Category: Therapy

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Think like A Therapist

  • “How do you do it?” i.e. “How do therapists spend all day listening to the emotional duress of others?”. Our training includes tools and perspectives that enable us to listen with a buffer. Read more if you too want to learn more about not taking other’s struggles home with you.
  • One (but not the only) reason folks often struggle to tolerate painful emotions is because it triggers a “fix-it mode” in us that leaves us wanting to take action in a way that makes the situation better. The trouble is, we can’t “fix” all situations in life and emotions are not light switches that can be turned on and off.
  • So, we need perspective one: You cannot stop someone (yourself included) from feeling their feelings. Take that pressure off of yourself and the situation. We can distract or ground at times of emotional intensity, but big picture what alleviates negative feelings is learning how to tolerate, work through, release, and ride them out.
  • Learning how to have a sustainable relationship with our emotions can take time (and therapy), though we can channel our desires to “fix-it” into efforts to connect, which can help someone struggling feel better even if a problem remains. This means offering the person in duress (you included) genuine empathy, compassion, validation, and support.
  • To offer that softness we need perspective two: Trust that the emotions are valid, even if we don’t fully understand them. Fighting or denying negative emotions often interferes with the process of releasing them in ourselves, and spurs disconnection and the experience invalidation (which creates a whole other host of problems) in others.
  • Big picture: release the idea that negative feelings are “bad”, “avoidable”, “problematic” etc. For us to be happy and satisfied we need to accept that negative feelings are a part of life, and it is our job to learn to sustainably live with both our negative and positive feelings.
  • Holding these perspectives when we (or others) are struggling means our “job” becomes less about “doing” (i.e. fixing or problem solving) and more about “being” (i.e. trusting, connecting and listening). This takes pressure off the situation and often makes listening and tolerating easier and less stressful for all parties.
  • Therapists are also comforted by their trust in the therapeutic process and see pain (and safely working through it) as a necessary part of the journey to a happier and more fulfilled life. This helps anchor us in those difficult moments; we know your pain and working through it is a necessary step along the way to feeling better.
  • If you too can try and develop that trust that you (or others) will make it though, you might find you feel safer, less frantic, and more comforted at difficult times. You may need to actively remind yourself or others that you can and will feel better some day – and that you have felt better in the past, even when it felt inaccessible at the time.
  • Lastly, we therapists know that the more we work through pain points in our lives, the less other people’s pain points trigger us. This is called widening our window of tolerance, and it means we can, over time (and often with therapy) learn how to be with intense feelings in a manner that doesn’t overwhelm us.

I get asked all the time, “How do you do it? How do you sit with people’s emotional pain as your job?” “Doesn’t it exhaust you, doesn’t it burn you out?”. Today, I am attempting to answer that question, and share some of the tools us therapists use to manage our work of sitting with painful topics. While this isn’t training on how to be a therapist, if you can adopt the perspectives in this post you may find yourself more at peace with your negative feelings, and more able to stay present, supportive, and connected to others when they are struggling.

When our relationship with our emotions is working well, emotions come and go. When we struggle with our emotions it’s usually because we have some hangup in the process of finding, feeling, accepting, and releasing our emotions. Big picture, our job, as your therapist, is to help you learn how to process through your thoughts and feelings so you can eventually do that work outside of therapy (without us). For that reason, us therapists are often looking for opportunities to accompany you alongside your painful emotions so you can experience, with support, your emotions in a manner that helps you productively work through them, learn from them, and make use of them.

For this reason, your therapist is not afraid of your emotions or the intense feelings and reactions you have to your life. In fact, it’s the opposite; your therapist is actually actively looking for those “pain points” and is working to help you process through (rather than avoid them or linger over them). It’s ok to need help in this process, that’s why we therapists exist. Not everyone has the intuition, models (or both) for how to have a constructive relationship with our feelings.

If you struggle with others painful emotions, try and be curious with yourself about what may be happening, and explore whether or not you truly buy into the perspectives in this post. More often than not, our struggles tolerating others pain comes from our own difficulties with accepting that negative emotions, and learning to be at peace with their existence, is a necessary fact of life.

Comments:

  1. Today’s topic is complicated. While we aren’t “therapists” for our friends and family members, to have close relationships we do need to be able to hear people’s struggles in a manner that is sustainable for us, and that doesn’t put the burden of their problem on us. At times, in relationships, folks look to others to solve their problems for them or to take accountability they themselves don’t take. This helplessness can be a problem, quite separate from any discomfort we may hold listening to the struggle of another person. Today’s post is simply meant to help offer a handful of perspectives that might help you be more at ease when someone is sharing their struggles with you.
  2. There are other ways us therapists manage the emotional intensity of our work too (things like only seeing a certain number of clients a day, or a week, etc). When we struggle, we often seek out consultation to make sure we’re offering what our clients need from us. There are many other ways we take care of ourselves in our job. Don’t expect that holding these perspectives is all that a person would need to tolerate an emotionally difficult topic, just know that holding these perspectives helps.
  3. Remember to trust your intuition, if you are listening to someone and really feeling like they are struggling too much, or are in a major crisis – this is a time to reach out to professionals for help. We therapists don’t exclusively rely on “trust in the process”, we also call in for extra help and supports (like medications, hospitalizations, outside consultation for us to get a second opinion on our work with a client) when needed.
  4. In your own therapy (if you’re in it) be curious about temptations you have to withhold from your therapist due to concerns with “burdening” your therapist with too much. One of the points of the therapeutic relationship is to have a safe place where you feel unrestricted in your ability to share whatever pain or hardship you are enduring. If you find yourself withholding, talk to your therapist about your fears that what you’re experiencing may be “too much”. There is probably a lot of fertile ground and opportunities for healing for you to explore what “too much” is, how you know if you’re “too much” and how you perceive in others cues that you’re “too much” for them. For more on this, I have a whole post on the things we don’t say in therapy, and how that effects from treatment .
  5. I talk about the importance of going through stages of processing with your emotions. For more about how emotions “work” when they are “working well” see my posts explaining emotions and their brevity.
  6. Unclear what I mean when I say we need to learn from our feelings? See post about how emotions are like traffic signals.
  7. I mention the window of tolerance in this post, a foundational framework for understanding what a constructive relationship with our inner wold looks like.
  8. Brene Brown has a great little video on the power of connecting through empathy, and how we can help alleviate emotional struggles by being empathic with one another. In addition, if find you have a difficult time accepting the pain of others I have another post that may help you dig deeper into what’s happening as you try and tolerate another’s trauma.
  9. I talk about the connecting nature of offering validation in this post. I have another post on why validation is important.
  10. I mention that sometimes emotions are too intense to be present with, and we need tools like grounding and distraction. There are a host of distress tolerance skills that can help at times of emotions intensity. More to come in future posts.
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Insight and Reflection

