O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Psychologists Need Self-Care Too

Self-care and ethics for psychologistsWho Helps the Helper?

Self-care and Professional Ethics

Most psychologists get into this profession because we get deep satisfaction from helping people. But who helps the helpers?

What about us, anyway? We sit for hour after hour, year after year, listening to our patients’ troubles. We help them make sense of what brings them to our office. We help them deepen their understanding of themselves, working with them to bring meaning and healing. But as psychologists, our training is not very conducive to our taking care of ourselves. The doctorate alone requires years of study, often at great expense, to say nothing of the 3,000 hours of unpaid or poorly pay internships, post-docs, and fellowships. It doesn’t end there; paying back debt and building a practice all take a toll on our self-care.

And of course, while dealing with these stresses, we must be effective and ethical therapists, even when clients may be testing our limits, perplexing us, or causing us worry.

A therapist’s most valuable tool is the therapist’s own self. We need to model a healthy self to our patients, and this is where self-care comes in. In fact, self-care is an ethical obligation to maintain our competence as psychologists. Caring for ourselves as well as others is an inherently integrated and reciprocal process. When we “more readily realize the false demarcations between ourselves and our clients, self-care becomes both an ethical imperative, and a humanistic one.”

So as a therapist, don’t forget to ask “What about me?” Issues that can challenge self-care include:

  • Balancing our own and clients’ needs
  • Countertransference reactions such as envy or erotic feelings
  • Confidentiality

For example, let’s take envy, a problem that can loom large in this time of widening income inequality or for any therapist working with wealthier patients. No one likes to admit to these feelings, but denial is never a good strategy.

And this can especially be a problem if we feel stalled in our own lives. We’re in the trenches; meanwhile, we’re helping others live fuller lives. They write books, get fit, flourish. Good for them—but here we sit, with unfinished books, unexercised bodies, unexplored possibilities.

Here’s an example from practice.  I had a patient with a lucrative professional job who came to me for anxiety. His wife was leading one of my dream lives, an unlived life: owning, showing, and riding horses.  I thought “Damn, she is lucky.” I felt impatient with his problems and had to stop myself from telling him his wife should get a job. Because we have lots of training in recognizing when our reactions are countertransference, I was able to see my envy at the moment so as not to let it interfere with my client’s process.

Or again, I authorized a patient’s disability leave. He got four months of paid time off, lost 20 pounds, got a personal trainer, went on a luxurious retreat, and returned looking 15 years younger. Good for him again, but I was seeing 30 patients a week and couldn’t help contrasting my responsibilities with his fortune. For those of us in private practice, taking time off is tricky. We lose income, and our clients may have a hard time without the continuity of their therapy.

When our patients improve and surpass us, how do we deal with that? That’s our goal, after all, to help them attain full lives and be the best selves they can. It’s not their fault we haven’t achieved the same goals. We must move forward in our own lives if we’re going to maintain ethical principles and standards.

Another challenge can be secrecy. Keeping patients’ secrets is an ethical imperative, but not always easy. A very famous person came to me for something highly scandalous, something I was dying to tell—but even married to a psychologist, I could only mention broad strokes, no name, and no juicy details. It’d be a great story to tell at parties, but I have to keep all such secrets locked in a vault. It’s a peculiar situation to know more about the inner world of a very famous person than anyone else and not be able to tell a soul, but as an ethical psychologist, I can’t.

Heal Thyself, Know Thyself

The arduous, never-ending self-scrutiny and inner work required by our profession is like no other. Gaining deep intimacy with our clients requires us to be just as deeply familiar with our own feelings. As therapists, we’re already familiar with the value of therapeutic lifestyle changes in areas like exercise, nutrition, rest and relaxation, maintaining good relationships, and service to others. We recommend these to our clients, so we should also practice them ourselves, along with helpful interventions like apps to help monitor diet, movement, and sleep. To that list, we should add personal therapy and development for ourselves, not just clients.

This is because our work depends on the personal/professional therapeutic bond. In turn, this largely reflects and depends on the therapist’s interpersonal skills and capacities, which must be developed in the therapist’s personal growth. The link between ethics and self-care is professional competence, which is necessary to protect our patients. Clients’ experiences of the therapeutic relationship—the respective interpersonal capacities of the client and therapist—are among the strongest predictors of outcome in psychotherapy. Those of us who are reluctant to practice self-care techniques should remember that we are decreasing our competence as therapists.

