Therapy

The Choice to Grow

Oprah has a different voice when she’s talking about growth, trauma, and spiritual things. Have you noticed? She get that wispy, deep tone and the words hang in the air.

It drives me crazy. Nothing against her, but growth is not a wispy, dreamy, philosophical breeze. It is hard and painful and every step of the way it feels like a terrible idea.

Initially when something stressful or traumatic happens there is a messy mix of being shocked, addressing concrete needs, and experiencing acute grief and loss (of a person, a home, a hoped-for life, a career, you name it and if it is meaningful, it can be grieved). After a while of grieving and feeling numb, I often see people get fed up and want something different but not know what or how.  

Then, there are a few different ways people respond in the long-term aftermath of a stressful or traumatic event. We ignore, restore/recover, or grow. It is not a linear or step-wise process, moving from one to the other, though that can happen.

Houstonians, a good metaphor for this is how people respond when they were flooded during Harvey. After the initial rescue, displacement, return, and immediate mucking there is a pause when you decide what to do next. You decide which contractors to call and how things will be put back together again. Ignoring what happened in this metaphor (and real-life situation) involves putting things back together as they were before, ignoring that there is a threat of the same thing happening again. It involves just getting through and trying to think about it as little as possible.

Restoring and recovering involves a similar process but also acknowledges the reality of threat. This is rebuilding but then intentionally keeping the drains and gutters clear, installing tile or wood floors instead of re-installing carpet. Sometimes this is all we have the capacity for. Sometimes, this is the most we can handle. That is okay; it is enough.

Growth involves taking it one step further when a person has the capacity, resources, and energy. It is renovating while we’ve got the contractor over and the house torn apart. It is looking at the blue prints and seeing what renovations might be not just be helpful but might also really spruce up the place. It is seeing the challenge of coping with what has happened and digging into how it has affected us and how we want to live in light of this experience. It is an intentional choice that involves turning away from how things have been done and turning toward something with greater complexity. Struggle and growth, when we are so able and willing to allow it to, can increase the depth and breadth of our life experience.

We don’t grow by moving forward right away. We grow by digging. It is painful, dirty and can take time.

Why bother? Weren’t things just fine before? Aren’t I too old for any of this growth business?

Novelty is good for the brain. When we try new foods, go to new places, learn new skills, it allows our brain to create new connections. Like a baby learning to use a new toy, throughout our lifetime, we can enrich and feed our brains with new experiences. This includes looking at yourself, others, and the world in new ways. This includes choosing to try to think about things differently or taking on new challenges. This gives our brain new life.

Growth can take a couple forms: perspective- or action-centered growth. Essentially, we’re growing in “being” or “doing” (or both). Both are positive, and neither one is better than the other. Perspective-centered growth is a positive change in how we mentally engage with ourselves, others, or the world, such as a significant shift in priorities, a significant positive revision in how we see ourselves. It can be existential or spiritual or purely personal. Action-centered growth involves doing things differently, trying new things, experimenting with what you are capable of.

Both, however, involve digging to see what is not working, what you’re not happy with, or what feels stagnant. It can involve acknowledging mistakes, weakness, and vulnerability. And it will certainly involve change in some way. If it makes you want to run away, you’re probably on the right track. There are an infinite number of reasons to let these things stop us from working on growing, to let the nay-saying voice in our heads keep us from trying and trying again. It involves an investment of spending some time and emotional energy (when we have it) looking around in the darkness. It involves believing that our lives are worth the investment.

Find the area of tension, the area of discomfort, the thing your mind runs away from every time it pops up. When you are ready, set up camp there. Dig. Redesign. Rebuild.

This is all still a dramatic over-simplification of the complex experience of growth, but I wanted to dip into the messy, scary reality of it. If we believe it is something hippies do or that it is easy breezy, if we try but into a challenging aspect, we might think we’re doing something wrong or that we should definitely turn back when that is not the case at all.

Allow it to be something that is complex and doesn’t make sense for a while. Allow it to not fit into a neat package or inspiring message. Allow it to not fit any words at all.

So much more than just listening

Many people wonder what goes on in a therapist's head during a session or what they are doing. 

We listen, of course, but there's a whole lot more going on. All those years of education and training shape the thought process before, during, and after a session. 

There are three general processes involved in helping people achieve meaningful change: approach and conceptualization, treatment planning, and treatment. 

Approach and conceptualization involves having a general theory for understanding people and seeing how it makes sense for this individual. If you haven't taken a psychology course, you might never have thought about the questions, "What motivates people's behavior?" and "Why and how do people change?" Take a minute. Think about it. How have you changed?

