Waiting Room Therapy I


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“So you go to therapy too huh?”

“Used to. I don’t now, just waiting for my friend.”

“I see. Why did you stop going?”

“I know what my problem is.”

“Do tell.”

“I like change too much.” (pauses) “And I’m too hard on myself.”

“Ah, learned that from the best didn’t you? Who was it, your mom? My dad loved to point out all my mistakes, I could never do anything right, I could never be good enough, no matter how much I tried. He would come to my baseball games and shout from the sidelines what he thought to be encouragement but I was mortified and embarrassed.”

“Ha. I can’t complain about my parents really. They would tell me all the time how proud they were of me and brag to all the family and friends about my accomplishments…I don’t think of those times though when I think back. I think of how one B in 4 years of straight As forever defined me as ALMOST perfect.”

“I wish I was good with change. I’m a creature of habit. I eat the same breakfast everyday, eat lunch and dinner at the same time everyday and I always have a salad with my meals. And a glass of milk before bed. I always wake up at the same time every morning, I like to watch traffic and weather. Be prepared, you know…My mother had Bipolar. She would do crazy things like wake us kids up at the crack of dawn, pack us up in her Impala like sardines and take a road trip to Atlantic City for no reason at all. Or I would come home and she’d be painting my room a bright turquoise. They fought a lot, my parents. You never knew what you were walking into.”

“When I was about 15 my parents were both abroad and my grandmother and brother were in charge. It was summer. I did not leave my house for a month and a half, didn’t talk much to anyone most days. I read a lot. And listened to music. A lot. I ate, slept, sat, stared out the window, you know the normal teenage stuff. For a month and a half in the summer I did not leave the house. And now, the house eats at me. I don’t like to be home. I hate routines too. And silence. I particularly hate silence.”

“That doesn’t really explain why you like change though.”

“Maybe I don’t really like change. Maybe I dislike sitting still.”

“I started drinking heavily after my wife left me. And it dawned on me, it was probably because the house was too quiet. But you see, me drinking wasn’t the problem. My drink was my companion. I could always rely on it. Problem was, I didn’t want to face things changing around me, didn’t want to adapt to losing my job after 15 years, admit to failing my marriage or watch my parents get old and sick. Drinking was the only steady thing. The only thing I could control. Even when everything was falling apart I could drink to perfection. How about that?”

“I hate feeling powerless. It makes me driven to change. Change gives me a goal, something to look forward to. But sometimes it messes with things that aren’t broken, ya know? I have a dilemma as a matter of fact. A puzzle. A problem without a solution. And I have absolutely no idea what to do about it. I mean, I can make the change. That’s easy, I know how to do that. Yet I’m paralyzed. What if this one doesn’t need fixing? What if this a puzzle that will reveal itself slowly, on it’s own time? Will my immobility cost me dearly?”

“There’s gotta be something in between, right? Change when you have to, sit the rest of it out. But then how do you know you’re just being lazy, coming up with excuses?”

“It’s knowing how to tell the difference that is particularly challenging.”

“So what will you do?”

(after a long pause) “I think I’ll sit this one out.”

…to be continued

 

 

 


On Personal Failure and Self-Affirmation.


It’s September and the Red Sox are losing as usual for this time of year.  Did you know that in major league baseball, a hitter could have a long and productive career by maintaining a .300 average—that is, by getting a base hit 30% of the time? A great deal of money could be earned and fame accrued. Yet the other 70% of the time, this player would have failed. I wonder what 30% success rate does to your Ego.

In the past month I have had two couples not return to therapy after their first session. Two. Granted, one I think it’s simply a scheduling issue. Truthfully, I know it’s my fault for possibly having challenged them too early. I actually have no doubt about it. Therapy is not a precise science. There are no absolute measures for success but there are some. And one of them requires that the client physically returns to see you.

Before I get all caught up in telling you how unhappy I am about this turn of events, let me focus on the subject matter at hand.

Self-Affirmation.

