This man, like many I know, deals heroically every day with the special needs challenges in his family. He and his wife step up in a non-traditional, focused, determined manner with love and spirit that is hard for outsiders to imagine. He is the frog in the pot, so it is nearly impossible for him to see how exceptional he is.

His reaction to me was: “Are you asking me to lower my expectations?”

No, I said, I’m asking you to blow them up, destroy them, obliterate them to dust. I hate that term: ‘lower expectations’, (can you tell?) as if by thinking differently we are less ourselves instead of more.

Here are some tips:

1. Start with a clean slate. Be honest with yourself. Are the expectations you are holding onto really your own? Or are they some one else’s? If they are someone else’s ditch them.

2. Brain storm. Write a stream of consciousness, without censor, without judgement. You can cull out the absurd (I expect to be America’s Next Top Model!) later.

3. Embrace where you are in life, because where ever you are, even if it’s really hard, it is Good.

4. Create goals, expectations, standards, whatever you want to call them, that work with you instead of against you. I may not ever be America’s Next Top Model, but maybe I could walk more.

5. Keep the expectations fluid. Your needs in life will change for good and all. Keep light on your feet.

At the end of Working Girl, (an ’80′s iconic movie that you have got to see just for the hair!), a titan of industry tells a story to his board of directors that goes something like this:

One day in the Lincoln Tunnel, traffic came to a stop. A huge 18-wheel truck exceeded the clearance of the tunnel and got stuck. It couldn’t move forward or backward. The emergency crew were at a loss, scratching their heads as tempers began to fray all around them. Finally a little boy from a car waiting patiently behind the rig piped up: “Why don’t you just let air out of the tires?” Which, of course, they promptly did, lowering the truck which allowed it to move forward.

Life generally requires at least a few of those deflating-the-tires moments. My life is actually full of them and they haven’t been easy to deal with. Here’s why.

Even though I know I have to deflate my tires I resist it. My heart tells me I am not living up to potential yet again! So many times I asked myself if it was time to lower my expectations. In a small but very significant way it was having a chronic illness that first taught me that the old expectations of myself were keeping me frustrated and depressed. As long as I held on to the notion that I had to have the same production levels as I did when I was healthy I was letting myself and in my eyes, everyone around me, down. It finally occurred to me that since my illness was not going away I had to face some choices.

Either I keep banging my head against the Old Expectations Wall or I blow the damn thing up and build a brand new wall, or dig a tunnel under it or an airplane to fly over it!

Picture this: Raiders of the Lost Ark. Harrison Ford plays Indiana Jones (“it’s not the years, it’s the mileage”) who has battled and out-raced countless henchmen bent on his destruction. He lands in a market square and out of nowhere comes a seven foot tall giant brandishing the mother of all swords! Indy sighs, takes out his gun and shoots him.

Wow! Legend has it that Harrison Ford improvised this scene because he really was sick and too tired to do the choreographed sword fight. His flash of creativity became one of the most popular and iconic scenes in filmdom.

During my twenties when I was first confronted by a sickness that wasn’t going away I had a therapist who helped me break through my old expectations. It took over six years for me to get my B.A but I managed it. Then when I was thirty, I bit the bullet and went to graduate school thinking I would be the old lady in the class. Guess what? There were many like me, some even older, who had postponed their post-grad education for whatever reasons.

Later, I struggled with the reality accepting a life without kids. I married late and I was sick a lot, but by some miracle they arrived. It wasn’t easy, but now I have kids the same age as my great nieces and nephews. It’s a hoot!

My career expectation was to climb the corporate ladder to a satisfying administrative position. After hitting the glass ceiling I quit and struck out on my own. That was over fifteen years ago. The road to fulfilling my dream of a private practice for the 21st century has been rocky but every time I hit a rut, I remember I can change course and still move forward.

Hanging on to expectations that work against us is like trying to pull our fingers out of a Chinese finger trap. The more you yank and pull the tighter the damn thing traps your fingers. The trick is to keep calm, relax and let your clever brain find another way. Then your fingers slip out easily!

On the day of the shooting I went to two holiday parties where everyone carefully avoided talking about what happened just hours earlier. It was weird and a relief at the same time.

Someone wrote that even those of us far away from the incident still may need to go through the five stages of grief as described by Dr. Elizabeth Kubler-Ross.

The day it happened, as we discovered the horror, many of us clung to the denial and bargaining phases. We did not want to believe we were all so vulnerable and made up reasons to avoid going there. Some just went straight to anger, even depression. None of us was ready for acceptance.

As with any act of terrorism, if we give in to depression and anger and let it obliterate the happy and good in the world, the terrorists win.

Now for our spirit’s sake we need to give ourselves permission to engage in the brightness and goodness of life. But how?

In cognitive-behavioral therapy we learn that our thoughts affect how we feel. And when our thoughts skew to the dark side the result can be feelings of anxiety or depression, sometimes both.

We can easily identify our negative, judging thoughts: “I must be a bad person that I want to be happy when there are parents whose little child died violently.” It’s harder to look for the reasonable thought that brings us back to a real place of balance: “I am not a bad person. I feel empathy for those who lost a cherished loved one. I can feel bad for them and still wish to be happy at the same time.”

Life is not purely negative or purely positive. Life can be a confusing, messy mix of both light and dark. The result is not just the grey between the black and white but a 3D Technicolor full spectrum of thought and feeling.

The key to getting back to normal is to tolerate the ambivalence. Be OK with it. Recognize it as normal and human. Exercise compassion not just for the victims in Newtown but also for yourself.

Photo courtesy of bradwilsonem via Flickr.

I hate so much of what has happened recently.

I hate the senseless loss of the innocents. I hate the loss of good people who cared for the innocents.

From there it gets a little murky.

I hate that I have to separate myself from this tragedy in order to survive it. This is happening to them, not to me. I am safe, my children are safe.

In graduate school I learned about cognitive dissonance: the struggle of the brain to reconcile what we know to be true with what we want to be true. I want to believe that what happened in Newtown would never happen in my town. That desire belies what I know too well, that it can happen anywhere. We are all vulnerable. I have to admit that the chances of violence really happening to my loved ones are microscopic, just as the chances of a plane falling on my house are microscopic. But a plane really did fall on a house not far from where I live. So where does that leave me?

