Although it’s very common for individuals to call my office in search of Cognitive-Behavioral Therapy, it’s rare for someone to call and ask for Psychodynamic Therapy.

And yet recent research has now shown psychodynamic therapy to be an “evidence-based” practice. In other words, research shows it works.

(Click here to see the article featured in Scientific American. This article highlights the work of Jonathan Shedler, who conducted a meta-analysis to show that psychodynamic therapy is indeed effective. Meta-analysis is a sophisticated statistical technique for putting studies on a common yardstick so that can be quantitatively compared).

What is psychodynamic therapy?

Well, for starters it’s not psychoanalysis, though many people erroneously equate the two.

Whereas cognitive therapy places emphasis on cognition or thought, distorted thinking, and dysfunctional beliefs, psychodynamic therapy places emphasis on emotion, processes of self-deception, anxiety, and hidden feelings -- in the context of relationships.

Whereas cognitive therapy stays strictly in the here-and-now, psychodynamic therapy places symptoms and problems in the context of one’s personal history.

Whereas cognitive therapy relies heavily on psycho-education (how thoughts influences emotions and behaviors), psychodynamic therapy relies on discovering patterns and themes in the patient’s psychological life, which may be just outside of the patient’s everyday awareness.

Cognitive therapy has received a great deal of air-play in the last couple decades, so people are aware of it. And frankly, unlike psychodynamic therapy, cognitive therapy is easy to understand. But some problems do not yield to cognitive interventions. Sometimes we really do need to get dig just a bit deeper into the psyche to resolve certain types of difficulties. Psychodynamic therapy is one way to go about that. It’s nice to see researchers put their stamp of approval on the method.

Tags: psychodynamic therapy

Maybe you want to feel better or do better or make some personal habit change. Maybe you’re fed with the emotional or behavioral status quo, whatever it is, and you tell yourself you want to change, but something -- something almost as powerful as a magnetic force -- pulls you back. What is that something?

Could be any number of things. Here are some possible candidates.

• Awareness
• Motivation
• Willingness to tolerate anxiety or discomfort
• Know-how
• Support from others
• Willingness to exert effort

Awareness. Obviously, changing anything about yourself starts with awareness. First you must be aware that you have a problem. Of course, it’s not awareness that holds you back so much the things that block awareness: minimization, rationalization, blaming others, and denial. These things are like veils that keep you from seeing the true consequences of the problem or issue. First step: lift the veil. See reality clearly.

Motivation. Recognizing that something is a problem doesn’t necessarily mean you’re motivated to do anything about it. Indeed, many people wait until the consequences of having the problem outweigh the discomfort of facing it before they embark on change. But it doesn’t have to be this way. You can make a list of the consequences to build motivation. And you can make a list of the benefits of change.

Willingness to tolerate anxiety or discomfort. Almost of any change generates anxiety or discomfort as you move out of your comfort zone and experiment with new thinking and action. Human beings are nothing if not self-consistent. Stepping out of old grooves, even grooves that are ultimately not in your best interests, will trip the alarm in your psychological system. Anxiety or discomfort is an uncomfortable state. To make it go away, you revert back to old patterns. But this is a trick. This is what keeps your stuck. If you’re serious about change, you must be willing to bear a bit of discomfort.

Know-how. Knowing how-to lose weight is not the same as knowing how-to get undepressed or how-to conquer agoraphobia. Problems vary and solutions vary. Do your homework. Study the strategies that others have used to solve your particular problem. Don’t re-invent the wheel if you don’t have to.

Support from others. Change is something you can do alone, but it’s probably easier when you have someone in your camp who is willing to root for you. Someone who knows not only what you’re doing, but why you’re doing it. Someone who cares enough about you to pick you up when you stumble. Never underestimate the value of supportive relationships. Conversely, be wary of those individuals who have something to gain if you fail. (e.g., domestic violence).

Willingness to exert effort. If only the infomercials were correct: that there really was such a thing as effortless change. But real change -- change that endures -- requires hard work. You must focus on the problem, think about it, feel the discomfort associated with it, come up with strategies or solutions, and start anew when lapses occur, as they most certainly will. If a problem is really a problem, you must be willing to throw some effort at it to make it different. Maybe that means reading books, tracking progress, attending therapy sessions, or just keeping the problem front and center for a while. No one will do for it; indeed, no one can.


