O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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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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Anxiety Knows No Age Limits: Each moment is all we really ever have

We all get anxious from time to time. Even mild panic that’s morphed from mere anxiety is normal. Most often, though, anxiety will peak right before an event that makes us worry, such as an exam or dinner party—a kind of anticipatory anxiety—and then fade 10 minutes into the event. The ebb and flow of anxiety can be unpleasant but usually isn’t a major concern.

But the usual ebb and flow can worsen. According to the American Psychiatric Association’s most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), normal anxiety becomes diagnosable as generalized anxiety disorder when:

  • Excessive anxiety and worry occurs more days than not, for at least six months, about several events or activities (for example, performance at school or work)
  • Controlling the worry is difficult
  • The anxiety/worry includes at least three out of six symptoms (in diagnosing children, just one of these symptoms is required): restlessness or feeling on edge; being easily fatigued; difficulty concentrating, or the mind going blank; irritability; muscle tension; sleep disturbance
  • These symptoms cause significant distress in functioning
  • The disturbance isn’t related to medication, drugs, or a medical condition
  • The disturbance isn’t explainable by another mental disorder

I recently saw an 88-year old woman who was referred by her internist for anxiety. Her primary symptoms were her mind going blank, trouble letting go of thoughts, and agoraphobia (the desire to avoid leaving her home). The usual culprits were ruled out: hyperthyroidism, a medication side effect, or, given the client’s advanced age, dementia.

Composedly, my client said her anxiety came from feeling pressured to do more, and a sense of failure for not being good enough. This surprised me; I had expected her to talk about a fear of approaching mortality.

It’s a psychologist’s job to ask the hard questions, the ones that seem most obvious—the ones most friends and family wouldn’t touch for fear of making the person feel worse. So, I gently inquired if some of her anxiety could be related to thoughts about aging and death. But my client was quite definite that that was not the case! Her physician had assured her she would live to be 94 years old. I did a quick calculation—math was never my strength as I still count in my head with little dots—and determined that would give her five more years. Wouldn’t such a short countdown to death be enough to bring about anxiety, I still wondered?

Another job of a psychologist is not to jump to conclusions or make assumptions. Using inquiry, we ask for further thoughts, feelings, and associations. Some of her anxiety, she acknowledged,  was longstanding, but a new worry was that she was no longer as interested in venturing from home. What was this about?  Was she worried about taking a fall, breaking a bone, and ending up in the hospital? Again, no, it wasn’t fear that losing her balance and falling would lead to death because she knew that it most likely would. Anyone who reaches the age of 88 has seen in their own peer group how a broken hip can spiral downwards to a skilled nursing facility, with all the loss of dignity that brings.

Perhaps the most important part of our job as a psychologist is to trust that our clients know what they’re talking about. That trust is huge because it eventually leads us to an understanding of what is going on inside, in the deeper places we can touch if given time and attention. It turned out that my client’s anxiety was about just what she’d said it was. She was feeling like she should be doing more, going out more, and accomplishing more. Until she retired 23 years ago, she had been very productive in her job as an accountant. She loved her work, and she loved her retirement. She hadn’t slowed down in retirement until recently. She couldn’t understand the desire to just stay home. It was unlike her, and she felt she should be keeping up the pace she was accustomed to.

We discussed her symptoms; a mind going blank can be due to anxiety, and also to what my neuropsychologist husband refers to as benign senescent forgetfulness. (He tells me I have a mild case of it—our brains shrink as we get older, it’s entirely normal.) I also recommended that she turn off CNN. I wasn’t being flippant: Non-stop watching the news these days is making a lot of us anxious. Being bombarded with daily images of worldwide pain and suffering pervades our senses and creates disturbances that go deep into our unconscious minds, harming emotional health.

What about not wanting to leave the house? She wasn’t worried about going outside, but rather, as we figured out together, she desired to retreat from the world, to reflect and take time to appreciate her many gifts: a life well lived, a 65-year marriage to a good man, and her overall sense was that she had had a good, if not perfect, life. It was time to turn inward a bit more and let herself off the hook. Over the next several weeks, we explored how she could do just that.

Acceptance of who we are, imperfect and flawed, allows us to live more fully each moment, for as is said in mindfulness practices, each moment is all we really ever have.

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How to Be Sad

Psychotherapy for depression helps people accept that we can't force happiness.There’s a plethora of information about happiness.

My literature search on this subject yielded over 13,000 scholarly research articles and over one thousand books. Advice about how to be happy floods the internet daily with simplistic listicles and click-bait articles that make it all seem so easy.

But their advice, like telling a sad person to think about all the reasons they shouldn’t be sad, or a depressed person to just get up and exercise, doesn’t work. Thinking about the good things in life can sometimes ameliorate sad feelings, but usually, trying to grasp at happiness when in the grip of a depressed mood leads to failure. And while the research on exercise’s positive effect on depression is robust and persuasive, depressed people lack the drive to work out: that’s what depression means.

These suggestions, though well-meant, amount to telling depressed persons to snap out of it—or it’s their fault. This shames the sufferer, making things worse. And the resulting family strife doesn’t help. Well-intentioned spouses and parents who believe that snapping out of it actually is within a depressed person’s power will eventually succumb to exasperation and resignation.