  • Usually people start therapy (or struggle) because there is some ongoing dynamic they can’t solve or change. Things like: “I can’t find a partner”, “I don’t have great relationships with my friends”, “I’m angry all the time” etc.
  • The journey then begins to try and uncover the mystery of what may be happening. The starting block of this understanding is reflecting – i.e. getting in touch with thoughts and feelings (and perhaps putting some patterns together that can help you better understand what has happened and why).
  • But for many, developing insight, which is awareness into how our way of being effects those around us (and subsequently our relationships), is desperately needed to inform a sense of direction, yet is inaccessible to discover (or accept) – perhaps because it requires a level of vulnerability from us.
  • To develop insight there needs to be a willingness to see ourselves outside of our rationalizations, explanations, and justifications for why we behave the way we do. It requires a willingness to see parts of yourself you like and don’t like and to examine how those parts of you effect others and your relationships. 
  • Very often, a reflective stance (where we get in touch with thoughts and feelings) is confused with an insightful stance (where we understand our impact on others). Having the capacity to reflect can lead to insight, but we can spend a lot of time reflecting and still not seeing how we are participating in creating outcomes in our lives.
  • An example: Imagine it’s hard for me to open up because I fear rejection. When I am reflective I’m aware of my fear of rejection and being hurt. I might explore the current impact of prior experiences of rejection. When I’m insightful I’m aware my guarded nature creates a wall between me and others making it difficult for others to get close to me.
  • When we can see how we effect others, we can start to see how we may inadvertently get in our own way. We can use the knowledge we gain from our newfound insight into our impact on others to help us experiment with making changes that will enable us to relate to those around us in ways that are more likely to lead to the outcomes we want.
  • In our example, I might need to take a leap of faith and work towards being more vulnerable with others in spite of my fears. This path might not otherwise cross my mind given my fears of rejection if not for my insight that the ways in which I withhold from others creates a barrier to having the close relationships I want. 
  • We can “hold on” (internally) to our insight about what changes are needed as a guiding path at those times when we realize there is a disconnect between what we want in our relationships with others and how we participate in them. That insight can anchor us to help us muster up the bravery to try something new.
  • More in today’s post about how to build insight and the differences (and links between) reflection and insight.

People come to therapy with a lot of beliefs and assumptions about “what it’s supposed to be like”.  For many people that includes some version of getting in touch with and processing their thoughts and feelings, revisiting and processing formative moments in their lives, and making connections about what’s happening now and what has happened in the past.


All of these are excellent uses of therapy and can be the building blocks of developing insight. Folks can get stuck, however, in therapy (and in life) when they struggle to more directly work towards taking that next step, which is building insight and awareness into how they effect others, the environment around them, and how they participate in the outcomes they have experienced in their lives.


When we are busy justifying, defending, or rationalizing we often too wrapped up in ourselves to notice how we may be effecting others and the outcomes we experience. To be insightful we need look at the facts of how we treat others from a perspective that isn’t informed by all the awareness we hold about how or why we are justified in doing or saying what we do or say. Empathy can be a component of self-awareness: imagine yourself in the shoes of the other party and think about how you might react toward you if you were on the receiving end of your own words or actions (without the internal information you hold that informs your decisions to treat others or behave the way you do).


To try and build more insight get invested in the idea that you are likely effecting and contributing to the outcomes in your life, even if you don’t want that to be the case. Ask yourself, “how have I participated in this?” What might I be communicating with my action / inaction, tone, body language, or responsiveness?”.  Pay attention to dynamics like reciprocity. Ask yourself how much trust or suspicion informs your stance in a relationship. Although others can’t read our minds, they can pick up on cues from us that inform the dynamic between us.


Reflection and self-awareness are different from one another, but both important in understanding yourself, making changes in your life, and improving your relationships.

Comments:

