This Thanksgiving, do as the Astros do

Holiday stress often comes from rigid expectations and fear of criticism. Rigidly holding traditions, wanting to make a good impression, and getting over-ambitious with what we take on (and then not letting it go when it is very clearly too much…) can become a negative voice in our heads that takes over. It pushes us to be anxious, irritable, passive aggressive, and stressed out.

Even though it is almost the end of November, Houston is still savoring the Astros World Series win, and perhaps their spirit can help us keep our eyes on joy this holiday season.  After the epic Game 5 win, Alex Bregman described perfectly their approach: “Have fun, play loose.” The Astros always did best when they were having fun. You always knew they would win if Altuve was smiling. 

Holidays may come with all the stress and pressure of a World Series, but if the Astros can take on the pressure of big money teams, if they can have fun, play loose, and win like they did, then that gives me hope for the rest of us.

This Thanksgiving, embrace the spirit of traditions rather than the precision of them. Enjoy being with company more than trying to impress or serve them. Let go of the “shoulds” and expectations that come from others and yourself. Don’t let stress get between you and your loved ones.

Allow for imperfections, roll with it. Allow for forgotten sides and burnt pie crusts; there will still be plenty of food. Be curious about new and distant family or friends, and allow them to be imperfect, too.

Have fun, play loose, and enjoy the holidays. Go ‘Stros!

(And if politics comes up, this and this may help.)

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.   

"What's wrong with me?"

Diagnoses matter, and they also don't matter. 

Diagnoses aren't the cause of emotional and behavioral problems; they simply describe clusters of symptoms that generally hang together and generally respond similarly to the same treatment. Sometimes they also described related physiological states, but we're still in the early stages of understanding all that (and more). With severe mood disorders and disorders involving psychosis, it can be particularly helpful to tease apart what is what, which is a difficult process that takes time and lots of points of information in order to identify the most effective psychological and psychiatric treatment. I, personally, am not specifically trained in bipolar disorder and schizophrenic disorders, so I refer these clients to clinicians who are so trained, so that they can get the best treatment possible.  

In my work, diagnoses aren't terribly helpful. What is helpful is understanding the whole person, the world they live in, and the life they've come from. What is helpful is understanding how they see the world. 

When my clients ask me, "what's wrong with me?" as they very often do, the answer is never a diagnosis.  

The answer always involves shining a light on all the experiences and contexts that have made life a struggle. It involves shining a light on why it has been difficult to make things better. Often people get stuck in a place where they only see their imperfections, their failures, their traumas. People get stuck in a place where they don't see the entire picture anymore, including the wonderful parts of themselves, their successes, their efforts, and those who love them.

People often have superhuman expectations of being able to deal with terrible situations, and they often expect themselves to cope and express emotions masterfully when they may never have had good models for doing so (which includes most people in the world, for the record).

"Depression" or "Anxiety" are not the problem, but they provide words to describe the states we find ourselves in at points along the journey. The pain and the struggle are clues that something isn't working quite right. They are signs that the gears need to be oiled a bit, or there is a crack in the windshield that needs some attention. What is wrong may, more accurately, be not having enough self-compassion, having unrealistic expectations for yourself, having experienced persistent dehumanization, or having experienced significant losses, for example, but no, there is not some fundamental flaw in you. You are not broken anymore than anyone else in this world. 

There is nothing wrong with you, things are just hard. And there are things that can help get you through, ways of thinking about things, and different things to try that might make life less of a dark tunnel and more of an interesting and beautiful journey. 

On Loneliness

Not having friends does not mean that you are not worthy of having friends. It does not mean that you are not capable of having friends. You can be a kind, loving, friendly person and still not have friends. You can also be a pretty terrible person and have lots of friends. There is next to no connection between the quality of you and the number of friends you have. 

There is definitely a lack of research on loneliness in psychology (what is out there refers to "social support" or lack thereof, and is a very messy topic) -- but there are some significant studies looking at loneliness and health outcomes, all pretty much saying that loneliness negatively impacts health. This is such a compelling and consistent line of research that the former surgeon general, Dr. Vivek Murthy, calls it an epidemic  (scroll down on that one, also see this great interview about it). 

