Tuesday, March 22, 2011

Working with metaphor

One of the best things about my job is that some of my clients are students working their way toward a doctorate in clinical psychology.

One of the hardest things about my job is that some of my clients are students working their way toward a doctorate in clinical psychology.

I have heard that there are therapists who don't like working with therapy students. Apparently, those clinicians don't like the fact that the student can "see what's coming," or that the student is second-guessing the therapist's interventions. I guess that this is the equivalent of driving Dale Earnhardt Jr. to the store on a Sunday afternoon. You know you're pretty good at finding your way to the store, but you wonder if Dale is questioning your technique.

As I've worked with students over the last few years, what I've come to understand is that no matter how sophisticated someone is about therapy, no matter how big their particular bag of tricks might be, helping someone change comes down to the simplest of things. Whether or not someone can point out where they are in Prochaska's stages-of-change model ends up having not much to do with whether or not any therapeutic work gets done. Like anyone else, these future psychologists come into the room after having tried to feel better on their own.

With all of my clients, whether they're studying to become therapists, dental assistants, optometrists or artists, metaphor is an important part of our work together. Metaphor cuts through all the sophisticated terms, all the tightly-held defenses. Metaphor gives us common ground, becomes a base where my client and I can meet and look at things in the same way. A powerful image will often carry through an entire therapy, from start to finish.

We work with what the client brings. So often, those images are of destruction. Words can fall short of the ability to convey how it feels to someone to be wrecked, or broken... to have their lives swept up in what feels to them like an all-consuming conflagration. If that's where we start, it's where we start.

The important part is where we finish.

Some clients are mired in a shipwreck. They're hung up on an uncharted sandbar or attacked by a terrifying serpent at the edge of the world, all hands abandoning ship, jumping into the mysteries of the freezing ocean rather than facing certain doom on board. At this point, it makes no difference whether the client can name what is happening to them. It doesn't matter if they can call it Major Depression, Moderate, Recurrent with Full Inter-episode Recovery. Their memorization of the DSM-IV codes is of no help. They're sinking. It is important to them that I see that. It is of deep and consequential meaning that I can hear the cries of the sailors as they grasp at the rail, the sea churning below. They need me to be there with them at that exact moment that it becomes clear that the ship is breaking apart.

This is when I assure them that I have survived such shipwrecks before. As the sea begins to calm, and it will, we will search together for each piece of mast, each floating deck plank, every brass fitting we can find. We'll find a calm island, we will mark its location by the stars, and we will return to it as many times as it takes to make a drydock, to hew new decking, to fashion a sturdy new mast from a tree we've felled. When my client is ready, they will make that maiden voyage. On their own.

At that point, I watch from shore. Long after they've disappeared over the horizon, a message in a corked bottle, borne by the waves, will wash up at my feet. "Told you I was in the Contemplative Stage," it will say.

Wednesday, March 16, 2011

Do you talk money with your therapist?

Back in the grad-school days, when I was just Masters Degree Jeff instead of Doctor Jeff, there were a handful of things that our professors told us over and over. Therapy is based on a good relationship with the client. Self-disclosure tricky. No, you can't have an A on that paper just because you remembered to single-space this time. And, they stressed, there are some topics that are just difficult for therapists to approach with their clients no matter how hard schools try to teach otherwise.

They told us that therapists do not like to talk religion with their clients. They said that sex was something that we pretended to be comfortable with, but that we avoided in session. And, said our teachers, we seemed to avoid politics like the plague for fear of breaking that important therapeutic bond.

Atlanta psychologist Joe Lowrance would like to add another topic to the list. He says that most of us don't like talking money with our clients, and he thinks we should. He makes the point that a growing pile of clinical evidence and research shows that there's a strong correlation between money worries and mental health issues, especially in these days of the "financial crisis."

I'll admit it: we therapists are just like the rest of the people in the world - like other social taboos, talking about money can make us initially a little uncomfortable. This is NOT to say that we can't overcome that gut-reaction feeling, or that you should avoid talking about anything in therapy based on a worry that your therapist is squeamish about it. We are trained to deal with that kind of thing, and we're good at looking at our reactions and opening ourselves up to what our client is dealing with. We deal with a number of power differentials in therapy, starting with the basic fact that people come to us seeking help. That puts the power in our hands from the start. Add to that the fact that we're perceived as "experts," that there is often an income difference between us and our clients, and the result is that we have to be really aware of where our blind spots are, and willing to address and overcome them in order to best help our clients.

So, Dr. Lowrance, I will pay (ha! see what I did there?) heed to your admonishment, and do my best to make sure that my client's finances are on the table and as easily accessed as other topics.

Monday, March 14, 2011

Note to the young:

It will find you.

You'll be at the beach, lost in the soothing rhythm of the waves, the sweet bracing sting of salt air in your lungs, and for one primordial sweep of the sea that pounding on the shore will sound like the ticking of a clock.

You'll be looking in the mirror one morning, post-shave, post-curling iron, and while you're looking to make sure you didn't miss a spot, you'll find a wrinkle. Then two. Then three.

