A Clarification for Therapy Consumers

Some problems that come up for people paying for therapy with health insurance

 Surprisingly sometimes clients in therapy are confused about who the insurance company is and who their therapist is...  Somehow the fact that they are 2 different entities escapes the understanding of the client.  When you pay for therapy with insurance (usually it is the bulk of the fee paid by the insurance and the patient pays a small co-payment), the insurance comes with you, not the therapist.  You are a subscriber to that insurance; your employer has made an agreement with them to pay a certain amount per employee every year to them and, in exchange, they will pay for a certain amount of therapy for any employee who chooses to use it.

 It has nothing to do with the therapist:  The therapist doesn't make their rules nor determine how they do business.  The therapist is independent.  They have created and built their practice; it belongs to them; it is an entity on it's own with nothing to do with your particular insurance company.  (In fact, sometimes some of us feel like the insurance companies have taken advantage of us by inserting themselves in between us and our patients)

Most insurance that therapy clients present with are called HMO's. This means that the company will only pay "providers" (this is what they call therapists) who are on their list.  To be on that list, a therapist agrees to their conditions, primarily to be paid at usually about half their normal rate.  For a new therapist, just building their practice, this is helpful to them as it brings patients to their practice.  For a seasoned, established therapist, they are doing you a favor to agree to deal with your insurance.  That's because for the therapist, it is extra paperwork, tracking, and phone calls-so, they do more work for less money.

The reason I am bringing this up is the occasional odd and unpleasant interactions I have had with some patients over insurance issues.  Somehow, they think I am responsible for what their insurance company does!  And the insurance companies, for their part, do seem to set it up that way, i.e. to make it look that way.  (They leave it to us to do their dirty work as you will see in the following 2 examples).
 
For example, recently one of the companies a few of my patients use, decided to raise the co-payment on some of their subscribers.  They didn't inform anyone---not me, not the patients.  It wasn't until I sent in my claims that I  saw this discrepancy.  Since I usually bill for a number of sessions at a time, usually about 6, there were some debts accumulated.  In this case, they had more than doubled the co-payment.  So, I had the unhappy task of telling my patients that they owed me money.  Some of them reacted angrily to me as if it were my doing.  One patient said:  "It sounds like the old 'bait and switch' to me."
Another time, the company decided that the patient had used enough of their benefit and, basically, didn't want to pay for anymore therapy for that patient.   When I told the patient, word for word, what the insurance representative had told me (basically that a limited number of sessions could be used going forward and that they had an end date), he thought that I was throwing him out of therapy.  I was able to straighten that out with him but, then, when I suggested that he could continue, paying himself for his sessions, he immediately and unequivocally refused.

Maybe you can see that these kinds of incidences can be hard on the therapist.  From our point of view, it is unfair.  Sometimes we feel devalued.  These examples I gave are but 2 of many things like this that happen.  So, I just thought that, for the sake of all of us---patients who want to use insurance to pay for the bulk of their therapy, and all therapists who agree to accept insurance---that I would try to clarify how this works.
Insurance is just an alternative method of payment but therapists are independent entities and are not the insurance company and have zero power over them.  (Most health insurers are for-profit businesses and so, naturally they have their eye on the bottom line; they are not helping professionals; they are in business to make a profit, not to help people.)
The therapists are just as subject to the whims of the insurance companies as the clients are.

Was this explanation useful to you?

Oldies But Goodies

Some posts I like

Shyly is a post that touches on Jungian theory, discusses Western culture in comparison to others and, includes a personal note from me.  http://therapiststhoughts.blogspot.com/2009/07/shyly.html

"I've Lost 38 pounds..." describes how therapy can actually be a magical process at times.  http://therapiststhoughts.blogspot.com/2009/09/ive-lost-38-pounds.html


The Delivery is about how your communication style can make all the difference in how well you are heard  http://therapiststhoughts.blogspot.com/2009/10/delivery.html.

Depression Prevention talks about how sometimes depression in adult life can be rooted in an earlier stage of life---how to understand this in yourself and to avoid seeing it develop in a child  http://therapiststhoughts.blogspot.com/2009/10/depression-prevention.html.

                                                                                   Maybe some of these will be of interest to you.

The Imperfect Therapist, Part III

Clients assessing the therapist

                                              Sculpture by Christine Kaiser

  Sometimes a therapist may look more flawed than they are.  
People come to therapy with certain expectations---sometimes they are happily surprised, sometimes they may feel they are not getting what they were looking for.

In this last case, we therapists sometimes receive criticism.  It has happened to me a few times.  When it is warranted, I am fine with it.  When it  isn't, I find it really hard to take.  But, the therapy session isn't the place for the therapist to become defensive...!  So, I feel it is actually much easier to take a deserved criticism as feedback and an opportunity to improve than it is to try to redeem yourself when a patient has complained inappropriately.  How do you stick up for yourself?  Difficult to do.

One time I got told that I didn't give enough direction and that I was more of a "listener type".  Actually, as therapists go, I am probably on the more talkative end of the spectrum (you may have figured that out if you've looked through this blog at all---lots of posts in a shorter time than most...!)
I am not one of those, "uh-huh, yes, ummm", silent type therapists (and I have also received compliments on that from other patients).  I am more of an engaged in an exchange type of therapist than most.   So, this felt quite unjust.
 I do listen though.  I have to know what the actual problem is and that takes some attention and time.  As a matter of fact, I often have to restrain myself because it is so tempting to tell people what to do which is not our job.
I do give suggestions however.  And, this comment seemed particularly undeserved as it was a case wherein I had made more suggestions than usual and really tried to work out a plan of action with the patient, only to have it ignored.
(Have you ever noticed how sometimes a person does something themselves and then blames another?  Very common.)