His points are numerous and important. 

His point on the stigma of loneliness is huge. We don't talk about it, and all too often we believe that if we did we would be judged for it -- that people would think that there's something wrong or that we would seem defective or unloveable. It's really a shame, because that is a complete lie. 

As Dr. Murthy discusses in the article, our culture is task-oriented and doesn't provide many opportunities for genuine sharing and connection. Instead we have a culture of superficial sharing (i.e. Facebook), where it seems like other people are connecting, and we feel like we should be connecting, but the ratio of actual genuine connecting that is happening is minimal. We may even have lots of friends and maybe a partner, but for a range of reasons, but we might still feel lonely.

On top of that, as he mentions, people move around and change jobs a whole lot more than they used to, so there are many times we might find ourself "starting over." And having children? Yes, that too. Loneliness in these situations isn't a function of anything to do with you but rather the situation, and the seemingly endless time (years?) and effort it takes to build positive, mutually supportive relationships. 

Add to that, people can be pretty risk averse. Making a friend can be risky. Maybe the person won't like you, maybe you won't like them, maybe it will be okay but totally draining and not mutual. Maybe you won't like their other friends. Maybe you will become friends and then they move again. (There's a This American Life bit that hits on the comedy that is making friends as an adult really well.) So, why bother? 

Because then we end up lonely. We can end up depressed or anxious, and we may end up in co-dependent relationships, where we look to our partner (who we also likely didn't meet in real life) to fulfill our social needs. And, as the research cited above shows, our health suffers. 

I don't say this to be the gloom and doom monster or make you feel worse, but I say it because loneliness is normal and shouldn't be stigmatized; it is temporary, and it is worth the risk to push through. Do what you love with or without people around (even the introverts), take some risks, allow people to support you, share bits of yourself gradually over time with people. Be patient, love yourself, and others will love you too. 

Gratitude for others

In the last post, I discussed how gratitude can make life less overwhelming and stressful by creating a comfortable space in the present moment, when typically we might prefer to run away from into the past or the future. 

The kicker that really brings it home is when you're able to share these moments of appreciation with someone else, to build the connection to the person and the experience.

"I'm really grateful for your willingness to help."

"I so appreciate your taking to meet today, it means a lot to me."

"I'm really glad we were able to do this, I know it's not always easy."

These involve stepping outside yourself, getting out of your head and getting into the moment. It involves thinking about the other person in the moment, what they bring, what they give. 

It involves letting go of what "should be" about the moment or experience and appreciates what is there. 

People, sadly, have gotten used to going through most days not being seen and not being appreciated. But just because we've gotten used to it, doesn't mean it's okay. When you take the time to see them, to appreciate an effort, a spirit, an attempt or good intention, it is a gift. It is that rare and valuable human kindness. 

Getting in the habit of noticing others' efforts and intentions, weaving these moments into your daily interactions takes intentional practice, but it's worth it. When you bring kind gratitude into your relationships, it helps two-fold. The gift of gifts is in the giving, giving with good intention feels good. It's incredibly rewarding to be able to make someone else smile and feel appreciated. In ongoing relationships, it can become the norm, with the other person returning the kindness, though that should never be the expectation (giving only to get always ends badly). 

Let go of what "should be" and of how you wanted things to go. Let go of the worries about looking stupid or awkward. Let go of worries about the next week, month, and year when you're with someone. Instead, sit back, look around. Look at what has been given, whether it's your first choice or not, because it still matters. Moments of connecting matter, moments of real heartfelt gratitude matter. 

Why I'm grateful for gratitude

I like gratitude but not for the typical reasons. Yes, it helps you focus on what you have rather than what you don't, and that's great. Some research (but not all) has shown that it can boost our general sense of well-being and, in some cases, happiness. A paper I'm working on (that may or may not ever get finished) shows, also, that it is one factor that can help people experience posttraumatic growth.