I hate that yet again debate for gun control vs. Second Amendment rights saturate the op-ed pages everywhere. The answer to stopping mass shootings is tougher gun laws; the answer is to give teachers guns. Whatever side of this debate you are on, can you all just hold off a minute to let us catch our breath? Honestly! These are important issues so why do they only present in the immediate wake of blood spilled?

I hate that we have more examples of talking heads with a microphone saying stupid, hurtful things (see Mike Huckabee). Here is a good example of how some people try to reconcile cognitive dissonance with hubris and magical thinking. It is irresponsible and disgusting because it blames the victims.

I hate that the entire population of people suffering from mental illness, innocent people, are victims of stigma and subject to profiling. Efforts to come up with a way to predict that a certain person will act in violence do not work:

“Because a tragedy of this proportion can’t fit into any rational container. It is a purely irrational, criminal act that has little explanation. It happens so rarely that, like most random terrorist acts, it cannot be prevented. The signs we would look for from this single individual would do little to help us with the next person — who will act in a way quite unique to their own upbringing, history, and psyche.” Dr. John Grohol, Making Sense of Tragedy

I hate that the media can’t just report and step away to give us time to process. Instead we are bombarded by the grief of strangers that we know too well, by the ‘experts’ telling us why and how, by children’s firsthand description of horror. The line that divides the responsibility to inform and the drive to sell is messy. If they won’t draw it for us we need to draw it for ourselves.

I hate that I could cut and paste this list and apply it to so many mass shootings and tragedies we have endured in the past.

When we feel so powerless, what can we do?

1. Use our heads. Instead of being afraid of people with mental illness and thus perpetuating harmful, meaningless stigma, learn more about the millions of individuals who live with mental illness. Mental illness is not evil. Evil is evil. People with severe mental illness are more likely to be the victim of violence than the other way around.

2. Share in our humanity. Highly sensitive people (and who among us is not?) feel empathy profoundly. Just because it has not happened to us directly does not mean we do not grieve. Even from a great distance we are sensitive to the depth of loss. Cry, be sad. Allow grief to happen. Then wash your face, breathe deeply and allow life to happen, too.

3. Turn off the radio, television, step away from the computer and put down the newspaper. Allow yourself the space to adjust to the news at your pace, not theirs.

4. Do good. I do not mean make a donation or give blood. Although all that is good, there is more we can do. I mean what Chris said in a comment he left on my blog the day of the shooting, let us out-grace one another. Let us look for opportunities to act with kindness. Pay forward the kindness received from others. Let us breathe in the healing love and goodness in the universe and breathe out the poison.

5. Stop the hate. Now that I’ve breathed out the hate I am hopeful I can let it go.

My dad was a psychiatrist/ psychoanalyst of the old school. Which is to say he was brilliant, but also a man of his particular age. Which is to further say his fury was directed at the APA for taking homosexuality as a diagnosable mental illness out of the manual. It was 1973.

Hardly aware of what he was so upset about, I did hear him dramatically declare that he was withdrawing his membership in the APA. My dad loved being a psychoanalyst and he loved being a physician but he wasn’t that crazy (you should forgive the word) about being a psychiatrist. His prescription pad gathered dust as he focused on talk therapy. So his threat to quit the APA wasn’t idle. But it wasn’t like he was giving up his beloved couch.

By the time I got to graduate school, the DSM had gone through at least four more mutations. Partly because of my experience with my dad, but also because my mom was addicted to the Merck Manual of Diagnosis and Treatment (in which every twinge or sore throat could become a sign of impending doom), I maintained a skeptic’s view of the DSM.

If the DSM really is the behavioral health professional’s “bible,” then I am a doubting Thomas.

I’m comfortable with that. Take the latest edition, the DSM-5, finalized just aweek ago by the APA. I’m not overly excited about it because:

1. The DSM is subject to the times.

For homosexuality to be taken out of the DSM in 1973, it had to have been in there in the first place, probably starting in 1952 when the manual was first compiled. Certain diagnoses, just like some humans, can have their 15 minutes of fame. With problems such as hoarding, which was added to the DSM-5 lexicon, I have to wonder: Why? Do we really need more diagnoses when the condition was fine where it was, as a subtype of obsessive-compulsive disorder?

2. The DSM is subject to politics.

Stakeholders — including drug companies, insurance companies and researchers seeking grants — all have a serious interest in what is deemed a diagnosable mental illness.

3. A little knowledge can be a dangerous thing.

From Homeland (bipolar) to The United States of Tara (dissociative identity disorder), I get the uneasy feeling that having a mental illness can be romanticized. When a character feels flat I imagine screenwriters in Hollywood asking themselves, “What will spice them up? Let’s look up something in the DSM!”

This is no joke when there are plenty of people who seriously suffer from these disorders and stigma is still such an issue. No matter how responsibly the media present mental illness, there is still the danger that the regular person will assume they know everything when they only have one part of the elephant.

Do not get me wrong. I am not saying the DSM should be chucked out the window, baby, bathwater and all. When I need to wade through differential diagnoses to get a clearer picture of what is going on with a patient, so that I can develop an appropriate treatment plan, I have turned to the DSM many times; but I was trained many years to be able to do that. If looking at the DSM doesn’t help, I call on a colleague who is much better at diagnostics than I am or once in a while I will do some strategic psychometric testing. This is how many clinicians on the ground use the DSM. Researchers need an even more fine-tuned instrument upon which to base their methodologies. It is all in the service of helping the patient, not in the questionable pleasure of labeling them.

The DSM has its place. It has gone a long way toward helping mental health professionals speak the same language. It has helped researchers define mental health issues. It provides understanding of psychiatric conditions and helps many to understand themselves better. It is certainly better than nothing. I have great respect for the Herculean effort the committees of knowledgeable professionals had to put into this thing. They are the best in their fields, but they, like my dad, are creatures of their time and culture.

The DSM is a tool, like a hammer, or maybe more like a good Swiss Army knife. You can use it to open a can of beans or you can cut yourself.

It is not the Bible. Otherwise we’d be on Bible No. 1352 by now. God help us.