  1. Insight and self-awareness are used interchangeably in this post, and some would call “insight” holding an awareness of your thoughts and feelings. I’m using the term reflection to refer to having awareness of your inner world, and insight to have the awareness of your impact on others as a way to highlight the different nature of these two components of emotional and relational awareness.
  2. What I hope we can avoid here is too much confusion around semantics. I’m less concerned that you pin point when you are reflecting versus demonstrating insight, and am more interested in having you be invested in both, seeing the value in both, and recognizing an opportunity to incorporate both into your life (and – if applicable – your therapy). I’m also not communicating that reflecting is “inferior” to insight. Reflecting is important because it helps us find patterns, make connections, and get in touch with our inner world; it’s valuable in and of itself. 
  3. One thing that’s a bit tricky about building insight is we aren’t often told (directly) by others how we are impacting them or the community around us – people don’t usually say “you’re not getting that promotion because you can’t collaborate well and take in others ideas and so others around you see you as controlling and domineering” it’s often more like “we’re looking to see you continue to grow and work as a teammate with your colleagues, try and work on delegating”. So we have to do a bit of intuiting and piecing together based on patterns we observe and feedback we do get. This can run right into predispositions we hold to make assumptions or read situations based on our histories, so sometimes our attempts to build insight can be thwarted because we are trying to understand how we may be effecting others without necessarily having all the information. A tip here: Ask a safe, nonjudgmental person in your life for their honest feedback if you have a theory about how your way of being might effect them (or others). Another tip: Take a look at how you act/behave and what you say, and then work to observe how others around you handle similar situations (and how folks respond to them). You can learn a lot from watching what works (and doesn’t work) for others. I personally had a very transformative experience once when I went into a store and silently watched how a friend handled a return (in a way that was foreign and un-intuitive to me, but effective). There can be small teaching moments for us to tap into in our lives if we are looking to make use of them.
  4. A potential blockage to self-awareness / insight?: Anxiety or Depression. In our efforts to cope with our emotional state we may start to ask for things like reassurance, only be comfortable interacting under certain conditions, have difficulties tolerating conversations where others don’t agree with us etc. Ultimately, all of that effects our relationships with others AND simultaneously feels necessary for us to cope with our emotional state. This is where learning new coping skills can come in very handy (once we have a sense of how our response to our symptoms is effecting others and our relationships).
  5. You can think of “coping by distancing” as an example of a time when our thoughts, beliefs, and coping mechanisms may effect those around us in an unintended manner. Another example of us coping in a manner that might negatively effect our relationships is displacement.
  6. This post encourages you to make changes. This post is full of tips on making changes in a sustainable manner. 
  7. For more on how we can inadvertently participate in creating outcomes in our life see my post on cyclical psychodynamics.
  8. Looking to try and build more awareness into how your thinking informs how you approach others and problem solving? See my post on Internalizing and Externalizing.
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Why We Need Coping Skills

  • It’s not uncommon for many people, mental health professionals included, to think of coping skills as “a crutch”.
  • Many folks get stuck because they hold beliefs that they (or their patients) “should be able to feel their feelings as they are”, rather than accept that people may need to learn how to tolerate their emotional world through the use of moderators (like coping skills) that make emotions tolerable enough for us to be present with and then make use of.
  • We all have varying levels of skill at interfacing with our emotional world constructively. Those of us that didn’t have strong models for accepting, managing, and constructively expressing emotions are more likely to need to learn coping skills. Those of us that had them modeled for us are likely to find the tactics and concepts intuitive.
  • When we are not as skilled at naturally accessing our emotions in a constructive manner we may feel overwhelmed by them or numb and unable to be in touch with them. This is where the intentional use of coping skills tailored to you and your individual strengths and needs come in.
  • Those that struggle with flooding / emotional overwhelm may need distraction and present centered coping mechanisms (like grounding or meditation). Those that struggle with finding and feeling their emotions may need embodiment based coping skills like body scans, or deep breathing which help you connect more sustainably to yourself.
  • Even if you have strong emotional regulation skills (whether they were learned or came to you intuitively) there are also conceptual coping skills that are useful for everyone to learn and practice that help improve relationships with others, your relationship with yourself, and your communication.
  • There are many conceptual coping skills (see comments for ones I have covered in this account). An example: approaching a situation from a nonjudgmental stance. Instead we work to be descriptive and in doing so reduce the likelihood that judgments get in the way of our ability to get to the core of our reactions, preferences, values, and needs.
  • Other conceptual coping skills include acceptance, (where we work to acknowledge the limits of our control, and the reality – as it really is – in front of us) and willingness (which means openness and readiness to interface with your situation in in a manner that has your short and long term goals in mind).
  • Many of us get stuck because our life long way of doing things, feeling our feelings, problem solving, and addressing conflict feel like a core part of us – just who we are and how we are. But, if we can be open to expanding our approach, and integrating coping skills we can change lifelong patterns that haven’t served us.

One of the things I encourage in my practice, as well as in this account, is being able to live in harmony with your inner world, which does require an ability to tolerate your feelings and respond to them in a constructive manner. However, many of us get stuck because we don’t know how to feel our feelings without ruminating (I.e. keeping them activated in a cyclical manner without working though them); or some version of numbness (where we can’t feel our feelings and experience ourselves as cut off from them).

When we struggle to have a harmonious relationship with our feelings we can get pushed out of our window of tolerance to a place where our thinking world and our emotional world cannot work together. At those times, it is difficult to step back and get to a reflective place where we can notice, make sense of, feel AND think through what may be happening in an integrated manner.

A lot of therapists and self-help books encourage you to “feel your feelings”, which yes! We need to do. But we need to do so constructively and in a manner that helps of make use of them. Our emotional worlds can be chaotic and overwhelming; coping skills are tools that help us manage, navigate, and make use of our emotions in a constructive manner so they don’t overpower us.

There are in the moment coping skills like deep breathing or body scans that help to alleviate the intensity of emotion, or help us get in touch with our emotions. There are also conceptual coping skills that are windows through which we are work to see our lives, relationships, responsibilities and goals. When we use conceptual coping skills we are shifting our mindset so we can respond to the moment with what the moment needs, and what we need to bring about long and short-term success.

Often, once we’ve developed a regular practice with coping skills we actually have an increased tolerance for our capacity to feel our emotions at depth; this is because we know and trust we can feel deeply without being overrun. Our therapies, relationships, capacity for vulnerability and communication are all positively effected because we can fully feel our feelings, think and reflect in an integrated manner.

