Calling for a Loved One

It is not uncommon for people to call to set up therapy for a loved one. This is perfectly okay, and I wanted to share some ideas for how to navigate these waters, which can be difficult at times. Whenever possible, it is best to make sure that your loved one does in fact want to attend therapy, or is at least open to it. If you have not yet had this conversation, it is usually a good idea to do it first before you start calling therapists. This is important for several reasons, first during this conversation, you may learn more about what your loved one is looking for in a therapist, what time and days of week work best, and what their budget/insurance situation is. All of this information can better enable you and them to find a therapist that fits their needs. Secondly, if someone absolutely does not want to be in therapy, this is good to find out before you spend your time and energy looking for a therapist for them. It is easy for resentment to build on both ends when people put energy into a task that is not wanted or appreciated. Entering therapy is a very personal decision, and ideally, one should be decided without coercion. That being said, it is not uncommon for people to originally come to therapy at the urging of someone else, but if the client themselves cannot find their own motivation or goals, then therapy is likely to be short lived. Assuming that your loved one has expressed an interest in being in therapy, and they have some type of barrier to calling for themselves, such as time constraints, anxiety (or other symptoms that can be a barrier to reaching out), age, or other barriers, then please feel free to call for them, keeping in mind the following issues.

-In almost all cases, it will be necessary for me to eventually talk with them over the phone before we meet in person. This is to verify that they are in fact interested, and to assess that I believe that I will be able to effectively work with them.

-As soon as I do have contact with them, I will not be able to continue to have contact with you. I will not even be able to verify if they have called, etc. This is because they are assured of certain confidentiality and privacy rights that would be violated if I revealed any information at all. In the case that you are a part of a couple, and are seeking couple’s therapy, then I would be able to talk with either you or your partner about making appointments, treatment, etc. If you are a parent of a minor, in most cases I would be able to give you basic information, as well.

If you are concerned about a love one and think that therapy could be appropriate for them and are considering broaching the subject, here are some things to keep in mind:

–       First, respect their right to find other ways to get help. For some people this could include social outlets, religious/spiritual outlets, 12-step groups, etc. Not everyone is interested in therapy.

–       Sometimes people have had negative experiences with therapy in the past. It is important to remember (and okay to communicate to your loved one) that every therapist is different, with a slightly different approach and personality. People are encouraged to look for a good fit in terms of therapeutic approach and personality. Most therapists would be happy to discuss this with their patients and all therapists are required to give referrals to other therapists if the patients requests this, or if the patient ends therapy because of a fit issue.

–       Try to speak for yourself, and for your own experience watching them try to cope with challenging symptoms, relationships, life circumstances, etc. Try to avoid blaming, diagnosing, and demanding. Most people do not respond well when they feel blamed, or attacked. Focus on your hopes for your loved one, and if applicable, your relationship with them. Ask them how you can help, if you are in fact available to do so.

–       If they are not immediately open or interested try to keep in mind that for many people, the decision to go to therapy is one that evolves slowly.

–       Finally, if you have concerns about their safety, call a suicide/crisis hotline (for a list of California Suicide and Crisis hotlines, as well as other information, go to: http://suicidehotlines.com/california.html), or 911.

-Dr. Megan Goodwin

Turning Toward in Relationships

A few weekends ago I was at a fabulous training for a type of couple’s therapy created by John and Julie Gottman, relationship researchers extraordinaire. The Gottman methods (sometimes called Sound Marital House Therapy) are unique because they sprung out of research, as opposed to coming from intellectual theory. John Gottman, for decades, studied couples interacting. He (and his research team) recorded couples living together in a hotel-type environment. He also recorded couples talking about problems, in shorter segments. Over the years, he and his team were able to extract behaviors that successful couples did, as well as behaviors of couples whose relationship were on the rocks, or did not last. There is a ton that could be said about the Gottman research and their approach to working with couples. But I want to focus on the idea of “turning toward” in this entry.

The Gottmans identified “turning toward” as a foundational and essential behavior of successful couples. Like most positive behaviors, it doesn’t have to be present 100% of time, but Gottman identified that when couples exhibited turning toward less then 50% of the time, it signaled a relationship in trouble. When a person initiates contact with their partner, and this can mean starting a conversation, make a passing comment, physical affection, or even a gesture, the other partner has basically 3 options. They can 1) turn toward, 2) turn against, or, 3) turn away. One basic premise for almost all couple’s therapy is that usually, thecontent of the communication (what is being discussed) is not as important as the process(how is it being discussed). So, in the examples below, you’ll notice the content is benign and superficial. However, the way Person B responds still has the chance of eliciting strong emotions in Person A, especially if the style of communication represents a larger issue for this pair.

