The Therapeutic Alliance

Big thanks to Deborah L. Cabaniss, M.D. for writing this great article!  It deserves a re-blog because it discusses a central and essential element of therapy that is often misunderstood: the relationship between the therapist and client.

The Therapeutic Alliance: The Essential Ingredient for Psychotherapy

Take care, Elena

Find Yourself Friday!

The Journey

One day you finally knew
what you had to do, and began,
though the voices around you
kept shouting
their bad advice—
though the whole house
began to tremble
and you felt the old tug
at your ankles.
“Mend my life!”
each voice cried.
But you didn’t stop.
You knew what you had to do,
though the wind pried
with its stiff fingers
at the very foundations,
though their melancholy
was terrible.
It was already late
enough, and a wild night,
and the road full of fallen
branches and stones.
But little by little,
as you left their voices behind,
the stars began to burn
through the sheets of clouds,
and there was a new voice
which you slowly
recognized as your own,
that kept you company
as you strode deeper and deeper
into the world,
determined to do
the only thing you could do—
determined to save
the only life you could save.

-Mary Oliver

What’s the Use in Being Sad?

One of the most common questions asked in therapy is, “why should I be sad when I can be happy?”  There are variations to this question like, “why would I want to focus on my difficult past when I can move forward and not be in pain?”  Or, “I don’t want to suffer anymore.  I came to relieve my pain, not feel it all over again.”

I empathize deeply with the idea that revisiting painful memories, events, and feelings can be overwhelming and seems an undue punishment on the path to healing.  However, I also know that the healing process rarely takes place without returning to the old (or fresh) wounds in order to tend to them.  As a therapist, I try to create an emotionally safe environment in which people can explore their feelings and leave knowing that they are cared for and perhaps even feeling better. This Pollyanna version of therapy occurs occasionally, but the reality is that emotions are messy, complex, and can be very overwhelming.  Sometimes digging up hard feelings can make things worse before they get better.  The process of unearthing pain and fear is courageous and facing an unknown process like therapy, while life-enhancing, is hard work.

One of my favorite authors/researchers/story tellers, Brené Brown, discusses the importance of dealing with “the things that get in the way of joy, meaning, and connection” in her 2010 book  The Gifts of Imperfection, which I highly recommend to everyone reading this post. Brené Brown is a fellow social worker (LMSW, PhD) who studies people and their experiences with shame, vulnerability, courage, and worthiness. Her thorough, evidence-based approach to the study of shame and other human emotions allows me to unequivocally recommend her work as an unbiased clinician.  My status as a total Brené-Brown-ophile lends me to speak from a vulnerable, human place of  admiration and to share that her work has changed my life, my work, and my connections with the people I love. If Brené Brown were Elvis, I would be the screaming, crying teenager watching her TED Talks. The following quotation caught my attention while reading The Gifts of Imperfection:

“If we want to live and love with our whole hearts, and if we want to engage with the world from a place of worthiness, we have to talk about the things that get in the way – especially shame, fear, and vulnerability.”

We have to talk about, process, feel, and share the things that get in the way of worthiness, connection, and happiness in order to define, look for, and live a life or worthiness, connection, and happiness.  Brené (yes, we’re on a first name basis) would call this way of living “wholehearted” and others may call it conscious, purposeful, connected, or self-aware.  Whatever you call it, the sentiment is the same: in order to experience joy and have meaningful relationships we must sort through the pain, hurt, and fear.

You are not alone if this sounds like a daunting, horrifying, or completely foreign concept. I too was among the horrified before finding the safety, patience, and motivation to endure this process. A good therapist was instrumental in this process for me – the safety of a warm, non-judgmental person who was dedicated to my care was extremely powerful through some of my most difficult growth. In fact, it is what drew me into the field of psychotherapy and guides me in my practice of empathy, compassion, and gentle exploration with my own clients.  Pretty powerful stuff.

After reading that paragraph you may be thinking, “ahem. I don’t want to BE a therapist.  Why, again, would any NORMAL person want to go through pain, terror, and negative feelings?”  I get it. What makes it worth it? And furthermore, why do we need someone else to witness, support, and be there for us through the vulnerable, life-altering process of healing?  This is my best shot at answering that question:

People are not emotionally wounded alone, they are wounded by and among other people.  The most powerful way to heal wounds is by vulnerably, bravely sharing the pain with another person(s) and receiving a corrective, kind response like empathy, compassion, protection, and care. You may find something more powerful than pain after experiencing it, knowing it, and moving through it.  Over time, you may find that pain is no longer terrifying, but tolerable after working your emotional muscles. You may find that you are your own courageous, badass, superhero.  You might, at last, love yourself not despite imperfection, but because of imperfection.  You might find that you are good enough, just the way you are.

