O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Marriage Takes Work, Care, and Attention

“Marriage, the Job: The Hard Work in ‘Before Midnight,’ Amour’ and Other Films and Shows,” A.O. Scott points out that in movies and TV, ”work and wedded bliss are now synonymous: the harder marriage is, the more romantic it seems.” Even a rich, famous, handsome actor like Ben Affleck, married to the equally rich, famous, and beautiful actress Jennifer Garner, could say when accepting his Oscar in front of millions of viewers that his marriage is work.

This might have surprised fans who assume that couples like Affleck and Garner naturally have marriages as glamorous as themselves, but Affleck was expressing a truism of our culture, says Scott. “The idea that lifetime love equals long-term labor pops up in rehearsal-dinner and anniversary-party toasts, and in parental advice and pastoral counseling sessions. It is one of those kernels of common sense that always seems to go without saying, but that also somehow requires constant reiteration.”

Scott shows that the most compelling films about wedded relationships depict real marriages with real problems; happily-ever-after marriages do not keep audiences engaged. This is because there are few completely happy marriages. Granted, I see a skewed sample in my work as a couples’ counselor. But aside from that, I know that my own marriage—any marriage—is an evolving process.

We know that marriage is hard work. We exchange our vows with every intention of keeping them till death do we part, but no one expects to have life problems that distance partners and erode intimacy. No one goes into marriage thinking their spouse will have an affair, or that the couple will face challenging problems with children or chronic health conditions. Life is not predictable.

Romance is thrilling. We go into monogamous relationships with every intention of keeping that thrill alive forever. Despite our best intentions, we grow apart. The demands of earning a living and raising a family take a toll. Couples may face challenging problems with children or chronic health conditions. Couples often come to counseling with the complaint that they are leading parallel lives. They feel more like roommates than the lovers they once were.

In a recently published study conducted at UCLA that examined 251 couples, the authors found that nearly all the spouses predicted that in the first four years of marriage, the relationship would be stable or improve. But in fact, the most optimistic wives “showed the steepest declines in marital satisfaction.” This optimism was also correlated with lower self-esteem, higher stress, and physical aggression toward their partners. Optimism can, in fact, be dangerous: “Believing that one’s marriage will improve does not make it so and instead may paradoxically mask risky relationships among women,” say the authors, adding that “nearly all couples overestimate the durability of their existing satisfied feelings at the start of their marriage.”

Why is marriage so much work? We have to face ourselves when we face our partner. When partners come to couples therapy for the first session, I caution them that this process will be difficult—informed consent, of a kind. Unlike individual psychotherapy where you can choose to talk about a conflict with your partner without his or her counter-argument, in couples therapy there is another person sitting next to you with their own version of what happened during an argument or incident. By necessity, each person must explore what he or she brings to the table. In couples therapy you need to speak your mind, but respect your partner’s view, and it is the therapist’s job to point out what happens in their interaction that gets in the way of understanding the complex dance that is marriage. I believe that a conscious marriage is a path to wholeness.

References:

Scott, A.O. (2013, June 23). Marriage, the Job: The Hard Work in ‘Before Midnight,’ Amour’ and Other Films and Shows. The New York Times. Retrieved from

Lavner, J. A., Karney, B. R., & Bradbury, T. N. (2013, June 24). Newlyweds’ Optimistic
Forecasts of Their Marriage: For Better or for Worse?. Journal of Family Psychology. Advance online publication. doi: 10.1037/a0033423

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Alternative & Complementary Treatment for Emotional and Physical Health

Self-care and ethics for psychologistsWith changes in health care following the Affordable Care Act, providers will soon emphasize health promotion over disease management. Integrating alternative and complementary approaches to well-being will provide patients with ways to manage their health and provide a foundation for preventing new health problems. Complementary and Alternative Medicine (CAM) has been practiced for the last 25+ years in the United States, but many of these approaches have a much longer history: well over 2,000 years, in the case of yoga. In the last decade, studies examining the effects of yoga have increased substantially—important for yoga’s acceptance as a mainstream treatment.

