Your Therapy Experience: What to Bring with You on Your 1st Appointment

We live in this modern and complicated world. When we are beset by troubles and seemingly insurmountable challenges in our lives, we often find it difficult to consider all of the viable alternatives. Having exhausted every possible course of action we can think of, we turn to friends and loved ones for guidance and reassurance. Often this resource can be successful in terms of providing comfort and support, but the deficit, the "problem" and the associated discomfort, pain and anguish are still there.

So we reach out further from our small circle for support from our community. We enlist the help of clergy, teachers, principals, our family doctor and other authority figures that we know and are familiar with and trust in our dealings of everyday life. Often the advice and wisdom of these authority figures proves fruitful and we are able to successfully address whatever mechanism is inhibiting our quest for personal happiness.

When these interventions do not work, the next logical step is to seek "professional help." This action is, in fact, often one of the solutions that is presented by these visible members of the community that your have relied on for many years. Behavior clinic's referral sources are prominently fueled by relationships with schools, doctor's and churches.

But, alas, so many are reluctant to take this next step. Although statistically supported as a viable resource for individuals who are in psychogenic pain or discomfort, many avoid the next step of talk therapy and are destined to unnecessarily suffer through many years of their lives. There are many reasons people are reluctant to do this. One I believe is cultural. An American value is to be self-reliant and vigilant. The shame and embarrassment of baring one's soul to a stranger and of being reliant on them for help contradicts this ingrained value of independence and autonomy. Another obstacle to people seeking treatment is the stigma that is attached to having their problems institutionally addressed. As one of my client's once said to me at an initial appointment "when I think of psychotherapy, I think of 'psycho,' like I am nuts or something is seriously wrong with me." There is this old-fashioned, archaic view of the therapist picking the client's brain apart over the course of many sessions and months and the identification of some serious mental disorder or cognitive deficit.

This "couch and chair," era of psychotherapy has given way to new and exciting treatment techniques that focus on one's personal betterment and more on what is "right" with the client than "wrong." Therapists identify client strengths and assets and help them develop and utilize them to overcome admitted weaknesses, deficits and external sources of stress. Hence, you are not the "problem," but it exists in your social or occupational environment and as therapists we are here to help you with that problem.

The 1st attitude "to bring with you," to an initial talk therapy session is an open mind. Do not suppose that your experience will be akin to something you were exposed to in the media or heard from a friend. Every client-therapist relationship is unique and has a life of its own. The course, quality and length of treatment are dependent on the invested energy and mutual development of trust and honesty by both parties. Relinquish that trust in your therapist at a pace you feel comfortable with, with the rate of your disclosure being one that he or she earns based on the quality of their input and the sincerity of their reactions. Remember, we are working for you.

Another important concept to grasp when preparing for that 1st session is one of equality or parity. A therapist will engage with you in a manner which is not condescending, self-righteous or critical. We are all frail human beings and it is the therapist's task to observe your behavior but not to past judgment or make value-laden recommendations. A competent and experienced therapist has been exposed to a wide spectrum of behaviors and should be accepting of yours. If the therapist can not objectively treat you based on a difference in personal values, then it is an ethical responsibility for the therapist to refer you to another. You also have the option to request another therapist if for some reason you feel uncomfortable with the current relationship.

So when you seek talk therapy services, give the therapist the benefit of the doubt. Be assured that this "stranger" will soon be a skilled confidant. Engage with them in a truthful manner and with an air of mutual respect and be comforted by the fact that there are many years of experience, training and education in the helping professions available as a resource for you. The result will be a happier, better adjusted, actualized you. The quality of future experiences and accomplishments for you, family and friends may very well depend on what you bring to that 1st appointment.

Pandora's Disgrace: The Bottomless Jar

I received this email yesterday, in the wee hours of the morning. The issues of marriage and family are very complex here as there are many considerations: culture shock and adjustment, depression due to illness, lifestyle changes. Included also are more familiar marital stressors such as financial difficulty and trust. The correspondence is printed as written, excepting the name which was changed to guarantee anonymity.

I married a Frenchman in California. Following a layoff and a narrow frame of "I am only qualified as an engineer to work with one specific product," we returned to France with our new born baby seeking stability and my understanding was that eventually we would return when the market picked up. Here we have too much stability. Stability that makes you not change, meaning you just sit in one place. Someone has to die or retire before moving up the latter. Salary increases are maybe 3%/year (if lucky) while cost of living increases by at least 10 - 20% per year.

