O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Teletherapy–One Year Later

Psychologists help people cope with change in ways that enlarge and nourish them. Perhaps the most important thing we do is witness our clients’ stories by the deceptively simple act of listening and observing. But that simple act became complicated when the COVID-19 pandemic thrust us overnight into the new territory of telemedicine.

The pandemic and quarantine were accompanied last year by unimaginable tectonic shifts in almost every aspect of life. Police violence, civil protests, and political unrest made us rethink our relationships with some of the most fundamental aspects of being human. We went through it all alongside our clients, yet our code of ethics demands keeping such fears to ourselves and keeping self-disclosure to a minimum.

For therapists and clients alike, teletherapy presented an unexpected and steep learning curve. Many patients felt awkward having painful or intimate discussions while being physically separated, sometimes while dealing with technological issues. Behind the scenes, therapists had to master new technology and change our billing and documentation procedures while ensuring the new system was secure and  HIPAA-compliant.

It could be awkward for us too. and I worried about staying attuned to my clients and whether I could still practice deep listening as described by Theodor Reik in his book Listening with the Third Ear.

We are… encouraged to rely on a series of most delicate communications… collecting all our impressions; to extend our feelers, to seize the secret messages that go from one unconscious to another. . . . The student often analyzes the material without considering that it is so much richer, subtler, finer than what can be caught in the net of conscious observation. The small fish that escapes through the mesh is often the most precious.

Nevertheless, we figured it out. Therapists and clients found that we could make deep contact even through a screen once the technology got sorted out. We learned new ways of observing and gaining information, and I was impressed to see my clients’ resilience in using telehealth apps from their cars, in a dark garage, or from a closet. We found ways to see the whole person without needing to see their whole body by listening with the fullness of all our senses.

In my practice, I’ve also observed how the pandemic has allowed more time for hobbies, family life, and other pursuits. Seeing opportunities for growth in the midst of difficulty is an insight with wide application beyond the pandemic. It’s helped me grow in my job as a psychologist; in the words of the Shaker hymn, I’ve found that to “turn, turn will be our delight, / Till by turning, turning we come ’round right.”

That said, it’s important to acknowledge that the terrifying awareness of our tremendous vulnerability and life’s fragility has severely tested our defenses. In our communities and the world, the grief we’ve experienced and witnessed differs from anything we’ve seen before. It’s what Pauline Boss calls “ambiguous loss”—unresolved loss without closure and no end in sight.

We must carry this ambiguous loss for our clients and ourselves, knowing that the way ahead is still dark. Fortunately, our training as psychologists provides us with the clinical foundation to continue to practice in empathic and ethical ways even as we traversed the chthonic underworld along with our clients. Our ability to stay with the depths of despair alongside the knowledge that we can still hope and dream is the stuff of our work and our personal lives. As the poet Theodore Roethke wrote, “In a dark time, the eye begins to see.”

 

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Passion and Sex in Long-Term Relationships

 

It is not uncommon to have romantic fantasies about people other than your partner. It’s not just normal; it can even enhance your marriage—that is, unless those fantasies cross the line, which is what I’ll talk about in this post.

In a long-term marriage, romance can depart, and sex can follow. From the outside, couples might seem to have perfect or near-perfect relationships, partnering well in work, raising kids, entertaining with other couples, and just plain building a life together that to everyone on the outside looks like a perfect or near-perfect relationship. But I can tell you that in my nearly 30 years of seeing couples, one of the biggest issues that get them into therapy is when they have not been having sex and one or the other of them feels neglected, rejected, and regret about years wasted in not having a sexual marriage.

The lack of sex often happens insidiously. It may start to decline as early as after the wedding, or after the first child is born. Maybe it begins when personal stressors take over a person’s psyche. Or it may start as late as after a woman goes through menopause and experiences dryness and pain with sex.

Life is difficult and often draining, taking a toll on our energy.

Once we get overwhelmed with responsibilities we try to use control to keep things together. What does that control look like? It can devolve into being snarky, snappy, or stingy. But admitting this to ourselves is threatening, so we compensate for those resentments or hurt feelings by making everything look more perfect on the outside so no one will guess how empty we feel on the inside.