Else:

If you are trying to change, don’t be discouraged by lapse, relapse, or resistance. To the contrary, expect these things. They’re simply part of the process.

If you are trying to change, know that change is seldom linear. It’s two steps forwards, one step back (or maybe sideways). Learn to look at the trend, not the moment.

If you are trying to change, celebrate your victories. We never outgrow our need for praise. Being an adult, however, means that sometimes we must provide it for ourselves.

If you are trying to change, but you are not there yet, give yourself the gift of self-compassion. There is little be gained by treating yourself badly when you aim at a target and miss. The rule of change is always about successive approximations, not absolutes.

For so many problems, the secret to real change is not in the strategies but in the persistence. You must try and then try some more. Persistence, along with the belief that you can change, wins the day.

Tags: Change

It takes a bit work to find the right therapist, doesn’t it?

Do you go with a psychologist (PhD), social worker (MSW), or counselor (MS or MA)? Do you search for a therapist who is the same gender as you, or who is about the same age? Can you rely on your insurance company to point you in the right direction, or should you ask around to find out who’s good? Or do you just figure they’re all pretty much the same, so why not hunt for the therapist with the lowest rates?

Well, folks, here’s what the research says.

Age, gender, and academic degree have not been show to be strong predictors of therapist effectiveness. In other words, men can do effective work with women (and vice versa) and young therapists can work effectively with older clients. Moreover, psychologists tend to be just as effective as social workers or practitioners with other degrees.

What does matter is whether your therapist has had experience with your type of problem, and how comfortable you feel when you talk to him (or her). These are the two things you should be looking for.

It’s relatively easy to determine the therapist’s level of experience (you can do this from a website, or a quick telephone conversation). But the only way you can truly figure out how comfortable you feel talking to the therapist is to make an appointment and try him out for a session.

So much of what happens in therapy depends on the therapy relationship itself. Our dentist or physician may work on us, but our psychotherapist can only work with us. We must trust her enough to disclose highly personal and private information, and we must rely upon her support as we confront those aspects of ourselves that we feel least proud of.

Don’t pick your therapist on the basis of gender, age, credential, race, reputation, or price. Pick him (her) on the basis of his experience and how comfortable you feeling sitting across from him in his office.

Tags: Finding a therapist

I was reading Seth Godin’s blog the other day and he made the this statement: “The only real help is self-help. Anything else is just designed to get your to the point where you can help yourself.”

(Seth’s blog posts are pithy, which is one the reasons I read him.)

I agree with his statement. Psychologists, for instance, do not change people. But they do help people change themselves.

What’s the difference? Better yet, why bother consulting a psychologist if all help is self-help?

Answer: what psychologists really do is help you understand the emotional elements behind resistance. When we try to change something about ourselves, we take a step or two but soon fall back to old patterns. Why? Why do we have this contradiction in ourselves?

This is what a psychologist tries to help you understand. You may consciously will new behavior to come about, but if it fails, is there a belief or feeling or schema that’s holding you back? Probably.

Human beings are remarkably self-consistent, even when the behavior in question is maladaptive. If you want to change, you’ll have to de-automate the pattern. (Yes, I just made that word up.) If the problem is serious -- depression, anxiety, eating disorder -- it’s not likely to yield to willpower alone. You’ll have to dig deeper.

Fortunately, you don’t have to do this alone.


Related post: Digging Deep in the Psychological Soil

Tags: Self-help

Sometimes in therapy we need to focus on emotional reactions to situational problems. A common example of this is the person who is in the throes of a stressful experience. A divorce perhaps, or a job loss, or maybe the death of a family member. In these instances, we try to help the person marshal their resources and figure out healthy ways to cope with a difficult and painful situation.

But what does it mean to dig deeper into the psychological soil?

Symptoms related to depression and anxiety are often tied to underlying issues that have to do with dysfunctional beliefs about oneself (or others), or with feelings that have been avoided because they are simply to painful to tolerate.