Turns out now my husband doesn't want to return to the US and I feel totally betrayed, tricked, swindled...whatever the word is.
I spent the first three years in France raising our child without any family or support around. It wasn't easy, but I'm happy I was able to be there. Kids start school at age 3 in France, so when my child started school, I was hired at a French company. After I realized I was paying 50% in taxes (government retirement included), my contract was up and I decided to stop working. I had searched for work before my child started school but never found anything. It's a very difficult job market in France. Then when you finally do find work, you wind up paying most of your salary in social charges and taxes. I was hired for almost 3X minimum wage. After taxes my net was 400 Euros above minimum wage. Do you get what I'm saying?
So I have spent 5 years of my life in this country that I never really cared for, except the beautiful vacations, which entail 3 weeks/year. My husband is in hog heaven back in his country and has no intention of returning to the US, though he has said otherwise, his actions have led me to realize he really has no intention. I must say that he was diagnosed with Multiple Sclerosis about 10 years ago and doesn't want to live in the US without health insurance, and I do fully understand that. But so far his disease has not at all been progressive, yet this is the kind of disease that's very hard to predict.
I grew up in a divorced family. I didn't like it and said I would never put my child through such an unfortunate situation. But now I am like, at what point does my happiness count as equal value to the happiness of my husband's and my child's? I have always felt selfish for wanting to be happy when my child's needs are very important. But I have to acknowledge that if a child's mother is not happy then that could eventually radiate towards the child. I hide my unhappiness as best as possible, but after 5 years I know it can't go on. I don't want my husband to loose the house he so loves and paid for because of a divorce, which will happen, but at the same time - all of our money is in the house. I can't leave empty handed either. I need as much as possible to rebuild in the US.
We all know French stereotypes, and I have to say hygeine is another issue. My husband still uses cotton hankerchiefs. He blows his nose on one and then puts it back in his pocket only to reuse the same one throughout the day. This time of year, he has come down with a cold. So there is excessive mucus and he is still using and reusing the cotton ones. I have bought the pocket sized paper ones and put them in the drawer where he keeps the cotton ones but he refuses. He also left one full of mucus lying on the kitchen counter. He blows his nose in the shower only for me to find "remains" on the shower curtain. I think he has IBS and is constantly having diarreah and there are always spots on the toilette for me to clean up. I hate to sound petty, but these things really bother me. The good news is he does shower every day.
Also, the cost of living in France is more expensive than most Americans could imagine, except for maybe New Yorkers. Even then, electricity and gas (heating) and gas for cars are cheaper than in France. So we bought a house in a town with a really bad reputation, high-rise housing projects all over the place, full of Muslim immigrants, and I just don't feel safe in this town. I mean, I know most Muslims are innocent and kind people, but here we have extremists, women walking around in Burkas, with only a slit for their eyes. Men wearing long robes with long beards. It freaks me out. I guess I might have a slight phobia. But I just don't feel safe given the current political situation between the US and the Arab world.
We almost didn't get the loan for this house because of my husband's multiple sclerosis because in France, everyone is required to have a PMI (private mortgage insurance) in the case of death or disability, the insurance is required to pay our mortgage. So he doesn't want to buy a house anywhere else because of the paperwork nightmare and the high cost of this insurance.
I am just totally lost. I mean maybe the answer is obvious for you. I know the choice isn't easy. But I just don't know what to do. I was always an ambitious person. Always seeking to better myself through work and education. Working and education have come to a screeching halt in this country. And it's not from a lack of effort.
Please advise.....
Sally

This women is overwhelmed with negative emotions. In the last 6 years, her world has been turned upside down. This series of events has helped foster hopeless and helpless feelings regarding her life and future. Seemingly she is trapped in a foreign land with her child and a man she has lost genuine feelings for. Her mindset is such that she feels she has few alternatives. She feels subject to despair and isolation and blames her husband for her miserable condition.

We are culturally taught that times of adversity will be followed by some form of reprieve. Our situation can only get so bad then there will be a glimmer of hope, the light at the end of the tunnel, that the sun will shine tomorrow. In Sally's case, there is seemingly no possibility of reversing this negative trend. The adversity she experiences has been accumulating for so long, it will seemingly never end.

Understandably, her mindset is negative and her clarity of thought has been diminished. Because she has been bombarded with these personal challenges, she has narrowed her alternatives down to a lose/lose dilemma: Either live her life in a place where she can never be happy or betray the continuity of her family and return to the states.

The truth of the matter is there is always more than 2 alternatives to a dilemma. Sally must re nurture that part of her mind that gives us hope in the face of adversity. She must begin to consider what she can do to restructure her marriage and reconstruct her life. If after she has exhausted all of her alternatives and has come to the realization that despite her efforts her life in France will be woeful and miserable, then she can make that choice to leave, with the conviction that she truly tried to rectify her marriage and that leaving is the best action to ensure her child's happiness.