CAM includes health-care practices that have not generally been considered part of conventional medicine. In 1991 Congress passed legislation to provide the National Institute of Health (NIH) with $2 million in order to study unconventional medicine. Some of the most widely studied alternative approaches to health promotion and maintenance include biofeedback, meditation, dietary supplements, chiropractic treatment, massage therapy, relaxation training, movement therapy, art therapy, and acupuncture, together with spirituality, religion, and prayer. Other approaches, such as hypnosis and bodywork (including Reiki, Hanna Somatic Education, and Feldenkrais), have also been used for several decades.

Biofeedback is One of Many Treatments Shown to be Effective in Treating Medical Problems

Biofeedback can help many medical problems.
Biofeedback Before the Digital Age

I incorporated biofeedback training for the patients I saw during the eight years I worked at Kaiser Hospital in Vallejo, CA. Biofeedback informs a patient of important physical measures such as muscle tension, skin temperature, brain wave activity, and heart rate. The photo shows what was state-of-the-art equipment at the time (circa 1988.)
I treated patients referred by their PCPs, neurologists, and orthopedic physicians for chronic medical problems. These patients were considered ‘high utilizers’ of medical services such as doctor office visits, prescription drugs, and special procedures. Using a treatment model that included cognitive-behavioral therapy, biofeedback, relaxation and meditation training, patients suffering with chronic headache were able to reduce doctor’s office visits by 75%, medications by 56%, emergency room visits by 19%, and special procedures by 6% for up to five years after treatment.

We have come a long way since then. Digital developments since those early years have dramatically changed the way biofeedback services are delivered. But the principle is the same: taking responsibility for your own health.

Taking Responsibility for Your Health is Key to Lasting Change

Teaching a client to control muscle tension so they can reduce musculoskeletal pain, or showing a migraine sufferer how to increase hand temperature through relaxation and biofeedback, involves learning to be aware of stress and the body’s automatic reaction to it. Of course there are some that would rather take a pill to relax, but that doesn’t change the psychophysiological baseline. Taking a pill or a drink will give temporary relief, but will not lead to lasting changes in how the body handles stress, thereby preventing headaches or pain altogether—not treating them once they occur. Implementing positive health behaviors require discipline and consistency. When physicians have 20-minute appointments –once or twice a year—there is not sufficient time to instruct and follow-up on a patient’s exercise or yoga practice. For people who are dealing with significant life stress, medical problems or depression, making life style changes can feel insurmountable. One yoga class will not help an achy back, nor will a meditation class help control anxiety if the home practice component is ignored. Psychotherapy aimed at helping integrate and continue healthy changes can help.

Wearable sensors such as Nike+ FuelBand or the Fitbit One monitor everything from heart rate, steps taken, sleep quality, energy used, and skin temperature. As a recent New York Times article reported, there is even an app to detect signs of depression in diabetes patients through smartphones.

Taking responsibility for health by using both ancient practices and newly emerging technologies and treatments will improve lives and ultimately reduce medical costs. But the most profound outcome is engagement with a life lived fully.

References:

“The Integration of Complementary and Alternative Medicine (CAM) Into
the Practice of Psychology: A Vision for the Future,” in Professional Psychology: Research and Practice, 2012, Vol. 43, No. 6, 576–585.

Changes in medical utilization after biofeedback treatment for headache: Long-term follow-up. O’Grady, Susan J. Dissertation Abstracts International, Vol 49(1-B), Jul 1988, 241.

National Institutes of Health (NIH). (2011). NIH—The NIH almanac (NCCAM). http://www.nih.gov/about/almanac/ organization/NCCAM.htm

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Depressed, anxious, or both? Part Two

Depression is a Treatable Illness

According to the National Institute of Mental Health, an estimated 17 million adult Americans suffer from depression during any 1-year period. Depression is an illness that carries with it a high cost in terms of relationship problems, family suffering and lost work productivity. Yet, depression is treatable.