Sometimes we speak of schema -- packets of information that contain beliefs, emotions, memories, sensations. Schema help us navigate the world because they allow us to make use of prior knowledge. But schema about oneself, especially if it is negative, can color the way we evaluate our personal experiences. If one has a schema, for instance, that one is inadequate, inferior, or defective in some way, one is much more apt to selectively filter out information that refutes this notion but allow information in that confirms it.

In therapy, going deeper often means uncovering these schema and examining them for truth. The thing about schema is, we often develop them when we are very young, which is say, when we are not yet mature, experienced, or wise. And because they've always been there, or so it seems, we seldom question their validity and we don’t always appreciate the long shadow they cast over our lives.

Because schema are often planted early, they are not easy to uproot, especially by oneself.

But this is precisely what a therapist can help you do. We can dig deeper. Uproot the bad. Save the good. Help replant as necessary.



Related post: Core Belief: Inadequacy

Tags: Schema

What is the purpose of suffering?

This is not a question psychologists can answer. We can establish that suffering exists, in all its various forms, but no psychological theory can explain why it exists in the universe. This is the bailiwick of theologians and holy persons, I suppose.

And yet.

And yet, in my role as therapist, listening to people in psychological pain, I’ve come to believe that suffering has something to teach us. At least if we let it. Suffering teaches us about compassion. Because if we did not suffer, if we ourselves never knew distress, how would we ever feel compassion for our fellow man? If would be too easy to ignore him, dismiss him, judge him.

There is nothing quite so heart-warming as watching one panic-attack sufferer, or depressed person, helping another.

Come to think of it, therapists are people, too. Which means we’re not exempt from suffering, pain, or loss. Which is why we listen with our hearts, not just our minds.

Tags: Suffering

Frequently people come to therapy because they feel anxious or depressed and they want those symptoms to stop. Fair enough.

But knowing that you’re depressed or anxious is just the beginning. What we really want to know is why these symptoms are occurring, or rather, what they mean. Although it’s true that some individuals inherit a predisposition towards certain kinds of symptoms, this does not mean there is no psychology involved. Symptoms are not causes. They are expressions of underlying issues. Just as your body gives you pain to signal something is wrong, your psyche gives you anxiety and depression to signal the presence of psychological issues. These issues are complex, and may involve thinking patterns, belief systems, conflicted emotions, relational patterns, responses to stressors, and possibly temperament.

Sure, you can take a pill to feel better. Frankly, drug companies would rather you did. They’d rather you chalk up your symptoms to the so-called “chemical imbalance.” The chemicals they’re talking about are neurotransmitters, chemical messengers in the brain. What drug companies fail to mention, however, is that there is no actual medical test for a chemical imbalance. Moreover, medication isn’t the only thing that alters your neurochemistry. Life changes your brain chemistry. As does therapy.

It’s not that I’m against taking pills for relief of symptoms. I routinely refer people to psychiatrists, especially in cases of severe, unremitting depression. Indeed, some clients need both therapy and medication to combat their symptoms before they can begin to function again. What I am suggesting, however, is that we listen to your symptoms in a deep way. Not just as something to be rid of, but as clues to your psychological system.

Sometimes symptoms are just your psyche’s way of telling you that it’s time to trying walking a different path. But unless you listen for deeper meanings, how will you know which way to go?



(photo credit: simonsterg)

Tags: Symptoms

A few years back, I taught a graduate class in group therapy. One of the exercises I had the students do was to break into small groups and complete the following exercise: “Each of you will have five minutes to talk about yourself. While one member is talking, the other members must listen intently. What you talk about is entirely up to you, but you must talk for the entire time and the other members of the group must listen with respect and without comment.” After the exercise was completed, we’d come back to the class and talk about what happened.

What most students discovered was that five minutes of talking about yourself is actually harder than it sounds. They’d start out strong, talking the usual biographical identifiers like what program they were in, whether they were married or not, where they were from, what their goals were in pursing a graduate studies, and so forth. But they tended to exhaust this public-self information fairly quickly. Then they had to decide what to reveal about their private-self. Mind you, I put no stipulation on what they talked about. That was entirely their call.