Of course, most people don't necessarily understand how therapy works, even some who have partaken of it for a long time.  When I go to therapy myself, I am not only working on myself or my own issues but, I am taking full advantage of the process.  Of course, that's because I know what it is.  
It would be a benefit to patients or potential patients to learn about how therapy actually works and why it helps, what a therapist's role is, and how the patient can make the most of their experience!      (Here is a post on that topic:  http://therapiststhoughts.blogspot.com/2011/12/biggest-bang-for-your-buck.html)
I don't believe in keeping therapy a mystery or a secret---that's one reason I do this blog---the more you can understand how the process works, the better position you are in to take the full benefit.  Here is another post on how you can best benefit from your therapy process:  http://therapiststhoughts.blogspot.com/2010/04/your-side-of-street.html 
Some people are more difficult to help than others:   

• Some come to therapy---a place, by definition, for change---very resistant to change.  
• Some present themselves to a therapist for help with a thorny problem and then withhold some of the pertinent information, leaving the therapy process handicapped.  
• Some repeat the same problem over and over but never apply in their life what insight or decision was arrived at in any of the sessions.  
• Some want things to be different in their lives but are interested only in 'tea and sympathy'.  
• Some would like it very much if others in their life would change but refuse to try anything differently themselves (even how they think about something).  
• There are patients who lie to their therapists sometimes which, of course, makes it impossibly difficult to help appropriately. 
• I have even had someone say, at the end of a session, wherein we developed a detailed plan about how to deal with a difficult family member, "Oh, I just wish she'd just stop causing problems."  It was clear to me at that point that none of the planning we had done was going to be applied.

Nonetheless, we therapists in such situations usually keep trying, every week, to think creatively about the patient's problem, to come up with a new angle of approach, and to maintain our compassion for the person before us.

You can imagine how hard it would be to take criticism in one of these scenarios...!

Lest I end this view on one of the challenges of being in the therapist role on a sour note, I will share with you a wonderful bit of an assessment I received today from a young client of mine---a cute teenager:  She said:  "I like it that this is like a conversation and I am not feeling like I am getting the 3rd degree!  I like having a regular weekly meeting even though I don't always have a crisis, it's nice to know this is here for me in case I do.  I'm glad we can laugh together sometimes.  I feel like you really care."
That little girl made my day! 

Please share your feelings in a comment below or in the reaction boxes.  

(This is Part III of the series, The Imperfect Therapist, which has continued to attract many readers; the second post in the series is here: 
  http://therapiststhoughts.blogspot.com/2012/03/look-before-you-leapthe-imperfect.html)

Celebration!!! Three Years.

 This is the blog anniversary

 The 1st post was written on Friday, June 26, 2009

 What am I doing here?  I am trying to provide a useful service.  During the time since I achieved my license and have been in practice, I have seen hundreds of people.  They have shared with me---they've shared their shame, their joy, their struggle, their wishes, their disappointments, their accomplishments, their love, their pain, their ideas; in short, they've shared with me their inner lives.  

I sure hope I have learned something from this.  And that learning is what I hope to impart to you.  If you have never seen the inside of a therapy office, I think that this blog will give you a small taste of what that may be like.  

If you have been in therapy or are currently engaged in that process, this blog should work for you as a stimulating adjunct to your own therapy effort.  If psychology is an interest of yours, the latest information from the researchers in the field is here.  If you'd enjoy a peek into what occurs between me and my patients, there's a bit of that here.  If you want to know what it's like to be a therapist, that has now been incorporated into the blog.   At first, my aim was to provide growth-provoking material in written form.  But, as I've gone along, it's become abundantly clear that you, my readers, actually want to know about me, or, people like me.  Now I have a label, "About therapists" so you can find out something about us.

I am also hoping to provide a place you can trust.  I try my best, in my profession, to function with integrity.  Naturally, everything I write here cannot be perfectly correct.  On the other hand, I didn't begin this blog until I had a whole lot of experience under my belt.  I have an intrinsic interest in my field so, even if I weren't required to complete continuing education, I would be attending seminars and reading about psychology anyway.  I know what is in my heart.  And my wish  to offer something here that will be helpful to some of you out there in the world, is real.  So, I hope that when you are perusing these posts and wandering around in the blog that you feel, confident and comfortable.

If you are curious, if you have a drive to understand, if you are seeking inspiration, you will be able to find resources for those quests here.

I am on a mission (and I don't mean to sound overly dramatic but that is how I feel) to add something good into the mix that is our human world.  At the same time, it also makes me happy to create the blog:  I feel inspired myself, I utilize my creative energy, and I am giving out all that I have.  I don't want to stop until I am on empty!

It seems like there does need to be some sort of change though, in how the blog is done.  As I've said before, I work many hours every week on it.  I rarely miss a day, believe it or not-yes-I work here every day.

I have to find a way to support this.  I've asked for your suggestions (Post, titled, Call For Participation addressed that problem) but I didn't get any.  My best that I can come up with is to place a Donation Button on the blog.  If you feel you received some value from visiting here, you may wish to help me to continue to offer my particular brand of encouragement for self-actualization and living life to the fullest.
 I want to continue to give you what you want (and, please, if there are topics you want me to address, ask me for it in one of the comment sections!) and, at the same time, I want to take care of myself.

Don't get me wrong, it is, as a matter of fact, a magnificent feeling, to altruistically give whatever you may have to offer, freely to the whole world.  It's wonderful.   (Bless the internet)

But! as one of my patients so wisely once said:  "If you don't deal with reality, it will deal with you."