Comments:

  1. *For the mental health professionals out there*: you may recognize this post as talking about the division we so often see between the cognitive / behaviorally oriented treatments and psychodynamically / relationally oriented treatments. I hear time and again how there is this divide in the field, often with skepticism about the validity of the treatment the other party offers. From my perspective, folks who are seeing limited progress from the relationally or psychodynamically based approaches may need some of the coping skills I describe in this account that fall into the behavioral or cognitive category. The coping skills provided by those interventions can create internal safety for our clients, which eventually enable them to lean more fully in to the psychodynamically and relationally oriented treatments which often require a level of collaboration and openness that may not be accessible without having some core distress tolerance, emotional regulation, and cognitive challenging skills. Similarly, clients who have solely done skill building work may eventually benefit from the insight oriented and relationally based work of a more psychodynamic and relational oriented therapy; having the tools to tolerate their inner world may enable them to not just use skills, but to work to begin to relate and connect to others (and them selves) in new and more effective patterns. It is not uncommon for me to work with psychodynamically oriented clinicians and see their “stuck” patients for skill building. Similarly, for my clients who I work with from a more relational or psychodynamic perspective, sometimes our work needs to shift into skill building to tolerate the depth of the insight oriented work. It doesn’t need to be either/or!
  2. *For folks in therapy that feel stuck*: Talk to your therapist about the style of therapy they are doing with you! Do you feel like you can’t think / feel / reflect at the same time? You might need something more concrete from your therapist to get you adequate coping skills to handle what arises in your life. Alternately, do you feel you have great coping skills, but haven’t seen the kind of pattern change you would like? Talk to your therapist about looking at patterns and doing insight oriented work to help break old patterns that are no longer serving you.
  3. I briefly mention “non-judgmentally” in this post. I have three extensive posts on this. If you (and most of us do) struggle with judgments please read further on how to take a nonjudgmental stance, how to deconstruct judgments, and the problems judgements create for us .
  4. More here on a conceptual coping skill on finding balance in relationships, and effectively considering ourselves and others (at the same time).
  5. For Communication coping skills to reduce conflict see this post on taking a pause from conflict; this post on patterns to avoid in your relationship and in conflict.
  6. For help with the conceptual coping skill of acceptance see, more here.
  7. For help with tolerating very difficult times see a collection of coping skills under the acronym IMPROVE.
  8. For help with learning how to be in the present (which is useful if you are prone to flooding or disconnecting) see posts on being one-minded; meditation, and for newbies to meditation I’d encourage you to start with introductory meditation for mental health.
  9. This post contains a fusion of perspectives from attachment theory (which prioritizes finding safety), DBT (which emphasizes the role of therapist as both supporter and teacher), and mindfulness based therapy. For more reading on any of these topics see Daniel Siegel’s mindsight (which goes into more depth on the impact of leaving the window of tolerance), Marsha Linehan’s textbook on DBT (this book is VERY dense and is a textbook used in graduate level classes), and David Wallin’s Attachment in Psychotherapy which is meant for clinicians but is more accessible to a non-clinician audience than the Linehan book.
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Acceptance vs Hopelessness

  • What if it’s hopelessness, rather than acceptance, when we tell ourselves or others “this is just how I am”?
  • One of the biggest precipitants to disengaging too early from treatment, to not starting treatment at all, or to not really being “in” treatment even when you’re in it are beliefs we hold about what is fixed within ourselves, what cannot be changed, and what is possible for us.
  • A core tenant of finding satisfaction in life centers around acceptance; acceptance of what we cannot change, acceptance of how our development shaped us and informs how we are predisposed to interpreting the world, and acceptance of what we can and cannot control.
  • But how do we know when we’ve accepted something that might actually be more malleable than we realize? And what about those times when our acceptance is actually just us giving up because we’ve tried but been unable to shift something?
  • The short answer to that question is, of course, there is no way to “know” for certain, but if something doesn’t work for you, creates problems for you, or creates problems in your relationships let that be enough of an indicator that you (and others) are probably “tolerating” rather than “accepting”.
  • This is because we and others will carry anger, resentment, shame, guilt, frustration, fear and all sorts of other cues that there is a problem that needs to be addressed when something disrupts us, our responsibilities, and our relationships in this manner.
  • So now we are in a bind, where something within us seems as though it cannot change, and yet it causes problems in such a way that we need it to change for us to find satisfaction or peace in ourselves and our relationships.
  • “This is just how I am”, is usually also, “this is how I have been up until now, living life as I know it, with the beliefs that I hold about how change happens and what is possible for me”.
  • I often find when folks are in this spot they have previously tried to make a change, sometimes putting themselves through intense scrutiny or demands (I’m going to read every book on this, try these 300 different tactics, completely turn my schedule upside down…etc).
  • When those tactics don’t work, or don’t work sustainably / in the long run, take that as a cue you may be substituting discipline or control for what’s actually needed; trying differently, rather than trying harder. See more in today’s post.

Many of us go into treatment (and through our lives) with a lot of unquestioned notions about what is possible for us and our well being. “I’ve always been this way”, ‘I’ve tried and never been able to change it”, and “my family is this way too”, are just a few of the thoughts that can inform our sense of what is possible for us.

Holding on to those notions also influences what we see as “on the table” for working on in ourselves or in our treatment; if we’ve made up our minds it won’t change, we’re less inclined to talk about it as actively as something that we do hold more hope around. Some of the most important moments in my work come when my client and I realize I hold a belief that something within them can change that they themselves had given up on.

When we’ve given up on the possibility that some dynamic can change within us, we are usually asking others and ourselves to live with something that isn’t working; a temper, a drinking problem, a spending problem, an intimacy problem – etc.

