O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Educational Engagement : Learning to Learn

Red Brick, Ivy, and Spiderwebs: Learning to Engage

I spent my first two years as an undergraduate at a red-brick ivy-covered college. I remember very little of those two years, but not because I was partying. I was in a different kind of daze, induced by class sizes of up to 200 and studying for tests that required bloodless rote memorization, devoid of joy. The only professor I remember was my biology teacher, Mr. Jenkins. I was enthralled with his course. It was taught in an enormous lecture hall but did not feel big because Mr. Jenkins was so animated, clearly delighted in his subject.  He walked back and forth on stage in front of a screen displaying his photos of spiderwebs, flora, and fauna. Each intricate web was unique, many glistening with dew in early morning light, evening light, and moonlight. The slides were awe-inspiring.

During the first exam for this class, I sat stunned, tears falling down my cheeks, as I realized that I could not answer most of the questions. I had studied, yet I was unable to finish three-fourths of the test. Noticing my distress, Mr. Jenkins gently touched my arm and asked to see me after the exam.  In his office, he asked me how I studied for the test and I told him about flashcards and notes. That was all. Without chastising me for poor study skills, he showed me more of the beautiful photos he had taken with his son, who had died, he told me.  His kindness and his openness about the loss of his son had a big impact on me.  I realized I wanted more connection with my professors.  I wanted my education to include dialogue and engagement with the subject.

Somehow I had made it to college with no idea how to learn. I wasn’t even burdened with attention deficit disorder (ADD) or some similar diagnosis. What I assumed were good study skills were completely off base. It was an awakening.  I did not know how to memorize and assumed that I was incapable of being successful as a student.

Something in me persevered—I think it had to do with those dewy spider webs. Without consulting my parents or friends, and in a time that pre-dated the now ubiquitous larger web, I discovered an experimental college in the woods.

I entered The Evergreen State College because I wanted to learn without the focus on grades. I found a good fit. The class sizes were under 20 and the professors knew our names, and skied with us on Friday nights. They read our journals and interacted with us at all stages of the course.

I discovered I could learn. It developed imperceptibly at first as I read Montaigne and dialogued with him in my journal. I argued with Nietzsche and ranted at Machiavelli. I empathized with Faust and the urge for power and knowledge that led him to sell his soul. I fell in love with Don Quixote and Sancho Panza. Unlike my first two years of college, the last two are a vivid, still-living memory. While I did not return to the study of biology, I discovered a love of liberal arts.  Active engagement with the reading took organization and skill.  These were not simple books but through discussion and writing, they came alive.

How To Do What You Love

Engagement, I found, is the key to learning. Today’s children face enormous pressure to ace standardized tests and get into only the top colleges. If they have ADD/ADHD or other learning disorders, good medications and therapies exist for them. But do they care about learning? Do they love it? Do they know how to structure their time and work with their minds and hearts in the ongoing process that learning requires? In my practice, I have seen the results when kids fail to engage. They become dependent learners. Apathy and boredom are common.

Paul Graham—programmer, venture capitalist, and essayist—writes in   How to Do What You Love” about the intricate dance of finding meaning in what you do and sticking with difficult tasks. Nothing can be achieved without effort. Engagement is not about taking an easy road. We will serve ourselves and our children well by modeling discipline and love of learning. When my girls were little, we would watch spiders make their slow crawl over the lawn, in awe of their perseverance.  Tiny legs, and impossibly large grass obstacles, yet biology won out as they did want they are designed to do.  When our resident mockingbird would call from the chimney, we would run outside to listen to the concert. These simple experiences would later be woven into a story or a dinner discussion.  Bringing mindfulness to everyday life leads to a plethora of opportunities to find fullness in life, and in learning.

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Learning to Stay Calm During Difficult Discussions

By the time couples come to couples therapy they have a built up a lot of tension around recurring problems. For instance, when Joe and Amy came to therapy they had been arguing about who has it harder with respect to chores and child-care. Each felt they were sacrificing more than the other. This led to the typical quid pro quo or tit-for-tat scenario. Many of their arguments were just different versions of the same core conflict. Their discussions quickly escalate.