***Primarily, though, this is time to celebrate---3 years of writing about us, people, fascinating creatures that we are---344 posts and counting!***

Again I invite you to join my blog as a Follower; it would mean a lot to me.  Write what you think, how you feel, what your questions are, in the comment boxes.  Talk to me.  Express yourself to the other interesting people who read this blog.

Celebrate!  Dance!  Listen to the music!  I am celebrating my accomplishment and I celebrate you in your personal quest!

"There are many times in our life when we may feel as small as a butterfly, and when we think that the things we can do have as little effect as the fluttering of a butterfly’s wings.  We think that in our own little space allotted to us, in the small roles given us to play, we make almost no difference in the lives of those around us.

Little however do we know that what we do may truly result to a big difference later on, creating waves of change that wouldn’t have happened had we not taken the initiative to do our part.

Let us remember the Butterfly Effect.  For who knows?  Your little deeds may just yield a tornado of blessings to countless others around you, even to those whom you haven’t even met."

I will be looking for your comments.

Wishes Come True

A fantasy of mine or, imagining having a magic wand

This weekend, I bought a state lottery ticket.  The jackpot is $241,000,000.  It's a lot of money in my book.  Isn't it fun to dream about what you will do if you win?

One of the things that I like to think about is how I could make wishes come true.  

My dear friend who has a terminal illness and is struggling and fighting to stay alive---I would pay for the world's best doctors who specialize in his diagnosis.  I have a young relative who really wants to move but doesn't have the wherewithal to accomplish that.  Voila!  I would move her.  I know a couple who have a house and a car but they need a second car and a new house.  Or, even more fun would be to re-model, completely, the house they have.  Speaking of properties, I do know someone who is caught in this 'under water' loan situation that now exists here (value at which property was bought and for which a bank loan was procured, is now worth thousands of dollars less); I would take care of that in a minute!  I have a colleague, a wonderful, talented therapist who has her office in the middle of a very poor community.  She has made the interior of her office very attractive but, her landlord at her building is unwilling to do any repairs or upkeep.  It would be fun to buy that building, get her a receptionist and fix it all up so she could be comfortable in that important work she is doing.  Thinking about work, I know an artist and a yoga teacher each of whom would be ecstatic to have their own studio.  Done!  Magic!

Daydreaming:  I love to fantasize about this.  How would I do it?  Would I be an anonymous good fairy or a joyful friend?  

Every time I ponder this, I think of different people who have shared their dreams with me or, even who haven't but, just obviously could flourish with that one added thing that is out of their reach financially.
 It's fun.
This is a huge departure for me.  I've never written on the blog about anything so simply personal.  Sharing a bit of my inner child, I guess.  Usually you only hear my adult, professional voice.  I thought maybe there would be someone out there who could understand this fantasy, so I indulged myself today.

By the way, it isn't that I don't have my own wishes.  Of course I do.  Just like anybody does.  And I like to imagine being able to have those too.  It's all part of a happy daydream.

P.S.  No sooner did I write this (not posted yet, still in draft) but one of my clients said, sharing a regret:  "Every day I wake up  wishing I had finished school."  Funny how that happened, huh.  Wish I could make his dream come true.

The Big Sigh

"Ahh-h-h-h..".

Some people do this when they enter my office and sit down.  They let out a sigh of relief.  It happened today:  My patient said:  "Oh, I just feel so safe in here, as if I am protected from the world.  It's as if I'm inside a bubble.  No one can get to me here."
(and, in fact, I always deadbolt the door, from the inside, after the patient enters, so as to be sure that no one can interrupt us).  There are big windows wrapping around a corner of my office and this particular patient mentioned that too, saying she liked it that she could see out but, since we are on the second floor, no one can see in.
Earlier in the week, another person made that sound after he came in and said:  "I feel like now things will be sorted out.  I can get squared away."
In a recent post, I wrote about a woman who said, following the initial sigh, "I feel like I can say anything here.  I can pour it all out.  Everyone should have this.  It's my sanctuary."

Everyone feels differently about therapy.  People come for different reasons; they have varying expectations; they interpret the experience in their own individual way.  But this sigh at the beginning happens often enough that I have taken note of it.  Apparently for some people, the therapy setting is, amongst other things a respite from a demanding, difficult, sometimes challenging world. 
Therapy can provide many things---a place for confession, a chance to sort out problems with assistance, an opportunity for personal review,  a person from whom to get suggestions, new ideas, a sounding board, a relationship different from all others, a place to think out loud, and more.  But, I am noticing, it can also be this other thing---a sanctum.

Any comments?

The Imperfect Therapist

                                      What can you expect of a therapist?
Good therapists, bad therapists, outright quacks, inspired brilliant therapists, terrible therapists, therapists who have a seemingly endless reservoir of compassion, and, the truly gifted therapist---they're all out there.  I get some of the fall-out in my office from the not-so-good counselors and it is sometimes astonishing to me, the things I hear clients tell me that happened to them with another therapist.  Some of the outrageous things I have heard include, the therapist falling asleep in the session, the therapist reprimanding a patient for nervously wringing her hands in a first session, the therapist asking a question and then getting angry at the patient for their (honest) answer.  And the list goes on and on.  The resilience and determination of these people who got unlucky on their first try but still persisted until they found someone who could actually help, is laudable.
Therapy is a valuable and wonderful resource for us all.  In the post titled, Cute Client Comment, I have a link to a concise article about the benefits of psychotherapy.  But to be effective, it has to be the right match.  No therapist is going to be the best choice for everyone.  But, there are some, who are almost in a calling to the profession,  and those, will be best for most people.