More information on these principles can be found in the American Psychological Association’s “Ethical Principles of Psychologists and Code of Conduct.”

Taking care of ourselves

When we say we’re not taking care of ourselves, what does that mean? Examples include overbooking or double-booking clients and working late; taking no breaks; being distracted, impatient, or bored; giving clients the same exercise as last week; talking about your problems instead of the client’s; or falling asleep. As you can see, these actions affect clients as well as ourselves. If we’re not getting our needs met, we may look to our clients to meet them, a violation of their boundaries.

Occupational hazards

In our jobs, occupational hazards include isolation, demands on body and psyche, frustration, and never-ending self-scrutiny. Burnout, compassion fatigue, secondary traumatic stress, suicidal patients or our own suicidal feelings, depression, anxiety, boredom, conflicts with co-workers, practice logistics, insurance company hassle, money problems, personal losses—these can all add to professional stress. To cope, we need inner strength, self-soothing skills, and awareness of our own strengths and vulnerabilities.

Even when we’re well aware of the damages we’ve suffered, we can fall into the mistake of projecting all such woundedness onto patients, and claiming the role of healer—and healed—for ourselves. Self-knowledge helps prevent this trap. It’s also important to seek peer support through professional groups and other networks, social support from friends, and develop coping methods like cultivating humor and a positive attitude.

Occupational Privileges

 As psychologists, we live a life of service. We are always growing and our work protects us from stagnation. As Irvin Yalom states in his book The Gift of Therapy, we daily transcend our personal wishes and turn our gaze toward the needs and growth of the other. We take pleasure in the growth of our patients and also in the ripple effect–the salutary influence our patients have upon those whom they though in life.   Viewed the right way, the very stresses of our job help prevent stagnation. Continual growth and self-examination help us to see the world, ourselves, and our patients for what they are, making us better able to help—which is what brought us into this field in the first place.

The result of my exploration on this topic is that I am taking a sabbatical during the month of January. I plan to write, read, and spend more time deepening my self-care.

References

In pursuit of wellness: The self-care imperative. Barnett, J. E., Baker, E. K., Elman, N. S., & Schoener, G. R. (2007). Professional Psychology: Research and Practice, 38(6), 603–612. http://doi.org/10.1037/0735-7028.38.6.603

What Therapists Don’t Talk About and Why: Understanding taboos that hurt us and our clients.  Kenneth S. Pope, PhD, Janet L. Sonne, PhD, and Beverly Greene, PhD Second Edition, APA Books, second edition, 2006.

Ethics, self-care and well-being for psychologists:  Reenvisioning the stress-distress continuum. Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Professional Psychology: Research and Practice, 43(5), 487–494. http://doi.org/10.1037/a0029446

Ethical principles of psychologists and code of conduct. The American Psychologist, 57(12), 1060–1073. http://doi.org/10.1037/0003-066X.57.12.1060

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Suffering, Compassion, and a Skate Ramp

 

Last summer my neighbor’s son built a huge skate ramp right next to our property line. (We’re on different streets, so I’d never met him or his family.) First sawing, then drills, and eventually it was finished. I was glad for the wild Toyon bushes that grew high along a chain-link fence, blocking the view—but they didn’t block the noise. In use, a wooden skate ramp has a distinctive mechanical rhythmic sound. It’s similar to the poinging back-and-forth of a tennis match, but is contiguous and unvarying, except for sudden yelps from the kid or his friends.

My work as a psychotherapist is focused and can be intense. Quiet time in my garden is where I replenish by slipping into reverie and stillness. I love the silence, punctuated only by bird song and breeze-tossed tree branches. But now all I could hear, from morning to dusk, was the skate ramp. I tried to counter my disgruntlement by reminding myself ”At least it’s not a meth lab, and I could be glad he’s getting healthy outdoor exercise instead of playing violent video games and watching TV all day.” But in truth, my first thought when occasionally I heard a thud followed by silence was ”Yes! A broken ankle.” I did also think ”Oh no, he could be seriously hurt.” But then the skating would start up again, shattering my peace and sending me back inside, grumbling to myself.