The 1st dynamic to consider is the mental state of her husband. From what is revealed in the letter, he appears to be chronically depressed. His pain inducing illnesses (MS and IBS) are one indicator. His deteriorating hygiene can not be chalked up to simply a difference in cultural norms. I am certain he did not present himself in this insalubrious manner when he 1st met Sally, or she never would have married him. He appears in need of professional mental health intervention and lacks the awareness to seek help.

So Sally can help him reach this insight. If his mood and personal habits change, it would provide much relief to her stress and the perception that she is being objectified by him. Which leads us to the 2nd dynamic, that there is a profound diminished communication between this couple. This would further explain his depression and Sally's dilemma. Both parties have no one to reveal their innermost thoughts directly to and receive nonjudgmental feedback. For Sally, this emotional isolation is furthered by being so far away from friends and family. Sally is reluctant to engage in any serious and productive conversation because she no longer trusts him. She feels tricked and manipulated into living a life she did not choose. Her husband is so distracted by his medical challenges and depression he can not organize his thoughts well enough to identify and elicit his feelings. And yes, he has become so focused on himself that he is severely ignoring the needs of his wife. There is an impasse in terms of honest discourse and she must make an effort to break it. The first step to improving their communication is for him to seek the aforementioned help he needs.

During this process Sally must ask herself some honest questions. One would be hypothetically "could I be happy in France if I had the love and support of my husband?" I have a feeling that with him as an ally she could overcome some of the discomfort and fears she experiences from living there and these cultural anomalies could be tolerated at least until the child is raised and she is released from the obligation to keep the family cohesive. If she feels she no longer loves this man, she must ask herself given her resentment, could she ever love him again.

If she can answer yes to all of these questions, if she can visualize tolerating the differences of those around her and a profound change in her husband's mood, she will once again become hopeful. She can envision a family life where everyone is working toward common goals of emotional stability and material betterment. If she makes this full effort to change her current familial and martial conditions and fails, at least she will have the peace of mind that she explored every option before her flight from France. She can wash her hands of this situation and never have to second guess this decision.

In these troubled times, all of us, like Sally, face some profound challenges. In order to endure our ills and the obstacles we are plagued with, we must summon all our energy and reach deeply into that vessel and obtain both strength and resolve. We must realize that hope is not to be utilized as our last resort or a means of comfort after we have conceded defeat, but is a valuable tool in addressing the seemingly insurmountable challenges of our lives.

I leave you with a quote by a colleague and coworker of mine, Dr. Ken Cunningham.

"The substance of hope is our entire narrative and our capacity to say we possess it. Our hope is a result of having lived with and being influenced by others, and when we are shaken, our hope holds us and we learn to reinvest in life. When our hope is gone, changed or altered, it takes something to give it back to us. Undoubtedly, that something is often relationship or experientially based, and in that, we learn to consider hope again."

Treatment Considerations and a Case Study

This is my first day "on the blog," so I am giving treatment considerations and a case study in lieu of advice. This will not be my usual format, but an opportunity to see how I approach one on one therapy.

Life in this modern world zips by. We are in a fast-paced society that is fueled by impulsively and the need for immediate gratification. To compliment this facet of society, professional and self-help must be geared for a quick solution to a presenting problem.

In the realm of psychotherapy, long gone are the days of an elaborate clinical course utilizing psychoanalytic techniques. The recline on the couch and the reciting of childhood memories have been outmoded due to the restrictions of managed health care, the time constraints and personal demands of the client.

Solution-focused therapy holds the belief that the client has already done allot of deliberate internalizing regarding "the problem." When they present to a therapist, assuming they are fairly high functioning, the process of solving the problem is already well underway. It is the therapist's job to identify the stumbling blocks, obstacles or where the client got stuck in trying to resolve their issues along the way. The therapist may present some ideas to overcome these obstacles that were not previously considered by the client. He/she may propose ways to alter or "tweak" approaches that have already been attempted.

It would be easy but ineffective to mechanize therapy and categorize presenting problems and create pat answers and solutions for those in need. This is where adept and advanced listening skills come into play. The active listener will absorb the details and nuances of the situation and be able to hypothetically place themselves in the clients’s realm while having an appreciation of their background, personality, demeanor and deficits and attributes. I call this ability "Individualizing," the ability to immerse one's self into the present day challenges of the client with an appreciation of their past experience, present dilemma and future aspirations and dreams. I suppose a frivolous analogy could be made with the sci-fi "mind melding" fantasy. This treatment approach is selfless, time consuming and requires a tremendous amount of energy. But I would argue that is the only way to be an effective behavioral counselor. The complicated problem solving process can not take place without these devote approaches to therapy.

