Accepting “clean pain” and letting go of “dirty pain”

A few winters ago, I broke my toe when I rammed it into the corner of my couch. I knew I had injured it, but promptly went into denial. I ignored it for a few days, walking on it, exercising, jamming my feet into snow boots (gotta love Chicago winters), till the swelling and pain became so excruciating that I could hardly walk. I got it checked out and was given one of those open-toed orthopedic shoes to wear. Turned out, I had probably started off with a small fracture but made it worse by continuing to bear weight, jump, run, kick, etc.

I was PISSED. I would stew on how pissed I was as I hobbled down the street, furious and impatient with myself for taking twenty minutes to walk a mere two blocks. I griped about having to “waste” money on cabs and bus fare for distances I normally could walk. I cried with frustration about not getting to exercise or do yoga, and I felt SUPER antsy. I cursed my body for failing me and cursed myself for being such a klutz. I went back over the scene of crime dozens of times, each time agonizing over how I “should have” been more cautious, should be more coordinated, should be smarter. The thoughts in my brain made me feel like a total idiot for messing up the simple act of walking across a room. I have a tendency to be pretty harsh towards myself.  After all, in the scheme of things, it was just a few weeks of my life where I was inconvenienced while healing an injury.

Reflecting on that incident, I can see just how silly and irrational all of those nasty thoughts were at the time. But that didn’t stop my brain from giving me all of that BS.  If you’re a fellow human, you can probably relate to the feeling of RAGING against yourself when you make a mistake or get hurt. Maybe you can relate to raging against your body for experiencing pain at an “inconvenient” time. Have you ever been upset that you got sick right before a big event and had to miss it? Or run outside to catch the bus, only to see it pulling away, then started cursing everyone and everything for your bad luck? Or guilted yourself for getting upset at something that “isn’t a big deal?” We’ve all been there.

In Acceptance and Commitment Therapy (ACT), this is explained by the concepts of “Clean Pain” and “Dirty Pain.”  Clean pain is natural.  Pain is a part of being human.  We fall and scrape a knee, and it hurts. We get broken up with, and the rejection hurts. A pet or a loved one passes away, and it hurts. The fact that these experiences naturally create pain is not BAD or WRONG. It’s just an inevitable part of life. Clean pain is any pain that arises from the experiences we have as humans moving through the world.

So to recap: we experience pain, and there’s nothing we can do to change this fact. However, us humans like to be TOTALLY IN CONTROL of everything, everywhere, all of the time. So we get upset when pain happens because it reminds us that there are things we can’t control. We naturally fight against our pain, either by getting caught up in thoughts about how it’s NOT FAIR that we are dealing with pain, or looking for someone or something to blame for it happening. We get stuck in beliefs about how it is BAD or WRONG that the pain happened. We beat ourselves up for being human (e.g., when that bully in your brain starts saying stuff like “I’m so stupid! I’m such a failure. I’m never gonna get it right. I’m overreacting. Other people have it much worse than me. This is really not a big deal at all. It’s ridiculous that I’m upset by this”). Or we blame others for causing us pain, and we stew on feelings of resentment or even hatred (“How could he do this?  Who does she think she is? He only cares about himself. Why do they keep screwing me over? I hope he gets his heart broken”). We get sucked into feelings of anger, frustration, shame, impatience, sadness, and hopelessness. We look for ways to “solve” the pain, by numbing out through drinking or drugs, making efforts to control our bodies and minds through self-harm, restricting, binge-eating, purging, and exercising, ignoring or distorting reality, or trying to avoid any situation we think might cause us more pain. Does any of this sound familiar to you?

When pain happens, we try to comfort ourselves by looking for ways to prevent future pain. We try to regain that false sense of being “totally in control” of everything. Our brains don’t think we “should” experience pain, so we treat it as something “wrong” with us or consider ourselves “weak” (especially if the pain comes in the form of a difficult emotion that we were taught we should not have).  These responses to “clean pain” are examples of what’s called “dirty pain.” Dirty pain is any reaction to clean pain that we inadvertently create, like beating ourselves up mentally for being so clumsy, ignoring an injury and making it worse, or self-sabotaging in our next relationship out of fear of getting hurt again.

If you’re familiar with my whole philosophy on human experience, you know that I talk a lot about how we can’t control what thoughts or feelings arise in us.  So you might be wondering, “If we can’t control what we think about or how we feel, how can we ‘stop’ our unhelpful reactions to pain?” That’s a fair question, and a good point. We can’t stop the thoughts or feelings from popping up, but we CAN start seeing them for what they truly are: unhelpful reactions (often in the form of commentary from that “bully” voice inside our brains). That bully or inner critic has a field day every time something unwanted happens to us.

The key to dealing with those dirty pain reactions is to practice acceptance. Acceptance doesn’t mean you like, want, enjoy, or welcome something. After all, who WANTS to feel grief and sadness when they suffer a loss? Acceptance just means we are allowing something to be a part of our current reality.  It means we are willing to tolerate something uncomfortable, painful, or unpleasant for the sake of getting to be alive. Accepting clean pain helps us to disengage from the dirty pain, and as a result, the clean pain naturally feels a little less “painful.” It becomes a little less intense and overpowering. The key though is that you have to stop trying to make the clean pain go away in order for this to work, which can be tricky.

In numerous research studies, when folks with chronic pain learn to practice mindfulness and acceptance, they become more functional and they experience their pain as subjectively less distressing and less intense than it was before they accepted it. The SAME pain felt LESS painful because they changed their relationship to the pain. Cool, right? (Click here to check out a randomized controlled trial on ACT with pediatric pain, and click here or here for some correlational studies).

When I work with people on clean/ dirty pain, we talk about all of the ways they’ve tried to control or avoid certain internal experiences (thoughts, feelings, memories, sensations, or physiological pain) and how each strategy has worked for them.  Often, people realize that they’ve spent so much energy trying to make pain go away or trying to make sure they never experience a certain type of pain (like rejection or embarrassment) that it’s taken over their lives and has become a central focus. Learning to let go of efforts to control or prevent pain can be challenging (it means you have to FEEL the pain, which can be pretty intense or uncomfortable), but the trade-off is that you gain freedom. When you accept that “it is what it is,” you allow yourself to invest your energy into things that will actually have a payoff. It takes practice, but through mindfulness and acceptance, you learn to have a different type of relationship with pain.