Turning away usually looks like ignoring the bid for connection. Sometimes it might look like a total absence of response, or maybe a response that seems to be completely unrelated. Here is an example:

Person A: “I’ve always wanted to learn to sail, I wonder how hard that would be…”

Person B: “I can’t believe the Giants won the Superbowl.”

Person B, in this instance, probably did not have any ill will toward Person A, but nevertheless sent a message that they were not interested, or not focused on communicating or connecting with them in that moment. They “turned away” from the bid for connection. Usually when a person’s bid is ignored in this way, they do not make the same bid again in the future. You can see how, over time, fewer and fewer bids for connection are made if the ones that are made are ignored.

Turning Against. It’s usually a lot easier to see how turning against someone in conversation is destructive. Yet, most of us still do this at times. This is what it might look like, although it could be subtler, or more overt then this:

Person A: “I’ve always wanted to learn to sail, I wonder how hard that would be…”

Person B:“I don’t know why you want to do that. You’re always starting things that you don’t finish. Why would this be any different?”

Ouch. Person A at this moment might feel angry, hurt, sad, shut down. Depending on their personality, they may react either by escalating (possibly an argument will start), or by withdrawal/shutting down. Both are destructive. Not only that, in this example, Person B is criticizing Person A in a general, global manner (“you’re ALWAYS starting things you don’t finish), which is also a destructive behavior.

Turning Toward. When we respond with interest and positivity, we turn toward another person. Our answer might be simple and affirmative, or more involved and deepening. But it leaves the speaker feeling heard and validated.

Person A: “I’ve always wanted to learn to sail, I wonder how hard that would be…”

Person B: “I don’t know, I’m sure you could figure it out with lessons or something. What is it you like about sailing?”

Being conscience of how you respond to others is important. And these little exchanges throughout the day, though they may seem petty and insignificant, are what create the patterns and mood in your relationships. Remember, it is always tempting to focus on the content of your communication, but also, look for ways that you can improve the flow, the process.

Engagement is a pillar of positive psychology. One of the exercises that I’ve taught in positive psychology groups is called “active-constructive listening”; it is essentially the same thing asturning toward. Through listening in an engaged manner, we can put more energy into the relationship, strengthen the connection, increase positive feelings both for ourselves, and for the speaker, and possibly even broaden our worldview or knowledge about the other person. All of these things furthermore buffer us against negativity or other relationship issues. If generally, you feel engaged with, listened to, and understood, this, alone provides some degree of protection from other negative factors in relationships. Put simply, if you have generally positive feelings toward another person, you will be more understanding when you do have a conflict with them.

Think about how this particular principle applies to different types of relationships parent/child, relationship partners, friendships, co-workers. Do you have an easier time staying engaged in certain types of relationships? Unfortunately, many of us are more engaged with those relationships that are less close to our hearts, like those with our co-workers. There are good, and totally understandable reasons for this, but when we notice how we disperse our energy and attention, then sometimes we want to make adjustments that better reflect our deeper values.

For more reading, check out John Gottman’s book, 7 Principles for Making Marriage Work.

In it, he writes about the principle of turning towards, as well as many others that he found to be important factors in lasting relationships. This is an excellent book that I recommend to all of the couples that I work with, as well as individuals wanting to improve their relationships.

http://www.amazon.com/Seven-Principles-Making-Marriage-Work/dp/0609805797

Reducing Depression and Anxiety

Other than relationship problems, anxiety and depression symptoms are the leading reasons why people seek out therapy. And of course, relationship issues are often accompanied by anxious or depressed feelings.

Anxiety and depression, like most other psychological issues, run on a spectrum, ranging from mild to severe, feeling fairly manageable, to feeling “out of control”. It’s important to remember that all people experience anxiety and/or depression symptoms at some point in life, and this hardly means that they have a psychological disorder. Often the most natural, and healthiest response to a stressor or life circumstance may be anxiety or depression symptoms.

That being said, on the severe end of the spectrum, people are dealing with a true psychological disorder, are acutely suffering, and are living a small fraction of the life they’d be living without the symptoms. There are many factors that come together to create these issue: genes, physiology, family upbringing, life circumstances, lifestyle, health, social support, etc. Because all people are in some ways effected by depression, anxiety, or both (either personally or second hand), a lot of research has been focused on understand and helping people suffering from them. It should also be noted, that although there are many similarities between depression and anxiety, and there is almost always some overlap, there are also many important ways that they are very different. Indeed, they are distinct disorders.