The point of the lesson was to get the student-therapists to reflect on what their future clients might be experiencing when they came to therapy for the first time. The first-time client is faced with trying to figure not just what to say, but how much to say, and how to say it. It’s not unusual for people think about going to therapy for a while before they actually get themselves to that first appointment. After all, maybe the problem will go away, or maybe they’ll be able to resolve it on their own. If they finally decide that therapy is what they need, they’ve generally had some time to rehearse what they’re going to say--at least for those opening few minutes. After that, they’re not sure what to expect.

Here’s the thing: therapy is all about the private self. What you think about and feel; what want and need from others; how your react; and more. If therapy is to be life-changing, we must plunge into the deep waters of your subjective world. This is where real change happens.

Therapy is not about one person giving advice to another. Rather, it’s about one person inviting another person to make contact with their truest, deepest, most private self. When this happens, you forge an inner strength. You become clearer about who you are and about what you need to do make your life better.


Related post: Will Therapy Help?

After hundreds of hours of doing therapy with people who struggle with depression and anxiety, one of the core pains I hear again and again is the bone-deep notion that one is inadequate. This is when you have the sense you simply aren’t good enough, or that you’re deficient or defective in some way.

This type of belief has at least three powerful consequences.

First, you’re more likely to find evidence to support your notion of not being good enough when you size up situations, and you’re more apt to reject evidence that contradicts it. Beliefs bias our perceptions.

Second, if you belief, deep down, that you are truly inadequate, you’re much more likely to experience strong, crippling emotions such as despair, sadness, hopeless, and shame. Beliefs influence our emotions.

Third, you’re more likely to develop compensatory strategies for the belief, even if you are not aware of the particular psychological functions that these behaviors serve. For example, you work extra hard in virtually at all endeavors, accepting nothing less than perfection. It’s as if you’re engaged in a constant series of personal tests of self, always trying to prove that the belief is not really true. Unfortunately, perfection is difficult to achieve, especially if you strive for perfection in all things. Conversely, someone else with this belief may take the opposite strategy: he or she may try to avoid endeavors where there is a risk of failure. This strategy helps you avoid being reminded of the belief. In other words, it helps you avoid painful emotion that accompanies the belief.

Once the inadequacy belief is installed into the psyche, it’s resistant to change. Our psyches are built in such a way that we seek consistency in our views of ourselves, even if those views are erroneous, painful, or maladaptive. The notions that we hold about ourselves go stronger as time goes on, no doubt from sheer repetition of concluding and re-concluding that, once again, we come of short.

So what can we do about it? One of the things I ask my therapy patients to do is to explore the validity of the conclusion. Beliefs about self often start when we are young. Unfortunately, we may draw conclusions about ourselves using child or adolescent logic; we do not have the wisdom and experience that we will acquire in adulthood. Yet, even after we acquire such wisdom, we seldom go back and edit the self. Rather, we take our earliest conclusions for granted. They must be true because they feel true, and because we’ve always thought that way. I ask my clients to give themselves permission to examine these bone-deep beliefs through the eyes of their adult selves. Maybe you really are inadequate, but then again, maybe not. Maybe things aren’t quite as simply as they appeared to you as a child. Maybe you have learned some things about yourself as adult (or your situation growing up) that were not factored into the early--dare we say, premature--conclusions that you reached about yourself.

This is how we start.

Tags: Inadequacy

If this were an infomercial, I’d promise that therapy can help anyone, anytime, anywhere, and I’d guarantee results in thirty days or your money back. But this isn’t a commercial and I’m not trying to sell you anything.

Frankly, therapy is work. When it comes to alleviating distress or creating personal growth, effortless change is a myth. If you want the pain to stop, regardless of the form it takes, you’ll have to direct your attention to your inner life, your relationships, and your actions. You’ll have to seek new insights into who you really are, and you’ll have to tolerate the anxiety that invariably comes from giving old patterns and trying new ones.

Still with me? I hope so. Because therapy works for most people, most of the time. Research consistently shows that people who undergo therapy are better off than approximately 75-80 % of the people who don’t (but have comparable problems or concerns). Frankly, therapy results may not be be guaranteed, but these are pretty good odds, if you ask me.