Over the history of psychology there have been different movements that have inspired different approaches to answering these questions. Freud and the old school analytics talk about unconscious forces and our early life experiences shape our behavior. Then came the behaviorists saying that our thoughts and behaviors are based on consequences such as punishments or rewards or that it is based on learned associations. For example, people go to work because they get a paycheck (a reward or reinforcement) and they also have positive experiences (or at least enough positive experiences) that they learn that it isn't terrible (and maybe pretty good sometimes), so they go back.

Then about thirty years ago our experiences began to be seen as a function of the interactions of thoughts, behaviors, and emotions, within ourselves and in interaction with other people. For example, we have the thought that we can handle rejection, so we pursue relationships, and feel curious and adventurous. Even more recently, values-centered perspectives that integrate mindfulness have become popular. For example, if you value relationships, you may pay more attention during time with loved ones rather than fretting about the past or future, freeing you of having to think about future fears of rejection, improving your mood and quality of life.

Conceptualization involves mapping the approach to the individual and their current struggle, allowing the theory to help guide you to understand better the broader themes and connections in a person's life. For example, if I am using a values-based approach, I might explore (as I often do) what the person values and to whether they are able to live in a way consistent with those values, or a way that furthers their values. Areas of conflict, where people are feeling disconnected from their values then provides a lens for understanding current stress. (This is a significant oversimplification, but that's the general idea). 

Then we use the conceptualization to guide the plan for treatment. So if you say it is a values conflict causing a problem for a person with symptoms of depression, you're not going to help them build coping skills, you're going to help them explore different ways to live in ways that is more consistent with their values. It should all generally line up. It should also be a plan that science agrees with. I'm not a fan of doing things just because I think they're good ideas or because they are warm and fuzzy; I do things because I have good reason to believe they will help. How do I know? Science. Researchers have spent generations comparing different approaches and different treatments, and seeing what is ultimately most beneficial. 

Then you do the thing where you sit in the room with the person, and the treatment magic happens. You have a general idea or roadmap for treatment with specific techniques, again consistent with your theory and conceptualization, but you always have to bend and flex to where the client is at that moment and how s/he responds to each step you take on that map, making constant adjustments. After each session we have more information to enrich or adjust our work for the next time. It is not a journey of giving a solution but of guiding the person to where they might find the answers themselves, to where they may ultimately find peace.

It's a really exciting process, and for the most part, clients don't have to know about any of it. I prefer they not worry about, but leave that to me. I prefer my clients to just be themselves, that that is how they can make the most out of their therapy experience. When they are themselves, I can more clearly see their wonderful personalities and quirks and strengths, and then I can help them the best that I can, in turn.   

Crisis

I know I'm jinxing myself by saying it, but I have been lucky enough to have only had to hospitalize one person in my career so far, which is six years at this point. 

Within the profession of psychology we have a lot of fancy words for talking about people who are intent on killing themselves or others, a mental health "crisis," "not being able to keep yourself safe," "danger to self," etc., but I don't know if any of those make sense to people. Let's clear that up first. The have a way I like to talk about it, which clients generally nod their head to, that I hope gets the idea across, but I'm sure there are still pieces that might not be clear. I like to say that it is common to have thoughts of wanting to kill yourself and sometimes even fantasies of people you don't like coming to an untimely end. A supervisor once told me that if everyone who had such thoughts were hospitalized, the streets would be full of ambulances. There is a line though that defines where thoughts, and even having a plan, turn then to having the means and intent to act, to or not being able to trust yourself to not act in an impulsive or inebriated moment).

We like to think this line is clear and that all mental health and medical professionals would all do the same thorough risk assessment and agree. Like most things though there is some gray. The overall point is the same that the thoughts can go from normal to worrisome to concerning to "crisis," at which point the person knows what they're gonna do, have the way to do it, and are choosing that option, whether or not they've done anything to act on it yet. It's the point at which they not only don't see other options but are already mentally pursuing killing themselves-- and that train needs to get turned around immediately.  

The one time I have had to, it was clear, it was an instant stomach-dropping feeling, not of worry or fear, but of intense pain, of feeling where the person is for this to be the only option.  It comes in many forms, and I'll see it again in someone, a different someone, a different situation, but the same pain and loss. 

Typically it is my job to help people not get to that point, but iIn those situations, it is my job to help keep the person safe. It is a crisis, and what has to happen in a crisis is for the person to be stabilized, for the person to just get out of crisis mode. It is not to solve all their problems, it is to just get them to be able to breathe in and out of another day. 