Giving up on the belief that something could be different for us usually follows extensive effort on our part to elicit change in the ways we know how to. If you find yourself trying to put more and more control, discipline, or strategy into it, if you’re living your life jumping through hoops for this, or, if you’ve just outright given up even though the issue remains, I’d encourage you to take your emphasis off of how “hard” you are trying and focus more on trying differently.

Unfortunately there is not one single answer to what it means to “try differently”, but it usually starts with broadening your scope of looking at the issue. This could mean accepting secondary gains you experience from the “problematic” dynamic; identifying when you are relying too heavily on pulling away from or stuffing down emotions rather than using them as guide posts to learn from; challenging difficulties with trust or boundaries; or trying to be more open to something that might actually be helpful that you don’t want to need or rely on (i.e. coping skills, medication, limits, meditation, etc).

Everyone can learn, grow, and change. Don’t give up. More in today’s comments.

Comments:

  1. One very important key fact here: while we can change how we behave, relate, process, and make decisions we cannot change what thoughts or feelings arise in us. We can learn to tolerate them, take care of them, honor them, distract from them, and a whole host of other practices – but the content of our thoughts and feelings cannot be controlled and is ours to learn to tolerate and live alongside.
  2. I mention the idea of “broadening” the scope of how you conceptualize the problem at hand in this post. I heard another therapist use this metaphor once and it has always stayed with me. Think about a leak in your ceiling. Where you see the wet spot doesn’t necessarily tell you where the issue is. You often have to open up more of your house than you would have guessed to take care of the leak. Our internal worlds are like that home. If we focus our energy exclusively on the target “part” of us we want to change (or leaky spot) we often miss the big picture of what’s happening, and we are at risk of it continuing to happen without getting at what the larger system (i.e. whole person – i.e YOU) needs to function well, and function consistently. Often times folks that are trying to manage a systemic issue with discipline or control are missing out on addressing the root cause of the “leak”. This would be the equivalent of painting over the wet spot, or constantly using a hair dryer on it; labor intensive tactics that don’t get to the core problem at hand.
  3. There’s a great joke that I reference all the time in therapy – “How many therapists does it take to change a light bulb?” the answer “One, but the light bulb has to really really really really really want to change”. Now of course, it’s not that simple, motivation is hugely informed by hope and trust, which we can all lose access to based on our prior experiences (so sometimes we have to start first with building hope and trust before motivation can arise – and this can take years, especially if you have a history of relational trauma ). BUT, the key take away from the joke, which I try and help my clients with, is that the desire to change, and a willingness to have the accountability for that change come back to you (rather than others or outside forces) is one of the most important influencers of change and success in treatment. This joke also holds another important point in it about boundaries; it doesn’t matter how dark the room is, or how much change is needed/urged/requested/desired from outside forces, the desire for change still has to come from within. While we can influence others with our expressions of how they effect us, our concern for them, or our perspective on how their life could be better, we cannot (even by forcing someone to go to therapy) make people want to change without there being some desire from within them for their life to be different or better in some way.
  4. An area where I see this attempt for control often is around food and dieting. “If I could just stop eating these bad foods I would be able to keep the weight off”, so now I don’t eat chocolate, or I only eat it on weekends, and I have to count out every nut, and fruit is bad because it has sugar – etc”. While I am not a dietician (and I have to be careful here not to speak outside of the scope of my training), I have referred many of my clients who have struggled with eating / weight problems to dietitians and spoken to those dietitians along the way about their treatment recommendations and notion of healthy eating. Without fail, I have been told that “controlled” eating is usually on the disordered spectrum, which includes any kind of restrictive diet or rule based relationship with food that classifies some foods and “good” and others as “bad”. It’s not uncommon to have to unlearn the habit of trying to eat in an intellectual manner (i.e. counting calories, only eating “good” foods, restricting “bad” foods etc) and to have to learn how to listen to cues from your body about when, what, and how much to eat. I would call this an example of trying differently; your intuition may be to double down on your discipline and efforts to control, the path out may actually be controlling less and learning to listen to you body more. If this sounds like you please listen to the actual dietitians out there: Christy Harrison (a registered dietician) has a great podcast called “Food Psych” that covers many topics related to binge eating, restricting food, dieting, the link between anxiety/depression and eating; I’ve also encouraged clients to read books like “Mindful Eating: A Guide to Rediscovering a Healthy and Joyful Relationship with Food” by Jan Chozen Bays; or “Intuitive Eating “by Evelyn Triobole and Elyse Resch.
  5. I mention how overly relying on pushing away emotions can get us into trouble. More on understanding our triggers here.
  6. I talk about how difficulties with communication can be a common dynamic people tolerate between one another. For tips on effective communication see my posts on fair fighting and on the benefits of taking space in conflict.
  7. One of the places we can go when we’ve given up hope on the possibility of being different is classifying ourselves or others as “lazy”. More here on how to deconstruct laziness .
  8. Sometimes we have a lot of trouble being open to something that might really help us because we don’t think we SHOULD need it or we don’t want to need it. If that sounds like you, read this post on acceptance.
  9. I talk more about the notion of holding accountability towards one self for the life you want to have in this prior post.
  10. What I am writing about in this post is drawn somewhat from Marsha Linehan’s conceptual skill, “Willingness”, which she defines in her manual as, “Accepting what is, together with responding to what is, in an effective and appropriate way. It is doing what works. It is doing just what is needed in the current situation or moment”, rather than imposing your will or your sense of what is “right” when it conflicts with what is actually needed to meet your goals for the situation.
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The “Rules” in Therapy