Couples come to therapy to resolve conflicts and learn better ways to communicate when disagreements arise. When the same issues arise again and again—often over seemingly simple daily routines like who does what in terms of housework, childcare, or social and recreational time— we call this a perpetual problem. Stressful times or life transitions such as retirement, job loss, childbirth, empty nest, or illness can activate these perpetual problems, leading to increased conflict and negative feelings about the marriage.

When a couple first starts therapy, one or both partners will be thinking negative thoughts about their partner.

Gottman Method Couples Therapy, developed by Drs. John and Julie Gottman teaches couples to manage conflict rather than eliminate it, and learning to stay calm during difficult discussions is an important tool in managing that conflict. The stress of arguments creates a “fight or flight” response that is both physical and emotional: the heart rate increases, muscles become tense, blood flow decreases to the hands and feet. These physiologic signs are signals that one is overwhelmed or “flooded.”

Studies have shown that this level of heightened arousal affects the ability to accurately recall events, stay focused, and listen to another. Feeling flooded can also lead to the defense mechanism of stonewalling, or shutting down.

Shutting down serves to protect the stonewaller from the discomfort of increased flooding, but it effectively stalls further communication. Indeed, stonewalling is the fourth and most dangerous of the “Four Horsemen of the Apocalypse,” emotional patterns that can sabotage a relationship, according to John Gottman’s book Why Marriages Succeed or Fail.

The Importance of Self-soothing During Conflicts

Calming down, then, in the midst of a conflicted discussion allows both partners to continue to work on the issue in a more productive and compassionate way. In couples therapy, when one partner is flooded, I gently stop them and ask them to become aware of their arousal level. I have seen profound effects from this simple intervention. It is one of the cornerstones of the Gottman approach and one that has proved to be immensely helpful. This step alone increases the client’s attention to their own reactions and can take them away from the blame game. Later, clients can be taught to recognize for themselves the sometimes subtle onset of tension that can quickly escalate to anger.

Simply noticing heightened arousal may not be enough, and this is where therapists can help teach self-soothing techniques. Many couples therapists will tell their clients to “take a time out” when overwhelmed with emotion. However, many people who come to counseling simply don’t know how to relax during a difficult conversation. Taking just ten minutes of a session to do a relaxation exercise—focusing on slowing breathing, heart rate, and noticing sensations of warmth and letting go of unnecessary muscle tension—can give that necessary pause before resuming a dialogue that has become heated. When Joe and Amy become flooded in a session, they stop looking at each other, shrug their shoulders, and stop talking. Other couples may raise their voices and talk at each other, rather than with each other. It is at this point, that I may ask them to take a few minutes to pay attention to their breathing.

That’s especially important because when one partner is flooded, both are flooded: the emotional build-up is reciprocal. Teaching self-soothing in the moment will lead to new skills in communication and will improve conflict management. The awareness of cues that lead to over-arousal is the first step in helping a couple slow down enough to effectively process and continue a conversation. What we are in fact doing is teaching a form of mindfulness, even during an argument.

Using self-soothing during a couples session when one or the other partner is flooded is surprisingly easy. Perhaps couples’ therapists do not use this powerful technique because they assume that it will take the couple away from the issue they are discussing in a therapy session. However, to let an argument continue to the point of emotional and physical flooding will only leave the couple feeling worse at the end of the therapy hour. Taking just a few minutes of the session to be guided into a relaxation exercise can have profound effects because it will slow things down enough so that the discussion can continue in a more productive and caring way.

It is my deep belief that teaching a couple to self-soothe and ultimately to soothe one another brings depth and empathic attunement to the marriage. This obviously benefits the couple but has a ripple effect on the family. As we know, children model their parents’ emotional regulation or dis-regulation. When kids are able to feel safe around parents, even in the midst of an argument, they will gradually internalize the ability to do their own self-soothing.