When one is experiencing depression or anxiety, it can feel overwhelming, exhausting, hopeless. People often go through phases of how they handle their symptoms, and most people try many things before they even consider therapy. Unfortunately, often the symptoms themselves make reaching out very difficult. With depression, people’s energy is often very low and depressive thoughts such as “nothing will help”, or “I’d be too humiliated to talk to anyone” stand in the way of setting up therapy. For anxiety, there is often a strong feeling of wanting to avoid things that feel uncomfortable. This avoidance alone is often strong enough to prevent people from reaching out, and there are also common anxious thoughts and worries that also stand in the way.

If you relate to the above paragraph, first of all, know that what you are experiencing is very common. But also, keep in mind, that by reaching out for help, you are taking the first step in fighting back against the depression or anxiety symptoms that you may be experiencing.

It can also help people to have a sense of what they might experience if they were to start therapy to address these types of issues. I like to start with Cognitive-Behavioral Therapy (CBT) when working with people who are experiencing depression or anxiety symptoms. I incorporate other approaches as well, including positive psychology, and other acceptance and mindfulness-based practices. This entry will be focused on CBT and how it works.

The basic premise of CBT is that our thoughts about ourselves, others, and our circumstances effect the way we feel, the choices we perceive, and therefore, our behaviors. Our behaviors, in turn, slowly but surely, shape our lives. CBT believes that our thoughts, feelings, behaviors, and outside circumstances/stressors, are engaged in a feedback loop, and that intervention at any point has the potential to change the pattern, hopefully for the better. However, it is felt that certain factors are easier to influence then others. For example, CBT focuses on trying to change thoughts and behaviors, because they are thought to be easier (though not necessary easy) to change then moods, emotions, outside circumstances, and other people.

When using CBT to work with a client, therapists might do a number of things, depending on how strictly they are adhering to CBT protocol and if they are incorporating other types of therapy, as well. Also, different presenting issues will influence the type of interventions that are used. And of course, everyone is different, and some people prefer other types of interventions.

CBT interventions can be thought of as targeting cognitive symptoms, behavioral symptoms, or both. Cognitive interventions target thoughts. All of us have thoughts that help us through difficult situations, as well as thoughts that stand in our way. Sometimes these thoughts are clearly, explicitly, stated to ourselves, while other times, they are unarticulated assumptions that lay the foundation of how we live. The first step to working with these thoughts is to notice them, and to start tracking them. When do they arise, how do they make us feel, how do we act when we believe them? Once we feel like we have a good understanding of the types of thoughts that are standing in our way, making us feel worse, etc, we can start to challenge them. This is called cognitive restructuring, and includes many potential CBT interventions that are designed to create more flexibility around these thoughts so that they are less influential and harmful to our mood.

Here is a common example. A depressed person might have a foundational belief (in CBT, called a core belief) that he or she is a failure. Perhaps, they don’t really feel this way when they’re not feeling depressed, but when something happens, like getting fired from a job, or getting a bad grade in a class, then this belief is triggered. If 100 people were fired from their jobs, all 100 of them could have slightly different interpretations of why. If you are the person who believes deep down that the reason for getting fired is because you are a failure, doomed to fail, etc, then you are going to feel much worse about yourself, possibly be overcome with a sense of hopelessness, self-loathing, shame, and therefore, withdraw from friends or family, not jump into job searching, etc. If this person is prone to depression, then this alone can get the ball rolling in having a depressive mood or episode.

Cognitively, there may be many things that this person is telling himself or herself on a daily (or hourly) basis that is adding fuel to the fire of depression. CBT would try to identify these thoughts, and work at changing them, or at least, lessening their grip on the person’s mood and behavior.

This takes us to the importance of using behavioral interventions as well. As mentioned, our thoughts and behaviors almost always go hand in hand. If you are telling yourself that it was your fault you were fired, because you are a failure, and you are feeling worthless, ashamed, hopeless, then you are likely to withdraw, shut down, or lapse into bad habits. Although we often want to wait until we feel better to do a certain behavior (like jump into job searching), we do not have to feel better to engage in proactive, healthy behaviors. Going to the gym is a perfect example of this. Many people would never go to the gym is they waited until they felt like it.

In our example, we would encourage our fictional person to behave as if they were not depressed. In this example, we might encourage them to get out of the house, exercise, interact with friends and family, and actively job search. Behavioral interventions would be aimed at encouraging breaking the behavioral aspect of the depression cycle.

Behavioral interventions are especially important for anxiety symptoms, which can only persist with behavioral avoidance. In other words, if something makes you anxious, and you know that the anxiety is not helpful (some anxiety keeps us safe from dangerous situations), the anxiety cannot go away unless you do the feared behavior. If you have a flying phobia, it does not matter how much you may intellectually understand that flying is safe, you will still be scared the first (few) times you fly, but then gradually, the anxiety will reduce, if your thoughts are also supporting your new belief that flying is safe. If you’re considering therapy for anxiety but are concerned about being forced to do behaviors that you don’t want to do, rest assured that therapy is done at your pace.

