman Cliff Jumping Competition and were therefore more likely to survive. For modern people who don't live in poverty or a war-torn country, anxiety is a remnant of an earlier time. Here is a synopsis of this idea. 

I don't believe this theory. I don't think there is an evolutionary advantage to being anxious. Ok, maybe a little bit of anxiety helps motivate you to do the stuff you need to do - study for a test instead of partying for instance. But how well do you perform with a knot in your gut and worries in your head? 

Evolution has two main goals - survival and reproduction - and I contend anxiety doesn't help with either. Would you rather go hunting when you felt calm or anxious? How about picking up a potential sex partner? Anxiety is catchy and it is a libido killer.

I would say that being alert has an evolutionary advantage. Being alert to danger can keep you alive. An alert hunter is aware but calm, receptive to sight, sound, and smell, patient and poised to strike. An anxious hunter is more prone to drop his spear.

So why are so many people in our society anxious? I believe that anxiety is not left-over from an earlier age, but rather created by the isolation of this age. In this society, most of us lack a connection to an extended family group or meaningful community, we don't live close to nature, we don't have a sense of our place in the cosmos, and we don't know what the hell we are doing here. We feel alone and without a sense of purpose. And on a day in day out basis, that is more anxiety making than having to watch out for saber tooth tigers and woolly mammoths.

Chemical Imbalance

Once in a while, I hear a bit of news that gives me hope. Today, the Department of Health and Human Services said that the CEO of Forest Laboratories, Howard Solomon could no longer do business with the government as punishment for his company's marketing of its antidepressants Celexa and Lexapro to children prior to FDA approval. Here is the full story. 

This means Forest Labs has to dump Solomon because, like every drug company, it needs the US govt as a buyer. In the bigger picture it means the government may start going after CEOs from all sorts of different industries when their companies do illegal things. About time...

It is worth noting that the govt also slapped Forest Labs with a $313 million fine, and that this kind of money is chump change to the company. Money is of course power, and the drug companies have way too much power in the way mental health care is carried out in this country. They pull the strings of the lawmakers, they fund and therefore influence the research, they send out teams of attractive salespeople who use perks to influence doctors, and they put commercials on tv telling you to "talk to your doctor" about their latest drug to make your life better. Here is Chris Rock talking about these commercials:

For the record, I am not against psych meds. I have worked with people whose lives have been saved by these drugs. I often suggest that clients see psychiatrists for med evals.

I think my problem with psych meds can be summed up by the words "chemical imbalance".  I don't know where the term came from, but it is genius. My life is not working because I have a chemical imbalance. Solution: a pill to balance my chemicals. It's so elegant. 

This formulation divorces your life problem from your life. Its just the chemicals in your head. When people start thinking this way, they stop thinking about their family, their work, their attitude, their exercise, their relationship with drugs and alcohol, thier hopes, their dreams, their demons. They become dis-empowered. 

Again, I am for the idea of pills being part of the solution in some cases. I am against the idea of pills being the solution.

Ultimately, I believe life is for growing, and I believe that the drug companies and their hordes of cash do a disservice to humanity by selling us on the idea that problems in living can be solved simply by taking a pill.

7CBTY6ZNNRR3

You are (probably) not bipolar!

The word "bipolar" has now entered the vocabulary of the average 17 year old American. On the street, the word is used to describe someone who has intense, unpredictable mood swings, as in "Ever since my boyfriend broke up with me, I have been so bipolar. I am fine one moment and then I just feel like crying." 

When a word becomes slang its original meaning gets watered down (see, "awesome," "pimp," and "rock star"). This is well and good. The problem here is that the loose definition of this word on the street mirrors the loose definition of the word in the psychiatric world. And that is a problem.

Here is the full DSM-IV criteria for bipolar disorder. For the record, in this post, I am talking about bipolar 1 disorder which involves full-blown manic episodes, not bipolar II disorder which involves hypo-manic (meaning smaller manic), episodes.

As the name implies, bi-polar disorder, which used to be called manic-depression, involves two poles - mania and depression. Technically, you don't actually have to have depression to be bi-polar but most people with bi-polar have both. 

Most people know more or less what depression looks like, but most people have not seen full-on mania. Therefore I will try to describe it:

A manic episode is essentially a huge increase of energy in the person's system. It is not subtle. It differs from a normal mood swing because a. it is much more intense and b. It lasts at least a week and without meds can go on for weeks before it peters out.