You would think, with all the training* that we are required to get, that we would all be excellent helpers, but, just like doctors---some are better than others.  Part of the effectiveness of the therapist is in the match or, that elusive thing we sometimes call, "chemistry":   How do you feel in that person's presence?  How's the interaction between the two of you?  Do you feel accepted?  Does the therapist seem comfortable in their job, comfortable with you, and in considering the problems you present?  Does the therapist seem to have less anxiety than you do?!
 
As time goes on, you should begin to feel that you are in a real relationship.  A professional helping relationship is, of course, different from your friendships---you want it to be; that's why you're there.  It is mostly one-sided, you will not learn much about the therapist's personal life.  They may share a little, here and there-especially the more relaxed, experienced ones or they may share for a purpose:  There may be something you are struggling with and the therapist herself has a good example from her personal life to illuminate the topic.  Or, sometimes a therapist may share with you that something difficult is going on with them in their own life so that the patient doesn't sense something is wrong and misinterpret it to be about them.  I have done both of these.  But, generally, a therapist is trained to be not too revealing and there is solid scientific reason for that.


If you are currently in therapy, there are a few things you should not hold against your therapist.  The therapist may not always remember every detail of your life.  This is especially true if you don't attend regular weekly sessions.  There's something about that consistent contact that seems to keep the file on you in the forward position in the therapist's mind.  But, think for a minute how much a therapist has to remember...They have to keep the names, relationships, events, and facts of a person's entire life---whatever has been shared in the therapy office---in their immediate memory.  And the therapist has to do this for a number of people.  It isn't easy to remember all about a person you've never met but we must do that as, often, patients want counseling about their relationships with other people in their lives.  Thus the therapist has to remember and retain an impression of, and even facts about, that other person-so important to the patient but, only heard about-by the therapist.  Sometimes my patients will bring me a picture, a snapshot of their family or, a particular person they have issues with.  That helps me to fill out the image in my mind.

A reason that I may miss a detail (and so I imagine other therapists may do this too-I hope they do!), is that facts are not where my focus is.  I am looking for the deeper meaning for the patient or I am working on delineating a pattern in the person's functioning or I may be noticing an incongruency that seems important.  This kind of listening is what is different from what one can expect from a friend.  It is what you come to a therapist for.  So, try not to be impatient if a therapist forgets one little fact.  Try not to say to your therapist:  "I told you that!!"

Also, while it appears that therapists make big money, we don't.  The public sees us getting anywhere from $40. to $200 or more, per session, and multiplies that by 40 hours per week.  Well, with all the paperwork, phone calls, treatment planning, and, yes, sometimes worrying about people, we do clock in 40 hours, and then some.  However, a full-time practice is but 20 sessions per week.  Some practitioners can't tolerate even that much and only see a few patients---6 or 12.   (The last survey by my professional association reported an average fee of $70. per session and this does not subtract rent, phone, insurance, licensing fees, association dues etc., in other words, overhead). This  is why private practice therapists usually don't have secretaries or receptionists.  Sometimes in a building that rents to  therapists only, a receptionist salary can be shared.  But, by and large, therapists do all of your letter writing, filing, insurance claims, report writing, copying , etc. for you, themselves.  The nice part for you is that it all is, really private.  No one else sees anything to do with you but the therapist himself.  If you pay for your own treatment (don't use insurance), it is really exclusive because, in that case, even  insurance company personnel will not see your paperwork.
  So, just don't be annoyed if the therapist asks you to do some part of this yourself or maybe complains a bit about your insurance company (most are difficult and time-consuming to deal with), or isn't as quick as you would like with whatever---writing a letter for you, having your account at the ready, etc.  Each patient has a different payment method, and this the therapist also has to keep track of.  It can be complicated.  Most of us don't like this part as we are clinicians and were not trained to do clerical work (and aren't good at it!).  We want to do the interpersonal work.  So, if you have a therapist you respect and are fond of, help him or her out by keeping it (the business aspect) simple.
Most of us are used to the doctor's office where all paperwork is handled by support staff.  When you have a therapist who agrees to do this for you, they are actually doing you a favor.

Therapists  may sometimes behave in ways that seem really odd.  If you don't fully understand the powerful constraints of confidentiality, you may be taken aback when you accidentally bump into your therapist in a public place and the therapist doesn't run over to you to say "Hi!"  We must wait to see what you do---you may be with someone, you may have any number of circumstances at that time, you may for some reason  not want to reveal that you are acquainted with the therapist; so the therapist will follow your lead.  They try to gracefully await a sign from you as to whether or not you want to be acknowledged.  But, it is awkward sometimes.

The other part of that problem is, what if the therapist is out with someone?  If you were to speak to each other, the polite thing to do is to introduce people.  But, if the therapist introduces you to her companion, she cannot say, "I'd like you to meet Mary Smith, one of my patients."  This would betray confidentiality.  Probably, a friendly nod is really the best bet most of the time.

Therapists are not allowed to have what is referred to as "dual relationships".  It may seem so natural to you to invite your long-standing, beloved therapist to your daughter's wedding.  But, the therapist cannot attend.  The definition and protection of the therapy relationship requires it to be kept separate from the other parts of your life.  We can't go into business with you,we aren't even allowed to do bartering; we cannot exchange our services for yours, we can't ask you for hot stock tips, etc!!!  (You can, however, give us a raise...!)