You can probably see how cognitive and behavioral interventions can work to benefit each other. For instance, if I start to break down the belief that I am a failure, it will be easier to be pro-active, gather support for myself, and try again after a loss. Conversely, if I am putting myself out there, and start having little successes, and have a little more energy because I am being active, then I will have more evidence to fight my unhelpful beliefs.

If you do a quick Google-scholar search you will see thousands of articles reflecting countless studies about CBT having great success in treating depression, and anxiety (including panic). If you are experiencing these symptoms, consider if therapy could be a helpful next step. Do not hesitate to contact me if you’d like to discuss a consultation to see if therapy is a good fit for you, or if you have other questions about this issue.

-Dr. Megan Goodwin

Positive Principles in Therapy

There are literally hundreds of philosophies about how to conduct therapy. All therapists, at some point in their career have to try to define their approach to working with clients. A small percentage of therapists strictly adhere to one approach, some learn to use that one approach masterfully. Most though, including myself, have a more eclectic approach, trying to figure out the right approach for each client. Of course, there are pros and cons to each style. But, regardless, I tend to think that most therapists choose approaches that fit some aspect of their personality. Therapy is all about interpersonal connectiveness, communication, learning together, sharing ideas and experiences. These are in some ways, quite intimate. If a therapist is fighting their authentic personality, then it can be difficult. This is not to say that there is no difference between how I am when I am “being a therapist”, compared to “being a friend”, or “being a sister”, but my point is that, at least for me, there needs to be some overlap in terms of style. Also, I should say that a part of being a good therapist is one’s own inter and intrapersonal growth. So, some of my default characteristics may not be the best fit for therapy, personal relationships, or in some cases, either. These qualities can be highlighted in therapy, and a good therapist is often thinking about their own growth, just as they are thinking about the growth of their clients.

So, that was a long introduction to the main point of this entry. I’ve always been attracted to positive interventions and approaches. I think that this is a reflection of my personality and my personal philosophy. Positives approaches can include things such as positive psychology, compassion based therapy, and really any intervention that specifically tries to increase/enhance positive emotion, positive experience, or positive thoughts. I don’t think that “negative” experiences, symptoms, etc, should be ignored, but I do believe in the power of helping people get in touch with a spark of inner optimism, passion, value, anything that is powerful and important to them.

Some approaches, on the other hand have more of a neutral bend, and some approaches actively seek out sources of pain (with the intention of working through them). I have respect for these approaches too, and believe that in some instances, they are the more appropriate then simply positive approaches. Ideally, there would be a balance between these different stances. But, the thing that is novel about positive approaches is that they are actually pretty new, at least to the field of modern psychology (but certainly not to other disciplines like philosophy, religion, etc). The idea that a therapist might bias themselves to focus on their patients strengths, goals, and values, even prioritizing these things over pain, symptoms, traumas, is new. And, it’s understandable that this makes some people uncomfortable. One might worry, “what if that symptoms gets worse because we’re focusing on other things”…”what if we ignore the root of the problem”. Fortunately, the field of psychology has started looking at these questions with rigorous research and we now understand that, in fact, positive interventions can not only improve our moods and functioning, but can also lower negative symptoms, even if this is not the treatment focus. Future entries will discuss the “how” in more detail. Of course, if a client does not believe in this approach in principle, even after education about it, it would not be a wise approach (clients need to have some confidence that the approach will be helpful, no matter what it is). I would never force an intervention. But, I do believe that despite the enormous amount of suffering that we experience as humans, during this short time that we have, there is also an incredibly strong, power, beautiful essence inside of us (or outside, if that is your belief) that most people are able to tap into, either on their own, or sometimes with help. Tapping into this experience has given people the ability and energy to get through even the toughest of circumstances. And, when things in life are going more smoothly, being mindful of the positive, helps us to experience gratitude, balance, and wisdom. You will notice that this philosophy is embedded in many of my posts, and it is, in fact, a large reason why I entered this field to begin with, and what keeps me connected to it.

If this is a topic that you are interested in, an excellent book is Christopher Peterson’s, A Primer in Positive Psychology, http://www.amazon.com/Primer-Positive-Psychology-Oxford/dp/0195188330

Peterson does a fabulous job of describing ways that people can incorporate positive principles into their lives and the scientific reasons for how these interventions increase happiness. It’s easy and fun to read, and set up like a text book (though it reads so much better then most), so you can flip around to chapters that catch you attention.

One final though… What are you grateful for? Even if life is at it’s hardest right now… What are the dreams, values, relationships, that motivate you and support you? And, does being in touch with this information make a difference in how you go through your day?

-Dr. Megan Goodwin