Because of all this energy the person experiencing the episode may:

1. 1. need much less sleep than normal. (While this is not a requirement for a manic episode, I have not seen a case where this was not true.) This is different from insomnia. With insomnia a person wants to sleep, and feels crappy because they cannot. With a manic episode, the person doesn't need to sleep as much as normal and still has plenty of energy.
2. talk a mile a minute, as if their words cannot catch up to the speed of their thoughts and this is exactly what is happening. Sometimes their speech is not pressured but their thoughts are still moving too fast for the person to follow them.
3.  be super distracted, again due to the speed of their thoughts. 
4. experience a massive increase in their sense of self-importance. At one end of the spectrum this looks as if the person suddenly becomes as confident as the Situation on Jersey Shore and at the other end, the person truly believes they are like Jesus or Neo, blessed with special powers and here to save other people.
5. loose inhibition and do things they normally wouldn't such as go on gambling, sex, or shopping sprees.
6. work single-mindedly and with great intensity on a project. Sometimes the person can make progress (it is likely that some great works of art have been created during manic episodes). Other times, the person is just too disorganized to make anything other than a mess.
7. feel either GREAT or very irritable
8. become psychotic (losing touch with reality) and think all number of crazy things such as they are the savior, people are out to get them, they have special powers, ect.

Some of these symptoms can be caused by problems other than bi-polar disorder. For a psychiatrist or a therapist, it can be hard when taking someone's history to sus out whether the person truly has bi-polar disorder. What sounds like bi-polar disorder can actually be a history of drug abuse, particularly cocaine or meth abuse. The drama that surrounds the life of someone with borderline personality disorder can also look like bi-polar disorder.

Another way people get misdiagnosed with bipolar disorder is that they are helped by mood stabilizers, the class of medication used to treat bi-polar disorder, even though they are not bi-polar. Here is what I have seen happen: A client gives a murky history to their overworked psychiatrist and in the history it sounds like their could be symptoms of bi-polar disorder. The psychiatrist wants to treat with a mood stabilizer and so diagnoses the patient with bi-polar disorder.

Diagnoses in general, including misdiagnoses, tend to follow the client. Other clinicians will see the diagnosis and unless they are really on the ball, they will just keep the diagnosis already in place. 

The primary treatment for bipolar disorder is medicine. The person will be told to take their meds or risk having another episode. They will be told to watch for red flags that they are getting manic, and if they notice red flags, to call their psychiatrist to up their meds. This is not a bad thing, and mood stabilizers have helped a number of people with bipolar disorder to lead normal lives.

The problem is, if you are misdiagnosed as bipolar, you will be told you have a biological illness for life and the treatment is to take your meds. These meds may help but they may also zonk you out, so you don't feel fully awake. Some cause pretty severe weight gain. Psychosocial treatments (therapy, group therapy) that focus on your life circumstances will likely be de-emphasized in your treatment plan. This takes away your autonomy - the sense that with help you can grow and change your life for the better. Instead, you have an illness and you need meds.

This is natural in a health care system that wants to minimize costs - drugs are cheaper than therapy.

My advice: if you receive a diagnosis of bipolar disorder, do your research and really talk it over with the person who diagnosed you. Do not be a passive recipient of psychiatric care. Mood stabilizers have saved the lives of some people with bipolar disorder and others that do not have bipolar, but no matter what diagnosis you actually have, do not underestimate the role of your relationships, work, health habits, thoughts, feelings, and your own will in creating a life that works.

Wishing things were different

This is my definition of mental health: the ability to see and accept reality and react to it constructively. 

In an earlier post, I wrote about a client letting herself have her feelings instead of telling herself how she should feel. The reason I try not to tell myself I should feel a certain way is that it doesn't work. If I feel sad, and then I tell myself I shouldn't feel sad, I end up feeling sad and guilty for feeling sad. The reason it doesn't work is that it puts my wish to feel not sad against the reality that I feel sad. And in the fight between what I want and reality, reality always wins.  

Getting rid of shoulds about me is half the battle. The other half is getting rid of shoulds about the world. Here is one of my favorite Buddhist teachers, Pema Chodron talking about this concept:

I worked with a woman who had spent the last decade of her life wanting the father of her son (who she was no longer with) to be a better father. He was in and out of the boy's life and frequently broke dates to spend time with his son. Every time he stood up her son, this woman was shocked, angry, and hurt. This went on for literally the boy's whole life. "He should be a better father," she said, her body tight with her desire for it to be so. 