The stories people tell about their time being hospitalized are almost never positive. I can tell you from my experience that the people working there do care and are trying to help, but their job is just to stabilize a person, to get them on medication and, hopefully, if the person doesn't already have a therapist and psychiatrist, to get a treatment plan in place for that. I don't want people to have to go to the hospital but if it will keep someone safe and alive, I'm all about that. 

That said, I do not generally work with clients who have chronic, severe suicidal crises (multiple attempts and/or hospitalizations). Honestly, just because my heart can't handle it day in and day out. There are other professionals out there who can, and I'd rather people find their good fit. I can point you to someone else, but I'm probably not your person. If you're struggling with trauma and pain and having trouble finding a reason to go but are still willing to look, I'm your gal.

If you are struggling either way, reach out and ask for help. If you feel you are in crisis and can safely get to an emergency room, do so, if not call 911 (it's okay, they may handcuff you, but only for your safety and theirs, and usually they'll take you to the nearest hospital in an ambulance, not the back of a cop car, because you are not feeling well, not in trouble). Mental health issues are some of the most common issues police and hospital staff see. 

If you're not sure or if you're not quite at that point but you're worried and need to talk (or are worried about a loved one), please call the National Suicide Prevention Lifeline at 1-800-273-8255. Talk. It's okay. No one can help unless they know what the issue is and how bad the pain is. They are available 24/7, and their website is a wonderful resource about many things on the topic, including what to expect when you call. Check it out. 

I can tell you, from the one person I have had to hospitalize, I'm glad that I was able to be there to help and that that individual was open to the idea of accepting the help. 

Like I said, I hope people don't get to that point, but every day lots of people do, so I'd rather put more good information out there instead of people suffering additionally from fear of the unknown or from choices based on misinformation.

Thanks for reading, y'all. Just keep breathing

Hurricane Harvey: Strong and Suffering

You can be strong and still experience suffering. 

You can be grateful and still experience grief. 

It is normal, and it is okay. Both are sides of the experience are important and necessary. 

A common question after catastrophes like Hurricane Harvey is about trauma and PTSD. The first thing I talk about is how normal it is to have emotional responses to reminders within the first few weeks following a traumatic event. People often would prefer to avoid certain places or have a heightened emotional response to an everyday experience, like going to sleep, checking your phone, watching the news, or listening to the rain. Within the first few weeks after an event, it is normal and natural to have these reactions. As you proceed through your life, they typically fade away within a month or so. If you continue to engage in the avoided or emotional activities it is more likely to fade, and fade faster the more you do those things. 

If they do not fade within a month, then it may be helpful to talk to a professional about it. Traumatic stress symptoms are very treatable, and the sooner you can treat them, the better. 

More common than traumatic stress reactions in some cases though is depression. Depression caused by chronic stress or by pain and sadness that got stuck.  

Some people have difficulty tolerating emotions such as suffering and grief, with some turning to substances or problematic behaviors (such as over-working, addictive or compulsive behaviors) to not have to feel the feelings. This digs the hole even deeper. Putting the pain off does not make it go away. Giving yourself permission to be sad and grieve helps. Talking to a professional about these issues is a good idea so that you can feel the pain and let it wash away rather exhausting yourself trying to push them away.

In a different way, some people keep busy cleaning and moving and saying how grateful they are to be safe, so that they don't have to feel the loss, the sadness, the grief. The loss is enormous and deserves to be acknowledged, just as much as the things you are grateful for. You cannot simply paint over grief with gratitude in the same way you can't just paint over sopping wet drywall. You have to clear out the room, pull up the floors, look at how much needs to be cut, and piece by piece, take down the drywall and insulation behind before putting up new drywall and moving on. So too there is emotional work. Grieving fully all that is lost, materially and immaterially. Each memento lost and each object that provided comfort or security matters and will have a felt impact. Loss of comfort, security, and routine matter. Chances are, within the first week you cried for your city, for your friends and family, for yourself. Know that it is okay. Know that it is necessary. 

Like the financial toll, it is too soon to say what the real psychological toll of Hurricane Harvey will be on Houston, but there is and will continue to be overwhelming suffering and sadness.  Allow it to be felt until it no longer needs to be felt. That requires the strength of being truly Texas and Houston Strong. 

Psychology and Religion

It never ceases to surprise me how there are so often unspoken boundaries between psychology and religion. Understandably, mental health is a messy business, and church staff are rarely trained to deal well with mental health issues. At the same time, may psychologists shy away from in-depth discussion of religion because it is also not something we're particularly trained in. We are instead trained to know our fastball and stick to it. 