It’s true that in many ways, mine was a problem of privilege. I was just irritated by a noisy nuisance, while some people are living in refugee camps or dodging bullets in their own neighborhoods. Many people have no quiet, private, beautiful place whose silence can be invaded. But most everyone can relate to feeling dominated by difficult or negative emotions like helplessness and anger.

Finding Another View: Opening a window

This summer, though, something happened to help me accept the noisy interruption of my peace. When a Monterey pine succumbed to bark beetles, the tree guys removed some of the Toyon bushes, opening the way to roll giant slices of the dead tree to the driveway. For the first time, I had a window to view of the skate ramp. The opening allowed me to see a shadow dance, the blur of back-and-forth movement, that accompanied the rhythmic skating sound. Actually seeing the annoying kid had the interesting effect of making me less annoyed. Suddenly he was a person, a kid in a baseball hat having fun, not just a maddening, repetitive sound.

I felt compassion; I wasn’t trying to feel compassion, talking myself into it, as I had before. Catching glimpses of the kid trullunking on his skate ramp allowed me to view it differently. I can now sit in my backyard and know that the neighbor kid is doing what he enjoys. I can occupy that space literally alongside him. It becomes background sound, along with the birdsong and an occasional leaf blower. And it also nice to notice when it stops.

How does my experience relate to suffering and compassion? Because it’s only when we can see the humanity of others and acknowledge our own uncomfortable thoughts that we can transform them. When I couldn’t see what annoyed me, all I could do was feel passive and irritated. Once the view was clear, I saw the source of my feelings and could accept it. A kid having fun. On a skate ramp in his backyard, which happens to abut my backyard. We all have hedges that obscure our view and block compassionate response.

In psychotherapy, and in mindfulness-based therapies, we learn to see that our emotional suffering and problems in life are not only caused by external circumstances but by the way we react to them. When our minds are dominated by difficult or negative emotions, we feel out of control. We employ defense mechanisms like withdrawal, projection, and demonizing the other. In contrast, meditation and practicing mindfulness is helpful because we cultivate the capacity to watch what is arising in our mind.

We sit with feelings and thoughts, noting but not getting caught up in them as we refocus on breathing and sitting. Witnessing our thoughts and feelings and allowing them to move on, rather than reacting unreflectively, gives us more emotional control, more choices about how to respond with our better, less overwhelmed selves. Meditation provides a window to compassion, something like the window through the hedges. We may begin to see that things are not so bad.

W.H. Auden’s poem “As I Walked Out One Evening” contrasts the idealistic hopes of lovers with the quelling voice of Time, which recommends looking in the mirror—accepting things as they are—and the healing that comes from putting aside illusion:

‘O stand, stand at the window

As the tears scald and start;

You shall love your crooked neighbour

With your crooked heart.’

With my crooked heart, I do.

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Waking up on the Grumpy Side of the Bed: Coping with difficult moods

Coping with depression and difficult emotions.“Yesterday all day a small gardenia was a great consolation.”

Thomas Merton

A Year with Thomas Merton: Daily Meditations from His Journals

Some days are harder than others. It’s tempting to find something or someone to blame, even if it’s just the wrong side of the bed. Yesterday, I woke up grumpy, but instead of fault-finding, I announced to my family that I was grumpy and not to take anything that happens between us too personally.

My bad mood persisted through breakfast. In fact, I kind of enjoyed feeling grumpy. Especially because there was no apparent reason and I didn’t care to find one. I felt defiant.

I took my hike as I usually do, on this sunny morning. I begrudgingly admitted it was a stunning day. Yet my mood persisted—and became worse as a large group of hikers, some meet-up group or club, began to pass me on the narrow trail. As I walked in the opposite direction up the hill while they clomped down, one by one, they each said good morning, smiling as if the day was something really special. In my sour mood I thought, ”How many more are there? Don’t they realize that, as one person going against the tide of walkers, I would already have been greeted numerous times? And how many more good mornings and fake smiles do I have to return?”