"You are right," I said "he should, but he isn't." 

I wanted her to accept the reality of who this man was because then she could choose how best to protect her son and herself from the disappointment of his failure to show up.  That's the thing.  Acceptance brings choice. He's a lousy father. Now what do I do.

Instead, her should kept her banging her head against the same wall of how he actually was: He should be this way. Bonk! He's not. Repeat.

Worse, because she could not accept that this man had failed in his responsibility to be a father, she somehow made it her fault. She beat herself up when he broke appointments, told herself that if she had been a better woman to him when they were together, things would be different. 

As crazy and destructive as this was, there was a certain logic to it: things were not as she wanted them to be, so someone had to be to blame. She wasn't ready to blame him, so she blamed herself.

It was easier for her to attack herself than it was to accept the reality of who this guy was. As I write this, I realize I don't know why this was so hard for her. Of course, accepting that your son is not going to have the father you want him to have is crushing, but I suspect there was a shadow from her past making it even harder to face this reality.

It was short-term work, and we did not have the time to go deeper. Try as I might, I don't think I ever got her to loosen the grip of her passionate desire for him to be different. On one level, she knew he wasn't going to be the father she wanted him to be, but on another level, she kept hoping, hoping. Letting go is not easy. 

Self-blessing

Photo from Tom Curtis

http://www.freedigitalphotos.net/images/view_photog.php?photogid=178

 

In the blurb I wrote about myself for my provider profile on the insurance website, I talk about helping clients be kinder with themselves. Yet when I actually try to help clients with this, I often get the question: “How do I do this?” I’m still working this out myself.

This poem by Galway Kinnell has helped me:

St. Francis And The Sow:

The bud

stands for all things,

even those things that don't flower,

for everything flowers, from within, of self-blessing;

though sometimes it is necessary

to reteach a thing its loveliness,

to put a hand on its brow

of the flower

and retell it in words and in touch

it is lovely

until it flowers again from within, of self-blessing;

as St. Francis

put his hand on the creased forehead

of the sow, and told her in words and in touch

blessings of earth on the sow, and the sow

began remembering all down her thick length,

from the earthen snout all the way

through the fodder and slops to the spiritual curl of

the tail,

from the hard spininess spiked out from the spine

down through the great broken heart

to the blue milken dreaminess spurting and shuddering

from the fourteen teats into the fourteen mouths sucking

and blowing beneath them:

the long, perfect loveliness of sow.

For me, this poem is like drinking fresh juice. My body knows it is good. It reminds me of something I have lost that is waiting to be found. It reminds me that blessings are to be found here on earth, that they are in fact, all around me, and even, in me.

Like the sow, we are creatures of the earth. We have our spines, our fodder, our slop. Our perfect loveliness does not depend on transcending these things but is present in our earthiness, in our contradictions, scars, and coarseness. We too deserve blessings of the earth on us.

In the poem, it is St. Francis who reminds the sow of her loveliness, but this is so she can remember, so she can again flower from within of self-blessing.

So for me, self-blessing is an act of self-kindness, of reminding myself of my own goodness despite ways that I appear ugly to myself. Sometimes this requires a leap of faith – an openness to the possibility that I am in my heart good despite the fact I don’t feel that way at all.

Self-condemnation – telling myself there is something wrong with me – is an old habit, a well-worn path in my brain. It takes force of will to remind myself to self-bless. It is a discipline, a remembering again and again that beneath my fear and the ways I harden myself is my own heart both strong and broken.

How to choose a therapist

The first thing to know about choosing a therapist is that you should like your therapist. A big part of what helps people in therapy is their relationship with the therapist. A relationship grows over time, but when you start therapy, you want to have a good feeling about the therapist and your ability to trust him or her. It is important to trust your gut here. If you have a bad feeling about someone, or a kind of neutral feeling for them, I would suggest you try someone else. I am not saying you should love and wholeheartedly trust your new therapist after one session, but you should have the gut sense that this a person, who in time, you will be able to trust to know the parts of yourself you keep hidden from most of the world.

To this end, I think it makes sense to view a first appointment with a therapist as a trial session. If this first session doesn’t feel right, then move on to another therapist. Sometimes it may take more than one session to make this decision. Now seeing a few therapists before you find the right one could cost you some time and money. Of course, you probably want to get down to business and feel better/work on yourself/grow but taking the time to find the right person is crucial. You are engaging in therapy to make some change in yourself. This is important business and in the long run it will be cheaper and quicker to find the right therapist rather than start therapy with someone only later to discover that you don't work well with this person.  