Now we’re ripe for an effective distraction from having to think about these feelings of discouragement. Enter stage left a coworker, friend, or neighbor who listens to our feelings with rapt attention. With each interaction, new confidences are shared — just as we used to do with our partners when first falling in love, one of the best feelings in the world.  We feel our vitality is coming alive again from that dormant state, that deep freeze it had been in because romance and vitality are intimately tied together. Meanwhile, our partner is oblivious —  or, if they do suspect that a flirtation has progressed to a full-fledged emotional affair, we gaslight them, saying they’re crazy and have nothing to worry about.

Most relationships require that couples discuss and come to mutual agreements about fidelity issues, such as flirtation, porn, or time spent with the others that a spouse may find threatening. . When one partner strays, it’s often because these difficult discussions haven’t happened. Whether out of denial, fear, or just plain self-centeredness, the affair ends up coming like a bolt from the blue to the betrayed partner.

Of course, it’s never okay to violate the fundamental trust of your relationship by having an emotional or sexual affair or committing other indiscretions like visiting a sex-worker or getting a happy-ending massage. But it is each partner’s responsibility to check in with one another about where you’re both at with regard to your sex life, or lack of sex life.

When I’ve seen couples who come in for therapy to repair the damage from an affair, the betrayed partner will often say “I had no idea,”  “They never mentioned they were unhappy,” or ”I assumed we were on the same page.” Other times, the problem is right out in the open, with years of fighting about sex.  As with secrecy, that takes a toll too.

It’s important to get into counseling early—before the damage is done. There’s no doubt that affairs create deep pain. Even so, after the crisis has died down, infidelity can reignite the love you once had for each other. We are all multi-layered beings with complex feelings and needs, and we’re especially vulnerable when it comes to our sexuality. To protect yourself and your relationship, don’t neglect to have those difficult conversations.

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Bittersweet and Everything In Between

Being able to hold opposing emotions is one of the hallmarks of good mental health. Something can be both bitter and sweet, and we tend to feel that we must pick sides. To our confusion, we often can’t stick with one or the other feelings — either getting pulled back and forth, or stuck in one or the other. Getting mired in the bitter side can lead to depression, but the sweet side has its own pitfall, such as denial about problems.

What does it take to hold the tension of the opposites? A willingness to acknowledge that we can be both happy and sad, weak and strong, and that we are in a continual state of change. If we can’t accept that  impermanence underlies life, we can be badly rattled when fortune’s wheel turns for the worse, or overly elated (and sure that things won’t change) when it turns for the better.  We must learn to live in between, alongside the difficult and the pleasant. When we taste only sweetness, then bitterness will not long follow — because nothing lasts forever.

We are living through a historic pandemic that’s made more acute by the daily (or hourly!)  news we get on the ever-present phone in our pockets. Adding to the constant angst is social media, frequently showing a rosy view of other people’s lives— the victory garden that is blooming like crazy, the family game night, Instagram-ready special recipes . All of these are examples of how we have made sweetness of a difficult situation, but they don’t tell the whole story. They can  also serve as stark reminders of all we had intended to do in the weeks of our confinement leading to feelings of loss that, that when combined with daily news of deaths, disease, and economic hardship, are very real reminders of the bitter side of life.

These painful feelings can include missing  our friends, seeing our child deprived of a real graduation ceremony, and worrying about front-line health care providers and essential workers who make other people’s lives easier.  They’re certainly not getting time in their garden or finding creative ways to make a meal.

Holding opposites in tension is  based on an awareness of both good and bad, which are both always present as forces in the world and within us. It takes a great sense of balance to live with this paradox, and it’s rare to remain  in the place of balance for very long. The reason is that our thoughts and emotions will tug at us continually pulling us all along the spectrum from bitter to sweet and back.

When I first started writing this blog, I called it “Creating Well-Being.” That title no longer fits my thinking about suffering and growth. It does not represent the complexity of how we live in a world full of trauma, inequality, and paradox.

In my thirty years as a psychologist I have been seeing clients grapple with the paradoxes in their lives and within themselves. One wants to be good and moral, yet has affairs that he knows would hurt his wife; he’s unable to stop himself, unable even to see that he’s hurting himself too by being pulled apart. Another stays silent about years of sexually abusing a younger friend when they were kids, meanwhile marrying and starting a family with the burden of shame and guilt weighing him down. And often we  externalize these negative and difficult feelings, because it feels safer to blame another person, a job, or our lot in life for all that we don’t want to look at in ourselves. Instead of growing, we’re stuck.