Many, many more, it turned out, because the group numbered more than 80. And every single person smiled at me and said “Good morning,” or a variant of it. By about the 40th person, something happened without any volition on my part: I began to smile back with genuine happiness. At first, it was in amusement at my grumpy predicament of sharing a trail with 80 very happy hikers, but as the group moved past me, I felt a stirring of good will toward these cheerful strangers, who had unknowingly softened my mood.

Sometimes moods are like that: inexplicable and unpredictable. As a psychotherapist, I help people articulate their feelings. More expansive and more integrated awareness of emotions, achieved through therapy and mindfulness practice, helps people respond more healthily and flexibly in the moment and day by day. By doing so, we can change the quality of our lives.

It can feel as though we’re overpowered by emotions. We can become so absorbed in them that we become identified with what we feel and lose the ability to witness them. A simple misunderstanding with a friend can become an all-consuming and unbearable wound. In such cases, we risk getting stuck in a contracted state that can lead to depression or avoidance behaviors such as overeating, drinking, shopping, or sleeping, which provide a temporary illusion of feeling good. But as we know, those actions backfire, leading to more guilt and less overall effectiveness.

Noting and naming emotions, in contrast, gives us a path past denial or avoidance into acceptance, letting go, and even gratitude.

Sometimes our moods are not just difficult, but serious mood disorders, such as major depression. If feelings of sadness last longer than two weeks, and interfere with daily activities, it is important to get help from a psychotherapist to determine if psychotherapy and medication would benefit. Mindfulness-based cognitive therapy is often a good treatment for depression.

The solution is not to ignore our difficult moods, but to acknowledge them as they arise. In some situations we will be able to trace what we feel to a particular event that we can bring insight to. For other moods, like my waking up grumpy for no apparent reason, we accept them and watch what happens next, much as we do with the weather. Eighty happy hikers eventually made me smile and my bad mood passed as they passed by. That was essentially effortless, but it is often quite effortful to cope with hard emotions.

When we cultivate a disposition that witnesses and accepts passing experiences, we become more stable. In mindfulness meditation or contemplative prayer, we accept thoughts and feelings without judgment and with open and spacious awareness. Emotions arise and pass without interference. I acknowledged my grumpiness and warned my family not to mind me. In doing so, I took responsibility rather than looking for someone or something to blame. This allowed me not only to be open to my bad mood, but also to become open to the good mood that emerged later on.

Sometimes, of course, bad moods can arise for good reasons, not just something that inexplicably overtakes us. In his journal, Thomas Merton describes waking up with heart palpitations and shortness of breath, surely cause for concern. But instead of dwelling on his fear, he starts his page by recognizing the small gardenia as a consolation. He describes walking out into the woods and gazing at the tall straight oaks, closing his journal entry for that day with the lines:

“Sweet afternoon! Cool breezes and a clear sky! This day will not come again. The bulls lie under the tree in the corner of their field. Quiet afternoon! The blue hills, the daylilies in the wind. This day will not come again.”

That is more than acceptance; it’s real gratitude. It starts with accepting all our moods, the grumpy and the grateful. Without that, we can only approximate gratitude in a kind of pretending. With my softened mood, I continued on my way, grateful to the hikers, and happy to be spending my morning in the hills.

 

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Accepting Life’s Turbulence: Fasten Your Seatbelt

Life brings ups and downs and finding a way through the stormy turbulence takes courage and grace.
Thunder Cloud from 37,000 ft

This dramatic cumulonimbus was captured at 37,000 feet over the Rocky Mountains in Colorado. Pilots know to avoid going near these thunderclouds, charting a course around them for the comfort of passengers and safety of the aircraft. Even coming close will cause turbulence—the jet trembles and shakes, often violently.

Pilots rate turbulence as mild, medium, or severe. Thankfully, excellent communication between pilots means that patches of bumpy air can be predicted well ahead of time and avoided by changing elevation or course. But sometimes turbulence is unavoidable. In that situation, fearful flyers grip armrests, pop benzodiazepines, and turn up the volume on their headsets. Eventually the air smooths out, and everyone releases their breath…and their grips.