You can and should expect to be treated with regard and respect by your therapist.  Your therapist should be genuine and straightforward but professional in conduct.  Your therapist should not be expected to be and should not pose as, a 'guru'.  Your therapist should be human and compassionate.
In this unique, not like any other, sort of odd relationship, can you expect your therapist to care for you personally?  Maybe, but, not necessarily:  I have heard some therapists say that they can treat anyone, whether they like the person, or not.  Not me.  I have rarely refused to treat anyone, but if I can't find something in them to feel for, I would.    I look for that loving part or that growth motivated part or some part that I can connect with in a positive way, personally.  But, usually I find it easy to like the people who come my way.  Many therapists will become quite fond of a patient if they see them regularly for a long time.  The close attention that a therapist pays to a patient, the effort to understand what is beneath the surface, the careful listening, the thinking about that person and their issues, all of this leads to feeling affection.  It's normal; therapists are human.  At the same time , the therapist must maintain a professional position in relation to the client so that the client can feel that they can depend on the therapist.  And the therapist always has to remain ready to hear that client decide to say good-bye.

 There's so much to say on the subject of what you can expect from a therapist but this is already a long post.  If it gets a lot of traffic, I'll write more on this topic.  Be sure to let me know if you have any questions about this.  In any case, I hope that, in your therapy experience,  you are happily surprised.  I hope what I've offered here  helps.
If you'd like to read another therapist's offering on this subject, here's a link to one I think is down-to-earth and thorough.  It's also a chance to see the difference in style between she and I.  As I've mentioned, each therapist is so different and thus, you have to find the one who is a match for you. http://www.therapist4me.com/what_makes_a_good_therapist.htm
Here is another one with yet a different tone:  http://www.
wheneverydaymatters.com/?p=96
 
*The training is slightly different for each license but for my license, this is required: 19 years of school (not counting nursery school!), 3000 hours of supervised (unpaid) internship hours, an oral and written exam from the state and 36 hours of continuing education every 2 years.

Please join the discussion and leave a comment.

Addendum:  I said I would write more on this topic if it got a lot of traffic.  Turns out this has become one of the All Time Most Popular Posts and continues to be.  So, I did write more on the topic, as promised.  Here is Part 2:  http://therapiststhoughts.blogspot.com/2012/03/look-before-you-leapthe-imperfect.htm  And, you can look forward to more; there is a Part 3, in draft.

Expressing Yourself

A lighthearted quote with a bit of truth.

"Say what you want and how you feel
because those who mind don't matter and those who matter don't mind."
Dr. Seuss

Offered by a patient who speaks her truth without shame.

Oh! That First Visit

            Starting therapy  
 Today I was in a medical office for an appointment of my own and the nurse, who had previously asked me for a therapist referral, wanted to say how happy she was with the therapist I had sent her to.
As we talked, she said some things about how difficult it was for her, however, at first.  She said how, in the beginning, she felt unsure about the therapist as a person.  She saw therapy as "a commitment", something she wanted, but, would have to fit into an already busy schedule.  There's the cost to consider also.  And then, of course, the patient-to-be is proposing (to themselves) to offer up very personal information to someone who, at the beginning , is a complete stranger.  All of this can lead to some pretty strong reservations.  If the patient is brand new to the process, that is, has never been in therapy before, with anyone, it is even more daunting to be in that situation for the first time.
Some new patients are so uncomfortable, they just don't return.
And, yet, just yesterday, one of my patients (remember the patient in the I've Lost 38 Pounds post?---that patient), spontaneously said in the midst of the session:  "Oh, it just helps so much just to be able to talk about it."  At the end of the visit she stated:  "It is so important to have a place of your own, where you can go and just talk about anything-whatever is troubling you.  It's my own sanctuary."  And as she left, a heartfelt, "Thank you!".  So, if you stick it out (and sometimes it will not turn out to be the right therapist for you; but, if it is),------what a resource!

Note:  Two related posts are titled, A Healing Relationship and Marriage Counseling:
http://therapiststhoughts.blogspot.com/2010/04/healing-relationship.html
http://therapiststhoughts.blogspot.com/2011/03/marriage-counseling.html

Protecting Your Own Highest Good

  Prize your personal treasure

What is it that is central to you?  Essential.  Can you pick a condition or a personal state or an activity in your life that is the most important to you?
One way of zeroing in on what that one most important thing is  to make a short list first.  Then, imagine life without each one.  It's a way of backing in to feeling what you value most highly, if you don't know what it is for you.

This is partly a personal post-because I had been thinking about this for myself.  What is my most precious priority for me?  And, how will I protect it?  Then, as will sometimes serendipitously happen in therapy practices, a patient came in talking about that very subject.

In his case, it was quite sad as he had lost the most precious thing to him---so, here was a case of recognizing what was personally important, after the fact.

Whatever it is, it will be known only to you.  Others who are close to you may be able to make a good guess, but, only you can truly declare what that essential-to-you thing is. 

 It may be your religion, it may be your marriage, it may be your health, it may be your freedom, it may be your family's well-being, it may be your work, your business, an interest you pursue with a passion, maybe it's a person; it could be so many things.  

What is it for you?!

What I am considering myself is, how can each of us, once having identified that thing, sustain and protect it.  It seems that there must be a commitment.

I remember one former patient who had suffered great personal losses in her life.  She once told me that, at a certain point, she decided that she wanted a life that contained as few stressors as possible.  To that end, she had made many choices to create that condition for herself.

Sometimes we may have to give up something else to keep our one thing secure.  We may have to do things pro-actively to nourish it.  Above all, try to not have happen what did to the fellow I first mentioned who, inadvertently, despoiled his own most important thing---by neglect.

He, sadly, did not realize the significance of this thing in his life until it was lost. 

 So, first and foremost, identify it for yourself!

Not a Formula

One view of loss, grief, and recovery.