Want to learn more?
To read more on the specifics of the newly approved DSM-5 click here.

I have learned to slow myself down, detach myself from the process, and be absolutely truthful while remaining as unprovoked as possible. Otherwise it is an exhausting exercise.

One question did get me going, though. It revolved around whether or not a person can change and what causes a person in therapy to improve or not improve.

The conversation below is a dramatic re-enactment of real events…

Lawyer: Under what circumstances does a person in therapy not get well?

Me: Are you assuming the therapist is perfect? Because one reason a person does not improve may be the skills, knowledge and training limitations of the therapist.

Lawyer: Assume the therapist is perfect.

Me: So the lack of improvement is totally the responsibility of the patient?

Note to reader: This is rarely the case. Therapy by definition involves a minimum of two people who are human. In which case perfection is impossible. But we are in a court of law where reality seems always to be in question so…

Lawyer: Yes. Would level of intelligence be a reason?

Me: No. People with very high intelligence can be resistant to treatment, just as less intelligent people can.

Lawyer: Could the presence of a diagnosed mental illness or personality disorder be a reason?

Me: The presence of a mental illness diagnosis or personality disorder alone is not a reason for lack of improvement in therapy.

Lawyer: Then what would be a reason?

Me: There could be many reasons but underlying them is often anxiety. ‘What will happen to me if I change?’ Fear, basically.

At this point the lawyer switched to a completely different topic. My answers probably weren’t suitable to his argument so he gave up on me. Fine, but these questions kept echoing in my head.

Any therapist worth their salt will admit that they have had patients who seem to stay stuck for session after session. Maybe you have been in therapy and wondered if anything is really getting any better after making a big investment of time and money. What could be the reasons for lack of improvement?

Questions for Therapists About Lack of Progress in Therapy

Therapists learn about treatment resistance clients in the cradle of graduate school. Hitting a wall in therapy is not a reason to panic. In fact it could be an opportunity to step back and reassess. From the therapist’s point of view:

1. If someone is not showing improvement after a reasonable amount of time we may ask ourselves, are we the right therapist for this patient? Occasionally our patient would be better served with a specialist, sometimes in addition to, or in lieu of our own work. The patient may need supplementary professional help, for example a psychiatrist if medication might help.

2. Have we, with the patient, identified clear goals that give us a way of measuring improvement? Do we need to redefine or recalibrate our goals to be more achievable? We may decide to target specific behaviors, or identify mini-goals as appropriate steps toward the bigger one or stepping back or sideways to step ahead.

3. Are our interventions accessible to the patient? In other words, are we giving our patient tools within their reach? Tools they can use? Sometimes this takes thinking creatively, stepping out of the usual cookie-cutter solution.

4. Is it possible there is something about the patient we don’t like and therefore we are ineffective because we are holding ourselves back? This type of counter-transference can lead to therapist resistance if unchecked. It is an important part of our job to be aware of this and act accordingly.

5. Are we being patient enough? If most resistance to improvement comes from fear, what can we do to address the fear?

In my training, many years ago, I complained to my supervisor that I didn’t understand why a patient kept coming to see me week after week with no visible improvement. Being a great supervisor, she said to me, “Who makes you the judge? Your patient does not wish to fire you. She is getting something out of therapy. Be patient. Listen.”

Months later my patient revealed childhood sexual and physical abuse that she could not reveal until she was good and ready.

Why Patients Don’t Get Better

Usually the goal in therapy is some kind of change. To achieve this goal, both parties need to be truthful. What things may make a person in therapy afraid of revealing the truth and afraid of change?

1. Fear of judgment. If I could have a nickle for every time a patient prefaced a sentence with some variation of, “You will think this is awful…” I’d be on a beach in Maui right now. If you can identify with this, you may have held onto this awful thing for ages so it takes up an extraordinary amount of space in your brain and has probably bored a hole in your self-worth.

The therapist has a different perspective. He/she is trained to be non-judgmental. He/she has probably heard a ton of stuff much worse than whatever it is you think will horrify them. Even so, it is human to want others to think the best of us. It takes a lot of trust to tell the truth to your therapist. It takes faith to believe that the awful thing you are about to reveal will be treated with kindness. Yet to get unstuck that is precisely what is needed.

2. Fear of rejection. Underneath the fear of being judged is fear of rejection; a primal fear. That’s why shunning is such a devastating punishment. You may be wondering, ‘If I get better, will my family who is so used to my problems, still have a place for me? Will they still love me?’

3. Fear of assuming greater responsibility. Sometimes if we stay childlike we are rewarded by people taking care of us. It can be very uncomfortable to give up the sense of protection that staying dependent on others can give. The rewards of being an emotionally healthy well-integrated person are rich and complex, but not always obvious. It takes risk and belief in ourselves to take up the reins of adulthood.

4. Fear of success. What if you get better and you no longer have a reason to see your therapist? Fear that if you change too much your life may become unrecognizable could be a factor in being stuck in therapy. People can get used to failing. It can become their comfort zone. In that case, the lack of discomfort actually feels uncomfortable. Or, said another way, happiness just feels weird.

5. Fear of intimacy. Sharing our truth to another who respects it, “gets” it and reflects it back in kind, is the essence of intimacy. If we get close to people, if we reveal ourselves to another, we become vulnerable and that is scary.

Fundamentally we are talking about fear of pain and like every living being on the planet, we humans are hard-wired to resist pain by either running away from it or fighting it, tooth and nail. Why should therapy be any different?

We therapists need your feedback to work effectively for you. If you like your therapist and still feel stuck, try to get through the fear enough to bring up your feelings of stuck-ness so that you and your therapist can work on it together. You do not have to have the reasons for being stuck figured out. It is enough just to say, “I feel stuck. Could we please look at that?”

It takes a skilled, compassionate therapist and a motivated, brave patient to give the therapy process a chance.

What are some of the reasons you’ve found therapy seems not to be working? What have you or your therapist done to try and help move your psychotherapy forward?

A lot of people have trouble with Alcoholics Anonymous. AA is full of people and people can be messy and flawed.