Staying Steady During Turbulent Times

Jet travel is a great metaphor for life. Sometimes the bumpy moments are so extreme that there’s nothing you can do but sit with it and hope you don’t have to pee. But sitting with the rocky ups and downs of life isn’t always easy.

When a pilot acquaintance asked me how to survive the turbulence of his current marriage problems, I asked him what he tells his passengers to do when the flight encounters a rough patch.

He said, “I tell them to fasten their seat belts.” We have all heard the familiar words, “The captain has turned on the seat belt sign. Please return to your seats and fasten your seatbelts.” Now, I confess I sometimes use this moment to zip down the now suddenly empty aisle to use the lavatory (but only in mild turbulence.)  But basically, in bad weather you need to stay seated and wait it out.

I enjoy flying, but that wasn’t always true. I was a fearful flyer for about six years. I wasn’t phobic, I didn’t avoid flying or have panic attacks, but I was alert to every squeal of the engine, movement of the wing flaps, or ring of a cabin bell,. During euphemistically described moments of “bumpy air,” I would glance up at the flight attendants’ faces to see if they were showing signs of concern.

I wasn’t afraid of heights or of being in an enclosed space—my fear was simply of crashing. Kaput, end of life, and the imagined 60 seconds of sheer terror I expected to feel going headlong into death.

We have no control over death. Once I came to terms with accepting that I could die in a plane crash, I became less afraid. It wasn’t that I was convinced by statistics showing how rare such deaths are; fearful flyers are rarely comforted by the statistics. Acceptance, in contrast, goes a long way in dealing with the bumps we encounter in life.

I found out this week that I have a 50/50 chance of having the genetic mutation associated with hereditary breast and ovarian cancer (HBOC). My family on both sides has had lots of cancer. But through advanced genetic testing, I now know that my family members have the BRCA2 mutation going back three generations. As I await the results of my blood test, I am again reminded of our lack of control. For me, it’s the toss of a coin: I either have it or I don’t. If I do, I have an 85% chance of developing breast cancer and lower risk of other cancers (ovarian, pancreatic, melanoma, and stomach). I am not comforted by those odds.

Flying has infinitely better odds. But after a week of emotional turbulence, I will meet my fate with HBOC with as much grace as I can muster. It hasn’t been an easy week, to be sure, veering between certainty of bad results and certainty of escape. So while I wait and hope that I end up on the happier side of the 50-50 split, I will fasten my seatbelt and try to steer as safe a course through the thunderstorm as I can, with all the support I’ve gathered over the years: family, friendship, work that I love, and resources (such as FORCE). Coping skills, like seat belts, keep us safe. While we generally don’t enjoy restraints, a seatbelt helps to contain our emotions so they are less likely to overwhelm.

I am reminded, once again, of a lesson taught by Thich Nhat Hanh: “When we have a toothache, we know that not having a toothache is a wonderful thing.” (Peace Is Every Step: The Path of Mindfulness in Everyday Life, 1992, p. 38). Finding comfort in the face of difficulty is possible—by riding out the painful moments and trusting that the next moment contains a potential fullness, some simple pleasure waiting to be noticed. So when the seatbelt sign is again turned off,  you are free to move about the cabin. Add take a deep breath.

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Psychotherapy: A Safe and Sheltered Space

Psychotherapy is a safe place to explore what is causing you pain and how to cope.One size does not fit all when it comes to finding a good therapist. Many variables influence the extent to which people get better, solve problems, and grow. While empirical support is important in choosing what treatment to provide, psychotherapists shouldn’t stick rigidly to what studies suggest; instead, they should work from the position of evidence-informed practice. This allows for treatments that respond to what clients bring to therapy—their unique histories, temperaments, and narratives. Sometimes what may be most helpful in the therapy is intangible and unmeasurable by any study. In research, these are referred to as non-specific effects. These are uncontrollable factors: the usually small, barely noticed interactions that create an unexpected effect in the subject. In other words, they are not a part of the research experiment.

In Irvin Yalom’s book Existential Psychotherapy, he describes how, during a cooking class, he wondered why the instructor’s meal always tasted better than any of the his attempts at the same recipe. He learned why after catching the teacher’s assistant throwing fistfuls of various spices in the dish before putting it in the oven. This story has stayed with me since reading it in the early years of graduate school. The crucial ingredients—the “throw-ins”— of good therapy may be unquantifiable, and untaught; even the therapist may be unaware of them.