Still, I think there's something else to it, beyond just giving thanks.

The thing about gratitude is that it really solidly grounds you in the present moment. It doesn't let you keep thinking about the life we imagined for ourselves but are now grieving. It doesn't let you get lost in unrealistic fantasies about the future (positive or negative). It doesn't let you get bogged down by past mistakes, painful memories, or the glory days of old. It makes you look around at what you have now, what is going on in your life now that you appreciate. 

Have you heard of "mindfulness?" It's a word that encompasses a variety of mental exercises or practices to focus on the present moment, not the past or future (real or imagined). I first was taught it during a difficult time in my life, and would throw up my hands and ask, "well, what if I don't like the present moment? Why would I not want to drift away to the past or the future?" Eventually, I was able to find my way to giving it a shot and not totally hating it (the past and the future can be just a bit too much sometimes), but I couldn't find a way to naturally fit it into my life. 

But then I started noticing some really nice things in my life, which led me to noticing the smaller, still nice things. There were still bad things, and life still felt like a struggle when I started, but gratitude became a swiss army knife for life. It helped me: 

1) bring me into the present in a purposeful and rewarding way,

2) help me see the colors hiding in the shadows, and

3) when said out loud, give me a way to connect with another person in the present moment.

Number 2 is what people typically think of when they think about gratitude, but #1 and #3 are also pretty great. Put them together, and they're damn near magical.  

Gratitude, if thought or said in a fleeting way as a half-second passing thought, is a start, and then when you allow yourself a few more seconds to be in that moment of gratitude, it allows you a space in time to let go of the past, to let go of the pressure of figuring out the future; it allows you to see all that is around you, beyond the filter that sees only the wrongs and hurts, to acknowledge the full reality of the presence of good as well. 

When said out loud, you bring another person into that present moment, get to slow down, and connect with that moment and another person. You can look at it side by side, stepping out of loneliness and isolation into a real, shared space, glowing with gratitude.*

*Bonus points if it is gratitude for something about the person or what they do, but more on that next time, stay tuned! 

Depression time

Depression is a sneaky monster, but for many, it is a predictably sneaky monster. It can get bigger, louder, and in-your-face at specific times of day, most days.

For some people, it is first thing in the morning, there might be a glimmer of “new day” but then the stomach sinks and we feel the hole swallowing us up again. For others, it is mid-afternoon, a couple hours after lunch when our energy for the day is flagging, when we get bored and tired and all we want to do is crawl under the desk and hide away. For others it is night time, when our mental and emotional energy is out of sync with the energy of our bodies. The pit gets deeper and the negative thoughts get louder and harder to see past.  

It can be helpful to be aware of these patterns, knowing for yourself when the low times are more likely. Knowing that it is coming can help take its sting away and give you the power to call it out for what it is, to say “I see you there, and I don’t care. I’m going to be true and good to myself, and you can’t stop me.”

It can be helpful to be aware because sometimes a low mood may be our body trying to tell us that we need something, that we’re lacking something, such as food, water, or exercise. It may be a sign of frustration between our body’s energy and our mind’s energy, when our body is tired but our mind is still cranking away (or vice versa), inviting us to tune in and see what we can do to get them lined back up. This might include more exercise during the day if our bodies have more energy than mind, or it might include mindfulness or meditation (not rumination) to calm down energetic minds.

It can be helpful to be aware, so that we can create routines and plans of action to give you strength and peace. For instance, if your depression monster comes after you in the afternoon, you might plan ahead to schedule time for a snack, a big glass of water, and a walk around the block, or to plan to have a phone call with a friend or your therapy appointment around that time of day. If it comes more at night, having a peaceful night time routine can be helpful as well, such as curling up with a soft blanket and a cup of tea to read until you’re sleepy or having a mindfulness practice that you do after crawling into bed.

Instead of depression grabbing your hand and pulling you down regularly at the same time every day, it can be time to take extra care of yourself, nurture yourself, and show yourself the compassion and love you need.  Take that time back and make it special, make it yours. 

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.