That winter with my broken toe, what helped me let go of the “dirty pain” was gratitude. I realized how much I took for granted the fact that I had ten functional toes that supported me every day, and allowed me to balance and move my body with ease. I realized how lucky I was to only be inconvenienced for a couple of months, when plenty of people have injuries far more debilitating and permanent.  I tried to challenge my restlessness by finding moments of joy in stillness, and exploring other forms of meditation instead of my preferred physical activities.  I challenged thoughts from my inner bully that were urging me to ignore hunger cues or change my eating behaviors to “compensate” for being more sedentary than usual.  I listened to my body’s cues and forgave myself for being human. None of these responses were my natural, instinctive reactions, but I got there eventually.

Nobody is perfect, and even the most mindful and self-aware people will struggle at times to let go of their “dirty pain.” Be patient with yourself and with others.  Remember that I am always here to help you strengthen that mindfulness muscle and would be honored to join you in your journey towards acceptance.

7 Tips for Opening Up in Therapy

When you open up in therapy, it can be magical. It can lead to change, growth, insight, recovery, and healing. But being able to go “deeper” than surface-level topics can be challenging, especially if you’ve been hurt, dismissed, or embarrassed in the past, or if you’re having a hard time coming to terms with a piece of truth (and ironically, these are often the reasons a person comes to therapy in the first place!)

I’ve compiled a list below of tips to help move the process along and overcome whatever barriers are holding you back:

1. Clarify your goals. It’s impossible to know what the destination will look like (or to know if you’re even on the right track) if you don’t have a roadmap. Work together with your therapist to create a clear picture of what you’re seeking from treatment. This might be a specific goal to work towards, like a change in behavior, or it might be that you want to better understand a certain topic, gain and practice new tools for managing emotions, communicate more effectively in your relationships, or improve self-esteem. If you can’t quite articulate what you want, but you know things are feeling “off,” it’s okay to ask your therapist for some help with finding the words to explain what you’re looking for.

2. Clarify your feelings. I’ve been on both sides of the couch, so I know how overwhelming it can be when there are a billion thoughts and feelings swirling around as you sit there. It can be challenging to find language that pinpoints what you’re experiencing, and most of us haven’t been taught a very robust “emotional vocabulary” from a young age.  Plus, feelings can’t always be explained by a single word. Often, our feelings pop up in conjunction with one another, and we need several words to fully encompass what’s happening. Other times, we might “feel” in visual imagery, shapes, or physiological sensations (like nausea, chest tension, or butterflies in the stomach), or in a metaphor.

3. Write it down. If you know there is something you want to express but it’s hard to say it out loud in the presence of your therapist (or maybe it’s hard to say in front of anyone), try writing it down ahead of time. This is also a useful method for making sure you aren’t going to forget to bring something up. Write it down in a journal, or create a bullet-pointed list in a notebook or in the notes on your smartphone to bring into session. This can help you address a topic when you’re feeling urges to avoid it.

4. Give your therapist a “head’s up.” If they’re open to it, send an email or text to your therapist between sessions to let them know what you want to talk about. This is useful if there’s something you don’t think you’ll have the guts to say out loud. This can be an effective way to hold yourself accountable and to “let the cat out of the bag” before you even come to the session, especially if you’re someone whose anxiety tends to build in anticipation. A word of caution: it’s important to only do this if you have explicit agreement from your therapist. The policies and rules regarding how, when, and about what topics your therapist is able to communicate with you outside of session can vary for different providers, so be sure to ask if this is something they are open to doing.

5. Tinker with your therapy environment. Although therapists work hard to make sure their space is warm and inviting, it’s possible that the setup doesn’t suit your needs. If it’s too hot, cold, or bright in the room, or if you feel too pressured when you’re making direct eye contact, you might have a hard time opening up. Many people feel more at-ease if they’re fidgeting, doodling, or gazing out the window. I keep small objects, worry stones, or silly putty for clients to mess around with while we’re chatting, since occupying the hands can help some folks feel calmer. Try to sit or lounge comfortably, which can help you loosen up. Perhaps you’d feel more comfortable laying down, or sitting on the floor with your legs outstretched. I’ve noticed some people feel safer while hugging a throw pillow.

At my practice, we also have a “walk and talk” consent form that clients can sign if they’re interested in the option of walking around outside together during sessions. It’s important that your confidentiality is protected, so if your therapist’s office is in a busy, crowded, or high-traffic area, consider whether you’d be bothered by the risk of being seen or disrupted by passersby. If you have the ability to walk somewhere secluded and peaceful, though, it could be just the switch you need to start talking.

Overall, if you can take a creative approach to identifying your needs, it’s likely that your therapist will be supportive of these modifications. There’s no “wrong way” to settle in to the space, so think about what works well for you and then ask if it’s an option.

6. Ease into the session. It can sometimes feel abrupt to sit down and start talking right away. It can help to spend a few minutes at the beginning by shifting into the space and mindset of therapy. Ask your therapist if he/she would be open to guiding you through a relaxation exercise. This might mean engaging in a mindfulness meditation, guided imagery, deep breathing, or a body scan. These can be powerful ways to slow down and clear your mind. Starting with a meditation sets up your “baseline” so that if you do become emotionally activated when exploring difficult topics in session, you can always return to the soothing activity again to calm down. It can also help to end session with a similar grounding exercise, so that you feel rooted and stable before going back out into the “real world.”

7. Consider your relationship with your therapist. In order to be vulnerable in someone’s presence, you have to feel safe. The nature of the client-therapist relationship might take some getting used to, and at first it might feel like you’re opening up to a stranger. It can take time to get to know their personality and establish trust.

Therapy is different from your social interactions in “normal life.” Typically, you might be used to a certain back-and-forth exchange in your conversations: I ask you a question, and you answer it and then ask me a question and I answer it. This becomes second nature to us, so you might feel “rude” or just strange if you don’t ask a follow up question when your therapist asks you something. However, therapy is designed to be entirely focused on you, the client, so the therapist typically does not reveal much personal information, and this can be hard to adjust to.