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Summer Travels and Travails: Tips for Stress-free Vacations

 

Tips for Making Summer Vacations Stress-Proof: or at least stress-resistant

By now, most of us have either taken the long-awaited summer vacation or are in the midst of planning the final details of packing.  Whether you are fantasizing or fretting at this final stage of planning your vacation, there are several things you can do to ease into a trip.  Despite the sub-title, it is highly unlikely that there is such a thing as a stress-free vacation.   But by keeping a few concepts in mind, you can minimize the strain of travel, whether you are traveling alone, or with your partner, and even with the whole family.

Frantic trips to the travel section of the local drugstore for more bottles of hand-purifier or TSA approved packing gear add to the tension that precedes a trip. Last-minute hunts for supplies often attempt to manage travel anxiety.  Travel anxiety is normal.  In a piece about in-flight emergency medicine, the (June 21st) issue of the New York Times revealed the extent of this commonality:  When the captain of an international flight asked passengers if anyone had a pain-reliever for a sick passenger, only two or three hands went up, but when he asked if anyone had anxiety medication, fifty hands shot up.

If your expectations for a much-anticipated trip are too high, you may come home disappointed. Whether you get lost and miss your reservation, or you just get too tired to do everything you hoped, things rarely go exactly according to plan.  However, we can combat anxiety and disappointment by both setting realistic expectations and by allowing for the unexpected.

Accept that when you travel you take yourself with you.  You will get cranky or may develop some form of ailment, as minor as constipation or as major as a broken bone or appendicitis.   Unfamiliar noises and foreign beds disrupt sleep and add to everyone’s irritability.

Accept that being in a new location does not eliminate familial disagreements. Unless you are taking along a nanny, or are planning a trip that includes childcare such as a cruise or a Club-Med vacation, be prepared for family strife and squabbles.  Kids are going to complain of boredom. They will roll their eyes. They will be embarrassed by you.

Don’t expect kids to want to do the same activities you want.  Travel is an opportunity to teach compromise.  Look for child-friendly activities but don’t deny yourself the activities you enjoy.  Take turns in picking activities for each day.  Look for activities that involve the whole family as well.  Our family made a habit of listening to audiobooks on every driving vacation we took.  We let our daughters pick the book and were delighted with their choices.  Listening to books became so absorbing, that often when we arrived at our destination, we would continue listening in the cabin, tent, or hotel room.  It became a shared experience.  When tension became elevated due to hunger, PMS, or general irritability, we could use the characters in the book to express our feelings.  When we were all invested in the plot, a discussion of the book would help us all get over any bad moods.  Over the years, our family has listened to over 100 books.  (If you would like a list of our favorites, please email me.)

One of the advantages of listening to books as a family is that it is shared. Unlike letting each kid have his or her own movie or game, you can talk about the book together. Video games and movies are solitary.   Many families I see will spend a week or two together during their summer vacation, but hardly interact, each immersed in his or her own activity.

Accept that even in the most spectacular location, being together 24/7 is challenging.  Enjoying that beautiful sunset sometimes takes effort when you are angry with your spouse. When my husband and I set off on a trip to Chile, we predicted at least one argument.  When it inevitably occurred, we were able to laugh it off and said, “at least it’s over with now”.  You will not agree on everything.  As I say to couples in therapy, “you will never resolve conflict, but you can manage conflict.”

Accept that being away from home and routine does not automatically improve a couple’s sex life. Couples will often fantasize about the great sex they will have once they are away from the stress of daily life.  This almost always leads to problems—one partner will feel let down, and the other guilty.  Look for opportunities to be intimate emotionally, and let the sex follow from that.

Most of all, accept that travel causes some degree of anxiety.  Anxiety will take a different form for each of us.  Unfortunately, rushing around town for travel supplies when you are down-to-the-wire creates more stress because it crams frenzied shopping into the final days before embarking, leaving little time to relax before your flight or drive.  Think about non-medicinal strategies that help you relax.  Weave those into the week before travel.