I want to repeat one point here: Trust Your Gut! If someone doesn't feel right to you, trust that. Choose wisely. Don’t settle. Not every therapist is right for every person. Keep going until you get the sense that you have found the right person.

A word about money:

Therapists have a stated rate, but most also work on a sliding scale. It is standard practice to ask therapists if they have a sliding scale. A therapist's rate is usually up for discussion, however, be prepared to talk to the therapist about your financial situation and the role that money plays in your life. The therapist will likely view the conversation about the fee as part of the therapy.    

If you don't have insurance, and the therapists in your community have sliding scales that you can't afford, you can likely find low-cost therapy through graduate schools or community-based organizations in your community. To find graduate schools use the search term "psychology graduate program" "mft program" and "msw program" and the area you live in (ie. “psychology graduate program san Francisco”). Visit program's websites and see if they have a low-cost clinic. Some community based programs to check out are Catholic Charities and Jewish Family Services (these organizations serve people of all faiths and/or no faith).

You need to be able to afford therapy. But don't just go to the lowest-cost therapist you can find. Find the person who is right for you. Therapists who charge more usually have more experience. This is a plus, but it doesn't mean a new therapist can't be helpful to you.

How to find a therapist

Like most things in life, one of the best ways to find a therapist is to talk to friends and family. Ask people who you know who are in therapy who they see and if they have benefited from the therapy. Another option is to ask friends who are in the mental health field for a recommendation. If neither of these options is available, the web is a good place to find a therapist as many therapists have websites. Check out the site and see if you like what the person has to say about how they work. Visit a bunch of different therapists' sites so you can compare. Again trust your gut.  

Qualifications and training

First, know that it is perfectly acceptable to ask about a therapist's training and their experience working with people who are struggling with what you are struggling with. However, most therapists are generalists. That means that they work with people with a range of problems and life circumstances. So it is usually not necessary to find someone who is a specialist in your problem area but you also want someone who has some experience with what you are dealing with.

There are hundreds, perhaps thousands of types of therapy and it is well beyond the purview of this article to talk about this variety. Research has shown that, in general, therapy works and also in general, that one type of therapy is not better than other types (there are exceptions for certain problems, however). Furthermore, most therapists don’t practice one type of therapy, but instead combine different elements in their work. I suggest you ask the prospective therapist about his approach to therapy and get a sense if this is a fit for you. If you are a very spiritual person, you may want a therapist that includes this element in her work. If you a very logic driven person, you may want a therapy that relies heavily on rationality (ie coginitve-behavioral therapy). Include trauma.

What do those letters after the therapist's name mean?

There are a bunch of different degrees that allow someone to obtain a license from the state that allows them to practice psychotherapy. I am providing this information because people can be confused by this subject, but having one degree versus another is not a way that I distinguish who is a good therapist and who is not. My recommendation is to make sure someone is licensed by the state to practice psychotherapy and then to forget about the letters after their name. That said, here is what those letters mean:

Psychologist (Phd, Psyd, Edd) - Psychologists have a doctoral level degree. Traditionally, to be a psychologist, you had to go to a Phd program and learn how to do research.  The Psyd degree came into existence in the 1970s due to demand for more clinically-focused training. The Edd degree is less common and denotes that the psychology program was housed in an educational department of a university.

Social worker (msw, lcsw) Social workers have a master's degree. Msw is the degree you get when you graduate and lcsw is the letters you put after your name after you are licensed by the state to practice. Social work training often focuses more on learning how community systems help people.

Marriage and family therapist (Mft) - MFts have a master's degree. Their training ensures that the person has experience treating adults, children, and families.

Psychiatrists (MD) - These days most psychiatrists prescribe psychiatric medicines, but some still practice therapy. Psychiatrists went to medical school where they learned to be general practitioners and then went on to specialize in psychiatry.

A client teaches me about letting go

“Have you ever read the Dice Man?” Ana asked.

Ana is my client. She is a woman in her mid-twenties just getting out of a passionate and tumultuous relationship. In the wake of the break-up she has been thinking about excitement and attraction vs stability and safety. Like most people, she wants both but has found it difficult to find the balance.