If you find you’re having a hard time trusting your therapist, think about the factors contributing to the barrier. Do they seem too stiff, formal, or unexpressive? Or, do they respond to you in a way that helps you feel cared for, respected, and understood? Do you notice you’re censoring yourself or holding back out of fear of how they will react, or desire to influence how they perceive you? After all, we all want to be liked, so it’s hard to speak about things we feel guilty or ashamed about, even when we know the person won’t judge us. It’s natural to struggle with all of these things. As awkward as it might be to discuss them, by being honest you and your therapist can work together to facilitate a stronger connection.

 

At the end of the day, therapy is about you getting what you need, so it’s only going to be effective if you and your therapist are able to foster the right context for you to open up. If you look into all of these factors and you still don’t feel able to share, it’s possible that your therapist is not the best fit for you. Therapists come from a variety of backgrounds, educations, training, theoretical models, and clinical styles, so there’s no “one size fits all” approach. On top of that, every therapist is still just a person, and not every personality is the best fit for you. If you’re considering “breaking up” with your therapist or trying to figure out what you need, check out this blog post I wrote on the subject last month.

What helps you to open up in therapy? Feel free to share in the comments below or on my IG account (@mindful.drpaula) with any additional tips of your own, and let me know what works best for you!

Demystifying Mental Health Treatment: What to do if you’re feeling “stuck” in therapy

A couple weeks back, I shared my #2018resolution to work harder to demystify mental health treatment. One of the things that makes therapy so complex is that it’s designed to treat somewhat abstract human experiences, so it’s tricky to point to exactly what works and what doesn’t.  Because no two humans are exactly the same, there is no formula that guarantees therapy will go a certain way.  So today we address another common concern: what to do when you’re not “getting anything” out of therapy.  I’ve broken things down into three parts: exploring your options, analyzing the situation, and how to “break up.”

Part 1: Exploring your options

Remember that you have options! The best way to get what you want out of therapy is to find the right therapist. It’s useful to reflect on a few key things before you begin. If you’ve already started with someone, it’s not too late to consider these points for the future or to discuss in your next session.

  • It’s okay to shop around. Finding a therapist is a bit like finding a home. Everyone’s “wish list” is different, and not every home is suited to every renter. You might have some general ideas of what you’re looking for, but until you actually meet someone, you can’t be sure whether you really feel a connection. It’s totally natural to want to explore more than one possibility. A few things to think about if you shop around:
    • Ask to set up phone consultations before deciding to make an appointment. Many therapists offer these phone calls free of charge, and they will give you a chance to ask questions, get to know their style, and decide whether you feel they understand your unique situation. This also helps you screen and find the right person without having to juggle multiple appointments and tell your story over and over again.
    • If you make appointments with multiple therapists, keep in mind that some insurance plans won’t cover multiple therapy sessions in the same day (or week). If you are using insurance, you may end up having to pay out-of-pocket for some of these appointments unless you check ahead of time or spread them out over the course of a few weeks.
    • Be mindful of how many times you meet with a therapist before deciding to commit. If you’re meeting with two different therapists several times each, you’re at risk of developing “multiple relationships.” This makes it hard for either one to really be effective, since you may be inadvertently opening up to one more than the other, or focusing on comparing them instead of actually getting into the work. It may be best to meet once with each, and then pick one person. If after awhile, you aren’t getting what you wanted and are curious to go back to the other one, you can change your mind down the road.
    • Consider letting the therapists know that you are shopping around. This sets up an open dialogue from the start, and makes it easier to “break up” with them if you do go with someone else. It also opens the door to talking about what you’re looking for. Most therapists will be able to help you find a good match, even if it’s with someone else. Our egos can handle the rejection, and besides, it’s more important that you get the care you need.
  • Be clear about what you need. It’s okay if you’re not sure what exactly it is that you need, but be clear about the fact that you’re not sure! Some people are just looking for a sounding board, a place to “vent,” or a place to be validated and feel understood. Others are looking for a fresh perspective. Or, you might want to be challenged and given “tools” to take away and use in daily life. Often, people are sure on what they want the outcome to be (feel better, be more confident, have a healthier relationship, etc.) but are not sure what they want the journey to look like. That’s okay—tell your therapist those desired outcomes. That’s a good place to start.

Part 2: Figure out what is and is not working.

Therapy is one of those things in life that “works if you work it.” That is, you get out what you put in. If you are actively engaged and motivated to apply what you learn, it can enhance your life in a very meaningful way. Of course, this is most true if you have a strong therapeutic alliance, which I discussed in my last post, as well as if your therapist’s approach is right for you. If you’re giving it a fair shot, committing to the work, and regularly attending sessions, and you’re being honest with your therapist and with yourself, you’re doing your part. It’s important to be patient, but not passive. Keep in mind that things won’t change overnight, but if after several sessions you don’t think it’s working, here are some things to consider:

  • Therapy is not “one size fits all.” Every therapist has a unique style. This is influenced by differences in education, training, experience, personality, and preferences. You can read more here about different levels of therapist training. Many therapists consider themselves “integrative” in their approach to treatment, meaning they blend or pull from a variety of psychological theories. Some will rely more heavily on one theory or one treatment modality than others, or will pull from a given theory based on what symptoms or conditions the client is struggling with.
    • For example, I am trained in a variety of theories, but when I’m treating Obsessive-Compulsive Disorder (OCD), I rely most heavily on Cognitive-Behavioral Therapy and exposure therapies. These two theories have the most scientific evidence for successfully treating OCD symptoms, and I am confident in applying them. However, another therapist might use a totally different theoretical approach to the same set of symptoms, and can be just as effective. You can read more about some of the main theories of psychology here and here.
  • In addition to theoretical approaches, every therapist has a different degree of training and experience with certain populations, symptoms, and disorders. Ask your therapist about his/her specialty areas, but also keep in mind that a lot of us are trained to work with a variety of issues, so it’s not vital to find someone who “specializes” in order to receive effective treatment.
    • If you’re feeling stuck, you may need a different specialty or style than what your therapist is providing. It’s okay to ask your therapist what theoretical approach(es) they are using and why, and if you’re curious about trying others, ask whether they’ve been trained in other approaches or if they can refer you elsewhere.
  • Speak up when we do something that either helps or doesn’t help. I sometimes guide clients through a meditation at end of session, and I always appreciate when someone comes in and tells me they want to do it, instead of just hoping I suggest it myself that day. I’ve also had clients ask for more structure, so we set a clear agenda at the start of the session to be sure we get to all of the topics they wanted to cover.  This is always helpful feedback to give your therapist so they can tweak what they’re doing and you can walk away from sessions feeling like you’re getting something from them.
  • This one is tough: talk about your relationship with your therapist. I know it can be a little awkward, especially at first, to open up to a therapist because the focus is on YOU entirely. This is different from how most people interact in everyday life, where it’s polite to have a more back-and-forth Q&A with other people and not just have one person do all of the sharing. You might not know much about your therapist, and that’s typically a purposeful ethical decision your therapist has made. However, even though we don’t disclose about our personal lives, you can still get to know your therapist’s personality. You’re not talking to a robot or a brick wall. Some use humor, while others are more serious. Some focus on thoughts, some focus on feelings, some focus on your physical posture, and some focus on a combination of these. Some will want to dive deep into your past and unravel childhood experiences, while others will only be concerned with the present situation. If you are struggling to trust your therapist, or if you get upset or offended by something your therapist says or does, as tough as it is to address this, it will only help you in the end.