Like major league baseball players, people face failures and self-threats. These include substandard performance on the job or in class, frustrated goals or aspirations, information challenging the validity of long-held beliefs, illness,  scientific evidence suggesting that one is engaging in risky health behavior, negative feedback, rejection in  relationships and so on. In order to face these challenges we develop what is called a psychological immune system which initiates protective adaptations when an actual or impending threat is perceived (Gilbert, 1998). Psychological adaptations to threats include the various cognitive strategies and even distortions whereby people come to construe a situation in a manner that renders it less threatening to personal worth and well-being.

For example, in my case,  I would have told myself that my clients were not ready to change and them dropping out had more to do with their lack of motivation or (even worse) resistance. This is precisely what we call being defensive.

Self-affirmation theory (Steele, 1988; Aronson et al., 1999; Sherman & Cohen,2002) begins with the premise that people are motivated to maintain the integrity of the self. Integrity can be defined as the sense that, on the whole, one is a good and appropriate person. Here are the four basic tenets of self-affirmation theory:

1. People are motivated to protect the perceived integrity and worth of the self. The purpose of self-esteem is to  “maintain a phenomenal experience of the self … as adaptively and morally adequate, that is, competent, good, coherent, unitary, stable, capable of free choice, capable of controlling important outcomes…” (Steele 1988).

2. Motivations to protect self-integrity can result in defensive responses. When self-integrity is threatened, people are motivated to repair it, and this motivation can lead to defensive responses.

3. The self-system is flexible. People often compensate for failures in one aspect of their lives by emphasizing successes in other domains.

4. People can be affirmed by engaging in activities that remind them of “who they are” (and doing so reduces the implications for self-integrity of threatening events). Bummer for whomever is encouraging you to change. They will be out of luck.

Why is this helpful to you?

A great deal of research has used self-affirmation theory to address a wide range of social psychological phenomena, including biased information processing, causal attributions, cognitive dissonance, prejudice and stereotyping, stress and rumination.

People often interpret new information in a way that reinforces their beliefs and desires. In other words, people believe what they want to believe.

To take it one step further…

Defensive processing of new information can be particularly costly when it leads people to reject important health information. Think about that next time your doctor talks about you smoking, drinking too much or eating fat, salt and sugar…and not exercising.

Interestingly, high self-esteem individuals have greater affirmational resources, and are thus more resilient to threatening events than low self-esteem individuals as well as less likely to rationalize a choice they have made.

So next time someone challenges you (even if it is too early) think about why that’s bothering you. Is it because it goes against what you believe or what you want to believe about yourself? Or is it because it’s really untrue and unfair? And most importantly how do you know the difference?

How do you process personal failure? How do you self-affirm?

As for my failures, don’t fret my friends. Through meditation, self-awareness and humility, my big, defensive Ego has shriveled up to the size of a mango…OK I know I still have work to do.

So I leave you with some tea Tao wisdom.

“You are infinite.”