The human train wreck formally known as Charlie Sheen is a common sight in the AA meeting halls. The only difference between Mr. Sheen and other self-absorbed, delusional, frantic addicts is the size of the audience to which they rant. These people do not last long in AA. They mock the Fellowship and the 12 Steps (PDF) as too religious or simplistic. AA is beneath them.

Here are a few possible reasons why Charlie Sheen might hate AA so much.

Reasons Why Charlie Sheen May Hate AA

1. He would have to admit he is powerless.
2. He would need to embrace Humility.
3. Deep tissue Change would be required.
4. He would have to be Anonymous!
5. His Higher Power could not be Charlie Sheen.
6. He couldn’t blame anyone else for his troubles.
7. He would need to learn to be Grateful.

People can get sober without AA. It is not necessarily for everyone, by any means. Even so, I have a deep respect for it.

For a few years after getting my B.A. and before going to graduate school, I was a substance abuse counselor at the Substance Abuse Center of Johnson County, close to Kansas City, Kansas. What I learned there was worth five Ph.D.s. Not being an alcoholic, I thought it was important for me to know as much as I could about my clients’ experience. That’s why I attended as many open AA meetings as I could. It was an eye opener. The members made me feel welcome everywhere I went. One of my proudest possessions is my 30 day coin.

What did I learn? I learned that you can’t just go to one AA meeting and think you know AA. Every meeting, every location had its own kind of culture. There were the hard-core biker meetings, the white-collar professional meetings, the womens’ meetings, huge open meetings, more intimate closed meetings…. you get the picture.

There were also the religious meetings, yes, and the agnostic ones. I learned my higher power did not have to be God in the Judeo-Christian tradition, although a lot of people were comfortable with that. If I wanted my dog Snoopy to be my Higher Power I was encouraged to go for it, as long as I gave up my need to Control and was willing to give it to something meaningful outside myself.

I learned that AA was a great leveler. Everyone was the essentially same: the lawyer and the short-order cook, the doctor and the housewife. Each were equally brave. Each deeply respected for the courage it took to just show up.

Sadly, all this Mr. Charlie Sheen, gripped by his illness, cannot comprehend. It must be terrifying for him to imagine a place where he would no longer be CHARLIE SHEEN!

He would just be Charlie.

Back in the old days, however, it was odd for a woman to confess that she didn’t feel a strong traditional pull to be a mother. We’re talking way back — before cell phones, before the Internet, before Facebook, even before reality television shows!

For my husband and me, circumstances beyond our control forced us to consider life without children. Having the choice taken away from us because of my chronic illness was depressing and we had to work to accept it. Just as I was wrapping my brain around being childless, the disease went into remission, and my doctors gave us a green light. When I got pregnant easily it felt like a miracle.

Fast forward to the day after my son’s delivery, which, through no desire of mine, was experienced without the joy of drugs. He was perfect. A healthy, big seven pound, eleven ounce baby boy. My husband sat on the edge of my bed, held his son in his arms.

“I love you,” he whispered to the baby, “I love you.”

I couldn’t relate. I didn’t love my son. It was weird. All I felt was exhaustion and anger for what he put me through. Where was that maternal instinct? Was there a delay switch? Did it come with the breast milk which they said would be ‘letting down’ in a few days?

Here’s the really bad part: I hated breast feeding. Hated it. Hate-ed-it! Those pictures of serene madonnas content and complacent, giving their infants the milk of life, lied. Breast feeding was painful! Whenever my son ‘latched on’ it was like a vacuum was sucking the very soul out of me. There you have it. I didn’t love my son and I dreaded feeding him. Bad mommy!

Today I know what I had was a typical case of postpartum blues or baby blues, a much misunderstood condition often confused with postpartum depression. Over 50% of new mothers experience lowered mood, tearfulness, irritability, etc.; eMedicineHealth.com reports as many as 80% of new mothers “feel upset, alone, afraid, or unloving toward their baby, and guilt for having these feelings.” The baby blues typically lifts after several days to two weeks with no need for treatment.

If I had known that baby blues existed and was so common, I wouldn’t have felt like such a freak.

The more severe condition, postpartum depression, occurs in 10-20% of women after giving birth. The Mayo Clinic says:

Postpartum depression may appear to be the baby blues at first — but the signs and symptoms are more intense and longer lasting, eventually interfering with your ability to care for your baby and handle other daily tasks. Signs and symptoms of postpartum depression may include:

• Loss of appetite
• Insomnia
• Intense irritability and anger
• Overwhelming fatigue
• Loss of interest in sex
• Lack of joy in life
• Feelings of shame, guilt or inadequacy
• Severe mood swings
• Difficulty bonding with the baby
• Withdrawal from family and friends
• Thoughts of harming yourself or the baby

If this describes you, or someone you care for, call your OB-GYN and let them know what’s going on. He or she may ask to see you right away and refer you to a psychologist for psychotherapy and/or a psychiatrist for a medication consultation.

In my case, after coming home from the hospital, with the help of my husband and my mother, over time I bonded slowly with my son but love was still elusive. Breast feeding got easier, although I was never crazy about it. My husband woke up with me in the night to feed the baby, participated in his care and my mother assured me everything was normal. Boy, did I need to hear that. I think we all do.

Weeks later, I quietly rocked and contemplated the sleeping baby in my arms, smelled his sweet smell, in awe of his perfection. Suddenly I was overwhelmed by a tide of emotion that swelled from my heart and rushed to my head like a geyser! It happened so quickly it made me high as a kite.

‘Wow!’ I thought, ‘So this is love.’

Photo courtesy of fotorita via Flickr

Occasionally people ask me, “How do you listen to peoples’ problems all day long without becoming depressed yourself?” The answer is the same for whatever the job is: we need to pay attention to balance. I do my best to balance the hours I dedicate to work, for family time, and for just plain old time off and play.

But to be perfectly honest, there are those days when I find myself severely stressed out. It could be I’ve over-booked myself too many days in a row, or had a series of challenging sessions or maybe just one person I wonder if I’m really helping.

On those days, before I decide to chuck it all, I remind myself of what Dr. John Ludgate, of the Cognitive-Behavioral Therapy Center of Western North Carolina, wrote. He says turnabout is fair play and invites the therapist to use the Cognitive Behavioral Therapy (CBT) techniques they share with their patients on themselves.