Part 3: Maybe you just need to break up. We get it. No hard feelings.

Ultimately, I can give you all of these pointers but the biggest thing to remember is to trust YOURSELF when it comes down to who you keep in your life and who you let go. If you realize your therapist isn’t right for you, perhaps it’s time to say goodbye. If you’re still unsure what you’re looking for, this article talks about some more ways to assess whether your therapist is helping you.

  • Honesty really is the best policy. It might be tempting to “ghost,” especially if you’re someone who struggles with confrontation. Nobody will stop you from ghosting, but consider what you could gain from the tougher alternative. Sharing your feedback and being clear about your intentions are communication skills worth developing. Being able to express your feelings honestly, even if it’s uncomfortable to do so, might be one of the reasons you started therapy in the first place. It can be meaningful to walk away from a relationship that’s not working in your life (whether with your therapist or anyone else) by first asserting your needs, and then saying goodbye.
  • You might think that you’re sparing someone’s feelings by ghosting, but remember that your therapist is a person who cares about you and is invested in your wellbeing. You don’t owe us anything, but if you’re open about breaking up, we will know not to worry about your safety if we don’t hear from you again.
  • Most importantly, if we know you’re breaking up with us, we can help you find someone who is a better fit for you. You can let your therapist know that you’re ready to move on in person, by phone, or by email. If you tell us what didn’t work or what else you’re looking for, we can help you find a therapist who is a better match for you. Or, if you want to take a break from therapy entirely, we can discuss a game plan to check back in down the road and see whether you want to resume (or respect your wishes to be left alone if you no longer wish to receive communication).

The bottom line is that it’s YOUR life. At the end of the day, you’re the only one living it, and nobody else can tell you what you need. If you aren’t getting your needs met, please do what you need to do to advocate for yourself, as tough as that can be. If you need help learning to navigate these types of awkward encounters, that could be a great topic to explore with your next therapist!

Demystifying Mental Health Treatment: How long will I need therapy?

It’s the start of a new year, and while you don’t need the calendar to tell you when to make a change, the whole #resolutions thing makes it a convenient time for many to reflect on goals for themselves in the upcoming year and start taking action steps. My #resolution is to do my part to bust myths around mental health treatment, so that nobody has to feel embarrassed or judged for struggling. To get things going, I’ve decided to start off 2018 with a series of posts demystifying the process of therapy. I’ve noticed that many people considering therapy have the same questions and concerns about the process. Today, I’ll address the one I most frequently get: how long will this take?

Well… at the risk of sounding wishy-washy, the truth is that it’s different for everyone. People seek therapy for various reasons, so treatment is not “one size fits all.” Some people are struggling emotionally with things like depression, anxiety, or grief, or having difficulty coping with a past trauma, navigating a difficult relationship, or managing self-criticism. Others may be struggling to stop engaging in certain behaviors, like addiction, substance abuse, compulsive behaviors, or unhealthy eating and exercise habits. Some people may be looking for help adjusting to a major life change or while going through a life transition (such as graduating from college, starting a new job, getting fired, going through divorce, moving to a new city, grieving for a loved one, or having a child). The list could keep going on—humans are complex and messy, and so it is natural at some point in our lives to experience a disruption to our mental health, just like it’s natural to get sick or injured physically at some point.

I suspect that the reason this question is so common is that we like to know what we’re getting ourselves into. Totally fair. Humans are wired to solve problems. When something is bugging us, we want to figure it out right away so that we can fix it and move on. If you’re coming to therapy, you might have been experiencing difficulties for a long time and are finally ready to commit towards change and growth. Or, maybe something just recently popped up, and you want to “fix it” before things get worse. Either way, you probably want some instant gratification. So even though I can’t give you a straight answer about how long it will take, I can do my best to help you get some immediate relief, as soon as the very first session. In fact, it’s a good rule of thumb when you’re looking for a therapist to consider when you walk out of the first session whether or not you feel understood, supported, and hopeful about the possibility of change (even if you don’t feel “better” right away).

Research over the last several decades has shown that therapy has the best chance of being “successful” when the client and therapist have a strong rapport, or therapeutic alliance. Rapport is developed when the therapist and client build trust in one another and work as a collaborative team. Most people need a little while before they are comfortable opening up. However, if you’ve been going to your therapist for awhile and still don’t trust them, this is important to address. I’ll be writing a future post about what to do if therapy isn’t helping you or if you want to break up with your therapist, so stay tuned for more on that later. In the meantime, just know that the sooner you and your therapist form a connection, the sooner you can get to work.