~ Yogi Tea


Sober is Depressing


The other day a client asked me if being sober means being happy. This is a tough question. I don’t have a drug problem but does that mean I’m happy? Of course not. Some days I’m elated and some days I am grumpy and unpleasant to be around. These are just feelings, they come and go. But if you asked me if I’m generally happy with my life I would say “very much so”. Sometimes before you give up a drink or drug you want to know that you are doing it for something better. Unfortunately for some people that “better” life doesn’t come. A lot of people resent recovery but recovery alone doesn’t make you happy. It’s like “welcome to the misery called life but now you have to do it all sober”. But is sober life really that miserable? If you were completely happy using drugs or drinking would you even consider getting sober? I believe what makes recovery boring and depressing is a combination of unrealistic expectations and fear of what a sober tomorrow will bring.
If you haven’t read Stumbling on Happiness by Daniel Gilbert, I highly recommend it. Gilbert’s fundamental principle is that we are the only ape who looked forward. Our brains are constantly “nexting” and imagining the future. We spend 20% of our day imagining tomorrow. This is not anything new. What’s interesting is that we are mostly wrong about what the future will bring and/or about how we are going to feel about it when it does happen, hence setting ourselves up for disappointment and unhappiness. Basically, our unique ability to imagine the future is the very thing that sets us up for unhappiness. How? For one, our imagination is subjective. Not only are we overly optimistic about our future, we overestimate how much we are going to LIKE our futures. This is very true for relationships. How many times have you heard your girlfriends say “he was not what I imagined him to be!”? Well, he is who he his, the only thing fooling you is your own imagination about who he would be with you and how you would feel about it. I hear my clients say “recovery is not what I expected it to be”. If your addiction is creating problems in your life choosing recovery is not going to automatically make all problems disappear. You still have to deal with the daily responsibilities and struggles that everyone else faces like work, bills, childcare, taxes, illness, parenting, relationships, loneliness and just general human suffering.
The reason we’re so oblivious to how faulty our future predictions are, is the fact that we mistake our imagination for reality. Imagining tomorrow happens almost automatically. Our frontal lobe is programmed to imagine and think about the future just like our heart is programmed to pump blood. That’s why meditation is so difficult because it forces our frontal lobe to be in the present and STOP thinking about the future (I thought there was something wrong with me!). Also another reason why our imagination is faulty is that it is based on the present. If you go grocery shopping when you’re hungry, you will most likely largely overestimate how much you need to buy. This is the reason why it’s hard for people to reinvent themselves and imagine doing anything that is not based on what they do now or what they have done in the past. This is why dreaming big is usually out of our realm of dreaming.
So how to make recovery fun?
First, check your expectations at the door.You are not entitled to an “easier” life just because you are choosing a healthier path. In fact, you are not entitled at all. No one is. Our belief that good things happen when we make healthy choices is faulty too. Sometimes terrible things happen to people who have flown “straight” all their lives and have done everything “right”. Sometimes “bad” people get away with murder. The sooner you accept that life is not supposed to be fair the sooner you’ll be on your way to finding happiness.
Secondly, stop comparing recovery to your memory of being high. Notice I said memory. Here’s the tricky part. We tend to remember the pleasant parts about our addiction and forget the unpleasant parts that made us want to quit in the first place. Pain is easier to forget. Unless you prompt your brain to remember. Also our memory is very unreliable. It remembers your addiction being fun but was it really? Question your own memory and you’ll get to the truth.
Thirdly, having fun sometimes is learned. Initially, the lack of drugs or alcohol will make you depressed no matter how awesome your life is. This is simply brain chemistry. You have to give your brain some precious TIME to break old pathways and create new ones. For instance, if you have been using opiates you have significantly effected your brains ability to produce natural opiates (endorphins) which kill pain and make us happy. You have to learn to be patient with your brain. It’ll come around. Time is crucial.
Most importantly, don’t use your unhappiness or boredom as an excuse to go back to drugs. But if you do, it doesn’t make you a failure or a “chronic relapser” (I disagree with my profession’s tendency to label people). It simply means you’re not ready to let go and that’s important to talk about too.

How to Make Real Change and Transform Your Life


What do people want? Mostly to be happy. And proud, accomplished, popular, the list goes on. Some people just want to change. Yesterday I talked about resisting change. But what if you weren’t resistant at all? What if you really wanted to change but didn’t know how? What if you want to change so badly but it’s so darn hard and you have no clue where to begin? You have been contemplating change for a long time, maybe years have gone by and you still have this nagging feeling that you should be doing something different with your life or simply conquer a fear?

If you have been reading my blog you know by now that I like to talk about myself. It’s not an egocentric thing. I want everyone to know that being a therapist doesn’t exempt me from human suffering and struggles. May is the one year anniversary of one of the biggest changes I have made in my life in 32 years. And I like honoring anniversaries. This one is HUGE. I was so overcome with fear about making this change that I became paralyzed for years. I had put it off, made excuses about not changing, contemplated it but never thought I could do it, settled for the idea of never trying and even told myself and everybody else a pretty good story titled “I don’t drive”. Yes, you read it right. The change I had been wanting to make but wasn’t able to was to learn how to drive. Before you judge this as an insignificant matter, think of something that has been hard for you to accomplish. Further more try to imagine this. Imagine the fear, challenge and amount of adaptation it would take to move to a foreign country 6000 miles away from everyone and everything you know. Are you imagining? Are you there? Good. Now, multiply it by 100. That was the amount of fear and challenge learning how to drive represented for me. It’s been a year today since I got my driver’s license and I can say the story has changed significantly. The story now goes “I am a new driver”.