Psychotherapy is about finding the syntheses of opposites. A helpful technique is looking  for what’s left out of a clients’ narrative. Carrying secrets creates turmoil; the omitted truth wants to be heard, on levels that range from the faintest whisper in the back of the mind to a gnawing pain that keeps us tied up in knots.. ; When we ignore our full reality and drive awareness into the unconscious, we perpetuate default patterns that prevent us from becoming whole. It takes courage to open ourselves and allow a fuller view of consciousness to dawn. Expanding of one’s being means an enlargement, and enrichment of the personality and is no easy task —  arduous, but enlightening.  

The archetype of the shadow can be seen in many stories, such as Dr. Jekyll and Mr. Hyde, or in f Frankenstein, written by Mary Shelley in 1812. It struck a huge chord with the public as a profound example of the risks of disowning our dark side. In the story, Dr. Frankenstein is consumed by the needs of his ego to create life out of death. He works tirelessly, manically stitching together the parts of dead bodies to create his masterpiece. Avoiding all human contact for years, he is eventually successful in his ambitions. But on seeing  the creature he made, he recoils, calling it The Monster and abandoning it without a thought. He betrays his own creature, and it catches up to him, finding revenge in destroying the people Dr. Frankenstein loves most.

There is a bit of Dr. Frankenstein in all of us. We pursue our dreams and then when they do not satisfy us in the way we had expected, we abandon our creation — which has its revenge  in keeping us from full aliveness and wholeness. Or, because we’ve all been hurt, betrayed, or abandoned in some way, these unprocessed wounds can create a monster that’s embittered, enraged, and revenge-seeking, even taking the shape of self-harm. 

The poem “As I Walked Out One Evening” by W.H. Auden speaks of a healthy tension of opposites, which acknowledges the contradiction and beauty of human experience: 

‘O look, look in the mirror,

  O look in your distress:

Life remains a blessing

  Although you cannot bless.

‘O stand, stand at the window

  As the tears scald and start;

You shall love your crooked neighbour

  With your crooked heart.’

Personal growth through whole-hearted openness can  heal the split within ourselves, unifying opposites and defeating divisiveness. It is then that we can love our crooked neighbor with our own crooked heart.

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What to Do After a Fight and How to Repair

One of the most important skills you can learn to better manage conflict is how to make a repair AFTER you’ve had a fight, big or little. I’ll tell you right now, just saying you’re sorry is not going to cut it. In fact, even if you do get off the hook by simply apologizing, you won’t learn anything about how to improve things in the future. In my work with couples, we’ll take several sessions to build a kind of template, the “Aftermath of a Fight” exercise. Developed by Dr. John Gottman, the technique gives a way to talk over emotions and background issues after a recent argument in a more compassionate and productive way. By recent, I mean some time after the fight, when you’re no longer flooded with feelings.

Making Up After A Fight

Although at first you may feel awkward, you’ll find that the exercise becomes more automatic with practice.  You won’t have to go down the same rabbit hole with every disagreement. You’ll be able to understand each other better, and not just repair the current situation but also help prevent future arguments.

The guiding idea of the Aftermath of a Fight exercise is that there is no absolute reality in any relationship conflict, but rather two subjective realities or points of view. Both are right. By using the six key components of a post-fight debriefing, you’ll have a  help you to process without getting back into the fight.

“There is no absolute reality in a disagreement, but rather there are two subjective realities and points of view”

Aftermath of a Fight or Disagreement Debrief

Let’s look at each of the 6 key components for making effective repairs after a fight:

  1. What were your feelings during the argument?
  2. What was your subjective sense or reality about the argument?
  3. Can you find something you can understand about your partner’s position?
  4. Are you flooding as you talk about it during the debrief?
  5. Admit your role. What was your contribution to the fight?
  6. How can you each make it better in the future?

Step 1 is to describe what you were feeling during the argument. It’s important to follow the rules of active listening by using “I” statements — that is, describe simply how you feel without blaming your partner. So, you’d say “I felt worried,” not “You worried me,” or “I felt lonely,” not “You made me feel lonely.” Saying “I felt like you made me feel…” is cheating!