The length of therapy also can depend on how long you’ve been struggling with certain behaviors or experiencing symptoms, how motivated you are to change, the approach your therapist is using, and how open you are to trying new and sometimes difficult things. I often will suggest something many times, over the course of weeks or even months, before a client is willing to give it a try, and that’s okay. We can’t force change—you have to be ready for it when you’re ready for it. So that might take a degree of patience from both of us. Plus, it sometimes takes a lot of repetition before something finally “clicks,” since therapy involves shifting belief systems and worldviews that have been in place for many years. I like to tell people, “you didn’t get this way overnight, so you won’t change overnight either.” If you’re trying to change a lifelong habit, it can take some time to start seeing results because the habit might be really deeply ingrained, and you may not have ever really used other tools (or even known there were other tools available) for dealing with certain experiences. That being said, just because someone has been stuck in a certain pattern for 10 or 20 years does not mean it will take 10 or 20 years to change it. Just don’t expect to break longstanding habits in one session. If you find yourself feeling impatient with the pace of change, speak up. Therapists are not mind readers and if we know you’re feeling frustrated then we can figure out how to get “unstuck” and moving again.

Sometimes, we are chugging along nicely, and then – surprise – life drops a metaphorical bomb. Unexpected stressors can barge in (a breakup, a medical diagnosis, an accident, etc.) and interrupt progress or take priority over whatever we had originally been working on. That might mean we shift course and then return to the original plan at a later time (or abandon the original plan if necessary). It’s important to stay flexible as we go along. I’ve also found that as we progress, we sometimes uncover or make room for other topics to address that weren’t the original reasons for seeking therapy but that are still worth focusing on. For example, maybe you came in to treat your anxiety, but along the way we realize that most of your anxiety is work-related and it’s because you’re in a work environment that just isn’t right for you, so we start to explore a job change. Or, once we’ve helped you resolve depressive symptoms, we start to look at an unhealthy romantic relationship that you weren’t ready to address before.

If you’re dealing with trauma or grieving for a loss, the change may be slower than you’d like it to be, since the healing process often involves feeling an increase in pain or discomfort before experiencing any decreases. If you’re dealing with symptoms of an eating disorder, phobia, or obsessive-compulsive disorder, you also might notice symptoms worsening before they improve, because a component of treatment involves exposure to things that you prefer to avoid in order to get you more comfortable with anxiety “triggers.” This is often a very challenging and stressful process, but ultimately if you stick with it, you will find relief in the long run.

Typically, I like to start off meeting once weekly, and then scale down and meet less frequently as treatment progresses and you start to see change, to give you a chance to try things on your own. Occasionally, we may increase frequency to twice-weekly sessions for a brief period of time in situations where a person needs more support than once-weekly sessions can provide, and there are many clinicians who will meet two, three, or even four times weekly with their clients (this is not my policy). In the initial session, we can get a sense of what’s going on and what level of support would be best, and if you need more than what I am able to provide in a private practice (such as inpatient/ residential treatment or intensive outpatient treatment), I will refer you elsewhere. While it’s important to consider your unique situation when making decisions about how frequently to meet, I have generally found that people who commit to coming in regularly and making it a priority to stick with therapy have seen the fastest change.

Now, I don’t take it personally that you might not want to see me every week forever and ever. In fact, I have the opposite perspective. I don’t want my clients to have to come any longer than necessary. Once you’ve reached your treatment goals, we discuss whether anything new needs our attention, and if not, we decide that it’s time to say goodbye. My goal is to essentially make you into your own therapist, so that you can internalize our work and go about your merry way. As much as I love working with my clients, I also love sending them off into the world to spread their wings! That being said, in times of high stress, it’s not uncommon to slip back into old habits or patterns of thinking, feeling, and behaving. So my door is always open for a “booster” session down the road, even if we haven’t worked together in awhile.

Some clear outcomes of therapy include:

  • Developing skills for effective communication and problem-solving
  • Feeling more self-confident and becoming more compassionate towards yourself and others
  • Learning new ways to cope with stress and anxiety
  • Becoming more equipped to manage and regulate your mood
  • Improving your social, intimate partner relations, and family relationships
  • Changing old behavior patterns and developing new ones
  • Gaining self-awareness and a better understanding of your values

The start of a new year is the perfect time to begin making changes to enhance your life, and therapy might be part of the plan.

If you are considering therapy and want to know more, or if you have a question about how therapy works and would like to see a future post about it, comment in the section below or send me an email, drpaulafreedman@gmail.com.

Book Review: “I’m Fine… and Other Lies” by Whitney Cummings

Reading tends to be very “all or nothing” for me—I’m either totally consumed, turning pages for hours on end and ignoring the world around me and internal cues for food or sleep until I’m done, or I’m noncommittal, absent-mindedly skimming paragraphs until I inevitably abandon it to collect dust on my nightstand with all of the other “I’ve been meaning to finish that!” novels. To me, the sign of a good book is not “I can’t put it down until I KNOW what happens!” and it’s not “I’ll finish it eventually, if I have the time.” It’s that healthy middle ground, much like romantic relationships. Neither codependence (“I can’t live without you!”) nor too much independence (“I’m not even interested in connecting with you”) is consistently satisfying.

Perhaps you’ll find it ironic that I was able to enjoy a book about codependency while (for once) maintaining my healthy dependence and independence needs. As a story, it contained just enough psych-y content to appeal to my inner nerd, and just enough comedy to appeal to my inner self-care coach. It was engaging, satisfying, but not so consuming that I lost all ability to stay connected to my own priorities and identity. As far as book-relationships go, “I’m Fine” quickly became a lasting, rewarding love. So I wanted to share the love, by writing my first-ever book review. Here goes!

In case you’re not familiar with her work, Whitney Cummings writes, produces, and does stand-up comedy.  I’ve been a big fan of hers for several years. What’s always endeared her to me is her tendency to “plug” therapy (thanks for the free marketing, girl!) and to use humor as a way of coping with the dysfunctions of the human condition.

A lot of memoir-type books I’ve read have bugged me (and ended up as ex-lovers in the dusty nightstand pile) because the author tries too hard to sound self-actualized, taking on an annoying “wannabe-wise” tone in an effort to artfully conclude the general storyline of “I used to be naïve in how I handled life, and then I overcame some challenges.” Whitney writes like she’s in her 30s, and she is in her 30s. She’s not pretending like she’s 80 years old and has it all figured out, nor is she dwelling in adolescent insecurities. She takes semi-frequent breaks from her “I used to be so clueless” shtick to actually give herself credit for the growth and insights she has worked to gain, but she doesn’t succumb to the urge to tie it up neatly with a happily-ever-after type ending.