Except that our fastball really is the same. We both work tirelessly to help people to love, to love themselves well, and to love others well. Therefore, I ask for you to take a second to be open to considering the richness that might lie in the space where the two overlap, the space where we can help heal, challenge, and grow people into the best of what they can become, one step at a time. 

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The church and the therapy room are places for reaching people in their suffering, and it takes acknowledging that suffering in order for that connection and healing to take place.

If the pain goes unacknowledged then they may persist with self-blame and frustration or go away from the therapy session or the church feeling unseen, often not to return.

They can come away thinking that they don't belong, aren't worthy of love, or are too broken to be helped. Obviously the opposite is true. 

These processes are the same. 

I read an article recently where someone wrote that millennials don't go to church, they go to therapy. As a therapist, I'm not okay with that. Nor is the opposite side of the continuum helpful, where people of faith do not understand or appreciate the value of professional psychological services. It can be both, and too often individuals don't have the experience of how the church and mental health professionals interact, of how they are complimentary. Similarly when people go to therapy seeking to fill that sense of what is greater, they too often fill it with themselves or remain empty. Connection between the two spheres is a rich space for people to heal and grow, fully connecting with who they are meant to be.

Psychology is unique in that it is a science. It emphasizes use of the scientific method to address questions related to mood, behavior, thoughts, and interactions. We use these tools to help people in the most effective way possible, weaving techniques and approaches supported by research with our understanding of the core conditions that help a person feel loved and accepted. As clinical scientists and scientist practitioners do what we can with what we have here on earth. But Dr. Ken Pargament says it best in his excellent books on psychology and religion, that those who fear science debunking spirituality are vastly underestimating God and vastly overestimating science. Religion has nothing to fear from psychology and vice versa.

But we have so much to gain from each other. There can be shared information and learning; there can be greater appreciation and knowledge about mental health issues, resources, and providers within the church, and within psychology there is so much we can learn about the depth of the existential human experience from the people who have been the original counselors for thousands of years. 

This will the the first of many posts addressing the intersection of psychology and religion. There is so much healing possible at that intersection, and I am hopeful. 

The VA: The happiest place in America

On the walk into the VA and up to my office I've gotten in the habit of smiling and greeting the vets I pass. I've also started regularly taking walks around inside the main hallways when I have some free time or (more likely) when I need to get the hell away from my desk and reconnect with humanity. On those walks I greet people and offer a big, genuine smile. Most of the time I also encounter someone who is lost, and I get to walk them to where ever it is they're trying to go (I found two today!). The VA I work at is currently the second largest federal building, behind the Pentagon, so there's a lot of walking and a lot of people getting lost. All the time. 

When I think about the job I get to do within mental health, it really is an honor and privilege. Yes, I feel more like a square peg in a round hole there for many reasons, but in large part I also feel a great deal of gratitude just being able to work with the patients I do. I tell my them that often, but I don't think they really believe me. 

In part it is because of their service and sacrifice, that they answered a call to be a part of something bigger than themselves. Obviously there is much to be said about the gratitude for that. Another part of it though is that something about their service tells me that they care about others or at least wanted a better life for themselves. Despite whatever tough or grizzled exterior, lack of emotion, or explicit anger toward the world they may present with, they're still people with heart wandering around a place looking for care and healing. 

But of course then I guess we all are. 

As a psychology resident, I've learned a lot about the goodness in people, and I've learned just as much about it through my faith and my own therapy (which has been lots, believe me). It's easy to go with the trends of trying to impress people or tune people out and instead get buried in our phones. But the thing I have seen and the thing that I will continue to believe all the days of my life is that we need to see goodness in other people. We need to see the goodness in ourselves. Often we don't realize how many chances we have every day to do this. Many days there will be crap piled on top, but you would be surprised how quickly the crap melts away when someone genuinely smiles and asks how you're doing. 

Yes, bad, unimaginable things have happened and will happen again, I will fail, I will be disappointed and hurt, and there is evil in the world, but I have the choice to contribute positive or negative energy to the world. Some days my tank is empty, and I can't, so I appreciate all the more the days when I can forget whatever else is going on for a bit and be in the moment with the people I pass in the hall. I put aside what happened that morning or what might be waiting for me in my office, and I'm just there in those hallways, trying to do my part to make someone else smile and feel seen. 