Travel is an opportunity to know yourself in new ways.  Allow for surprise.  Remind yourself to be in the moment, to appreciate the world from a new vantage point.

As you cover the ground outwardly, develop fresh interpretations of yourself inwardly.

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Strains of Summer on Family Life

 

School is out.  Swim season is in full swing.  From my home, I hear the loud speaker blasting from the community pool.  Cheers erupt at regular intervals. Minivans and SUVs line the streets in the blocks adjacent to the swim club.  Like many parents residing in the suburbs, I enjoyed, sometimes endured, the annual ritual of Swim Team.  My daughters were only briefly interested in the glory of winning.  Mostly, they loved the Cup-of-Noodles and the ice-pops and talking to their friends under cover of gigantic towels.  Engagement in children’s activities is a good thing.  But often parents go too far in the direction of over-involvement.  Psychologists have studied the repercussions of what happens when parents are too attentive to their kids.  We describe this as enmeshment.

Focus on children’s activities often dominates family life in much of our country. We live in a child-centered era.  In the July 2 issue of The New Yorker, the article, ‘Spoiled Rotten’, Elizabeth Kolbert, profiled several families from diverse cultures.  How do parents of different cultures train young people to assume responsibilities?  Ms. Kolbert reports that the Matsigenka children from the Peruvian Amazon spontaneously help with a variety of chores, taking pleasure in their independence and helpfulness.  The Matsigenka culture prizes self-sufficiency and hard work.  They tell stories that reinforce these values.  The characters in their folklore are undone by laziness.

French kids will sit calmly through a three-course meal, while their American counterparts are throwing food before the main course arrives.  UCLA sociologists Carolina Izquierdo and Elinor Ochs assessed children’s participation in household responsibilities in a cohort of Los Angeles children. They found that no child routinely performed household chores without being instructed to.  Even when begged to do a chore, the vast majority still refused.

Here in the US, many well-meaning parents have inadvertently shaped their children to become dependent, manipulative and lazy.  As psychologists, we are often called to help restore harmony and balance to families in which kids rule the roost.

Summertime is often the most trying time for families. Frayed nerves, bored kids, too much time playing video games and watching TV, lead to thankful anticipation of the start of school for both parents and kids.  The comfort of daily routines is a welcome relief after a long, hot summer.

Inevitably, the return to structure and routine brings its own battles over homework and academics, in addition to the social strain of school.  There are ample opportunities for more squabbles and nagging, whining and complaining.  As the New Yorker article points out, parents often take the path of least resistance and do too much for their kids rather than face tantrums and meltdowns.

The fallout of raising over-indulged kids has to lead to a  ‘failure to launch’ for many young adults.  We have added this concept to our training and it is all too familiar in my practice.  Family therapy with adult children is now common.  While the economic troubles of the last three years have undoubtedly contributed to the large numbers of unemployed college graduates, but that is only part of the phenomenon.  As Hara Estroff articulated in Psychology Today, hovering “helicopter parents” are progressing to “jet-powered turbo attack model.” The looming pressures of getting accepted at a good college, SATs, extra-curricular cause yet more parental involvement.  With this degree of pressure, it is common for parents to let kids off the hook for chores and family commitments.

Teaching children to tolerate frustration, empathize with others and to persist in work is essential to raising independent young adults.  As psychologists, we help our clients to establish appropriate expectations for their kids and know when to step in to help and when to leave kids on their own.  In the next month, our clients will be transitioning from summer schedules to back-to-school routines.

 

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Chronic Pain and Narcotics

A Behavioral Approach to Treating Chronic Pain and Medical Problems

In the June 2 edition of The New York Times, the article “Pain Pills Add Cost and Delays to Job Injuries” Barry Meier points out that powerful drugs such as OxyContin actually delay recovery from injuries that occur at work. But beyond the financial cost of using opioid painkillers to treat back strain and other pain problems, the human costs are heartbreaking.