Whitney (I can’t bring myself to get formal and call her Ms. Cummings, sorry) demonstrates what happens when someone moves from being a blind, passive recipient of life experiences to being a self-aware, active shaper of her own reality through intentional choices. As a psychologist, I am grateful for her honest account of her experiences with several types of therapies. She also admits several times that she often rejected an idea or treatment approach (especially in her adolescence and early 20’s) because she wasn’t yet ready to have her defenses challenged. THANK YOU FOR OWNING THIS! I get so irritated when people say, “I tried therapy, but it didn’t work for me.” People, it works if you work it! So if someone’s in denial, nothing’s gonna change. Psychologists aren’t psychics or magicians. Though Whitney has apparently tried her hand at consulting psychics and magicians, too, which made for some fascinating early chapters. Anyway, I digress.

I also enjoyed her evaluations of what worked and didn’t work for her in the process of healing from various hurts. After all, mental health treatment is not one-size-fits-all. There are so many theoretical models and approaches out there. Vera, the therapist with whom she ended up finally forming a meaningful therapeutic relationship, sounded like a total badass; she was clinically well-versed, and fluent in Whitney’s language, helping her recognize the “addictive” patterns of her codependency and eating disorders.

Self-acceptance is a major theme in “I’m Fine.” Whitney’s exploration of how she developed and then healed from an eating disorder will hopefully shed light on an often-misunderstood constellation of symptoms, and the unhelpful thinking and mixed messages that are so easily internalized. Her honesty about struggles with “ED” is beyond refreshing. The media masterfully perpetuates an absurd mixed message, glorifying the woman who acts so totally chill and just LOOOVES eating carbs, and yet is constantly pulling up the waistband of her roomy size zero jeans, equating slimness with chillness and worthiness. I have lots to say about this ridiculousness, but I will have to save my rant for another time to stay on topic.

My point is, Whitney doesn’t fall for the BS of mixed messages and she actually talks about the monster life-sucker that is the “quest for physical perfection.” She calls herself out for sometimes buying into a disempowering cultural norm, and gives us all a reality check in the process. Her overall message is that it’s not only allowed, but truly vital for us all to meet our own basic human needs for food, water, love, and self-respect.

Speaking of basic human needs, Whitney also gives a shout-out to “inner-child work,” which is an element of therapy that can be so powerful in developing self-esteem. Basically, the premise is that humans actually age like trees. Remember how they taught us in school about how to tell how old a tree is? When you cut the trunk horizontally, you can see all of the “rings” in its cross-section. Each ring grows around the one within it as the tree ages. We’re like trees; every age contains every previous age within it. If we go down really deep, we’re all housing an inner five-year-old. When there’s a control-type issue (addiction, eating, OCD, perfectionism), it can often be traced to unmet childhood needs, so the inner child is still scrambling to get “adult you’s” attention.

In Whitney’s case, she learned to deny her needs from a young age, so as an adult she only felt in control if she was denying her needs. She learned that this was the only way to be worthy of love and belonging. For example, food is a basic need. Believing it is “bad” or “wrong” to eat is not only self-destructive, it’s downright mean. When she learned to “re-parent” her inner five-year-old, she was able to live more wholly and let go of old insecurities. That’s why I love this framework: most people can get on board with the fact that it’s pretty atrocious to act like an asshole towards a five-year-old. When you start to see that’s what you’ve been doing by self-punishing (forcing yourself to exercise, cursing yourself for eating the extra slice of pizza, forcing yourself to stay at the office till 11pm instead of getting much-needed sleep) you’re more inclined to soften up. A five-year-old doesn’t care about her weight; she just wants to enjoy life. She doesn’t care about your promotion at work; she just wants you to come home and play with her. We can all benefit from the reminder that we’ve each got a little kid living inside of us, just looking for love and acceptance, so we don’t need to be so damn hard on ourselves or each other.

One area left me wanting more: I still have so many questions about the specifics of her childhood. If she had chosen to share more details about what went down in her early childhood, it could have given the reader a richer picture of how her core beliefs were shaped. However, at the end of the day, my insatiable curiosity about the human condition aside, she certainly exposed insecurities and fears that most of us lack the courage to reveal, so I can’t blame her for choosing to gloss over some details. She gave us enough info to connect the dots, and I respect her decision to not be a completely open book. Yeah, pun intended, I couldn’t resist 🙂

I often struggle as a relatively young psychologist with “imposter syndrome,” fantasizing about the day when I’ll feel like an “expert.” Stories like Whitney’s remind me that I actually hope the opposite is true. I hope I never wake up one day thinking I know exactly how to handle things. That would feel robotic. I’m human and therefore I’m a messy work in progress. I struggle to practice what I preach. I get whispers from the demons in my head. I get caught up thinking I need to be “fine,” and thinking it’s my job to make other people “fine” as well, which it’s obviously not. Insecurity and self-doubt are all just part of the deal, and that’s okay.

“I’m Fine” is a hilarious and raw reminder that life gets ten billion times more rewarding when you stop pretending to be fine. I hope this book will serve as an example of the awesomeness that can come from authenticity, owning your shit, and opening up about mental health struggles. If you read it and want to share your reactions, please feel free to do so in the comments below! Oh, and if this book made you realize you’re not “fine” or it inspired you to seek therapy, I’m here for that, too.

Am I “Normal?”

One of the most common questions I’m asked by therapy and testing clients is “Am I normal?” It’s a fair question, and it makes sense that some people view psychologists as the people trained to give a solid answer. After all, one of the core educational requirements of anyone seeking a graduate degree in psychology is a course in “Abnormal Psychology.” It can certainly be fascinating to learn about “outliers” in any human trait—intelligence, athleticism, narcissism, and so forth. Plus, in order to accurately assess and diagnose, we need a framework for organizing whatever it is we are assessing and diagnosing. As such, the foundation of our field for the last century has been rooted in “mental illness” being just that—a diagnosis or label, assigned to people whose presentations are “not normal.” So I get why this is the burning question.