  

The Dice Man is a novel that was fashionable in the 1970s about a bored psychiatrist who begins making decisions based on the role of the dice. His method is to write out a list of options and then let the dice decide which one to take. Thus, he controls the parameters but the dice ultimately make the decision. The theory is that by listing options that you wouldn’t normally choose along with more conventional choices allows expression of parts of the personality that you usually doesn’t allow to see the light of day.

“Yeah, I read it,” I said.

“What did you think?”

“I’ve used the dice to determine what I do on a Saturday night, but I don’t recommend making major life decisions this way.”

“The Dice Man wasn’t reliable.”

 “No, he wasn’t. He left his wife because the dice told him to.”

“I want someone who is reliable”.

“But you knew that [dude she broke up with] wasn’t reliable from the beginning.”

“Yeah, I know.”

“The thing is I don’t want to always have to be reliable. I mean I am reliable. I was brought up this way. But what if I don’t always want to be there for the other person?”

Ana was wrestling with seeing life in grays instead of in black and white. There are parts of her that crave safety and reliability in a man, and other parts that want passion and wildness. Similarly, there are parts of her that like to be reliable and others that want to be wild and unpredictable.

“The crazy thing,” she said, “is that I have been watching myself and I can change pretty drastically in the span of a few minutes. This morning I felt sad about the break-up for a while, but I didn’t fight it and it went away.”

“Sounds like you are judging yourself less.” A few weeks ago, I pointed out to Ana how often she said she shouldn’t feel how she was feeling. I suggested dropping the shoulds and experimenting with letting herself experience her feelings more.

“I think of it as letting go,” she said. “You know, today I had this experience with this girl I work with. She is someone who I have felt like a mentor to. I am a little bit older, and I have worked at the job longer.  But now she got into law school which I have been thinking of applying to for a long time. And she got a date with this guy at work who I think is cute. I have been thinking about making a connection with him for a long time, but I just never did it.”

“How did that feel?” I hate this question, but sometimes it is appropriate.

“It’s funny. Normally, this would get me down. I would feel jealous. I would feel like I should have done what she did. But today it just struck me as kind of funny.”

“Funny?”

 “Yeah, like I just didn’t take it so serious. She used to look up to me, and now life has us switching roles.

“The student has become the master.”

“Yeah.”

There had been a similar yet subtle shift in the roles between me and Ana. By accepting her experience and lightening up, she was teaching me to do the same. Learning from clients is one of the best parts of therapy, but it also brings up some anxiety about roles.  Should I be accepting money from someone who is teaching me?

Feeling more like a chatty friend having a philosophical conversation than her therapist, I said, “Have you ever had the experience where you feel really attractive and cool and then later in the same day something happens and you feel like a loser?”

“Yeah. But I am feeling less hung up on it. And being the loser isn’t all bad. When I feel like a loser, I don’t experience so much pressure.”

“We can’t be winners all the time, and it is stressful to try to always be at the top.”

“No. And letting myself be both…it feels so more peaceful.”

Crisis-shift, suicidal client

Some writing I did towards the end of my stint at an outpatient psychiatric clinic at a large hospital:

 

Client wears blue track suit pants and brown v-neck sweater vest with no undershirt. He also wears a black newsboy cap. Except for the pants and the white sneakers, nothing matches. He is a little stocky, pale skin, dark hair, a little stubble, latino. He looks tired. I see him waiting in line when I am in the hall. He hangs around the desk until the secretary tells him to have a seat. He is looking at me as I talk to the secretary. I wonder why he is looking at me. I guess he is gay.

The secretary tells me he is a walk-in. I roll my eyes. On crisis, no walk-in means no work. A walk-in means work. Looking over his chart, I see he’s been in and out of the hospital twice this month. Suicidal. Borderline. He comes in and he is polite. He tells me he got out of the hospital Tuesday. He was good till Wedensday when the voices told him to kill himself. With a knife. He shows me the scar across his wrist with fresh sutures. He has made many suicide attempts since he was 12 and several this month: the wrist, 30 ecstasy, 40 anti-depressants, he tried to hang himself but started to cry and changed his mind. Just yesterday he got out a knife and touched it to his wrist. Then he took the tv cord and thought about hanging himself. 

“I am worried about my life. I am not ready to die,” he says. He has an accent. There is something sweet about him. Lost, sweet, innocent. “I was good for a long time. Then I have a breakup 3 months ago.”

“I think you need to go to the hospital.” 
He nods. “I am worried about my life.” 

I let him use my phone to call his sister. He speaks in Spanish. I tell the secretary to call security, standard procedure. I put him in another room and sit with him awkwardly until security shows up. 