I have treated chronic pain since I first began working as a psychotherapist. Using biofeedback, cognitive therapy, and relaxation training, I worked with medical patients referred by their physicians. The people I treated were on multiple medications from many different classifications within pharmacology. Sedatives were combined with opioids, sleeping pills, antidepressants, and mood stabilizers.

In the pre-digital age, where medical records were in the form of a paper chart, these patients had the thickest charts, often in several volumes. Pain patients can be docile, following doctor’s orders to take the pills exactly as prescribed. But in chronic pain, the tolerance to these strong medications grows. Increasing the drugs’ strength and frequency may not cure or even lessen pain; in fact, the pain is often made worse. In medical jargon, the pain becomes iatrogenic—meaning that the treatment causes the problem.

Over time, the side effects of taking opioids lead to a plethora of new medical and psychological problems. These drugs cause lethargy, drowsiness, depression, and irritability. The lifestyle behaviors that would ameliorate pain, such as exercise, relationships, and engagement in pleasurable activities, are difficult to do if one is bedridden due to stupor, further delaying recovery.

The cost to the patient’s family is also a big problem. The reduced income stresses everyone and reduces the patient’s self-esteem. The healthy partner becomes a caregiver, putting a strain on sex and intimacy. Pain patients take on what I call “pain behaviors” such as wincing, grimacing, and grunting, signals that often look like helpless dependency. Caregivers’ own helplessness to do anything, creates burnout, leading them to ignore patients’ suffering. Resentment grows on all sides. Marriage counseling is often warranted to help partners adapt to their spouses’ pain and to learn new ways of coping.

When I started treating chronic pain, Behavioral Intervention was the treatment model. Self-care was the cornerstone of healing, with medications as an adjunct. My work was to help patients see that being in bed most of the day and night was robbing them of their life. By suggesting and encouraging gradual exercise and teaching meditation and relaxation, I could help them begin to engage in life again. While working at Kaiser Hospital, I conducted research for my doctoral dissertation that showed a significant reduction in medical costs for patients who had completed short-term behavioral therapy for their chronic pain. The treatment was effective for reducing medical costs for up to five years after the therapy was concluded.

In addition to medical costs, the psychological literature has focused on the “secondary gain” of chronic pain. This refers to the usually unconscious benefits one derives from pain. This could come from worker’s compensation benefits, attention from family, or legal compensation from an injury incurred at work or an accident, but also the insidious creep of opioid dependence.

Chronic pain patients often fall through the cracks of the medical and legal system. Lawyers get involved. Settlements get delayed due to the difficulty getting appointments with doctors, medical examiners, and the many ancillary people involved in the care of these folks. This added complexity prolongs recovery thereby increasing the toll of chronic pain on the patient’s life.

A unified team approach is necessary to prevent this kind of delay. Delays cost in big ways. As the Times article states, insurers spend $1.4 billion a year on narcotic painkillers. If these medications are used too early, too frequently, or for too long, the disability payouts and expenses will end up delaying return to work and in many cases will lead to permanent disability. In 2010, prescribed opioids cost $252 million in California. This cost is passed onto the taxpayers, who underwrite coverage for public employees like firefighters and police officers.

In this time of budget cuts, and controversy regarding pension plans we need to work in a systematic way to help the patient learn to cope with pain without the use of addictive medications. This will alleviate the burden on many fronts. Psychologists have had a role in treating patients with medical conditions for many years, yet referrals for mental health treatment have been affected because of to the many restrictions insurance companies put on providers, and limited coverage for this form of treatment.

One of the most effective treatment approaches is Mindfulness-Based Cognitive Therapy and Stress Reduction. This approach often utilizes a group format so that coping techniques can be taught efficiently. A growing body of research supports the use of meditation, and acceptance, in the treatment of medical problems. Psychologists can diagnose other problems a patient may be experiencing such as depression and anxiety, that may be compounding recovery. I often make recommendations for couples therapy. A comprehensive team approach is the most effective way to help a patient recover so that use of addictive medications will not impede a return to living life well, despite recurrent medical problems.