“Normal” in 2017 is more elusive than ever. With technology at our fingertips, we ask Google, Wikipedia, and WebMD to weigh in. Social media has perhaps been most influential, taking the “am I normal?” question and providing “answers” by showing us what “everyone else” is doing with their lives. What does a “normal” body look like? A “normal” family? A “normal” person’s Saturday night? Consult social media, where you can decide if you measure up to the curated online images of people popping up in your newsfeed. For some people, it’s easy to feel lame and unsuccessful when it’s “normal” to censor ourselves and only show the public the highlights reel. For others, it’s a constant competition to set the new standard. I wonder what would change if everyone knew how much everyone else was asking whether “it’s normal to [fill in the blank]?” Maybe we’d have more tolerance for the full spectrum of our daily experiences if we could accept that “normal” doesn’t exist.

Perceptions, thoughts, feelings, sensations, and memories are subjective. They are often driven by context and filtered through the lenses we’ve developed through life experience. So what’s “normal” in one context may not be seen as normal in another. Walking down the sidewalk with one’s nose to the ground, sniffing for discarded food scraps = unusual for a human, “normal” for a dog. Sucking one’s thumb = unusual for a 45-year-old, “normal” for a 2-year-old. However, context isn’t always as clear as one’s species or age. Is it “cautious and smart” to lock and then double-check the locks on your doors and windows at night, or is it “paranoid and obsessive” to do so? It depends.

It’s “normal” (natural?) to be curious about whether our experiences and behaviors can be considered appropriate, acceptable, or healthy. But who is the authority on what is considered appropriate, acceptable, or healthy? Psychologists? We’re people too! I’m not the authority on “normal” just because I can tell you if you match up to an agreed-upon set of criteria published in a scientific manual. The reality is that you are the authority on yourself, so only you can answer whether your experience is adaptive or not.

For example, anxiety is “normal.” In fact, it’s a human necessity. It keeps us alert to danger and motivated to complete tasks. Without any anxiety, we have no urgency to get anything done. With too much anxiety, however, we become too overwhelmed to be productive. Finding that “sweet spot” of optimal anxiety for optimal performance on top of the inverted “U” illustrated by the Yerkes-Dodson Law  is the key to success. That sweet spot, however, is subjective to the individual experiencing it.

Current research shows that mental “illness” might be more of the “norm” than the outlier. The Dunedin Study in New Zealand has followed over 1,000 people from birth and over the course of their lives for the past 40 years, assessing them every few years to look at various health and mental health conditions. The most recent “check in” with study participants took place when they were 38-years-old. So far, only 17 percent of the sample has never met any criteria for a psychiatric disorder at any time in the study’s assessment points. This means that at some point in your life, it is likely that you meet criteria for a psychiatric diagnosis (most commonly something like depression, anxiety, an adjustment disorder, or substance abuse). While of course no single study can be generalized to reflect the whole world’s population, it gives us some pretty solid data.

Given these findings, we could argue that it’s “normal” to experience depression at some point in one’s life, just like it’s “normal” to get the flu or break a bone at some point in life. Whether your symptoms warrant treatment depends on how the symptoms are interfering with your life. Everything falls on a spectrum; just as there is a difference between bumping your head and bumping your head with such force that it’s deemed a concussion, there is a difference between feeling a flash of anxiety before a big presentation and feeling such debilitating anxiety that you cannot speak.

The newest version of the Diagnostic and Statistic Manual of Mental Disorders (DSM5), which mental health professionals use for making clinical diagnoses, has shifted towards a more dimensional approach that matches this concept of everything falling along a spectrum. Hopefully, in future editions, it will move even further away from categorizing people as “normal” vs. “abnormal” and help us remove the stigma from these diagnoses, especially since most diagnoses can be temporary. So is it “normal” to struggle at some point, and to have symptoms intense enough to meet criteria for a diagnosis? Absolutely. It’s part of being human.

Maybe we can let go of the need to know if we are “normal” and instead ask ourselves, “does this work for me?” or “is being this way helping me live a meaningful life?” When I first meet with someone seeking therapy, I ask them the “miracle question,” some variation of the following: “If I waved a magic wand and you walked out of here today completely cured of your [depression, anxiety, painful trauma memories, addiction, etc.], what would be different about your life? What would you be able to do?” Usually, the answer has something to do with more meaningful relationships with loved ones, a rewarding job, more energy, etc. Those answers become our treatment goals. If you’re able to move towards your values, the things that truly matter to you, then isn’t that more important than knowing if you’re “normal” by someone else’s standards?

New Year, Same Fear (Part 1)

It’s 2016! When did this even happen? Time seems to pass at weird rates.

How often have you asked someone about their day at work, and they replied, “Ugh, it was so LONG” or have you been asked about a trip and you responded, “it went by so FAST”?   The passing of time can feel excruciatingly slow or dizzyingly fast, depending on a million other internal and external factors.

Not to go all Literal Lucy here, but time actually moves at the same rate, no matter what. A minute is always sixty seconds. The reality is that this is 100% our perception and experience of time.

If we can recognize that the passing of time is only quickened or slowed down by our perceptions of it, we become better equipped for living fully in each moment. Time doesn’t have to be this slippery, elusive element that never seems to do what we want it to; time simply passes, and we can watch it, ignore it, lament what could have been, anticipate what is to come, or, trickiest of all, simply live in it.

What makes us wish time slowed down (or stopped) during the joyful moments is the same thing that makes us wish it sped up when our day feels sucky. It’s the phenomenon referred to in Acceptance and Commitment Therapy (ACT) as experiential avoidance or control, which is the attempt to control or alter the form, frequency, or situational sensitivity of internal experiences, such as thoughts, feelings, sensations, or memories, even when doing so causes us behavioral harm (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).

Okay, I’ll chill on the psych jargon and give it to you straight. Basically, we use all kinds of conscious and unconscious strategies to try to avoid, suppress, or ignore the things that we don’t enjoy (the long line at the supermarket, the obnoxious sound your partner makes when he chews his cereal, the throbbing pain of a sinus headache, the painful memories of a traumatic experience, the feeling of grief when we lose a loved one, the feeling of rejection when we get dumped). When we perceive something as crappy, we want to make it STOP or GO AWAY. On the other hand, we do the opposite and try to cling to, prolong, or drag out the things that give us pleasure (vacations, eating cake, having an orgasm, getting a good night’s sleep, feeling important or special when we get a promotion at work, feeling loved when our children climb into our laps with a book).