  • There’s a lot of popular notions about what therapy’s “supposed” to look like, but often when a client starts to have reactions to or about their therapist it goes unspoken between them
  • When any of us are in treatment we bring with it our expectation of how we’re “supposed” to be in relationships. Those expectations are formed by our prior relationships, prior therapies, and our culture.
  • Those expectations can leave us feeling like there are implicit “rules” between client and therapist. Can I ask about ____? I didn’t like what my therapist said, is it ok to tell them? I’m feeling like we’re stuck in treatment, is it ok to talk about it?
  • If you start withholding, or keeping something from your therapist, it can actually interfere with the speed and effectiveness of the treatment; now there are whole sections of your internal world that are off limits.
  • Sometimes we don’t bring things up because we feel like we’re not supposed to, the therapy is helpful enough, we are afraid we’ll hurt the therapist’s feelings, or perhaps we assume “they’re the professional, they know what they’re doing, right?”. 
  • Even if the therapist DOES know what they’re doing, that doesn’t mean how they are working with you feels right at any given point in time. When it doesn’t feel right that can leave the client feeling less safe. Without safety and trust we can start to withhold more and more.
  • For some of us, the “rules” we intuit in therapy are closely tied to social “rules” we feel in life. Rules that are sometimes so strong we don’t question them, and rules that effect how much we ask or expect of others, and how much we take on for ourselves.
  • In therapy, and in all relationships, we can get stuck in that space between “how we feel we’re supposed to be” and what we actually need. 
  • Therapy is a GREAT place to have that first experience of exploring and challenging that “supposed to” by working to unearth and talk through those expectations and how they effect you. The opening path to that is talking to your therapist about your expectations or concerns of your work together.

It’s not uncommon, in my personal life, for a friend or acquaintance to ask me about “the rules” of therapy. Am I allowed to ask about my therapist? What if I’m bothered by something my therapist does, is it ok for me to give them feedback?

The answer to these types of questions is somewhat nuanced, because each individual therapist will hold different boundaries for their practice – but – the overwhelming answer is  – YES – bring what you are thinking about or concerned about to your therapist.

“But I don’t want to hurt her feelings”, “I don’t want to seem like I’m prying” or “It just seems like this is how he is”, are common responses I hear.  So yes, on the one hand you want to be considerate of your therapist’s person-hood, but on the other hand, it is your therapist’s job to help you understand what you are experiencing with them in the context of what brings you to treatment. Feedback, questions, or concerns you have for your therapist can become barriers to you being comfortable in the room, and therapy works best when you feel at ease, and able to be open, vulnerable, and honest.

Additionally, (and here’s where it gets interesting) what you are experiencing with your therapist may be a microcosm of what you experience in other relationships. A skilled therapist will be able to help you think about how your feedback applies to both your relationship with them, as well as other relationships in your life and the themes you are discussing in treatment. A skilled therapist will also be able to help you process through how it felt to give feedback and your experience in life outside of therapy speaking up in ways that both get you what you need and take care of your relationships. 

If you ask a question about your therapist you may or may not get a direct answer, but you should learn something about yourself in the process. When it’s working well therapy is a collaborative process, which means the therapist will do his or her best to intuit what you need and what will be helpful, but they won’t always get it right. So, take a risk, and talk to your therapist about what you’re not talking to them about.

Notes:

1. . My post on Cyclical Psychodynamics covers more on how we can inadvertently and unknowingly participate in creating dynamics in our relationship with others that don’t work for us. 
2. Often times when we have “rules” hard wired into us about “how we’re supposed to be in relationships” we find we have a hard time balancing our needs and the needs of our relationships. Sometimes when we’re trying out new ways of being with others we quite literally feel like we don’t know how to say what we want to say in a way that feels honest, open, and kind.  See this post on how to find the balance between yourself, your goals, and your relationships.
3. This is a multi-part series that will aim to help you get the most out of your treatment. See the first part in this series “Tips for selecting a therapist”.

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The Myth of Exposure Therapy

  • Many of us wrongly believe that “exposure therapy” is repeatedly putting ourselves in a feared situation in the hopes it will decrease our anxiety in that situation.
  • I.e. “If I get on the plane enough times my fear of flying will go away”.
  • While low-level anxiety often dissipates with repeated exposure, higher level anxiety is made worse or stays the same with this tactic.
  • That’s because what makes exposure therapy effective is that the therapist exposes someone to a feared situation AND helps them have a different set of internal responses
  • It is that repeated experience of being in a situation and having a DIFFERENT internal experience that can shift our relationship with the situation.
  • An exposure therapist would NOT advocate for white knuckling your way through
    Exposure therapy isn’t the only way to deal with fears of this nature, but the key for any and every individual to be aware of is that exposure therapy is not simply putting yourself in the situation time and time again and “pushing” through it.
  • If you want to work on a feared situation I’d encourage you to work to increase your awareness of where that line is between “high” and “low” anxiety situations
  • In low-anxiety situations – sure – expose yourself. You may just need to get the hang of it. 
  • You can address high anxiety situations in a variety of ways including formal exposure therapy, standard therapy, working to build insight into what’s under the anxiety in an effort to help it dissipate, and increasing your mindfulness and grounding skills (info on those two in the comments).

I can’t tell you how many times a client has walked into my office talking about a struggle in a particular situation; a fear of flying, anxiety with public speaking, difficulties with crowds. Often, they tell me about how they have “white-knuckled” their way through this situation time and again in an attempt at “exposure therapy”. More often than not, they find it doesn’t work.


This is when I tell them that’s not how exposure therapy works. When a therapist is helping a client with an exposure the therapist is both EXPOSING the client to the situation they struggle with AND helping them have a DIFFERENT internal experience while doing so. It is that repeated experience of being in the situation and having a DIFFERENT internal experience that can shift our relationship with the situation. 


For most of us, if we knew how to have a different internal experience while in the situation we would have done that long ago. What may feel intuitive to us in those moments (and perhaps not in our control)  is to have the reaction we’ve always had. 