Before you go off reminiscing about old times when you learned how to drive, stop! This post isn’t about driving. It’s about how to conquer your fears and make significant changes in your life. My driving is just a story. And I like telling stories. So forgive me if I use it to illustrate the points I’m about to make. This post is about change. Real change. Change that transforms you in such a powerful way, that it sends waves to everyone around you. Change that redefines who you are, what you do, how you do things and what you are capable of. Change you have putting off for a while. There is no better time to change than now.

Giving up

Believe it or not you have to start with giving up. Whenever you make a change you have to give up something old to make room for something new. This is how the universe works (I believe), constantly seeking balance and equilibrium. If you want to stop drinking or drugging you have to give up something you love or something that has been your friend for a long time. If you want to leave your partner, you have to give them up knowing you may lose them for life. If you want to change your job you have to give up on the feeling of safety and security and on the belief that dreaming big is foolish. If you want to learn how to drive at 31 you have to give up the false security that taking the bus will protect you from human’s common fate: dying. Give up. Whatever it is you’ve been holding on to isn’t working. It’s time to try something new.

Fear of failing

Do you remember failing when you were a kid? What was the reaction of the adults around you? How did your parents respond? How did you feel and what lessons did you learn? If you are like most people, you learned failing isn’t fun. Making mistakes means there is something wrong with us. So we try very hard to avoid failure. And sometimes this leads us to success. But sometimes this leads us to avoid trying anything new. So let me ask you this? Are you not failing already? I had to take 2 buses to get to work. A normally 20 min commute would take me an hour and a half, each way everyday. I did this for 3 years. And every day for 3 years, even in the face of justification and rationalization (“I’m doing something good for the environment”, “I like the bus, I can read” etc etc) there wasn’t a day I didn’t feel like a loser.

Stubborn habits

We are creatures of habit. We are slaves to habits and rituals. They provide us with a sense of structure, safety, security, control and predictability. We love our habits. They make us who we are. Until they get in the way of who REALLY are. When people asked me how did I do it, taking the bus everyday, I would say “I’m used to it”. Do we even know we’re doing something simply out of habit? Where did we pick up the habit? Why did it stick with us? We are amazing learning machines. Repetition is powerful for human learning. Do something often enough and it will become second nature. But is it really natural? And if you learned it somewhere, shouldn’t you be able to unlearn it? The answer is yes. If we put as much effort into unlearning a habit as we do into stubbornly repeating it, change happens. If you chase recovery with the same passion that you chase drugs, healing happens.

We need the right tools.

During tax season there was this H&R Block commercial where they were trying to demolish a brick building using a giant stuffed bunny. And a bystander says “That’s not gonna work”. Very funny. Brilliant too. You can not succeed in change using the wrong tools. In the mental health and addiction field we have a saying “The definition of insanity is doing the same thing over and over again expecting different results.” If you want different results you have to employ a different strategy using different tools.

Befriend the change you want to make.

I know it’s scary. I know it’s hard. I know there are obstacles. One way to soothe your fears about something unknown is to familiarize yourself with it. They say you can’t learn to swim unless you go in the water. It turns out you can’t learn to drive from the passenger’s seat. I took 2 driver’s ed classes. The first teacher was OK but she didn’t challenge me. She catered to my fear by rarely taking me into high traffic areas. The second instructor tricked me into getting on the highway the second day. I freaked out completely. I thought I was going to have a panic attack. But he was very calm and confident. And against all odds, I survived. Nothing happened. Actually, something did happen. I became my fear’s friend. Wanting to get to know it better. My instructor taught me the laws of the road, helped me break things down so I could understand them better. When thing makes sense they are not so scary anymore.

The power of mental imagery

This is a little embarrassing but for the first 3 months after I started driving I would lay in bed and imagine my route to work the next morning. Granted a lot of this was fueled by worry and fear and some sort of obsessive thinking so I would caution you not to do this without some professional help. This is what a phobia expert would teach you in therapy. But I think imagining yourself changed, picturing the change, how it looks, how it feels, how it makes you feel, may actually be helpful. And the cool thing is it stays in your brain. No one ever has to know (unless of course you blog about it). Your brain is powerful. Use it.