For example, try to recall a time you have felt a positive feeling (such as pleasure or delight) and an experience that went along with it. For me, an easy example is when I’m eating a delicious ice cream sundae on a hot summer afternoon. With my first decadent bite, I can count on a slew of enjoyable feelings and internal experiences to pop up. I’ll think the thought, “this is delicious!” accompanied by my mouth watering when I taste the refreshing sensation of cold, creamy sweetness. Then… the moment I have these enjoyable experiences, my body and brain automatically go into experiential control efforts. No more than a few bites in, I may start to think, “I wish this bowl was bigger.” I start trying to eat very slowly and make it last longer, or I think about what else I can get to satisfy my insatiable sweet tooth after I finish. Sometimes I feel guilty over my indulgence, or I feel annoyed that it’s melting faster than I want to eat it. All at once, my experience of pleasure becomes tainted by my own reactions, my “control agenda” and the effort to hold onto ice-cream-induced pleasure forever and ever.

The same goes for avoidance efforts. Addiction often develops because of experiential avoidance. For example, a 35-year-old man feels self-conscious when socializing in groups, but he works in an office culture where the expectation is to attend work-related social functions. He finds that after a few drinks, his nerves are calmed and his anxiety is dulled. He starts to rely on this strategy more and more, to take the edge off. Over time, this behavior gets reinforced. He learns that when he drinks, the unpleasant feelings go away. His body builds tolerance to alcohol, and he must drink more and more to get the same effects. When he sobers up, he feels guilty and ashamed, on top of the anxiety he already was feeling. He starts drinking before work in the mornings, trying to prevent the unpleasant feelings before they overwhelm him. It’s easy to see how the man’s efforts to control his feelings lead to his feelings controlling him, as his daily life becomes focused on “not feeling anxious.”

As Brene Brown mentions in her popular Ted Talk, The Power of Vulnerability, we cannot selectively numb. We can’t choose to not feel anxiety ever, because anxiety is part of life. On a related note, we cannot selectively cling. We can’t choose to only feel joy all the time. Knowing this, it’s futile to tell someone (or to tell yourself) to “just stop thinking about it” or “perk up!” If you’ve ever been on the receiving end of these well-intentioned pieces of advice, you know how unhelpful they can feel. We don’t get to choose WHAT our thoughts, feelings, and internal experiences are. What we can choose is HOW WE RELATE to those experiences. We have a choice in how much attention we give to the thoughts, emotions, memories, and sensations that we experience, and how much we allow them to dictate our behaviors and control our daily lives.

Next time you feel like time is slipping through your fingers, or find yourself impatiently watching the clock, see if you can turn inward and tune into what else you’re feeling, not just what’s driving a sense of urgency.  And then, see if you can let go of the urgency and connect to the experience itself.  If you’re not sure how to do this, you’re not alone. It’s much easier said than done.

Stay tuned for a sequel to this post in the next few days, and as always, feel free to contact me for help or support.

 

Wishing everyone a warm and healthy new year!

If you had a weird rash, you’d go see a dermatologist… right?!

I feel such a mixture of puzzlement and sadness whenever I think about our country’s minimization of mental healthcare.  It’s funny (but no one’s really laughing here…) because so many of us are self-proclaimed “health nuts” who value wellness and want to live happy, fulfilling lives.  However, the reality is that many people, somewhere along the way (probably early in life), learned that when you feel a certain type of way, you “should” be able to change it or simply will yourself to feel differently.  And if you aren’t able to do that, you must not be “strong enough,” right? If you can’t just flip the figurative “switch” in your own brain and motivate yourself out of a difficult emotion, something is “wrong” with you, according to this belief system.  We therapists are here to remind people how warped and self-destructive that view can be. Let me explain…

When someone has a heart disease, you don’t say to them, “just stop having heart disease!” If you did, they’d either call your bullshit or, if they were a little more trusting initially, they’d sure find out pretty quickly that your advice is bogus! Without a real understanding of the healthy lifestyle choices and behavior changes necessary to improve cardiovascular health, a person cannot heal.  That’s why cardiologists exist. Sometimes, something more is required, maybe a medication or medical intervention.  Without the open-mindedness to see that something needs changing and the willingness to do what it takes to change it, we cannot heal.

Of course, we like to convince ourselves otherwise because change is uncomfortable.  But the discomfort of facing the pain is usually nothing compared to the fancy mental tricks we play on ourselves to try to avoid facing the pain. I’ll be writing more about this in a future post, on the ACT concept called “experiential avoidance,” but it pretty much goes like this: If I have a toothache and I don’t go to the dentist because I’m afraid of the pain that might come with the drill, I’ll have a toothache indefinitely… and it probably will end up getting worse and causing more problems down the road. Plus, on top of having the tooth pain, I’ll also have the fears and worries that come along with ignoring it. So not only have I not “solved” the problem of my toothache, I have also made the problem a bigger and more central part of my daily life.

Pretending something doesn’t exist has never worked out when it comes to our health, whether physical, mental, or spiritual. Let’s make it okay to seek treatment.

The Mental Health Association of Greater Chicago (MHAGC) is an organization that basically counteracts the logic of “just get over it” by raising awareness of mental health conditions and working to decrease stigma.  I think what’s coolest about MHAGC is that they intervene early with 9th graders to help educate them on mental health at the same time they are learning about physical health in school. I hope this will help reduce bullying in high schools by making kids more sensitive to mental health issues.  I also believe learning about conditions such as depression, bipolar disorder, and anxiety disorders can teach kids to recognize when they themselves might be struggling, and make it okay to seek help.  MHAGC’s first-annual “Breakfast with the Stars” will be held on Wednesday, November 11, 2015, Veteran’s Day.  To learn more about their powerful initiatives, or make a donation, visit http://www.mentalhealthchicago.org/mhagc/

Don’t you wish you had learned as a child that it’s normal and human to experience emotional pain, and that if it becomes overwhelming, you don’t have to go through the pain alone? I know I do.

If you are struggling or if someone you know is struggling, please visit the pages on this website to learn more about my practice and who I treat.