A recent New York Times article gives suggestions for eliminating negative thinking, and paraphrases  Rick Hanson, author of Hardwiring Happiness: The New Brain Science of Contentment, Calm, and Confidence: ” it might be helpful to ask yourself if you are accomplishing anything by dwelling on your negative thoughts.”

Depressed people have negative thoughts. Understandable. When we’re depressed, we’re likely to feel hopeless, inadequate, and a failure. While practicing controlled breathing and mindfulness even with your eyes open, as the article suggests, will help, how do we get to the point of making these actions regular parts of daily life? When sadness overwhelms, it is often impossible to follow well-meaning suggestions with regularity. Like New Years’ resolutions, these techniques fade quickly.

When Sadness is Normal

Sometimes sadness is normal. Experiencing a range of feelings in reaction to painful life events is understandable; these life stressors would make most of us depressed. When psychologists see a client for a first appointment, we assess mood, its duration, and the severity of distress. Is the client’s symptoms within normal limits given the precipitant for entering therapy, e.g., a marital crisis, job loss, or death of a family member? We would say a client’s feelings are “within normal limits” when they come to therapy with sadness after losing a loved one.

In my own practice, a former client returned to treatment recently because his wife had just died. He spoke of his inability to shake the feelings of loss and sadness. It had only been four weeks, and he asked me if it is normal to feel depressed, and the question that inevitably follows: how long it will last? It’s okay to feel sad—but to someone grieving, the feelings can be so intense that time stands still. Four weeks can feel like four years.

It’s hard to feel deep emotional distress, of course. Indeed, because suffering is part of the human condition, we’ve devised a vast repertoire of ways to avoid experiencing our painful emotions and worrisome thoughts, including self-medicating by substance use, distraction by Facebook and other media outlets, and much more. Americans account for two-thirds of the global market for antidepressants, which also happen to be the most commonly prescribed drugs in the United States. These drugs can play a vital role in helping many people cope with chronic depression, but all too often these medications are over prescribed or prescribed without looking at inner sources of depression.

When Positive Thinking and Life Coaching Make it Worse

Or, life coaches with little training in mood disorders are prescribing positive thinking the way many physicians prescribe mood stabilizers, but even positive thinking strategies are ways to avoid painful feelings. I have seen the disastrous results of life coaches who work remotely from home, charging enormous amounts of money to people desperate for help. Sadly, these coaches have not laid eyes on the people they propose to help. They are unable to see the dangerous weight loss or weight gain or pick up the nuanced suicidal non-verbal communications.

One client I saw judged himself to be a failure after his six-month life-coaching sessions because he was unable to feel better or do the things the coach was suggesting. When I saw him after his failed coaching experience, he was in a deep depression, his sadness palpable. I asked if he was suicidal and he admitted that he was—something his coach had never asked about. Alerting his partner and suggesting hospitalization was imperative. Alarmingly, he had already seen three different psychiatrists and obtained antidepressants from each, and not one of them had inquired about suicidality.

Another example from my practice is that of a woman who saw a life coach because she hated her job. They talked about the need to follow her bliss and sever ties with her employer. She took this advice, quit her job, and when her unemployment ended, she was unable to find another job. Despondent, she came to therapy to help sort out her feelings about her life and to find a way to understand why she was unhappy at her former job. She needed to understand her role in how she was sabotaging herself. She took the long road to what ultimately brought her fullness and acceptance of life and work.

Accepting Suffering as Unavoidable

Suffering can’t be avoided. (In Buddhism, it’s the first Noble Truth.) But allowing ourselves to express sadness and to accept deep pain will eventually allow these feelings to dissipate; blocking emotions only deepens problems. Also, giving ourselves time to settle into feeling allows us to recognize that they ebb and flow. Through this, we can accept that while old age and death are inevitable, and feeling sad is part of living, suffering is impermanent. By being able to sit with emotions and not get caught up in either rumination or anxious fretting, we develop a steadiness of mind. Meditation works by settling our turbulent thoughts and emotions so that we can titrate them into tolerable moments.

What works

When sadness becomes major depression, positive thinking (and related approaches, such as life coaching) are like putting a Band-Aid on a gushing wound. Facing our pain, learning to bear our suffering, and then doing the deep inner work of understanding our role in our troubles is a way out. It is often slow and filled with obstacles. Here are some steps in the process:

  1. Become aware of subtle emotions as you experience them. By becoming aware of emotions as you feel them, rather than pushing them away, you will be better able to use them to employ coping strategies.

 

  1. When emotions become intense, know that feelings don’t stay that way forever. All emotions are transient. Practices such as regular meditation help us not just to become aware of feeling but also not to indulge them.

 

  1. Remember that subtle change is hard to see. A broken bone mends slowly; in the early stages, healing is hardly noticeable on an X-ray.

 

  1. Look deeply at ourselves and the role we play in our mood. Doing so opens what is within, leading to understanding and insight.

 

  1. Take into account what precipitates depression. Learning to tolerate understandable sadness and some depression helps normalize what we are experiencing. All emotions have a role to play in living well; we must accept and not disown our most difficult feelings.

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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