Saturday, March 31, 2012


We seem to be hearing about it a lot these days.  Kony 2012 film creator Jason Russell strips naked on a San Diego street corner.  He paces, apparently agitated, and begins beating his fists on the sidewalk.  A JetBlue pilot exits the cockpit mid-flight and goes into a lengthy rant.  He talks about Iraq and Afghanistan and at one point claims there is a bomb on the plane.  He then starts banging on the cockpit door and has to be physically subdued by a group of passengers. 

These are seemingly "normal" people, probably dealing with the same types of daily stressors we all face.  They, like us, are going about the business of living life, with all the ups and downs that come with it...

Until something happens.  They have a meltdown.  They reach their breaking point; they snap.  They crack up, have a nervous breakdown, fall apart, come unglued, etc.  None of these are actual diagnoses, but the terms are part of our shared vernacular nonetheless.  They all refer to the collapse of mental and emotional strength in the face of overwhelming stress.  They all attempt to describe what happens when a person's stress reaches the point at which it overwhelms his ability to cope.  This can be due to the accumulation of stress over time; it can also occur in response to a single traumatic event.

So what happens when a person reaches his breaking point?  While no two people are the same, I believe it is possible to classify the majority of possible experiences into a few broad categories.

Psychosis: When a person becomes psychotic, his or her sense of reality becomes distorted.  He may see or hear things that aren't really there (hallucinations).  He may hold firm to beliefs that are inconsistent with what is actually taking place (delusions).  His thoughts are often disorganized, making it difficult to think clearly or to make sense of his experiences.  This is apparently what happened to Jason Russell.

Suicide: This refers not only to committing suicide but also to attempting or even seriously contemplating it.  A person seeks to end his own life when he sees no other way to cope with reality as it exists.  He reaches a point where he believes he has no other options.

Inability to function at the level required to complete activities necessary for survival: When a person reaches this point, he may not be able to bring himself to get out of bed in the morning.  Instead of going to work or to school (or instead of getting his kids off to school or doing whatever it is he is responsible for doing in the morning), he simply stays in bed.  He doesn't bother getting up to eat or to shower.  He isolates himself from his friends and family.  He lacks the energy and/or motivation to continue participating in life. 

Extreme/erratic behaviors: Often the behavior in question is an impulsive one.  For example, a person's boss criticizes him.  Overwhelmed by a multitude of stressors, he simply snaps.  He physically attacks his boss and has to be restrained by several coworkers.  The behavior of the aforementioned JetBlue pilot also falls into this category.  Sometimes the behavior is slightly less extreme but is completely out of character and not something the person would likely do under "normal" circumstances.  For example, I once knew someone who had graduated college a few months earlier and was feeling overwhelmed by the stress of her first "real" job.  She was a very responsible and conscientious person by nature.  She was scheduled to work one evening but, when the time came, she just could not bring herself to go.  Instead, she got in her car and just started driving.  She ended up several hundred miles away, in a neighboring state.  Her family became worried when her supervisor called to ask why she hadn't come to work.  She essentially "ran away" from life, leaving behind everyone and everything.

Could this happen to anybody?  Do we all have a breaking point?  I've often wondered about this, particularly in the case of psychosis.  Is it possible that any one of us could break with reality and become psychotic if faced with overwhelming trauma or stress?  I honestly don't know.  I am, however, fairly certain that we all have some sort of "breaking point."  Naturally, we all vary in our ability to cope with stress; some people are able to tolerate higher levels than others.  Still, nobody's ability to cope is unlimited; we all have limits to what we can endure.  It is important for us to remember that we cannot allow stress to accumulate unattended and expect to remain unaffected by it.  We significantly decrease the likelihood that we will ever reach our "breaking point" by coping with individual stressors as they arise and by making self care a priority.

Saturday, March 24, 2012

Thanks, I just needed to vent

According to the free dictionary, to "vent" is to give outlet to thoughts or emotions.  Alternatively, it is to unburden oneself of strong, pent up emotions. 

We have probably all had the experience of needing to vent.  We are upset about something and we feel like we might explode if we don't share it with someone.  For most of us, the identity of that someone matters.  We don't just go around venting to anyone who will listen.  Rather, we have a small group of people we feel comfortable venting to.  When we feel overwhelmed, we call one of these people and share our frustration.  By the end of the call, we tend to feel a bit better.  "Thanks for listening," we tell them.  "I just needed to vent."

The experience is so common that we don't really think about it.  Sometimes people need to vent; we vent, we feel better, right?

Actually, the research on venting is pretty clear.  Venting negative emotions leads to an increase in their intensity.  This is especially true when dealing with anger but seems to apply to other negative emotions as well. 

This seems to conflict with what we know from our own experience, right?  Not necessarily.  The literature seems to equate venting with throwing a "temper tantrum."  Personally, I refer to this tantrum-like activity as "bitching."  Others refer to it as whining or chronic complaining.  It implies the chronic, excessive expression of negative thoughts and feelings.  It is expression that serves no purpose; the expression itself is the goal. 