 This is not a formula, but a suggestion which emerged today from my own personal process.  I thought to share with you and hoped you'd share your own suggestions.
This is about the inevitable---loss.  We're all going to experience it one way or another from small incidents like finding our car in the parking lot with a new dent in it, to the death of a dear friend.
I think that the grief is unavoidable.  We must feel the emotion. And each event and each  person will have their own timing.  However, it seems to me, from experience of my own and observing my patients, that trying to skip the feeling only postpones it.
At the same time, it seems beneficial not to prolong it, if possible.  Feel it and then be done with it.  If we try to avoid the suffering, it will 'come back to bite us'.
I am reminded of a former patient who came in because five years previously he had lost a relationship and dealt with it by immediately 'moving on'.  So, five years later, it had suddenly come up full force and he was in grief.
While we cannot tell another when their sorrow should come to an end, we can give ourselves the best chance of a time-limited mourning if we let ourselves have it (completely-with anger, crying or whatever the feeling is) and then bring it to a close.
I think it is easier to heal and carry on with a productive attitude if you have a good measure of positive things going on in your life.  So, it behooves us to continue to "...make our own happiness", to nurture that which sustains us in our individuality, and to remember to be grateful.
The good stuff will prevent you from staying overlong in your sadness by beckoning to you; you will be attracted to that which brings you joy.

Cute Client Comment

As we were parting toward the end of our session this week, one of my patients made this happy statement:  "After a  therapy session, I feel like I do after I clean out a dresser drawer or de-clutter a cabinet."
I said I thought this was charming and that I would post it on my blog.
She then added, 

"I feel a load is lifted."

Follow the Leader

Two family styles described, including the ideal and distorted version of each with some recommendations.
 The autocratic and the democratic are two distinct family styles.  Therapists think that there should be a hierarchy in a normal family.  In other words, there is the executive sub-system (the parent or parents), a generational boundary, and the below that are the kids or kid.  The parents are in charge.  (There are clear and consistent limits and the consequence to crossing those lines is predictable and unwavering.  So a child knows, 'If I do that, this will happen').  Children have to live within the structure that the parents create.  I like to say that the kids can certainly grumble---they should have that right but, ultimately they benefit from the guidance, the scheduling, and the protection that the adults have to offer.

However there are variations in style to that general recommendation of how to develop a healthy family system.  The autocratic is the family where there is, a thicker line-so to speak- between the adults and the children.  The adults are the rulers and they dictate how things will go.  In some cases, this goes even further and the parents omit the teaching aspect of child-rearing by not explaining why they make a particular decision, not listening to the child's point of view and never apologizing (note:  a mistake recognized with dignity can be effective role-modeling).
Even further down this line are the parents who rule by fear.  They control their children through intimidation.  This last one, by the way, tends to produce sneakiness and lying in kids.  If they are afraid to express themselves directly, they will learn to be manipulative in order to get their way some of the time.

The other common style I will illuminate today is the democratic style family.  In this family, the parents are still in charge; they are reliable  and stable and the children feel safe under their purview.  The difference is in the leadership---there is more fluidity in the taking of the leadership role.  Children are not only listened to, they can express an opinion, an idea, or even a plan for anything that comes up in a family, from where to go for a vacation, to how to organize chores, to even participating in suggestions for consequences for the child when he or she misbehaves.  When this type of family slides too far to the end of the spectrum, the roles permanently reverse and you see what the therapist refers to as "the parentified child".
It's not only okay but, good for children to, occasionally, within appropriate limits, try on the leadership role.  But it must be temporary.  When a child is always needed to care for the parent, and to organize the household life, it leads to problems for that individual as an adult.
Returning to the happier version for now, this is a family in which the kids are given the opportunity to practice--to comfort, to problem solve, to create a new direction.  The parents remain responsible but are able to occasionally enjoy following the childrens' lead.

Most of life doesn't fall so neatly into one category or another.  Often you will see a mix of functioning styles in any one family.  It might be interesting for you to not only take a look at your current nuclear family but also at how your family of origin functioned.  What are the similarities? What has been changed?

Below is a real-life example I asked if I could share on my blog.  I think it speaks to enjoying and savoring the life stage that this family is in at this time:
"...and here's my story......

"Toasting my daughter upon her graduation from college, part 2 after a personal part 1, I alluded to a song by Crosby, Stills and Nash "Teach Your Children Well", and mentioned that the song ends with a twist saying that parents can learn from their children.   I went on to say something that I should learn but have very much admired and admire about my daughter throughout her 22 years is not just pursuing things that she does well (many, if not most things) but her ability to participate in and enjoy things she does not do well. That's a rare quality, and one that makes me so proud, because it's 100% Sara! To Sara!
As an aside I asked my 7 months pregnant niece and her husband to take notice. "
Credit:  Keith Layton

A Two-Way Street

In a discussion with Lauren Mcleod about learning, we were talking about what is required for new learning to take place.  When I said:  "Sometimes it takes repetition." Lauren said:  "Not if you are open to it."  If you are receptive and open in your therapy, not only to what your therapist offers, but, also, to what emerges in you, you will have the best chance of getting the most out of it.  Of course, this requires some degree of trust.  Maybe you need to assure yourself o f your therapist's credentials before you begin, maybe you need answers to some questions you have about the therapist's experience, or maybe, it will just take some time.  But if you are in therapy, it would be to your advantage to pay attention to how open you are in that relationship.

Today in a session I had with one of my patients who is a long-term recovering alcoholic, he quoted an AA saying;  " You can't give it away if you don't have it."  And this is the other side of the coin.  It seems to me to be most important for the person in the therapist's chair to have been and be in their own growth process.  A therapist is not a guru, shouldn't be a know-it-all, nor should they think they  have all the answers.  What you want for your witness, your guide, is a person who is in process, themselves.  The therapist must be learning and developing constantly.  There is a difference---between you and the therapist, between the therapist and your friends or relatives---that difference is, training, watching many others go through problems to reach resolution, and more experience with self-evaluation.  However, it seems to me that the therapist should be engaged in the act of introspection and in their own efforts of personal development just as their patient is.