Also, keep Step 1 brief. Avoid the temptation to explain at length, justify yourself, total up points, or add a laundry list of grievances. When that happens, I gently stop the partner and remind them to just say, “I felt” — fill in the blank. PERIOD. Long explanations just make the other partner defensive and get more flooded all over again. Yes, it’s very hard to own your own stuff, and much easier to project onto your partner. But I’ll tell you, that won’t get you anywhere but two steps backward.

I can’t tell you how often I’ve been with couples and seen how, as they listen to their partner express their feelings in a clear and non-blaming way, they react with much deeper empathy and understanding. This alone makes a huge difference.  

In Step 2, each of you  expresses your subjective reality or point of view in a couple of sentences. Sometimes condensing and consolidating your experience during the fight is an art in itself, because so often we want to bring in everything else that has angered us over the last months, or years! Step 2 gives  practice in knowing yourself and using mindful attention to be concise.                                

Step 3 is about empathy: how well can you understand your partner’s point of view? It can be hard to put yourself in someone else’s shoes — even, or maybe especially, your partner. You want to be able to say“I can see how you feel” about such and such, or “It makes sense that you can feel that way.” 

In Step 4, you check in with yourself to determine if you’re getting flooded. Many times when couples debrief after  a fight, they just get angry all over again, defeating the purpose.  In therapy, I might ask at this point if anyone is flooded. If so, Iwe stop the exercise for a few minutes until they can bring their heart rate down and then they can reengage in the discussion. This may seem like a small or unnecessary thing; even experienced couples’ therapists can neglect it. But believe me, it’s crucial.  Again, for more information please see my video covering this topic.

Step 5 is admitting how you contributed to the fight.This is one of my favorite steps; from my work with couples I can say that this alone is eye-opening for both people. It’s also  something you can take with you into any other relationships with family and friends. 

Admit your role! It is essential that each of you takes some responsibility for what went wrong during your discussion and what made it go sideways. As with Step 1,  you’ll also use a simple, brief sentence. For instance, you might say something like “I’ve been very stressed,” or “irritable,” or “overly sensitive,” irritable,” or “I haven’t expressed much appreciation toward my partner lately.”  Or “I need to be alone,” or “I haven’t made time for good things between us.”

So often in life we get caught up in being busy,  or stuck in our resentments, and we don’t reach out to our partner. Then we’re surprised that they have no idea how we’ve been feeling! The common denominator of Step 5 statements is that they fill in the blanks and show the backdrop to what contributed to the fight.

Finally, in Step 6 you consider how you could do better next time. So, you ask yourself very directly, what is one thing my partner can do differently next time? And what is one thing I can do differently next time? Answering these questions takes some emotional intelligence, first to figure out how you can ask directly for what you need, and then  to accept what your partner says would help them.

This is very different from just saying “I’m sorry we got into an argument last night.” I won’t kid you that this is easy. Even though it’s easier in a therapist’s office, it still takes practice at home. I also want you to remind you that this repair never works if you get flooded again. That’ll just reignite the original fight, and if this pattern continues, you’ll only compound your difficulty managing conflict and build even more negative feelings about the marriage and your partner.

The example to follow goes something like this:  “I want to apologize for my role in our disagreement last night. I’ve been thinking it over and I realize I came on really strong because I was feeling worried about finances. I got worked up and didn’t really listen to what you wanted to say. I can see that you may have felt dismissed by me and I want you to know that I didn’t mean to be dismissive of your ideas for our vacation,” or garden — you fill in the blank. “I think I have been very preoccupied lately with my job stress and I haven’t been giving you much attention and making time for you.“ 

Overall, then, this is a process, but it’s  a powerful one. When I work with couples, I give them a written summary of the steps so they have it handy and can practice it together after a fight. You may need to do it together in a formal way with the six steps for a few times, or a few dozen, but it really will become imprinted and integrated into one clear and heartfelt repair.

Try it, and good luck!

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Third Ear Listening: Ethics and Teletherapy in Quarantine

Social distancing due to COVID-19 has caused a radical shift in our work as psychologists. In talking with other therapists, I’ve found that many of us are feeling the strain of doing therapy by teleconferencing. Talking with our clients via a one-dimensional digital representation lacks the subtle interpersonal interaction and relationship that characterize psychotherapy. By now, we’ve created a facsimile of our psychotherapy office that accommodates teletherapy where we try to listen with free hovering attention sitting in front of a screen with a camera, microphone, and perhaps earphones.