Now this is something I'm familiar with!  I have, on occasion, had patients like this.  In fact, it was my current frustration with just such a patient that led me to write a post about venting.  My colleagues informed me that there is actually a name for this type of patient (or person, if the person purports to be asking for help): help-rejecting complainer.  I know, it seems a bit perjorative.  But if the shoe fits...

Let's go back to venting though.  So that we don't confuse venting with throwing a temper tantrum, let's define it as "verbally expressing negative thoughts and emotions."  When defined this way, can venting be therapeutic?  The answer is yes.  There are a number of circumstances in which verbally expressing negative thoughts or feelings to another person can be helpful. 

When someone "vents" to me, my initial response is the same, whether I'm in the role of therapist, friend, spouse, sister, or daughter: I listen and I validate.  I think that's what most of us want when we express our thouhts and feelings.  We want someone to understand how we feel and we want someone to tell us it's okay for us to feel that way.  For everyday frustrations, this is often enough to make the person venting feel better.

As a therapist, this is a good first step.  Listening empathically and validating a patient's emotions helps to build rapport.  The patient feels understood, validated, valued, and accepted; he or she leaves the first session with positive feelings about the therapist.  Venting in and of itself, however, does not bring about lasting change.  To be truly therapeutic, venting must be used as a catalyst for identifying patterns and gaining insight.  For a patient to make use of venting in therapy, he or she must be willing to accept feedback about the material vented.  The goal is for the patient to begin to consider alternative perspectives or to identify methods for accepting, tolerating, or coping.

All of us can benefit from considering a few things the next time we "need to vent."  Venting is not always helpful and can sometimes cause our negative emotions to intensify.  Do we simply need to be heard and validated?  Do we just want to know that someone understands?  Are you willing to accept feedback?  Are you willing to consider other ways of looking at the situation?  Are you asking for help?  Or do you just want someone to listen?  If the latter is true, let the other person know you just need them to listen.

Sunday, March 18, 2012

Do therapists practice what they preach?

Most people probably assume that their therapist is mentally and emotionally healthy.  After all, the therapist seems to have it all together: a good job, nice office, nice clothes, and a consistently calm demeanor that is both comforting and reassuring.  It certainly makes sense that a therapist should have good mental and emotional health; she has all the necessary tools and she knows how to use them.  But do therapists practice what they preach?

I can't speak for all therapists; I can only speak for myself.  Am I the picture of perfect mental and emotional functioning?  Absolutely not.  I do, however, practice what I preach.  One of the reasons I am able to "sell" certain strategies to my patients is because I know from personal experience that they work.  I'm a walking testimonial.  I'm quite proud of this.  I started out insecure and emotionally unstable.  Learning to "do" therapy is an ongoing process that for me started when I got my first job out of college.  From day one I started using what I learned to help myself.  I've come a long way since then and I'm proud of myself.

Imagine my chagrin, then, when six months into my marriage my mother suggested that my husband and I needed marriage counseling.  I resisted.  "We don't need a therapist," I thought.  "I am the therapist."  (I've since reconsidered my position).  Then I started thinking about all of the therapists I've worked with over the years; A LOT of them are divorced.  Even some of the therapists I know who are trained specifically in marriage and family therapy are divorced!  Apparently, when it comes to relationships there are a lot of us who have a hard time practicing what we preach.

I recently stumbled upon a research study that looked into this.  (The article is entitled "Do psychotherapists have better marriages than nonpsychotherapists?" and is found in the journal Psychotherapy: Theory Research, Practice, Training, Vol. 41, No. 3. The authors are Murstein and Mink).   The study measured marital adjustment in couples where neither spouse was a therapist, where one spouse was a therapist, and where both spouses were therapists.  Overall, they found no difference in levels of marital adjustment between couples where neither spouse was a therapist and couples with one or more therapist spouse.  In other words, couples with one or more therapist spouse did not have better marital adjustment than couples with no therapist.

They broke the results down into categories and found some very interesting results.  The couples with the highest indicators of marital adjustment in both partners were those composed of a therapist husband and a non-therapist wife.  The lowest ratings of marital adjustment came from husbands (both therapists and non-therapists) married to therapist wives.

This is, of course, extremely relevant to me, given that my husband is married to a therapist wife.  I started thinking about our "marital adjustment" and how me being a therapist affects  our relationship...

Early in our marriage, my husband had a terrible habit of not telling me when I did something to upset him.  Instead, he'd accumulate these instances in his mind and then throw them at me one by one whenever we had an argument.  This meant that if I complained about something he did that was really upsetting me, he would respond by going through a long list of examples of things I'd done to make him angry.   As a therapist, I knew he was breaking one of the cardinal rules of fair fighting: stick to the subject and stay in the present (don't bring up issues from the past).  I'd tell him, "Look, you're not supposed to do that when we're arguing."  The thing is, he didn't know anything about the fair fighting rules and he hadn't agreed to abide by them.  I know that at times he seemed to resent me telling him how we were "supposed" to communicate with each other (especially when I didn't always follow my own "rules").

I suppose my husband might have some theories of his own.  I plan to ask him.  I'll let you know if he has any interesting insights.