Whether we are new to the profession or seasoned, in private practice or in a not-for-profit setting, sometimes the therapist’s thinking could use a tune up to help them feel better about their work. That’s why I am happy that Dr. Ludgate agreed to be interviewed on this subject, one he describes as being close to his heart:

Me: Dr. Ludgate, in looking over the material you gave the attendees of your workshop, “Advancing Your CBT Skills”, I was pleasantly surprised to see “Common Negative Thoughts” and “Dysfunctional Beliefs” written specifically for therapists. Reading those pages for the first time I thought, “Wow, other therapists have these thoughts?” It was a revelation. When did you start looking into how therapists could use CBT for themselves?

Dr. Ludgate: Probably about 20 years ago when I realized how my own thoughts were getting in the way of doing effective CBT and also causing distress (anxiety, frustration etc). This was confirmed when I started supervising novice CBT practitioners who had these same issues and also as I realized just how little our training equips us for this part of our job!

Me: Is there something about therapists that makes them particularly vulnerable to critical self-judgment?

Dr. Ludgate: Absolutely. Therapists have been found to be very idealistic, have very high standards for themselves and have a very strong need to help others. All of which are great characteristics but they can set us up, too, if they are held too absolutely, and just like our clients, we fail to reality test our assumptions and beliefs.

Me: What has been your experience using this approach yourself or with your students/supervisees?

Dr. Ludgate: CBT is reflective and I believe it should be if it has any merit. CBT has helped me a lot professionally and personally. From students\supervisees it has elicited a very positive response as they have not had anything like this before and should have to deal with the challenges we all face and not get burnt out. There are no texts on CBT for therapists (I am trying to develop a workbook), no workshops, it is a sadly neglected area which we ought to be giving attention to in training, in supervision, in agency support groups and at conferences.

Me: Is there anything else that you would suggest for the therapist to keep a healthy balance in their approach to their work?

Dr. Ludgate: Yes, practice what we preach. Cut off from work at defined times, don’t have unrealistic expectations of yourself or your clients. Don’t take it home with you. Balance recreation and self care with work demands. Find healthy stress relievers and basically do all the things we encourage our clients to do, especially check out our own thinking when upset and recognize distortions, erroneous conclusions and come up with more balanced adaptive thinking which promotes better therapy and reduces our stress and frustration.

Click here to learn more about dysfunctional therapist beliefs, therapists’ negative automatic thoughts & what to do about them.

As I contemplated writing a post about how couples become vulnerable to affairs I read this interview of Ms. Kirshenbaum where she really says it all: Is Your Partner Cheating on You? on Mira’s blog. Here she talks not only about real risk factors, she also rules out signs that could be misread. In other words, not all suspicious signs point to an affair.

“…it’s not so much about warning signs. It’s about risk factors. And if you know what the risk factors are, you can do something about them and have a better relationship to boot…”

Here is an excerpt from the interview…

The Interviewer: …can you assess the risk that your relationship will be hit by an affair, that your partner (or maybe you!) will end up cheating one day soon?

Mira: Here are the three big, real danger signs that your relationship is at risk of one of you having an affair.

1) Things aren’t good between you. The two of you are distant, disconnected, fighting, not making love as often as you used to, and not having fun when you are together.

2) You’re leading very separate lives. You’re not spending much of your free time together.

3) Even if you’re not fighting and even if you are spending time together, if you start having the feeling that your guy just doesn’t care about you that much any more, that there’s a ‘whatever’ quality to how he treats you, then there’s a real risk that he is having an affair.

Q: Is this a risk factor? He flips the script. All of the sudden he wants to know where you are all the time and with whom. He’s realized that if he is cheating and it’s not that hard, well, you might be cheating on him too.

Mira: If a guy is cheating the last thing he wants to do is ruffle the waters. So he’s going to want to just tread very softly. It’s unlikely that he’s going to start acting all suspicious of you. If for no other reason than he’s not going to want to have the whole cheating issue out there in the open. If he flips the script on you, then he’s at risk of your flipping the script back on him. This has never happened in all the cases I’ve worked with. Only a very stupid person would do this.

Q: Is this a risk factor? Suddenly, Mr. Alpha Male is grooming “down there,” and will only wear designer underwear, whereas before his no-name tighty-whities were just fine.

Mira: Believing this kind of thing is a recipe for a lifetime of painful paranoia. It’s true that occasionally a guy who is having an affair will make certain changes in appearance, but lots of guys who are not cheating are doing things like that too! Men suddenly develop little pockets of vanity for seemingly no reason at all. It’s dangerous to read too much into it. And you’ll just make yourself miserable.

Q: Is this a risk factor: You’re having way more sex than usual. Alternate signs (same vein): He’s whistling or humming nonstop. Nothing phases him anymore. If he was short tempered before, now he’s downright giddy because he’s getting some from you and another woman.

Mira: Men cheat when there’s some disconnection or unhappiness in the relationship. The problem for guys doesn’t have to be sexual. And so it’s very possible that your guy could be cheating even though your sex life is basically the same. It’s [a] serious mistake to think that affairs are necessarily sexual. The risk of the affair being sexual is in reverse proportion to how good sex is between you. So a couple could have a good sexual relationship but then the guy cheats anyway and that would be because he’s unhappy in other parts of the relationship. If your guy is suddenly going around all happy and whistling and it doesn’t seem to have anything to do with you, then you need to find out why. I wouldn’t necessarily go to his cheating as the first reason but it could be.

Q: Is this a risk factor? He’s super protective of his gadgets. Touch his phone or computer and he flips out. That’s because it’s his lifeline to her. The number one ways that trysts are found out nowadays are via emails, chats, cell phone texts or bills.

Mira: This is absolutely true. But beware of any other hiding behavior, like if he’s suddenly vague about where he’s gone or what he’s done or with whom. Or if he suddenly starts being unavailable to you without good reasons. Or if there’s suddenly some new ‘project’ or ‘interest’ in his life that takes up his time and where you feel he’s hiding something.

Q: Is this a risk factor? He’s going on and on about a female friend who’s “super annoying” or “not that pretty” when you note that she dotes on him. Guys don’t think about girl friends that much—they simply don’t hang out with them if they suck. If he’s coming up with all these ways someone you know doesn’t measure up, something could be up with the two of them.