Take care of yourselves and others.

Visit Brené Brown’s blog to learn more about vulnerability, courage, and wholehearted living:  www.ordinarycourage.com

Brown, B. (2010). The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are. Center City, Minnesota: Hazelden.

How to Find the Right Therapist

“How do I find the right therapist?”

I am often asked this question and would like to preface my opinions by saying that they are just that – opinions. Therapists are as diverse as their clientele and I presume that all would have something to add to this discussion, or perhaps an entirely opposite perspective. If you are looking for a healing, caring, supportive, and emotionally challenging experience, this is my take.

The Basics

1. All therapists are different, but I would say that the primary characteristic of importance in your therapist is that he or she tries to make you feel comfortable and wants to be present with you.

2. Having said that, everyone will be nervous at the beginning of therapy, your therapist included if he or she is human, so give yourself a few weeks to settle in. If you feel inclined, talk to your therapist about feeling nervous and he or she should response empathically.

3. Therapy can be funny and light-hearted at times, but you should not feel the need to impress or entertain your therapist.

4. Therapy can be humorous, intellectual, and emotional, but remember that intellectualism and humor can be used to defend against difficult emotions. Therapists are in the business of emotions, so you may be challenged to access your own at times.

5. You should feel safe in therapy at all times and your therapist should be able to create that safety with you.

Soap box:

Many of the clients I see have discussed “settling” with their previous therapist(s).  He or she would listen most of the time, or was good enough is not an ideal therapeutic situation.  You have the right to the right fit for you.  If it isn’t ideal, talk to your therapist about what is missing.  If he or she responds in a way that upsets you, say that you’re upset.  If it gets to the point where you want to end the relationship because of this disconnect, talk about it.  A relationship with a therapist should enhance your ability to have relationships in the real world.  As a model of relationship, a therapist should encourage honesty, even when it is difficult, and should always have your interest first on the list of importance.

Step 1. Assess your needs.

What do you need and what do you want? You can have both needs and wants met in therapy with the right person. Read the following questions for guidance on your needs and wishes for therapy.

Are you going through a life transition like college, marriage, divorce, parenthood, or late adulthood?

Are you a member of an oppressed group? Is it important to you that your therapist is a part of this group or has special training around your difference?

Will it be difficult for you to speak to a stranger for the first time?

Have you had therapy experiences in the past that did NOT work? What was missing?

Are you depressed, anxious, sad, or do you have a dominating emotion that comes to mind?

Have you consulted a medical professional and if so, what does he or she recommend?

Do you just want to talk and have someone listen?

Do you want to explore your past or focus on the present? Or both?

Do you want to be challenged or supported unconditionally?

Do you want to talk about goals and be accountable to your therapist in attaining them?

Do you seek structure or freedom in therapy?

Are you more comfortable with a particular gender, and why? Would it be helpful to you to have a therapist representing the gender of comfort or perhaps to have a new experience with the gender you do not prefer?

Are you comfortable with a particular age group, and why? How would your experience be enhanced or compromised with different age groups?

What are you able to pay for therapy?

Step 2. Find a recommended therapist

Word of mouth is the most helpful way of finding a clinician but more and more, therapists are advertising and promoting themselves online. There are some websites that verify the credentials of the therapists who are advertising (psychologytoday.com, goodtherapy.org) so make sure that the therapists you read about have credentials.

Money is usually an uncomfortable topic for most people, but prospective therapists should be clear about charges when asked. Some therapists work on a “sliding scale” basis, meaning that they have different rates depending on financial need. If you are in need of financial assistance, think about what you are able to pay and ask the therapist if the rate would be acceptable.

Credentials:

LPC-i and LPC – These therapists are master’s level professional counselors who are seeking or have obtained a clinical licensure. You can expect to pay more to see an LPC than an LPC-Intern.

LMSW and LCSW – These therapists are master’s level social workers who are seeking or have obtained a clinical licensure. You can expect to pay more to see an LCSW than an LMSW.

Psy.D. or PhD. – Psychologists are doctorate level clinicians who perform therapy and also focus on psychological assessment or testing. Psy.D. is a newer degree plan focusing on clinical psychotherapy as well as research and testing. You can expect to pay more for a doctorate level clinician than an LPC or an LCSW.

M.D. or D.O. – Psychiatrists are medical doctors who are primarily focused on psychobiological assessment and medication management for patients. Some psychiatrists are trained in psychotherapeutic techniques but most have little training in psychotherapy. You can expect to pay the most for a psychiatrist since he or she has a medical license and can prescribe medication.