I recommend you give it a shot, in your work or school, or neighborhood, and see what happens and how you feel after. I dare you to make some positive moments in your day and maybe in the day of someone else. 

What does someone have to do to be a clinical psychologist?

Unless you know someone who has been through the gauntlet-like process of becoming a clinical psychologist, chances are you only have a general idea of what it means. It can be helpful for potential clients to know what goes into it and how "clinical psychologist" is different from counselor or social worker. Knowing these differences is an important part of being an informed consumer when it comes to therapy. Today I'll get us started then focus in on the Clinical Psychologist category. 

Categories of "therapists" or "counselors"-- master's level (Licensed Professional Counselor, Marriage and Family Therapist, Licensed Clinical Social Worker, etc) and doctoral level (Clinical Psychologist). "What about psychiatrists?" you say. They're MD's; they prescribed medication and get significantly less therapy training. 

Master's level clinicians have received a set amount of training and, once licensed, have completed a set number of hours of clinical training. Generally their therapy services cost a smidge less and are easier to find. Doctoral level clinicians have a bit more schooling and have better odds of being either informed about or engaged in research.  Being "up on the research" can make a difference in the same way you would want a surgeon up to date on the latest and most effective techniques rather than the same one he's been doing for thirty years. 

I'll talk more about master's level clinicians and how to find the right therapist for you in future posts, but for now I want to focus on that doctorate level side and what goes into that. 

Step 1: Getting into grad school.

There are two types of programs people (or cats) can do: PhD (doctorate of philosophy in clinical or counseling psychology) and PsyD (doctorate of psychology). Generally the difference is the level of time spent learning about or doing research. PhD's generally have a greater emphasis on learning how to do research and learning how to interpret other's research. PsyD's generally have a greater emphasis on training in clinical skills. So the balance of time between learning research and clinical skills is general even in a PhD and more heavy on the clinical side in a PsyD. Having a therapist who understands research can indicate that they are more likely to know which treatments have shown through repeated testing to be effective at helping people. 

Clinical psychology PhD programs are harder to get into than med school. The quality of programs varies. There are for-profit and online programs that are not accredited by the American Psychological Association (APA); these don't generally provide good training-- run away from these. Be sure to look for someone who went through an accredited program because this means their training met high standards of training and education. These programs are not big money makers for universities generally, so they aren't everywhere and programs generally take only 3-9 students per year. Many people end up moving far and wide to get into these PhD programs and make great sacrifices over the course of their 4-7 year training. 

2. Surviving grad school.

In addition to classes, every program has a qualifying exam of some kind. It is typically some demonstration of knowing a lot of information generally and/or some info on an area of specialty. That's in addition to classes, doing research in a lab (usually), and doing clinical practicum (learning how to do therapy - usually a couple years of this in different contexts).

You might happen upon one of these trainees when looking for affordable counseling. Many departments offer therapy through training clinics. They'll having basic skills and will be supervised by a licensed psychologist. For clients with relatively straight forward, short-term issues this is a great option.

Oh yeah, and they do a dissertation. It's terrible, but I don't want to talk about it. It's terrible.

3. Predoctoral internship.

The final year of grad school is an internship. Currently it is absurd and very competitive. Most people again pick up and move at least out of state, if not halfway across the country. It's a computer match system where students and sites (again, hopefully APA-accredited programs-- places like medical schools, hospitals, community mental health centers, prisons, etc), interview and rank each other. By now if the student isn't completely broke or deep in dept, that happens with traveling all over for interviews. The internship is almost always a year of working as a therapist full-time. Again, another chance to get cheap therapy!

4. Postdoctoral residency and licensure hoops.

Here things start varying widely from state to state. Every state has a Board of Psychology that can provide specific guidance for your state. Currently a postdoc residency (another full-time year of mostly clinical work) is necessary either for licensure as a psychologist in most states or to be competitive for professor-y jobs. Postdocs are less competitive than internships, but it's another hoop often involving moving across state lines. Then there is the big monster test, the EPPP (no, I don't know what it stands for, don't ask). It covers ALL of psychology. All of it. In Texas, there's also the jurisprudence exam (law and ethics) and an oral exam, where you have to go to Austin and sit in front of and handful of intimating experts and talk about what you would do with some hypothetical clients. And you pay, lots and lots of money actually, to take these tests. 

5. Licensed. Finally.

And then when school, internship, postdoc, and licensure tests are passed, then you have a clinical psychologist! Ta da! It's a uniquely harrowing combination of education and training that people only do if they're just crazy enough...

Nobody becomes a psychologist by accident.