In a previous post I wrote about love as part of the therapy. Love is a challenging factor to study because it is difficult to quantify and because love overlaps significantly with other emotional reactions such as respect, compassion and empathy, and curiosity.

What is the art of therapy? Sometimes it is as simple as being really present with clients during their pain. Being present means not interrupting, giving advice, or falling asleep, but instead staying tuned to a client’s process. As in meditation, a therapist who notices his or her mind wandering should first notice where it has gone (and if there is anything in that mental tangent that could provide meaning about the client’s situation) and second, return that attention to the client.

A safe and sheltered space

In ancient times a holy person who would descend into what was called an incubation chamber—a dark underground space—with someone in turmoil or grieving. They would remain together in the darkened underground space for three days. This practice illustrates how healing  comes through being present with feelings. When someone is suffering, the willingness to go into the dark with them as they express and move through their feelings is a large part of what we do as therapists. When suffering people can take what’s vague and private, locked inside their heads, and speak out loud the unspeakable, they can gain a depth of understanding and new self-compassion.

The popular 2015 Pixar film Inside Out shows how this works. Riley, the young protagonist must endure her family’s cross-country move, which takes her away from her friends, her home, and her beloved hockey team. Believing she must be perfectly mature, she suppresses her sadness. Five personified emotions–Joy, Sadness, Anger, Disgust, and Fear –live in her head and influence her actions and memories. The dominant voice is Joy, because being happy and not expressing our negative feelings is socially rewarded. But all emotions have a role to play in living well. When Riley tries to silence Sadness, she becomes numb to all feeling, including Joy, and pandemonium ensues. It’s only when Riley can fully acknowledge the sadness in her life that she can also remember the tender, loving moments. Therapy patients must similarly accept and not disown their most difficult feelings.

Good treatment isn’t always easily available. Many therapies lend themselves to apps and downloadable protocols, making these treatments more accessible for people who are unable to find (or afford) a good-fit therapist. Videoconferencing, mobile applications, g-chats, and web- or text-based therapy have a place, and can be powerful ways to change behavior and improve symptoms, especially for those who feel shy or stigmatized about talking to a therapist. But with something gained, sometimes something is also lost with techniques that avoid human interaction and relationship.

What’s missing are 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 speak in ways where texting is mute. Staying safely in front of a screen provides shelter, to be sure, but possibly also a place to hide.

To illustrate the importance of face-to-face therapy, there’s the example of my former client who returned to therapy after a seven-year break. He told me his physician kept increasing his antidepressant dosage, but he was getting worse, not better. After sitting with him for close to an hour, listening to the many stresses he described, I gently inquired about his subtle, yet noticeable twitching. His movements were suggestive of a genetic disorder and not merely anxious fidgeting. He immediately told me “My biological father [he was adopted at birth] was really strange before he died. He moved and twitched all the time—I haven’t thought about it in years but I know he had something wrong.”

At the conclusion of our session, he promised me that he would contact his cousin and find out the name of his father’s condition. I suspected it was Huntington’s disease, a rare genetic disorder. When he emailed me the confirmation, I was able to suggest genetic counseling and testing.

So what appeared to be depression and anxiety—and was being treated as such—was in fact a neurobiological condition. While the news was not good, he could be treated by the right physician for his condition and not keep taking medication that only made him feel worse.

The opportunity to look at your darkness with someone who respects you and your process can allow you to speak the unspeakable, giving room to the ineffable—those moments of awe that come only when we let the full range of who we are be seen and known.

Rumi stated it well in his mystical poem “A Garden Beyond Paradise”:

Everything you see has its roots in the unseen world.

The forms may change, yet the essence remains the same.

Every wonderful sight will vanish; every sweet word will fade,

But do not be disheartened,

The source they come from is eternal, growing,

Branching out, giving new life and new joy.

Why do you weep?

The source is within you

And this whole world is springing up from it.

 The joy of which he wrote cannot spring forth without awareness that it will also fade. Trust that the source of life is in sitting with and sharing the difficult parts of ourselves in a safe and sheltered space.