Unfortunately, when assessing therapists one can rarely tell which will be a fit on paper. You may be able to read a bio on the therapist that may help you get a feel for his or her personality and theoretical leanings, but having a conversation is the best way to assess goodness of fit.

Use the questions from Step 1 to guide you in expressing your needs and ask about their training, specialties, and areas of practice. Despite the traditional hierarchy, you may find your needs anywhere in this ranking of therapists.

Step 3: Get to know the therapist

In order to assess fit, one has to “talk the talk” in some ways to understand how a therapist operates. Read up on types of therapies and you may find that one resonates with you.

Psych Central’s article on Psychotherapy – check out the types of therapy on the left index

Ask questions and expect to get your needs met!  This principle is basic to living a life with healthy self-esteem and self-care.

As always, take care.

Humility

I recently had coffee with a former graduate school professor and was reminded of the importance of humility in therapeutic practice.  Not only was I reminded of my days as a student, stumbling through the wide world of social services, but also of the power, will, and strength of former clients.  I was comforted in the knowledge that every person who comes to therapy is the master of his or her own world, the key holder to the door that opens to new life experiences, and the expert of his or her desires and needs.

We, as clinicians, can become expert on subject matters, but we will never know more about a person than they already know.  Take comfort in the idea that you are the best person to solve problems and enhance your life.

And take care.

Power, Privilege, and Therapy

Why therapists must be allies and advocates for clients of different races, religions, sexual orientations, sizes, ethnicities, genders, and any other point of diversity.

I write this post after an incredibly fulfilling discussion among colleagues about power and privilege in the therapy room.  A colleague bravely disclosed that she feels that she should bring up the different racial backgrounds between her and a client of several months.  The client is Latina and the therapist is white.  The therapist feels at times that she is missing some of who the client is because she’s a “white lady” talking to a person of color and that the client could be holding back parts of herself in therapy because race has not been addressed.  Some felt that she should wait for the appropriate time to bring it up and some said that she should bring it up as soon as possible.

We arrived at the conclusion that as a therapist, we are put in a position of power from the beginning of every session.  We automatically sit in the chair with privilege as we delineate the “rules” of therapy, collect payment from clients, and are the ones to say when time is up.  When the therapist is in the position of power as the therapist and is in a position of power and privilege in society, it is doubly important to bring up issues of difference in the room so that the client can be free to explore, tell the truth, and be him/herself.

Here is how it could play out.  A white, female therapist sees a  black woman who comes to therapy every week.  The client talks about work stress and her family life but feels she must leave out any mention of racism at work or family dynamics that are central to her culture because the therapist may reject her thinking.  One day, the therapist brings up their difference; “you are black, and I am white.  What’s it like to talk to a white person about this?”  It may be an uncomfortable moment for one or both of the two women, but now, the topic of race is on the table.  Perhaps the client can label racism at work or explain family dynamics within her home and the black community once the issue is opened by the person who is seemingly in power.

When we hold power over our clients, we limit them from being able to have power in their own lives.  Clients should feel empowered in session, even if not in society, to talk about issues of race, gender, religion, language, LGBTQ issues, or any other topic of disempowerment in their lives.  The key to making this happen as a helping professional is a) recognizing your own privilege, and b) bringing up the difference between yourself and the client in session any time it could affect the therapy.

Our privileges can be things that are not conscious in our minds, like money, having a healthy marriage, having children, dressing nicely, speaking a certain way, being educated, feeling confident, being physically fit… it doesn’t take a white, straight, male to trigger feelings of inadequacy, privilege, and power in a client.

Here’s the really important part for clinicians and what I learned from the wisdom of the group; waiting until it’s “comfortable” to talk about issues of diversity is a privilege as well.  When I say that, I mean that when we think to ourselves, ‘gosh, it’s just not the right time,’ or ‘that would make things really awkward right now, I’d better wait,’ the person who is on the other side deals with that discomfort every day, everywhere he or she goes, and with everyone.  If you are gay, you don’t have the privilege of avoiding the topic of being gay.  Straight people, however, do have the privilege of avoiding the topic of being straight because it’s “the norm” in our society.  (I put “the norm” in quotations because it is unfortunate but also true.)

Take your own difference and use it to have empathy for others.  And take care of yourselves.

Happiness

Who has it?  What is it?  How do we get it?

Happiness is subjective for everyone, but happiness must be defined by every person in order to be palpable.  How does one achieve a goal without measurable tasks?  It seems impossible to seek happiness but not know what must be done daily to have it.