Everyone feels down from time to time, and often these feelings can be attributed to a situational or environmental cause. A rift with a friend, or the loss of a job, can cause feelings of self-doubt that will leave one feeling sad for a time. But when feelings such as helplessness, sadness, or hopelessness last longer than a month, there may be more going on.

In the case of job loss, it is normal to feel depressed and worried about the prospect of finding new work and to ponder what led to being let go, or fired. But if the thoughts turn to rumination about failure, and hopelessness about finding another job, then it may be time to seek treatment.
Depression wrecks motivation through its characteristic anhedonia—Latin for inability to feel pleasure. Often this is a gradual process, creeping up over time in such a way that even the depressed person doesn’t see it coming. One day, it is there. Unshakable, unspeakable. Shame and self-doubt take hold as feelings of worthlessness erode a once-affable person. Family and friends try to help, but often give up after their attempts are met with an attitude of hopelessness.

How Psychotherapy Can Help

In my work with clients who come in for psychotherapy because of depression or anxiety, I take a careful history to see if medical problems may be causing any or all of the symptoms. Biological factors can interact with mood, increasing the severity of depression. Medical disorders such as low thyroid can mimic depression and cause some of the same symptoms such as low energy, sleep disturbance, and difficulty with focus and concentration. Once medical causes are ruled out, we reconstruct the timeline of when they starting feeling depressed or anxious. Sometimes these feelings are rooted in childhood experiences and memories, but not always. We start where the clients are, giving them a wee bit of mastery so they can feel hopeful.
Recapturing a sense of mastery is vitally important in recovery from depression. In psychotherapy, we identify what negative or distorted thinking may be contributing to feelings of helplessness. Research has shown that when someone feels helpless and out of control, they tend to avoid those situations where they are likely to feel overwhelmed. Yet, like the phobic avoidance described in the previous post, the more you avoid life, the more depressed you will become. Psychotherapy helps people to see the choices they make and to slowly incorporate fulfilling activities back into their lives. Unlike a family member making the suggestions that can easily feel like a demand or criticism-the collaborative relationship developed in counseling, allows the depressed person to take ownership for their healing. This in itself gives back a sense of control. Gradually, people can identify options and set realistic goals that enhance their sense of well-being. Whatever triggered the depressed feelings is seen from a different vantage, and automatic negative thinking begins to diminish. Going back to bed becomes less appealing as life feels more enticing.

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Anxious, depressed, or both?

Anxious people fret. Depressed people brood.

Anxious people worry about what may happen, while depressed people ruminate about what has already happened. In each case, life becomes more and more constricted.

Sometimes the two conditions may look similar because both use avoidance as a coping strategy. Think of avoidance as going back to bed and pulling the covers over your head: back to the womb. Safe and secure. Everyone has the urge to go back to bed to avoid facing some task or situation at one time or another, but depressed or anxious people turn to avoidance habitually.

In both cases, the anxious or depressed person may even end up avoiding people, places, and things they used to love. The difference is that the anxious person is avoiding occasions that trigger overwhelming, out-of-control feelings of panic, while the depressed person has lost the ability to feel pleasure in once-loved activities.

Anxiety that Causes Phobias

For instance, Julie was missing out on occasions like social and family gatherings, going to a favorite antique store, or seeing shows she used to enjoy—all because she was afraid to drive on freeways. She would go far out of her way to avoid them. Google Maps allowed her to program her navigation system to skip all freeways and bridges. But just getting from point A to point B on surface streets was too time consuming and life restricting. She didn’t apply for jobs that required driving across a bridge. She stayed home more and more. Eventually, even driving across town was daunting. She was miserable.

When a phobia such as Julie’s is pervasive, it prevents experiencing the fullness of life. Because her anxiety was interfering with her happiness, Julie was motivated to tackle her fear of driving. She came to therapy with a willingness to stick with it, even though she knew her anxiety would increase (at least temporarily). We outlined a plan that would allow her to gradually try driving on the freeway—getting on an easy entrance close to her home, and then taking the very next exit. We worked on relaxation and self-soothing so that she would be able to calm herself when she noticed the beginnings of panic. We discussed ways she could cope when she felt anxious.