A case study:

Korrina was a 35 year old divorced female. She had 2 children and was in skilled trades. She presented as anxious and depressed. She stated she was in a "committed" relationship of almost 2 years. She complained that the relationship was not going anywhere. The commitment she spoke of was very arbitrary and ill defined. Her partner often referred to his own personal freedom as a means to avoid any obligation or emotional support to her. When she would make the subtlest of demands from him, he would castigate and demean her. He felt that she was always trying to pin him down and their weekend plans were often not settled until a day or 2 before they got together.

She realized that they wanted 2 completely different things in this relationship. She had tried to leave him a couple times, but a physical attachment had been formed and the idea of "starting all over again," seemed difficult. The idea of finding someone accepting of her and her preadolescent children, her past failed relationships and her busy work schedule made dumping her self-absorbed friend and finding the "right one" seem like an impossible task. She knew the current relationship was unhealthy to the point of fueling her anxiety and depression, but the physical attachment to her current partner and the belief that she was not "good enough," based on her past failed relationships kept her from moving on.

Korrina was at that immobilized or "stuck" point I referred to earlier. She was an intelligent, emotionally mature woman and had tried to change her life for the better in the past. As her therapist I had to identify the hurdles she had to overcome to solve her problem. It was also my task to identify what assets she had to overcome these obstacles and give her the confidence to operationalize the agents of change.

She had got as far as realizing the poor quality of her relationship and attempting to break things off. The obstacles were her perceived physical and emotional attachment and the belief that she wasn't capable or didn't "deserve" a healthy relationship.

One quick revelation I gave to her was how intertwined these 2 obstacles were. She had been programmed by her current partner to believe that she was inadequate to obtain the closeness she longed for in a relationship. In convincing her of these inadequacies she felt more and more dependent on him. Her physical dependence was not formed from admiration and genuine affection but the irrational belief that she was destined to be in a relationship where her partner was aloof and uncaring. She may have loved him, but for all of the wrong reasons.

The disappointment of her divorce and subsequent failed relationships had made her lose sight of what a healthy relationship was and discard the belief they could exist. I gave her examples of healthy relationship and encouraged her to describe some couples she personally knew who had been happy a long time. We kicked around what made them successful relationships. She began to appreciate that although there may be no prince charming or perfect man for her as she may have expected from a developmental, adolescent schema she had developed, there were healthy relationships out there.

The next task was getting her to refute the demeaning observations that her partner had made to her. He was trying to program her in such a way to keep her under his thumb. Without being flattering or flirtatious I contested his observations about her personality and appearance and help invigorate her self-esteem. I pointed to many of her outstanding personal qualities.

The identification of these personal strengths signaled the next phase of therapy. She was professionally employed in trades, committed to family life and of strong Christian faith. Her ability to love her children and God made an easy transition to self-love and a renewed confidence.

She had tried dating sites in the past, ones geared towards the general population and Christian oriented ones. She had always give them a half-hearted try because the thought of returning to the unhealthy relationship was always there and seemed like an easy way out. And the notion that she was truly in love. This obstacle was now removed due to the recent appreciation of how badly she had been treated, the realization that there was something better out there for her and her more positive self-concept. She began a more vigorous approach to Internet dating. More important she realized the value of her beliefs and children and gleaned the support of church and family. She had become more content, happy for who she was and not beholden to anyone.

After sometime dating several men she found someone who fit her values and beliefs and is fortunate enough to feel the genuine benefits of having someone whom is loving, considerate and caring and appreciates that she gives him all of these things in return. A happy ending.

To review the course of treatment and to try to step-by-step a very personalized process: 1) An identification of "the problem (in the context of the client's personal experience)," and where the client was at in terms of already solving that problem. 2) Specifically pinpointing the obstacles that were cause for the client to fall short of bettering her life. 3) The refuting of irrational beliefs, cognitive errors and long-held schema that were cause for emotional and mental paralysis and 4) The operalization of the client's strengths and assets in overcoming the pinpointed obstacles.

This is an example my approach to therapy. I am eclectic enough to use any modern treatment approach for the betterment of the client. In this case study, short-term, solution focused, cognitive-behavioral and strengths/asset based therapy were the recipe for my client’s betterment. May I leave you with a poem by Bessie Stanley:

Success

To laugh often and much;

To win the respect of intelligent people and the affection of children;

To earn the appreciation of honest critics and endure the betrayal of false friends;

To appreciate beauty, to find the best in others;

To leave the world a bit better, whether by a healthy child, a garden patch or a redeemed social condition;

To know even one life has breathed easier because you have lived.

This is to have succeeded.