Psychotherapy asks you to reflect deeply on your life: who you are, what you think, what you feel, and what you do. Believe it or not, this is not as easy as it sounds. All of us, it seems, are prone to a bit of self-deception. One of the benefits of working with a therapist is that he or she can help by virtue of having a measure of objectivity about you that you might not have. Of course, only you know what it’s like to be to you and to have had your life experiences. But if you’re like most of us, you will not always see yourself clearly. This is where a therapist can help you. A therapist will listen carefully to you and work very hard to understand you and your situation from your point-of-view. But after getting to know you, he or she will have insights about you that you may not have had. These insights, by the way, are informed by psychological knowledge and clinical experience. Your therapist tries to give you input that is unique to your particular psychology. This is the beginning to change.

Sometimes I get e-mails from people who are surfing the web, looking for answers. Maybe they want therapy, or maybe they’re just sending out missives to let somebody in the world know that they’re hurting. I always write them back and I invite them to call my office if they are serious about therapy. Usually, I don’t hear back. (The person who is serious about starting therapy is more apt to pick up the phone in the first place and make an appointment.) But I always wonder about the e-mailer I never hear back from. Did they find another therapist? Did they find a solution? Did they decided to bear the status quo for a little longer? Or were they doubtful about whether therapy--the so-called “talking cure”--could actually help them?

Again, if this were an infomercial, I’d say yes, absolutely, results guaranteed. But I tend to believe people are smarter than that. They know infomercials prey on their frustrations and secret wishes for easy, fast results (we all have them). Better, I say, to tell the truth. Therapy can help, but only if you’re willing to throw yourself into the project of finding out who you really are.

Tags: Therapy

This is part II of my post on behavior change. In part I said that I'm often asked how people change. Although there is no one-size-fits-all answer to this question, I did suggest a first step, which was useful for building motivation: make a list of all the ways your problem is costing you.

Now, for part II, I'm going to suggest you turn my first suggestion on its head: make a list of the payoffs the problem is giving you.

At first it may seems counter-intuitive to think this way. After all, a payoff implies something positive. If a problem is a problem how can it have a positive aspect to it? Let me illustrate what I mean with a common example: problem drinking.

Payoffs for problem drinking might be:

1. Generates positive affect (good feeling)
2. Reduces bodily tension from stress (calms the self)
3. Makes social interactions easier (decrease social anxiety)
4. Turns off the anxiety switch
5. Blots out memories
(And so on..)

In this example, the payoffs are fairly easy to spot. In the short run, alcohol can be quite effective in helping you cope. Unfortunately it's the long run that kills you.

Making a list of the potential payoffs is helpful because it helps you realize you may have to address more than just the defined problem. A problem drinker may be thrilled to finally get the monkey of alcohol off of his back--until he realizes he also has to deal with the underlying anxiety issue (or negative moods) masked by the alcohol. Making a list of payoffs helps you anticipate what you might miss if you decide to let the problem go.

The key point is this: sometimes our problems serve us in some hidden way. They may allow us to reduce anxiety, generate good feeling, or give us a reason to avoid something we’d rather not face. This may not be true with all emotional problems, but if you’re thinking about making a change you give it some thought.

Tags: payoffs

Often, when people want to resolve a personal problem, they ask me how to go about making a change. Unfortunately, the answer to the question may vary with the problem, the person, and the circumstances.

And yet, here’s one tactic you might try: as your first step, make a list of all the ways the problem is costing you. This doesn’t mean you’ve committed to change yet, it may only mean you’re getting ready.

Example: Let’s say you want to lose weight. (And who, in our culture, doesn’t?)

What’s the “price-tag” of this problem?

1. You find yourself squeezing into your jeans. Uncomfortable.
2. You find yourself worrying about your health. (Blood pressure, anyone?)
3. You find yourself spending too much money on food.
4. You worry about whether your partner or spouse finds you attractive.
5. You’re more easily winded going up stairs.
6. You don’t sleep as well.
7. (.....you get the picture. )

Why do this? Simple. Making a list of what the problem costs builds motivation.

Even if you’re not ready to make that change, this is a great way to start. In fact, while you’re working up your courage, review your list every day for a while.

Tags: Change