So what is happiness?  I ask clients to pretend as though they have a magic wand which they will use to make their life happy overnight.  Then I ask, ‘what has changed?’  I often hear crickets to this question because it is difficult to envision what needs to change in our lives in order to achieve happiness if we don’t really know what that means for us.  Many psychotherapist, psychologists, and others in helping professionals claim to be  happiness experts, but are we?  In reality, everyone who comes to therapy is the master and expert of his or her own happiness.  It takes applied self-exploration in order to find out what that means, however.

What does happiness mean to you?  Is it feeling fulfilled by your job and family?  Is it obtaining a goal, like a college degree or promotion?  Or is it living in the moment and taking in the beauty of your surroundings?  These are great questions to ask, but the deeper question left unanswered is, what measurable/attainable tasks must I accomplish each day in order to achieve my goals?

Instead of thinking that happiness is something that happens to you, try thinking that happiness is something you cultivate and nurture.  If the goal is happiness, fulfillment, or a great life, the tasks that are required every day to get there can be challenging. Ironically, being happy and fulfilled can be exhausting, taxing, and overwhelming, especially if you struggle with depression, anxiety, or other life stressors.

What does a state of happiness look like to you?  And what do you have to do daily to feel happy?

Happy New Year/National Hangover Day!

I joke, but it must be true!

Hangovers can be particularly brutal because they can come with so much mental, physical, and emotional turmoil.  Most commonly, those who suffer from severe symptoms find that their hangovers come with lots of anxiety.  People feel badly about themselves, ashamed of their behavior, and generally feel negatively about life when in this state.

Hangovers can cause extreme anxiety as a symptom of the withdrawal from alcohol or other substances.  Alcohol is a depressant, which means it slows the central nervous systems and blocks the brain’s ability to produce stimulating chemicals.  The withdrawal from this state of depression turns the system up-side-down.  If we think of depression and anxiety on a spectrum, with depression at the far right and anxiety at the far left side, you can picture a pendulum swinging from one extreme to the other.

While withdrawing from alcohol, the body overcompensates by “swinging” to the left, toward anxiety.  The central nervous system is very activated and the brain is producing stimulating chemicals, but the body and brain are tired, unrested, and confused.  Especially for those who suffer from anxiety naturally, this can be a powerful and awful experience.

Tips for getting through a hangover:

1. Take it easy on yourself. If you are turning your anxiety inward, meaning you are thinking bad thoughts about yourself, know that they are chemically induced.  Have a mantra and repeat it – “these thoughts aren’t real and I’m ok.”

2. Despite your urge to eat the entirety of the fast food menu, eat something good for your body.  A salad with veggies or some fruit can get you on your way back to health.  Alcohol also dehydrates the body so drink lots of water.

3. If you can bear it, exercise.  Exercise stimulates all the right chemicals in your brain to release and ease your body and mind.  It can also speed the release of toxins so that you can feel better faster.  Even a brisk walk can make you feel better since some say that fresh air is a cure to hangovers.

Happy New Year!  Take good care of yourselves.

The Versatile Blogger Award

I’m flattered and delighted to be nominated for the Versatile Blogger Award by Dr. Jim Amos!  I would like to sincerely thank Dr. Amos for putting incredible thought into his posts and working so hard to keep people informed about psychiatric issues.  Dr. Amos is a true pioneer in bridging the gap between mental health professionals and the general public.  If you have not already seen his blog, check it out at The Practical Psychosomaticist: James Amos, M.D.

In accepting this award, I am obligated to:

  1. Thank the Award giver and link back to them in my blog post
  2. Share seven things about myself
  3. Pass this award along to recently discovered blogs I enjoy reading
  4. Contact my chosen bloggers to let them know about the award and post the award picture

Bloggers I admire, and why:

I Choose Change – an amazing look at the power of change

Everyone Needs Therapy – for fighting the stigma of therapy

ProjectATTEMPTERS – for bravely shining light issues of suicidality in society

The Soulful Contrarian – for fearless authenticity

Transitionelle – for bravely seeking joy and challenging herself

BlissfulMindWellness – for offering practical ways to be mindful

7 Things About Myself:

  1. I have a weakness for chocolate.
  2. I am married to, in my opinion, the greatest man in the world.
  3. I love living in Austin, Texas and it is my favorite city in the U.S.
  4. I have never lived in a place where it snows.
  5. I love flavored coffee with lots of sweetener and coffeemate.
  6. I am an advocate and ally for social justice causes.
  7. I believe that people are inherently good and deserving of respect.

Thanks, again for this honor, Dr. Amos.  Take care all.

Parenting from the Inside Out

by Dr. Dan Siegel & Mary Hartzell

A great book for those of you who are looking for ways to be a better parent or working out

your feelings about the ways in which you were parented.

Take care.