Getting on the plane 35 times in an effort to expose yourself to a feared situation in the hopes it will neutralize (or numb) you to it can work with situations where you feel anxiety in a low intensity manner (i.e. think about performance anxiety where we are jittery the first few times, but with repeated experience we get more and more comfortable). With higher intensity anxiety you may actually be reinforcing (i.e. strengthening or making worse) the anxious response by exposing yourself to it without having built up coping strategies or skills for how to manage your internal world while you are exposed to the situation. 


What I can do with my clients, and what you can do too, is work know ourselves well enough to know where that line is between the “low(er)” anxiety situations and the “high(er)” anxiety situations. When our anxiety is lower we often just need to stick with it and get the hang of it. You should notice yourself feeling less and less anxious over time. When anxiety is higher, the anxiety doesn’t change or get worse with repeated exposure. That’s a cue not to keep going without a different set of internal responses.

Notes:

  1. How much anxiety we feel in a certain situation can vary based on a variety of factors. I.e. one day a situation might be “low intensity” and the next day the same situation might be “high intensity”.  The key here is to work to pay attention to knowing your own anxious cues and responding to what they tell you.
  2. I am not a specialist in exposure therapy, and in fact when I have clients in need of this type of treatment I will send them to a specialist for a series of sessions to work with someone in the situation they are struggling with to come up with strategies specific to their situation and their needs. This is often short-term work and it can be done alongside a longer therapy.
  3. One tactic you can try if you want to try building that different set of internal responses is strengthening your grounding based skills (those help combat anxiety by keeping you in the present) and mindfulness skills (those both keep you in the present and help you increase your ability to control your attention. Both Mindfulness and Grounding will help you “tame” your anxiety in those moments, though there are many more skills and techniques that an exposure specialist could work with you on (sometimes in as little as 4-6 sessions) if you’re really stuck with something. 
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American Insurance Networks

  • American Insurance is incredibly complicated, but understanding it empowers you and can save you thousands in your physical and mental health care
  • I do all of my own billing, and while I’m not an insurance broker I know a lot about common pitfalls that leave people confused and on the hook with surprise costs.
  • This multi-part series will break down this complicated system so you can get the most out of your benefits, access the care you need, and keep you as protected as possible from unexpected costs
  • Starting Broad. In the insurance world providers are divided into two categories: In Network and Out of Network. All plans have “in-network” and some plans have “out of network” benefits and they are most often different. Usually it costs you less to see someone in network, BUT depending on the plan some have excellent benefits in both categories
  • In Network:
    • The total amount a provider is paid per session is determined by the insurance company
    • How much you as a client pays is determined by the insurance company
    • Be on the lookout for carve outs! See post for details
  • Out of Network:
    • The total amount the provider is paid is determined by the PROVIDER. 
    • If your insurance plan has out of network benefits insurance may chip in none, some, or all of the cost depending on the specifics of your plan
    • Some providers are willing to send these sessions to insurance to help you save money. Some are not. Ask your provider.
  • Both in-work and out of network:
    • When using insurance know that your insurance company collects information about you to determine whether or not they consider this a “valid” use of the medical treatment provided. To cover a mental health session they always require a diagnosis. 
  • Yes. If you are in therapy and you or your therapist are sending claims to insurance this means you have a diagnosis. You have every right to ask what that diagnosis is, and to understand what symptoms your provider sees in you that led them to making that diagnosis. 
  • If you want to know costs in advance of scheduling with a provider you can ask the provider if they are in or out of network, and you can contact your insurance company to verify. You can also contact your insurance company and ask what you should expect your “out of pocket” (i.e. your personal) costs should be.
  • When calling insurance you can provide the CPT codes (these are billing codes providers use) to get exact dollar amounts:
    • Initial appointment is often: 90791
    • Additional appointments are often: 90837, 90834, and 90832 for individual work or 90847 and 90846 for family / couples work 

One major barrier to treatment in the United States – our incredibly complex insurance system.


Insurance networks have two categories: Providers that are in -network and providers that are out-of-network.


Some key differences:


A provider who is IN network is a provider who has signed a contract and agreed to set of rules for how to operate their practice. 


How this effects you: This means the provider has agreed to accept fees at a certain rate for the treatment they provide. This usually means the provider is responsible for billing the insurance company on your behalf. 


Example (with made up numbers): I say my fee for therapy is $150/hour. The insurance company says to be in our network you have to agree to be paid $100/hour. I can decide to accept that, try to bargain for a higher rate, or decide not to be in network, but once I decide I am “in the network” I have to agree to accept the rate the insurance company and I agreed to for every client I see who has that insurance. 


Things that make In-network more complicated:


 (1) There is a thing called “carve outs”. This is when you have a plan from one insurance company but they “carve out” a particular kind of health care to another insurance company. I.e. it says “Insurance A” on your card, but ACTUALLY your mental health benefits are through “Insurance company B”. The only way to know if this is the case with you plan is to call and ask before billing happens. 


(2) Insurance companies can decide change how much they pay providers. Which means your costs can change even if your plan doesn’t.


A provider who is OUT of network has decided not to sign a contact with an insurance company. Those providers set their own fees, which means the insurance company has no say over how much you will pay per session. 


Example continued: I say my fee is $150. You pay me $150.  The insurance company doesn’t have any say over it.


At the end of the day, you are responsible for the cost of your healthcare, so be your own advocate, protect your finances, and call your insurance company to make sure you understand what they will cover and what they won’t.