Going from “I can’t” to “I can”

Our brain is powerful. But it is also a trickster. It is constantly thinking. And some of it’s thoughts are irrational. You can change these thoughts. A professional counselor using Cognitive Behavioral Therapy can do this with you. If you want to try this on your own, do it to others first. Notice an irrational thought they have and challenge it. Then try doing it with your own thoughts. Thoughts are not facts. Take them with a grain of salt. You may think you can’t change, but that’s just a thought. It’s not a fact. Going from “can’t” to “can” needs to start in your head.

I apologize for the length of this post and I hope you’re still with me because I’m about to take it one step deeper. Stay with me!

Rewriting your story

Ultimately, change is about rewriting your story. Eric Berne didn’t say much about addiction but one thing he did say stayed with me. He said “Alcoholics need permission from their mothers to stop drinking.” How fascinating! I have found this to be true in my work, especially the need for permission part. The way I see it, everyone needs permission to be successful. Often from their parents but mostly, as adults, we need to give ourselves permission to succeed. Can we give ourselves permission to change the way the story goes? Can we rewrite the way the story ends? I gave myself permission to rewrite my story. My story was “I don’t drive. I can’t drive. I’m too scared to get in an accident and survive but be crippled for the rest of my life. I’m too scared to screw up”. I won’t get into where I learned that. But I will say I had to break it down and challenge it and rewrite it. So now my story goes like this: “I’m a new driver. I’m cautious when I’m on the road but I can drive. I have made silly mistakes since I started but I chose to see the humor in them. Driving has changed my career, my relationships and my beliefs about what I can accomplish.” Next year this story may be slightly different. Because change is a process not an event.

What will your new story say?


The Story of Pain


Somehow everything in the past 24 hours has been about pain. As a runner, I have the honor and privilege of experiencing a myriad of physical aliments associated with running on pavement (with the wrong shoes); first bursitis in my hip and now shin splints. Last night, I couldn’t run. My shins hurt so bad they felt like they were on fire. My feet were abnormally swollen, I felt fatigued and run down. And I thought to myself “this is not fun”. So yes, I know I should get better shoes, ice my shins, stretch properly, run less, rest more and watch my sodium intake. But all I kept thinking though was “God I’m turning into my father”. Both my parents suffer from rheumatoid arthritis. I grew up listening to their pain stories. And pain is a sophisticated story teller, more so than any other physical ailment. I started thinking about how my mother’s arthritis flare up put her in a rehab at 19 for 25 days, being pumped with every steroid imaginable and feeling like a water balloon ready to pop. And all of a sudden, my shins started to hurt more, and my heart started to pound and a puddle of embarrassing tears formed silently in my eyes. God, what a bummer!

This morning at the doctor’s office I rated my pain as a 10 from 1 to 10. But then I started thinking, was it really that bad? See, the problem with pain is, it’s very subjective. With all the science advances, we have not been able to come up with a pain “meter”. We rely on the patient’s subjective account of how much it hurts. And I guarantee you, that rating feels correct. My pain felt like a 10. But what makes my experience different from any other runner who has experienced shin splints, is my parent’s story and my fear of having the same painful fate. Fear. Fear is a powerful thing. Fear can propel your pain scale to the sky. Perception of that pain can too. Our minds are powerful; they can fuel our physical pain like oxygen does fire, keeping it alive and roaring. When you are in physical pain, you are in emotional pain too.

This morning I was listening to the Diane Rehm show on NPR as I’m driving to work. It’s on prescription drug abuse, with a focus on the Oxycontin epidemic. Professionally, this is right up my ally. You can listen to it here. As usual Diane has invited an impressive panel of pain doctors, substance abuse experts and a sheriff. The debate is very interesting, informative and important. Then a heroin addict in recovery calls and makes the most important point in the whole show. He’s talking about emotional pain.

Sure, we can do research and come up with telling statistics, sure we can blame Purdue and sue them for producing such an “evil” drug, sure we can talk about prevention, education and ways to decrease abuse and diversion while still helping people who are suffering from chronic pain and NEED these “evil” drugs. But are we talking enough about emotional pain?

In my years of experience working with people addicted to opiates, emotional pain is the one, single, most important aspect of their addiction and recovery. This is simply an observation, but emotional pain is the determining factor in whether or not that temporary prescription your dentist gave you for Hydrocodone is going to be just a pill or is going to turn into your love, you lifeline and ultimately your worst nightmare.