Exposure Therapy Helps Master Fears

We also explored how she was holding herself back from pleasurable activities. She listed the things she would like to do if able to drive further from home, such as visiting a certain antique shop and crossing the Bay Bridge to see a show in San Francisco. Making this list helped her stay motivated when she wanted to give up.

Psychologists call what we did exposure therapy. We slowly introduce the feared situation in a way that is tolerable. This allows for mastery and gradually increases confidence. Avoidance is the opposite of mastery. It is not easy to face fears. It takes persistence and sustained motivation.

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How Anger Hurts Relationships

Getting angry…is easy and everyone can do it; but doing it . . . in the right amount, at the right time, and for the right end, and in the right way is no longer easy, nor can everyone do it. —Aristotle, Nicomachean Ethics (II.9, 1109a2

Managing Conflict Rather than Eliminating Conflict

Conflict is inevitable in any long-term relationship. In the Gottman approach to couples counseling, we help clients understand that conflict is normal. Rather than eliminating conflict, we help them learn to manage it. Why can’t all conflicts be resolved? Because backgrounds and personalities don’t match exactly. Couples will always have some areas of disagreement: neat/tidy, disorganized/scheduled, emotionally expressive/keeps feelings inside, to name a few. Even two tidy people may disagree on who does more work around the house or, perhaps, what cleaning routine to follow.

By the time couples come to counseling, they have often been having the same argument in different forms for many years. The issue has become gridlocked—and just as drivers stuck in traffic feel angry and frustrated, partners who can’t move beyond an issue start having negative feelings about each other and the relationship.

Learning to Listen Without Anger

Anger is often the result of feeling misunderstood. When one partner feels like they are not being heard on a particular issue, and they likewise have trouble listening to their partner’s point of view, anger simmers, sometimes for years—finally coming to a roaring boil.

Jim and Joan came to counseling because she felt he stopped participating in the family years ago. Meanwhile, Jim felt disenfranchised. His views and opinions on how they were raising the kids were ignored and he felt he was “just a paycheck.” Joan felt he had checked out and was uninterested in her, the kids, or their home. They were both angry; they both felt the other was wrong. When they tried to discuss this problem it always escalated to screaming and yelling, often within earshot of the kids.

When they started couples counseling, they had had this same fight many, many times. Jim would withdraw; Joan would become more focused on her friends and the women in the neighborhood, whom she confided in and got support from. Joan and Jim were emotionally estranged. Not surprisingly, intimacy, both emotional and physical, had come to a grinding halt.

Gridlocked Problems: Begining to Compromise

When I listened to them discussing a variation of this gridlocked problem, I saw that each became angry quickly, and the result was they stopped listening to the other. Joan would lecture and Jim would face the other way, clamming up. People have many ways of expressing anger: he was seething inside quietly, and she was ranting loudly, but both were angry.

I stopped them when this happened and had them take just a few minutes to calm themselves. To go from anger to calm by learning to self-soothe is an important skill in all relationships, but especially in marriage. It can take just a few minutes to do this. This isn’t about swallowing or denying anger; the trick is to then re-engage in the conflict discussion with a more receptive and less defensive tone.

Staying angry is much easier, but “doing it in the right amount, at the right time, and for the right end, and in the right way” (as Aristotle said) produces quite different results when dealing with a perpetual problem. It is okay to be angry. But understanding why you are angry, and learning to express your feelings in a way that is clear and void of the four horsemen will lead to a very different conversation with a different outcome. Once Joan and Jim learned to talk about their conflicts without getting flooded, they listened to each other with deeper respect for the other’s feelings. This is the first step in learning to compromise.

Practicing self-soothing is something you can do at any age, and at just about any time. Listen to this simple three-minute ”breathing space” to feel the difference in your thoughts, feelings, and physical sensations when you take just a few minutes out of a difficult situation. For it is not just the repeated, unmanaged fights that damage the relationship, but the skewed and distorted perceptions that keep you stuck in gridlock, stewing, for years—over the same issue.

Try this brief relaxation exercise:  Three Minute Mindfulness