“Do you want a magazine to read?” 
“No I am allright”. He sits in a leather therapist chair staring vacantly.

In the staff room, I tell a therapist who knows him that he is the most obvious case for hospitalization I have ever seen. 
"Wrist cutting!" "Command hallucinations!" "Hanging!" "Pills!" These words roll off my tongue like punch lines. 
“Awww” my co-worker says, in a there-there voice. Something about my story has aroused compassion even though I didn’t say much about this client. 
“Stop,” I say, “you will remind me he is a person.”

After 4 hours the ambulance shows up. Per protocol, they haul him off on a stretcher even though he is fine to walk. His brother is there. He looks like a slimmer version of the patient. His track pants match his track jacket. He either has gold teeth or extensive dental work, I can’t tell which.

“My brother,” he says but he pronounces it like, “browther”. “My brother,” last time he went to Hospital X. “Today he is going to a Hospital Y where he went the time before.” “He makes a grimace. “Hospital Y is better.” 
“I am sorry," I say. "I don’t control this. I don’t make this decision. They put him in the hospital with the first bed available.”

I start to walk away. 

“I want to ask you another question. What happened to my brother?” 

Federal law prevents me from talking to a family member without consent, but it seems cruel to not say anything. We are in the hall and I lead him to my office. 

“Your brother was going too hurt himself.” 

He asks me for the number for the hospital. I have to turn the computer back on to get this information. I write it down for the brother. 

He says, “last time, they let him out of the hospital. My brother, he is… last time they let him out after a little time.” “

They let him out too soon,” I say. “

"Who let him out?” 

I point to the name of the doctor I wrote next to the phone number although this is the doctor who released him two trips ago. And this is a problem that goes way above this doctor’s pay grade. Still, it is helpful to have a scapegoat. 

“In this country, they let people out too soon. They push them out." I make a pushing motion with my arms and hands. “I am sorry.” 

The brother looks sad and troubled. “Thank you doctor,” he says and he shakes my hand. I am happy he is not unhappy with me. I am sad for this brother. I am sad for this patient. I leave the clinic. It is night. I see the ambulance pull out of the driveway and onto the street. I see the client on the stretcher. A female EMT is talking to him. I salute the client, but I am not sure he sees me. 

Disappointment in therapy

I saw my therapist for about a year, part of that time twice a week. I came to therapy with a specific issue. This issue did not get resolved.

Even so, I had gotten close with my therapist. Charlie is an older man, in his sixties I would guess. Through working with him, I have been reminded to get back to the fundamentals of therapy in my own work - to talk less, to listen more, and to be genuine with clients. Howard and I once even talked about aiming to be the Tim Duncan (basketball's Mr. Fundamental) of therapy.

I don’t know the details of Charlie's life, but I feel like I know Charlie because he is himself with me. He has a way of greeting me, putting his hand on my back and making eye contact that makes me feel liked. I want Charlie to like me.


He has been a father figure to me. I sometimes have the wish that we could know each other outside of the therapy office, that we could go fishing, not saying much, just spending time together. 

This has been the most important thing I have gotten from therapy - a relationship with an older man who gets me and accepts me for who I am.

Nevertheless, I hadn’t resolved the issue that brought me to therapy. It had been a year. I was going out of town for a few months, and the future of our therapeutic relationship was unclear.

I don’t remember how it came up, but I know I didn’t just bring it up. Charlie had to get it out of me: I was disappointed in him. I was disappointed that we had not resolved the issue that brought me in. I had avoided telling him this because I didn’t want to hurt his feelings and then have him like me less.

When I am the therapist, I encourage clients to talk to me about their feelings about our relationship, but here I was as the client hiding.

Now my disappointment was out in the open for us both to smell. I expected Charlie to try to fix it, to suggest ways we could work through the issue. But he didn’t. Neither did he seem offended or hurt. He didn’t take responsibility for not solving the issue but he didn’t try to absolve himself either. He just let it be.

He said he understood why I would feel that way, and he asked me why I hadn’t told him sooner. There was some urgency to this last question, as if he also meant, “I wish you had told me sooner. You don’t have to hide from me.”

I felt the relief of being honest, and I felt the relief of another person not running away from the truth I was hiding. 

Sometimes therapy works this way: You come looking for one thing, and you find something else. I came in looking for a solution to a specific issue. Instead, I found someone who challenged me to be more me.