We are a pill popping society. There is no doubt about it. The pharmaceutical companies and pill pushing doctors have perpetuated this “fast food” like culture of making your problems disappear. No one wants to talk about the underlying emotional pain. No. That’s a painful, grueling, long process. We can’t bare feeling exposed, powerless, weak, sad, lonely, fearful. We can’t sit with ourselves. Even when we think we have religion, many times we have lost our spirituality.

Many of my clients would initially talk about how their doctor didn’t warn them enough about the risks of becoming addicted and how a seemingly innocent prescription turned into something they needed to function every day. Even when they didn’t have any of the risk factors to becoming addicted such as biological/family predisposition or prior history of alcoholism or abusing illegal drugs, they became addicted. After a year or so in therapy their real stories start to come out. About how the pills did more than just kill back pain, how they liked the way it made them feel and how that was an escape from their reality. And then, slowly they start to open up about their emotional pain, which is the hardest to talk about. Somehow, physical pain is acceptable but God forbid our heart hurts and our brain feels like it’s going to explode. Somehow we are weak for experiencing that kind of pain. Somehow we should be tougher, stronger, saner. But we are not.

The scary part about this is that we are teaching this to our teenagers who are the most at risk  of developing an addiction to pain pills. Yes these pills are more available to them. Yes, people believe they are safer because they are legal and a doctor is prescribing them. Yes, they find these pills in your medicine cabinet. But what else is happening in our families that we are not talking about? Why are we so afraid to expose our demons? Why are we stubborn when it comes to change? What is the larger responsibility that our schools, communities, cultural, political and economical climates have on this epidemic?

And most importantly, why aren’t we in therapy more?


More on Emotion Regulation


As I mentioned previously, emotion regulation is a skill. To learn it you may need the help of a therapist. Once you learn this stuff, you will be able to be your own therapist, so to speak. Therapy would typically focus on:

  1. Self-monitoring: keeping daily diary cards of emotions and what event or thought provoked them as well as recording the impulse to react to that emotion with a particular behavior. There is no changing to be done here. You’d simply write things down as you notice them, without judging them. All that is required is acceptance and pen and paper.
  2. Skill training: focusing on breaking the event =>emotion =>reaction vicious cycle. Part of inability to regulate emotions lies in automatically reacting to them with a maladaptive behavior. For instance, for people who drink, an argument with the boss=anger=drinking. This happens without thinking. The goal here would be to break this chain.
  3. Exposure: this means to feel what you feel when you feel it. Soak it all up and sit with it without reacting. Yes, negative emotions are not pleasant but they are not the enemy here. The problem lies in low tolerance to negative emotions which leads to avoiding them by using other unhealthy distractions. Emotions do not last forever, they are just temporary states and riding them out helps you realize nothing extraordinary happened: you’re in one piece and the world is too.
  4. Behavioral activation: this means making actual changes. Trying new behaviors to replace the old ones. Argument with the boss may still equal anger but your reaction to it is no longer drinking. You want to think of a new behavior that is easy and somewhat pleasant to you. Because this is individual to you, it’s hard to come up with a magic formula.
  5. Cognitive restructuring: this entails breaking down irrational thoughts and challenging them with facts as if you and they were in an actual debate. Remember thoughts are not truth, they change as we change. Thoughts are not facts. And some thoughts are more rational than others. If you can change your thinking, you can change the way you feel and then there is nothing stopping you.

Here also some tips with Exposure (as this is very hard usually). The key to having a successful exposure is to master Core Mindfulness which entails several components:

1-Observe (sit in a quiet room with no distractions and as you settle into your breathing just notice what feelings and thought are coming up for you without reacting)

2-Describe (words are powerful, name your feelings, know the difference between angry and resentful, develop an emotional vocabulary)

3-Participate (this refers to developing a “wise mind” – the wise you, the observant you, the you who knows better, the you who occasionally talks to himself)

4-Be non-judgmental (observe and accept your feelings and thoughts without judging them, no negative self-talk, stop the parent in your brain telling you how bad you’ve been)

5-Be one-mindful (be in the present, your mind will try to propel you forward or keep you in the past, but the future doesn’t exist and the past is already gone, all you have is right now)