Video can be taxing due to the way digital images are encoded, which cause artifacts such as blurring, freezing, and audio that doesn’t always sync. We miss the powerful nonverbal communications that shed so much light on the intangibles of what might be contributing to a person’s issues. A blush, an eye-roll, a tear welling up, the fidgeting of someone with a secret, the nervous giggle, or shy smile—these nuanced communications can give us insight and aid our understanding of unconscious dynamics.

Whether in person or over the phone, we can still be attuned to our clients in the moment. In my psychotherapy practice, I have been influenced by Theodor Reik and his book Listening with the Third Ear (1943): 

We are… encouraged to rely on a series of most delicate communications… collecting all our impressions; to extend our feelers, to seize the secret messages that go from one unconscious to another. . . . The student often analyzes the material without considering that it is so much richer, subtler, finer than what can be caught in the net of conscious observation. The small fish that escapes through the mesh is often the most precious. 

Important in adjusting to providing teletherapy that most approximates in-person sessions is solving technical problems while paying attention to ethics (see updated information on ethical practice from the American Psychological Association) and HIPAA compliance. Some of these issues include:

  • Deciding on a HIPAA- compliant secure videoconference platform such as VSee, Zoom, Doxy, or Simple Practice (which I use.) 
  • Ensuring good WIFI (I had to buy an extender because my home office’s connection was sluggish and intermittent) and closing all other browser windows 
  • Learning how to code for insurance reimbursement
  • Giving clients clear instructions on how to access our video link and what to do if we get disconnected
  • Creating  a telehealth consent form and discussing potential risks and limitations of treatment 
  • Discussing safety plans
  • Confirming with clients how to ensure privacy and security before, during, and after our video call. 
  • Clarifying how to send payment
  • Asking for ID from new clients to confirm they live in California (unless we’re licensed to provide service in another state)

Other telehealth considerations have to do with making the session work visually. We’ve learned to position screens so the camera catches us from above and doesn’t show a double chin. To see each other clearly,  we’ve learned to position the lighting behind our screen, and when necessary, have instructed clients to do the same. To lessen distraction and be better present in the session, we avoid glancing down at our own image. Though it’s impossible to make real eye contact in a video call, we can better focus on a patient’s facial expressions by minimizing their image and moving it up the top of the screen nearer to the camera. This helps with connection, even if we can’t pass a tissue when we see our client cry. I have also discovered that sitting a little way back more clearly echoes sitting somewhat apart, as we would in person. There is more of a space between us. 

But there’s no new thing under the sun, and telemental health has been used for decades. Before smartphones, video chat, FaceTime, or Zoom, therapy via landline improved access to care, offering a cost-effective alternative to in-person therapy in many situations and populations. In Mules of Love (2002), Ellen Bass — poet and co-author of The Courage to Heal — wrote about the possibilities for therapeutic connection even across a seemingly impersonal, clunky telephone line:

Phone Therapy

I was relief, once, for a doctor on vacation

and got a call from a man on a window sill.

This was New York, a dozen stories up.

He was going to kill himself, he said.

I said everything I could think of.

And when nothing worked, when the guy

was still determined to slide out that window

and smash his delicate skull

on the indifferent sidewalk, “Do you think,”

I asked, “you could just postpone it

until Monday, when Dr. Lewis gets back?”

The cord that connected us—strung

under the dirty streets, the pizza parlors, taxis,

women in sneakers carrying their high heels,

drunks lying in piss—that thick coiled wire

waited for the waves of sound.

In the silence I could feel the air slip

in and out of his lungs and the moment

when the motion reversed, like a goldfish

making the turn at the glass end of its tank.

I matched my breath to his, slid

into the water and swam with him.

“Okay,” he agreed.

During this global crisis, doing psychotherapy so differently from our usual way of working requires facile adaptability, even once the practicalities are solved. But we can rely on our ethical principles to give us, and our clients, a safe and secure way to experience the moment. By endeavoring to listen and respond with the Third Ear, we strengthen our ability to make a healing therapeutic connection. In fact, being forced into this situation may reveal the usefulness of teletherapy that will last well beyond COVID-19.

This article was originally published in The Contra Costa Psychological Association Newsletter, May 2020.