Mira: This is a very unlikely scenario. The premise is wrong. Guys can dislike someone without it meaning that they’re having an affair with that person.

For more on Mira Kirshenbaum go to The Chestnut Hill Institute website.

It took a year and three doctors before I was diagnosed with scleroderma. Just remembering what I went through during that year-from-hell gets my blood boiling and I know I was one of the lucky ones.

If you are experiencing symptoms but don’t have a diagnosis yet, here are some tips that I hope will help you get through this trying time a little easier.

Trust yourself. You are not crazy. Physicians have referred many people to me before they had a diagnosis, even doctors who don’t know what else to do for their patients.

ALL of them eventually received a medical diagnosis. That’s right. All of them.

Maybe I see a skewed sample of the general population but I don’t think so. Medicine is slowly catching up to the experience of hundreds of thousands of people reporting symptoms for which there is no hard, “objective” test. They should be believed. Even the Veterans’ Administration has come to recognize that when a combat veteran says he is suffering from Post-Traumatic Stress Disorder, he is not faking. As a whole, human beings do not want to be sick and it just pours salt in the wound when anyone suggests we are making up painful and debilitating symptoms.

Learn who you can confide in and who it’s best not to. Your loved ones may be among those who have doubts, especially if you don’t look sick. They may not understand that there is a lot the science side of medicine just doesn’t know or needs a lot of time to figure out.

Many chronic illnesses develop slowly and the symptoms overlap. There are few ‘hard, objective’ diagnostic tests that rule-out or rule-in a particular disease. Your family and friends may be frustrated and confused. Before your struggle, they thought doctors knew everything and, like Gregory House, could have you diagnosed and treated within the time it takes to microwave the popcorn. When given a choice of trusting the doctor or trusting you, you might lose out.

For those who are open to it, you can try educating them to this process. To those who aren’t, avoid them like kryptonite. They will suck away your precious energy.

But I’m getting side-tracked. My point is, that even when those around you are questioning the reality of your symptoms, trust yourself first.

If anyone, friend, foe or doctor, tells you any variation of “It’s all in your head,” please, resist the urge to spit in their eye. On the other hand, I’m telling you, getting angry and defensive on your behalf is better than doubting yourself and becoming depressed. Just regulate your anger so that you don’t alienate the very people you need. Do that by being direct, controlled and civil when you say, “That makes me angry.” Then let it go.

When your doctor tells you to go to a psychotherapist, try not to throw the baby out with the bathwater. Some doctors will refer you to a psychologist because they truly believe it would benefit you to talk to a professional who can help you cope as they try to figure out what is going on medically. That is great. Take the referral and try it out.

On the other hand, many doctors will tell you to see a shrink because they don’t know what else to do with you. It could be your anxiety, depression and anger makes them uncomfortable. Sad but true. That doesn’t devalue the benefit of a good therapist. Take the referral or find your own. You may discover it is actually a relief to talk to a good therapist and there could be other benefits.

Deb wrote to me about her experience after reading my article, Five Rules for Living With Chronic Illness. Before she was diagnosed with neurocardiogenic syncope she was: “in and out of the emergency room for two years and saw scores of “ologists” – cardiologists, neurologists, endocrinologists, you name it. But because I never completely lost consciousness (I could always hear what was going on) the common theory was that my condition was psychosomatic. So I saw a psychologist. He saw one of my spells during one of our sessions and told me “it definitely is NOT psychosomatic, it’s physical.”"

It took two more frustrating years before Deb was accurately diagnosed but at least she had validation from an empathic, knowledgeable professional that her symptoms were real.

Hint to doctors: Listen to Deb, who wrote, “What doctors need to realize is that we, as patients, don’t expect them to know everything. We do expect them to listen and treat us like intelligent, rational people. Maybe some of us are square and don’t fit into the round holes most doctors see everyday; but that doesn’t mean our symptoms aren’t real.”

Finally, as hard as it is, nurture yourself. As a chronic illness patient you will be telling your story to a million people, a million times. You will visit a gaggle of doctors, nurses, lab technicians, receptionists, offices and hospitals. You will fill out reams of forms, give up quarts of blood and pee, be poked and prodded, dress and undress a thousand times. It is exhausting.

Stop long enough to replenish yourself body and soul. If you pray, pray. If you meditate, meditate. Give yourself a pity party for twenty minutes (no longer), complete with chocolate! Then, for God’s sake, laugh! And if you have just one person, place or thing that eases you back to your peaceful place, be grateful and spend time there.

Above all, listen to your gut.

The article is impressive in how it covers many of the challenges parents face every day rearing their children while their health is seriously compromised.

Below, I summarize the article’s most salient points and add my comments:

1. “Handling chronic illness is about learning to live in balance,” said Rosalind Doran, Psy.D.

Many of us learn the hard way that if we don’t pay attention to what and how much we do in all spheres of our lives we can quickly over-do. The result is the same as when the tires on our car are out of balance. We’re in for a very bumpy ride.

2. “You can’t dwell on questions like. ‘Why is this happening to me?’ or ‘What if it gets worse?’ It’s important to focus on feeling well and to maintain a positive outlook.”

Yes, this is more easily said then done but this is an important point and one I’ve made before. If you have a chronic illness, and I do, there is a danger that we will over-identify with being a sick person. We are not our illness and it really does matter that we make the effort to see the cup half full.

3. The first hurdle is revising expectations of family life.

“Of course, you can still be a loving parent, but some adjustments will have to be made. Your family will not look the way you imagined it would. That’s a loss, and it hurts a lot.”

In order to move on, down a new path, we need to let go of what may have happened if we had gone down another. If we hold on to, “What would my life have been like if I wasn’t sick?” we deny ourselves the opportunity to create a real and satisfying present.

4. A chronic illness may change your plans about having more children.

That may mean imagining a life with fewer kids, considering adoption or even remaining childless. I had to accept the very real possibility that I would not be able to have kids. As anyone who has been through such an agonizing reality, there is a mourning process, a grieving that takes place. For many women there is also a feeling of guilt (could I have done something to avoid this?) that must be let go.