Psychotherapy is a two-way street:  Both the patient and the therapist must take responsibility for their part in creating the healing relationship.

Do you think of your therapy as a collaboration?

A Healing Relationship

Yesterday a patient was in for her last session.  As we were reviewing the road we had traveled together---the work she had done, the progress she had made, her plans for future growth, I commented on the importance of what we were doing.  In other words, therapy has stages, a beginning, a middle and an ending stage.  We were, by doing this overview and tying up loose ends, moving through the last stage.
These stages will take place in varying time frames, anywhere from a few months to a number of years.  As we talked about that, I told her that many people skip the stage that she had been doing.  They terminate their therapy relationship by leaving a voice mail message.  (this is a disadvantage to both the patient and the therapist).  Her response was that she imagined that most people think of a therapist as simply a service provider who doesn't really care personally about them.  She thought it would be a common assumption for a patient that they are just one of many and don't matter much to the therapist.

I felt stunned when I heard this; it is such a different view from what my experience is.
After thinking about it a bit, I realized that, indeed some therapists do function this way; there is a position of indifference on the part of some. They may have a particular theory they have adopted and each client is run through that system, put through their paces, so to speak.   Other therapists take a teaching position.  Some say they can do therapy with anyone - it makes no difference; they do what they do regardless of who's in front of them.  I once had a therapist say to me:  Therapists sell their time.   These are all cold, detached positions to take, in my view, but the last struck me as burned out and bitter.

Fortunately, this grim picture is not my picture nor is it what I see most of my colleagues doing.  The truth is, I put my heart out to the people who come to see me.  I treat my patients with the highest regard.  I honor the fact that they are sharing their personal triumphs, the painful parts of their lives, their confusion, and sometimes their innermost secrets.  The empathy I feel is real.  The compassion I offer is true.  The respect I show is genuine.  In fact, it's difficult for me to imagine how a therapist could witness these intimate personal expressions that patients offer and not be moved.  Do we have to remain professional in demeanor, ethical in behavior, and, all the while keep our thinking caps on?  Yes, of course.  But, most of us are also human!

Part of the position I take in conducting therapy is that the therapy relationship itself is (or should be), healing.  I am there to learn about and accept this individual before me with all their assets and all their flaws.  I am there to join with that person, to create together, something completely new.  As I have said in earlier posts, I am convinced that each person in this world is unique.  So, while the problems presented in the therapy office have commonalities, the resolution is always different.

Therapy offers good attention.  You can't fake that.

In A Nutshell

"For me this is a special place I have where I can come and say everything and anything---no holds barred and I won't be judged.  I will be listened to and get some good suggestions." Remember the "I lost 38# since I've been seeing you" patient? This was offered up this week as her experience/description of what therapy is to her.  It's a good, short and to the point statement.

I would add a few things. ~ A therapist listens to you in a different way from what usually happens with a friend or relative.  One of the most meaningful of those is that the therapist listens to what may be unsaid, what is beneath the surface.  The therapist does take in your words, the facts of the
matter, of course, but, at the same time, there is this attention to what might be the deeper significance for you.
~Attention is also something most of us are unable to get or give very well in our demanding, busy lives.  A therapist puts their own issues and other distractions to the side and focuses on you for 45 minutes.  Good attention, quality attention is something that happens in therapy.
~Also, a therapist is trying to get to know you.  This goes beyond not judging; it is trying to know the many aspects of a single individual and to understand how they function in that person.
~The therapist takes a position of trying to promote your own tendencies to grow, improve, do your life better, or make more beneficial choices more often.  She is scanning for signs of a wish to change or an idea for a new direction, or a potential insight about the person's past that might be helpful in influencing new behavior.
~The therapist tries to help you clarify your own thinking about whatever the conundrum is that you bring up.

These particular parts of what a therapist does for a patient afford the patient an experience, an experience that is different from what happens anywhere else.

"Stress Reducing Methods"

A very popular post was the one listing the depression management techniques a long-term patient had developed.  So, this is a similar sharing.  This, on "stress reducing methods" from a returning patient (one who did a course of therapy previously, felt resolved, time passed, now she has returned).

  Here's an individual who has had more than her share of stressors to contend with; widowed at a young age, a single-parent, working full-time, son's fiance paralyzed in an accident, has an industrial injury and a number of health problems.  She recently came back to see me after 10 years (tho' she kept in  touch during that time) due to work-related issues and extended family problems.

So, here is her list:
~Mild stretching several times a day.
~At work:  takes breaks, looks out the window, takes short walks down the hall, gets a drink of water, changes work tasks frequently to avoid too much repetition, no heavy lifting and very conscious to stay in an ergonomic position at all times.
~Taking short walks---appreciating nature.
~Spending time with my family and my friends.
~Relaxing with my animals who make me smile.
~Adding beauty to my environment; hung a blooming plant by the front entrance to my house; it makes me smile as I enter my home.
~Making a point of watching the TV shows that I especially enjoy.
~Completing deep breathing exercises, relaxation exercises, visualization techniques, meditation, and prayer.
~Listening to music I like.
~Staying connected to friends & family by phone & e-mail while also remembering to limit home computer use and phone time.
~Meeting friends occasionally for a relaxing lunch or dinner together.
~I tried massage but it didn't work for me.
~I also tried physical therapy and chiropractic treatment, neither of these were good for me.
~I have several close friends who allow me to vent my feelings when I am frustrated or depressed.
~I see a psychotherapist weekly for stress reduction and help with coping.
~I have it in mind to try acupuncture but haven't yet.