Notes:

  1. I’m quite serious that knowing and understanding how insurance works can save you huge amounts of money. I can’t tell you how many times claims have been processed in a manner inconsistent with how I or my clients have understood their plans to work – and understanding this system has enabled both me and them to challenge an insurance company to have payments made where they were previously denied. 
  2. If you’re going to call an insurance company to check on costs, ask for a confirmation number at the end of the call ad write down / keep that number. If there is as issue down the road they will be able to find record of your call when you supply that confirmation number – which may be the “evidence” that you need to get the company to operate in a manner consistent with what they told you at that time (and yes, I have seen this happen many times before).
  3. In Illinois we have something called the “Illinois Dept of Insurance”.  I am guessing other states have it too if you want to dig around a bit. This is a government agency that investigates fraudulent uses of insurance by both providers and by insurance companies. If you are spinning because you know something isn’t right with how payment or insurance is being handled this free service will step in on your behalf and investigate. Don’t be afraid to file a claim, I’ve filed half a dozen or so over my last 10 years in business and it works. Sometimes we all need an outside advocate. https://mc.insurance.illinois.gov/messagecenter.nsf
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How to Pick a Therapist

The following are tips I would give anyone who is looking to start with a new therapist

  1. Trust your gut. If after 2-4 sessions it doesn’t feel right, move on. One of the most important things for treatment to be successful is for you to feel comfortable opening up and discussing difficult topics. If you feel uncomfortable it probably isn’t a great fit.  That doesn’t mean the person you are seeing isn’t high quality, they just may not be right for you – but if you find the next person isn’t a great fit it doesn’t mean it’s you, sometimes it takes a few rounds of trying.
  1. There is not a lot of quality control in the field. Many programs don’t require prospective applicants interview, have their own therapy, or have an analysis of their own mental health / wellbeing.  Don’t just assume that “someone knows what they are doing”, there is a huge range in skill sets of therapists out there so if someone seems off, not quite ok themselves, just trust it and move on.
  1. Look out for a therapist that seems reactive (i.e. seems highly emotionally charged) or defensive (preoccupied with rationalizing their perspective at the detriment of understanding, connection, and receiving feedback). Therapists are people too, with emotions of course, but we want you with a therapist who can manage their feelings. Sometimes therapists will have emotions in session that they will discuss with you, but the key is for the sessions to feel like they are largely about YOU.
  1. If you can get a personal recommendation, that’s always the best way to go (ask your doctors, friends or family who you trust to know you’re considering seeking treatment). 
  1. If you know someone that is seeing a therapist they love, ask them to ask their therapist for recommendations – high quality therapists often know of other high quality therapists.
  1. It is my opinion (spoken as an LCSW) that the degree (i.e. the letters that come after someone’s name like LCPC, LPC, LCSW, LMFT, PsyD, PhD etc) are less important than that items I mentioned above.

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Notes:

Note on item (1) after you’ve been in therapy with someone for a while and previously felt like you trusted them / vibed with them / liked them but are no longer feeling as comfortable this is a cue to talk to them about the shift in you from things feeling good / right / helpful to not as good / right / or helpful. This is a time to look our for reactivity or defensiveness from your therapist when having this discussion.

I mention in the post that you want to be weary of a therapist that spends a lot of time talking about themselves. There are therapists that work in what’s called a “relational” framework. This means that they talk about their experiences of you with you to help you better understand how you may impact relationships and people around you. This form of therapy can be incredibly effective when done well. Furthermore, some therapists will share something about themselves as a means to talking about your situation, struggles, or perspective – or as a way to help you feel at ease. It can be a delicate balance, but it’s not that it’s a “bad sign” if a therapist talks about themselves, the key here is the the sessions to feel predominantly focused around you, and to be on the lookout if that’s not your experience. 

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Couples Therapy

  • Many couples wait until it’s too late to start couples treatment
  • Your relationship is not flawed / defective / “not worth it” if you decide to try couples therapy.
  • There is no shame in going to couples treatment and working towards strengthening a partnership. 
  • This type of work is especially helpful if one or both parties want to work towards a different kind of relationship for their partnership than the one that was modeled for them growing up.
  • In my experience most insurance (including medicaid, medicare, and privately held insurance) covers couples work.

Too many couples wait until they are at their breaking point (or beyond) to start treatment. 


One of the first things said by my Couples Therapy professor at @Uchicago was that many couples wait too long to start treatment; for many of them it’s too late to help the relationship heal.


If there is one thing I wish more people knew about couples work it’s that it’s never too early to go, you don’t need for things to be “really bad”, and things don’t need to be “bad” at all to go in.


Therapists are not magicians, and they can only do so much to heal a relationship where both parties have been emotionally injuring one another for extended periods of time. Just like it’s better to start treating a cold or flu early on rather than leaving symptoms to grow and compound, it’s better to get in couples therapy earlier rather than later.


Yes, couples therapy can address problems but it can also help strengthen your foundation (improve communication, openness, and support), learn how to fight in ways that will not hurt the relationship or one another, navigate a transition (new job, a move, new baby), or just simply be a place to talk without distractions and with the help of an expert. In fact, getting in early before huge problems arise can build resilience and ward off problems that might have otherwise built up over time.


You don’t need to be married to go, and no, that does not mean your relationship is “doomed” or that you “shouldn’t need it” if you decide to go as an unmarried couple, a newly married couple, or a couple that’s been together for ages there is something to be learned and gained.


Find out if your insurance covers couples work. Call your member services number on the back of your insurance card and ask if “family therapy” is covered. If they ask you for a “CPT code” (this is a billing code) more often than not a therapist will bill code “90847”, so ask the therapist and the insurance company in advance so you can know if it is covered and what expected costs may be.

Notes:

Wondering how you can use couples therapy? Talk about how you fight. Talk about how you plan for the future together. Talk about your sex life. Talk about what needs are met by the relationship. Talk about what feels healing to you after conflict. Talk about what your triggers are. Talk about what you learned from prior relationships about what helps you function well in a relationship. 

Looking for help changing how you fight? See this prior post.

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