5. Fighting fatigue and dealing with the cycle of ‘good days’ and ‘bad days’.

For many, this is one of the most difficult stresses when coping with chronic illness. When my illness was active, I woke up thinking, “What kind of day will this be?” Simultaneously, I mentally did a full body check. If everything ached so much I didn’t want to move, I moved anyway, knowing that, like the Tin Man in the Wizard of Oz, if I didn’t move I would be stuck there forever.

6. Learning to put your needs ahead of your child and husband.

Another tough one but absolutely necessary. We are here, committed to the long haul, therefore we need to be cognizant of how we care and maintain ourselves to last.

7. Ask for help. Re-create a sense of extended family. Support groups.

There’s a man in the article who developed a group of Dad substitutes for his children in case he died before they were grown. That took guts and true friends.

8. Talk about your feelings with a mental health professional who gets it.

Yup. Consulting with a professional can really help you, not only with your own adjustments but also those of your spouse, helping him or her appreciate what’s going on.

9. Figure out how to navigate your new normal.

Allowing yourself to make needed adjustments when it comes to what you can do now takes a lot of love, kindness and patience. It can also mean trials and errors, experiments until the right formula presents itself and then that will need tweaking as circumstances change. It helps a great deal to have a team mate. My husband and I, married over 25 years now, check in regularly. Is our system still working?

10. Be open to the possibility that there is something actually positive in experiencing life with a chronic illness.

There is something to that old saying, ‘That which does not kill us makes us stronger.’ If it weren’t for having to deal with a chronic illness from early adulthood, would I have fully appreciated the great miracle life is? Would I have paced myself everyday to take the time to rest, to ‘smell the flowers’ as well as to work? Those of us who are veterans in living with a chronic illness try not to sweat the small stuff, value the gift of the moment and tend to catch ourselves early should ambition gallop ahead of what is healthy.

Speaking for myself, I know that coping with chronic illness has made me a better person, and, I like to think, a better therapist; more empathic, more patient, more open to happiness. It may sound crazy to some, but I truly believe I am blessed.

Read the entire article “Mommy Isn’t Feeling Well Today”, Parent’s Magazine, September 2010, page 96.

Mental illness is often a family issue. Parents, siblings, spouses and extended family provide housing, care and support, emotional and financial, sometimes to the point of becoming proverbial case managers. It’s hard enough when the chronic illness is something everyone recognizes, like diabetes. It’s a whole other thing when the disease is a mental illness which is ripe for misunderstanding, misinformation and stigma.

By helping yourself you will help your loved one better. Care givers often have a hard time with this concept. Here are a few tips:

1) Be informed. Go to the library or do a Google search to learn more about whatever diagnosis our loved one has. Be judicious, however. Go to reliable websites like the Mayo Clinic, National Institutes of Mental Health. I am proud to be part of the Psych Central community primarily because the information you find here is accurate, responsible and scientifically supported. As you do your research, remember that mental illness falls along a continuum of severity. One person’s depression, bipolar or borderline personality disorder may be quite different from someone else’s.

2) Join supportive organizations. Before you reject the idea of support groups because you are “not a joiner” or you “can’t relate to those people,” go to at least two meetings. I’d bet my favorite pair of shoes that you will be surprised who is there and what you get from them. Mental illness and addictions touch people everywhere from all walks of life.

The National Alliance on Mental Illness, NAMI, provides thousands of families with much needed support. NAMI’s mission statement says: From its inception in 1979, NAMI has been dedicated to improving the lives of individuals and families affected by mental illness. They have a terrific website and local meetings.

Al-Anon also has a great tradition of fellowship and comfort. Al-Anon and Alateen are a fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems. There are meetings everywhere, at all times of the day and night, all around the world.

3) Keep healthy boundaries. Boundaries are hard to maintain when you love someone with a mental illness, but it is crucial. Take time out for yourself. Nurture yourself by exercising, keeping involved in activities that bring you pleasure, getting respite and taking a trip. Keep up your connections to friends. Such actions are not self-indulgent, they are your prescription for good health and resiliency like food, water, and air.

4) Do not work harder than your loved one. It is their job to do what they can to get well. You cannot make them well. You cannot do their therapy homework. You cannot force them to go to sessions, groups or meetings. As much as you wish you could, you cannot take their medication for them.

Two good books to help you let go, even as you maintain a relationship with the person with mental illness, are Co-dependent No More by Melody Beattie and Stop Walking On Eggshells by Paul T. Mason and Randi Kreger. It doesn’t matter whether or not your mentally ill love is an addict or a borderline personality disorder. The insight and advice in these books are reassuring and practical and transcend diagnosis.

5) Find a therapist for yourself. Caregivers often get depressed themselves and could use a professional’s eyes and ears to help them gain perspective again. Please do not wait until you are down for the count before you give yourself this valuable gift.

Please share any other tips you have found helpful below in the comments.

Whenever we see people out of a familiar setting it can be awkward. The other day I was having dinner with my husband at a restaurant when a very familiar lady walked by and stopped to say hello. I couldn’t remember for the life of me where I had seen her before. My poor brain sifted through the files until finally it reported that she worked at the library where my kids and I go once a week. Whew. Embarrassment averted.

Occasionally I run into old or current patients in public, resulting in another kind of challenge. Do I say hello or not?

In my dad’s day, there would have been no question. Psychoanalytic thinking was very clear back then. Both patient and therapist should pretend they don’t see one another, even if it is obvious to both that they have.

There are reasons many therapists still feel that way. One is that it could be seen as inappropriate, even harmful, to acknowledge the working relationship outside of the ‘therapeutic frame,’ meaning the clear boundaries of the time and day of the session and the four walls of the office.

Plus there are the issues of confidentiality. Saying hi to my patient in public might put them in the uncomfortable position of explaining who I am and why they know me.

While these are good reasons to take such unexpected encounters seriously, I don’t believe we need to be all rigid about it.

Salman Akhtar, MD, renowned psychoanalyst and author, said that if a therapist runs into his patient outside of the office and the patient says hello, of course the therapist says hello back! That is just common courtesy and it can be done in a therapeutic, professional manner.