So, there you have it.  I changed very little.  Most of that is in her own words.  A valiant effort on her part, don't you think?

Will you adopt her list or perhaps generate one of your own?

More On Happiness

A few notes on  happiness---ideas and how-to's

 Hedonics, the interdisciplinary field of the study of happiness, says, according to Mirka Knaster that it is folly to "..equate personal happiness with material gain."  To find happiness, she writes, we must "..broaden our pursuits beyond the acquisition of wealth and status...".  She offers Richard Layard's advice;  "Enjoy things as they are, without comparing yourself to others, and discover what truly makes you happy.  He encouraged us to tame our rat-race instinct and train ourselves---using, for example, cognitive therapy, education, and Buddhist meditation techniques---to live in a more balanced way, not simply driven by competition for status."

Meditation instructor, James Baraz, offers the following suggestions:
~writing about what the word joy means to you
~doing some form of physical movement, such as yoga, dance, or taking walks

~making a "nourishment list" of activities you enjoy, checking off those you do regularly and circling the ones that could be done more often       
~checking in with your "joy buddy", a kind of running-partner in the pursuit of happiness.
One of the major blocks to happiness is a sense of isolation.

I would add that savoring good things that are already present in your life can contribute to a feeling of satisfaction.  When you get a new carpet, why is it exciting only at first?  Why not still think 2 years later how wonderful it is to have that plush soft carpet under your feet?
How about reviewing your accomplishments?  It doesn't always have to be a new achievement that rings your bell.  You can feel proud and gratified by what you've done in the past.
Tell me, have you found ways to promote happiness in yourself?

Remember our previous client quote:  "We make our own happiness."
http://therapiststhoughts.blogspot.com/2011/04/making-your-own-happiness.html

Wise Words From a Long-term Patient

The woman who talked to me today about how she has learned to manage, what was once a debilitating depression, has been in on-going weekly treatment for a number of years.  Over time, she has come to know herself and, with some trial and error, has learned how to take care of herself  in a way that is effective and also a relief to her family.

Coping with depression:
~When it occurs, I limit myself to 7 days.  If I still feel the same after that time has passed, I will make a life change.  Usually, it has abated by then.
~I don't exacerbate it.  When I feel bad, I don't allow myself to dump more discouraging thoughts upon myself.  So I don't continue to spiral down and feel worse and worse.
~ Continue to function.  ("Fake it 'till you make it")  I fulfill my responsibilities, take care of my child,--- despite feeling somewhat robotlike or, certainly joyless, at times.  Doing this keeps me out in the world, encountering people and new situations, which sometimes helps to change the mood during the 7 days.
~I say to my family what it is that I need at that time.  For example, in that state I am pre-occupied with trying to deal with myself.  So, I don't have much patience nor energy for listening.  I ask them to limit their quests for my attention.
~No externalizing.  For example, when I wake up to find myself depressed, I previously found it convenient to blame men.  However, when I began looking at my history, I realized that I was sometimes visited by depression when I was not even in a relationship with a man.  "I saw that it was not the world shitting on me but how I looked at the world."
~Don't shut out those who care.  I did hurt those close to me before I learned this (when I did do the closing out, that was something else to feel bad about).
~From the movie, Zombieland, I saw that when I learned something I could make a rule and enter it in my journal.  Also, that the rules are not written in stone; they can be amended or changed as needed.

These guidelines came of a long, consistent effort on the part of a person who suffered for years and now is living the majority of her life in a satisfactory state of mind.  When she is visited by depression, she isn't helpless; she has created a personalized program for staying in charge of her life.

Does this woman's story inspire you to try to develop your own self-help list?  What have you come up with?

Comforting

"Practicing loving-kindness toward ourselves seems as good a way as any to start illuminating the darkness of difficult times."  Pema Chodron.

Her book, When Things Fall Apart, heart advice for difficult times, can be a comfort when you feel like you are at the end of your rope.  She writes from her own experience, is plain-speaking and in reality.  There is no fluff.  Some people find that reassuring.
Here are a few of her ideas I have culled from repeated visits to this little book:
*Fear is natural
*Nature is calming
  If you have a backyard, let it draw you out.  In any case, just go outside sometimes.
*Give room to all your feeling-relief, grief, joy-give every feeling at least a moment of attention
  Don't resist all the time.
*Make friends with yourself
  (One of my patients came in just after the new year began and said her resolution was to learn to love herself unconditionally).
*Realize "...that whatever occurs is neither the beginning nor the end. It is just the same kind of normal human experience that's been happening to everyday people from the beginning of time".
*Activate your curiosity
*Slow down
 Notice the wonderful aroma of baking bread, appreciate bicyclists, feel the clean cool air on your face after a rain.
*Try not to harm others
*Understand other people when they are troubled in their lives
*Stop striving for perfection
 "...because sooner or later, we're going to have an experience we can't control..."
*Sort out the difference between opinion and fact
*Make use of your sense of humor
*Remember that life is intrinsically challenging when you find yourself struggling with plans and judgments
*Train yourself to relax when the phone rings
*"For some of us, working closely with a non-judgmental therapist allows us to overcome our fears and finally develop loving-kindness for ourselves."

"Learning how to be kind to ourselves, learning how to respect ourselves, is important.  The reason it's important is that, fundamentally, when we look into our own hearts and begin to discover what is confused and what is brilliant, what is bitter and what is sweet, it isn't just ourselves that we're discovering.  We're discovering the universe."