I can't tell you everything, but I can tell you about those isolated moments at the stop light when you are suddenly overcome with a deep but fleeting sense of loss, overwhelming in its magnitude, puzzling in its brevity, reassuring in its rapid disappearance. I won't share all, but I will share that the song that makes you fight tears will someday work its way into your soul, and I can tell you that you will welcome it there.

Find solace in smooth skin, in fleet foot, in sturdy stance. Run your fingertip over unbroken form. There comes a bump in the arc of your life when you look behind you and the ground is higher than the ground where you now stand.

Gravity will scare you at first. Maybe at some point, you'll welcome it as it pulls you into its embrace, but don't expect that time to come soon. You can decide to embrace it first, to glean character and outward signs of wisdom from what you feared would betray fatigue and irrelevance. People will reassure you, but you won't believe them until you believe yourself.

Maybe you will take the pounding of the waves, the ticking of the clock, and craft them into music.

Saturday, March 12, 2011

More evidence that talk therapy can change physically change your brain

I'm the first to admit that I didn't pay close enough attention in in my grad-school neuropsych class. No, wait, that's not exactly true. I paid plenty of attention - there was just a little too much hard science for this abstract thinker to wrap his mind around.

Regardless of my deficits in distinguishing my ass from my amygdala, I'm pretty good at observing and facilitating behavior change. And, in my line of work, sometimes it's nice to get a little scientific backup to what I've been saying all along - there's a lot more to talking about what's bugging you than just words. At its best, talk therapy will actually make permanent changes in the physical structure of your brain.

An upcoming article in the journal Psychological Science details a recent Canadian experiment with people diagnosed with social anxiety disorder. Through EEG readings, researchers showed a pattern of physical brain change without the administration of drugs (or cackling, demented scientists with wild hair performing experimental brain surgery while strongly lit from below, for that matter). This study is the latest in an expanding line of research bolstering talk therapy as a viable, "real" choice for longterm, positive brain change.

The article announcing the study concludes with a quote from the lead researcher that neatly encapsulates the idea of talk therapy and physical change.
"Laypeople tend to think that talk therapy is not 'real,' while they associate medications with hard science and physiologic change," lead author Vladimir Miskovic, a McMaster University doctoral candidate, said in a news release from the Association for Psychological Science. "But at the end of the day, the effectiveness of any program must be mediated by the brain and the nervous system. If the brain does not change, there won't be a change in behavior or emotion."

Saturday, March 5, 2011

NASA has me, again.

Things I wish that I'd saved: Everything in my mid-70s closet. My baseball cards. And, most of all, my carefully-glued model of the Lunar Lander.

I was a moonshot kid. When I was ten years old, Neil Armstrong, Michael Collins and Buzz Aldrin perched on top of a 363-foot cylinder of explosive fuel and were shot into the void of space, pointing toward a rendezvous a quarter of a million miles away. Most people of my vintage can easily recall the memory of standing, transfixed, as the grainy black and white images flickered across the TV screen. My family was assembled in our southern Oregon living room, holding our collective breath as Neil Armstrong descended the flimsy LEM ladder. 30 feet away, in my bedroom, the walls were covered with space posters. My models of the Saturn V, the command module, the LEM crowded my desk.

Armstrong later recalled that he really wasn't sure what was waiting for him on the surface. There was some speculation that his boot would sink much farther into the powdery gray lunar surface than it actually did.

As I write this, four decades later, I seem to be cycling back into a fascination with that time. The more complicated things get here on earth, the more I yearn for tales of simple heroism. Somewhere above our heads, people are living in earth orbit in the International Space Station. We can load a shuttle with astronauts and their cargo and, like an everyday commercial airline flight, they can guide their craft to any destination. Amazing, in its own right, but somehow the Gemini-Mercury-Apollo period has me in a much tighter grip. Something about the shuttle program and the space station seems vaguely soulless to me - a triumph of technology, maybe, a bloodless version of the white-knuckle bravado that propelled men into space in the first place.

When the Apollo 13 astronauts were returning to earth after a wire shorted out in an oxygen tank and nearly killed them on the spot, they were hoarding electrical power to keep their crippled ship limping home. Trajectory was critical - had they misjudged and gone in too shallow, they'd skip off the earth's atmosphere and be inexorably pulled into the sun, long after the stranded astronauts had perished from lack of air. Too deep, and they'd plunge toward earth like a runaway roller coaster car, burning up on reentry and making true the predictions of many who waited on the ground. How lonely and final, death in space.

The computers were shut off, as they drew power that was needed for later. All they had to rely on were optical sighting instruments, not much more advanced than those Copernicus would have used. They kept their ship intact and themselves alive by lining up the edge of the earth with a cross-hatch in the sight... and by calculating the exact time that the moon swung out of view behind their beautiful blue home planet.

The Apollo astronauts are in their 70s now. I've thought, so many times, of trying to express my admiration for them in letters - to tell them what it meant to me to see them venture into the void and return. But, really, there's nothing I could say to them that they didn't already know, and that they haven't already heard over and over again ever since they came home.

This will have to do.