Here are a few guidelines to help public encounters between patient and therapist feel as safe and comfortable as possible:

> Therapists usually take their cue from the patient. We will steer clear of saying hi unless our patient indicates in some way that it is OK. You are free to make the choice that feels right to you at the time. There is no judgment either way.

> If you do greet each other, the therapist does his/her best to put the patient at ease, keeping conversation friendly, short and sweet. Because the therapist is the professional in the relationship, the onus is on him/her to give guidance at a time when the patient may feel vulnerable.

> Neither party will say anything referring to your therapeutic work or relationship like, “Doc, I’m having trouble with that homework you gave me.” Or “We’ll talk about that in our next session.”

> If other people are present, do not feel obliged to introduce your therapist. Your therapist will understand your need for privacy. He/she probably won’t introduce you to whoever they are with, but if they do, do not feel obliged to say anything beyond, “Nice to meet you.”

> Debrief the encounter in your next therapy session if you have any lingering concerns. Whether or not you actually greeted each other, if you have any thoughts at all about running into your therapist in public, what you said, didn’t say… air it all out together.

> An ounce of prevention… Ask your therapist what to expect if you run into him/her in public before it happens. Such a conversation could be helpful to you both.

Photo courtesy of negra223 via Flickr

The cause was cancer, said her husband, Ronald Cohen.

Ms. Ross was a 25-year-old teacher on vacation in Salzburg, Austria, when she was struck by a sudden fear of heights — a fear that would, in time, make her a public figure. After learning to manage this dread in 1978, Ms. Ross joined the practice of Dr. Robert DuPont, a prominent psychiatrist in the Washington area, to help others do the same.

A skilled therapist and exuberant optimist, she soon had her own radio show, in the 1980s, where she became known as the “phobia lady.”

Ms. Ross testified before Congress on behalf of those with mental illnesses. She appeared on “The Oprah Winfrey Show” seven times over the years. And in countless newspaper and magazine articles, she explained persistent anxiety and how to live with and manage it. She was equal parts therapist, fellow sufferer and inspiration.

In 1980, with Dr. DuPont, she founded the organization that would become the Anxiety Disorders Association of America, which was integral in raising public awareness of, and research money for, problems like social anxiety, post-traumatic stress and obsessive-compulsive disorder. Ms. Ross was the director of the association until her death.

“The reality is, when we started that group, anxiety disorders were nowhere on mental health geography, period; they were thought of as trivial and rare,” Dr. DuPont said in an interview on Wednesday. “Well, that one woman carried the cause, got research funding” and put the disorders on the map.

Researchers now estimate that 30 million to 40 million Americans suffer from some form of nagging anxiety, from mild to severe.

Jerilyn Ross was born in the Bronx on Dec. 20, 1946. After graduating from the State University of New York, Cortland, in 1968, she worked as an elementary school math teacher in New York City. She earned a master’s in psychology at the New School for Social Research in 1975.

In 1994 Ms. Ross and the former first lady Rosalynn Carter published “Triumph Over Fear,” about anxiety disorders. Her book “One Less Thing to Worry About,” written with Robin Cantor-Cooke, was published last year.

In addition to her husband, she is survived by three children, Alan Cohen of Bethesda and Crain Cohen and Sue-Ann Siegel of Potomac; and seven grandchildren.

“Each of us has a different relationship with anxiety, just as each of us has a different relationship with our mothers, our fathers, our children, and everyone else in our lives,” she wrote in her second book. “What’s important is not learning the ‘right’ way to respond to anxiety but learning how you relate to it and whether or not the relationship is working.”

In Ten Ways to Find a Good Therapist I focused on how you can get promising referrals, an important step to locating a therapist who will work well with you. Once you have two or three names, then what?

Narrowing down your prospects is a lot like triage or 20 questions. You don’t want to spend a lot of time talking with someone about your problems only to find out they don’t have room for new patients. First contact is usually made by phone, but more and more frequently people are using email. Either way, making that first call or writing the first email to a prospect can add to your stress so here’s a script that I hope will help in your search:

Hello, my name is *** and I’m looking for a therapist. Your name was given to me by *** [or I found you on the Internet]…

1.Are you taking new patients? If the answer is NO you are done and you can say thank you and goodbye. If YES continue…

2. I am looking for someone to help me with… Briefly describe your most critical issue, the thing that is bothering you the most. Do you work with that? If YES continue to the next question.

3. Regarding your payment: Are you a participating provider on my insurance panel? Do you handle the claims? What types of payment do you take? Do not be afraid to be clear about your financial situation. They may have a sliding scale or payment options for you. If the answers to these questions are satisfactory, go on to the next question…

4. How soon could you see me? If they can see you within two weeks, that’s great. Some very good therapists, however, are booked weeks, even months ahead. This is especially true if their service is specialized, child or adolescent services, for example. If the therapist is still taking new patients, and so far you have a good feeling about them, go ahead and make an appointment. You can continue your search and if you find someone equally qualified who can see you sooner, take that appointment as well. Seeing more than two people face-to-face is a good idea, allowing you to have more certainty once you make a choice. Professionals are fine with this and understand you are doing your due diligence.

5. Is there anything else you need or anything I should know before our appointment? A catch-all question that could include directions to the office, receiving any paperwork to be filled out before the appointment, an exchange of essentials like contact information, cancellation policies, etc.

This conversation usually takes about fifteen minutes. Of course the therapist or office staff may have questions and procedures of their own.

In addition to gathering the obvious information, evaluate the experience of this first contact, as well. Whether you are talking to the therapist directly or to an intake/office person: Are they courteous, patient and reassuring or are they rude, irritable and dismissive? If you send the questions by email or have to leave a message, how quickly do you get a response? Expecting a response within forty-eight hours during regular business hours is reasonable. If they can’t see you for whatever reason do they offer help in your continuing search?

When your head and gut are telling you this contact could be a good therapist for you, make the appointment.

Because entering into therapy is a serious commitment, I offer the first session for no charge whether it be in the office, by phone or Skype. Many therapists do the same, although I can’t say that it is standard practice. It shouldn’t be a deal breaker if they don’t offer a gratis session.

If you found a good therapist, how did you find him/her? Would you add anything to this ‘first contact’ script? If you are a therapist, what suggestions do you have for people who are looking for good quality counseling?