Sunday, March 11, 2012

Good self, bad self

I think most of us want to be a "good person," although we all have different ideas about what that means.  Personally, the thing I value most in life is my relationships with the people I love.  This is where I derive my sense of purpose.  To me, life is meaningful because I can share it with people I love.  It quite naturally follows that my ideas about being a "good person" have to do with how I treat other people (especially the people I love).  Fortunately, I tend to be very lenient with myself.  I don't beat myself up or decide I'm a "bad person" if I don't feel like saying good morning to the people sharing the elevator with me.  I don't even judge myself harshly if I am short with (or even rude to) a telemarketer who refuses to accept that I am not interested in buying anything.  Of course I strive to be at the very least respectful to other people, but I don't necessarily feel like a "bad person" when I fall short of that standard.

What does make me feel like a bad person is when I say or do something unkind or hurtful to someone I love.  (Why does it seem like the people I love are also the people I am most likely to treat unkindly)?  It is extremely rare for me to be intentionally hurtful or unkind, especially to people I care about.  I do, however, occasionally do this unintentionally.

You see, I am a rather moody person.  This is especially true when I am tired or under a lot of stress.  Over the years, I've gotten pretty good at recognizing when I am feeling tired or stressed out.  This allows me to avoid being around people during these periods or to at least let them know that I'm in a bad mood and to apologize in advance for being less than friendly.  This works out well for most people most of the time.

About a year and a half ago, however, I got married.  It is extremely difficult to simply avoid interacting with my husband when I'm tired or stressed (it's possible sometimes, but definitely not all the time).  I try to let my husband know when I'm in a bad mood.  Sometimes, though, I'm under a lot of stress for an extended period of time; I know it must get old for my husband to hear from me every day that I'm in a bad mood and don't want to be bothered.  I wonder if there are times when he feels like he has to walk on eggshells around me.

And, of course, there are times when I snap at him or even yell at him just because I'm feeling irritable.  With everyone else in my life, I can structure my time in such a way that most of the time we spend together ends up being pleasant and enjoyable.  Not so with my husband.  He is with me at my best and my worst.  What I've discovered that perhaps I didn't realize before we got married is that me at my worst is really ugly.  There is this side of me that is impatient, demanding, intolerant, and unyielding.  This part of me wants everything my way and only my way.  She is selfish and lacks empathy.  She is inconsiderate and short tempered.

Who is this person?  I don't like the inevitable answer: she's me.  Or at least she's a part of me.  But she's a part of me I don't like at all and when she comes out, it makes me feel like a bad person.

I suppose this is what is meant by the "shadow self."  If so, then I've taken an important first step; I've forced my "shadow self" out of the shadows and into my conscious awareness.  I've taken ownership of the parts of myself that I don't like.  I haven't quite figured out what to do next, but I know I'll keep working on it.  I will keep you posted.

Sunday, March 4, 2012

Motivation and Emotion

"I'm not sure if I really need this treatment," a patient recently told me.  "I'm feeling a lot better than I was," he explained.  I looked at the symptom checklist he'd filled out before our session.  "According to this, you're still feeling anxious and on guard, you're still getting angry a lot, you're still not comfortable going anywhere that's crowded, and you're still having trouble sleeping," I pointed out.  My patient laughed.  "You have a good point," he said.

The following week I checked in with him.  "You were having some doubts about whether you needed the treatment," I recalled.  "How are you feeling about that now?"  The patient again expressed doubt, stating that he really is feeling a lot better.  "I'm to the point where I can contain the anxiety," he explained.

This happens a lot: a person starts to feel a little better and decides he doesn't need treatment anymore.  Granted, feeling better can be an indication that a patient's issues are resolved and that treatment can be terminated.  More often than not, however, feeling better simply removes the motivation to continue treatment; as a result, problems are left unresolved only to resurface again at some point in the future.

So what does motivate a person to invest in treatment?  Most people are motivated by emotional pain (sadness, grief, anger, anxiety, etc.).  More accurately, people tend to be motivated by their desire to be rid of emotional pain.  As long as the pain is there, they are willing to do the work of therapy.  Once the pain abates a little bit, the focus of therapy often shifts from acute symptoms to trying to get to the root of the problem.  This can mean working to change deeply ingrained mental and behavioral habits.  It is often a lot of work and without the pain, many people lack the motivation.

Ironically, a patient's emotional pain can be helpful to the therapist as well.  A person in pain is more likely to reveal his thoughts; these provide powerful clues as to what factors might be driving the patient's symptoms.  I find that, in therapy, people tend to be very short-sighted.  They tend to focus on their present experiences and their experiences from the recent past.  It is not unusual for a patient to come to my office and say, "I've been feeling good for the past few weeks.  I don't really have anything to talk about."  It then falls upon me to try to help the patient recall the times in his life when he was not feeling good, to identify what these times have in common, and to explore what ultimately helped him to recover so that he can use these strategies again in the future.  Typically, however, when a person feels good he does not want to think about feeling bad.  He doesn't want to remember; he wants to forget.

I an not trying to glorify emotional pain.  I am simply making the point that even negative emotions can be useful.  How many people would work to change and improve themselves in the absence of emotional pain? Sure, there would be some; most, though, would have no motivation to do so.

My Favorites