Category: Therapy Process

The Power of Pants

Recently I’ve been thinking a lot about pants. I’ve been thinking about what they mean, what they represent and what they can do.

Often when clients are dealing with a crisis, loss, or just feel weighed down by their emotions, they will tell me they don’t know how they will get through it. This is understandable and common. When our negative emotions are so strong and raw, it’s hard to remember that we can feel differently in the future, or that we have felt differently in the past. When a client tells me they don’t think they can get through something, I often respond, “You already are getting through it. You’re breathing, you’re sitting, you’re here, and you’re wearing pants.” That last part usually brings some humor into the room, and while that is some of my intention, I’m not saying it just to be funny. Putting on pants, or a dress or a skirt for that matter, is important.

Asking about Activities of Daily Living, or ADLs, as they are often referred to in the mental health field, is an important part of the assessment process. Do you shower? Get your laundry done? Can you cook, keep your room or home reasonably clean, and get yourself dressed every day? It sounds basic, and some clients initially laugh when I ask these questions. However, for anyone whose symptoms have been so overwhelming and intense that they are not able to keep up with ADLs, it is no longer possible to take them for granted.

On top of ADLs, many people go to work, take care of children, hand in research papers on time, and remember to call their mother for her birthday, even when depressed, during crisis, or while managing intense anxiety. Despite the intensity of these emotions, things get done. These people, who would be classified as “highly functioning” by a therapist, doctor, or society, usually do not give themselves enough credit. I’m often reminding clients that despite how bad they might feel, every morning they get up, put on pants, and start the day. There is a power in this, The Power of Pants.

Anxiety, depression, grief, loneliness, an unhealthy relationship or a bad job can all have a way of waking you up early, yet make you feel like you cannot get out of bed and face the day. Stepping out of bed, getting out of the pajamas or sweatpants, and putting on pants is a powerful step.  Even if the step feels very small, even if all you do is get into pants and sit on the couch to read, or go for a walk around the block to get coffee, you have taken that first step, which is the hardest one. The Power of Pants takes some of the power away from your symptoms, reminds you that symptoms do not have to define you, and shifts the narrative towards hope. Even if the shift it subtle, it is profound.

If nothing else, put on pants and see what happens.

The December Door Knob

After a year of talking, planning, debating, and ruminating, I recently decided to make a big professional move, leaving a full time job to focus more on my private practice and the professional world of Lauren Schiffer Therapy. I gave my notice on a Friday and met a close friend for brunch on Sunday. We had a lot of catching up to do. She had been sick for a few weeks, so we hadn’t been able to see each other, I had been too busy at work to write anything close to a thoughtful e-mail, she had a recent dating fiasco to share and we had plans and details of a mutual friend’s upcoming wedding to discuss. As we were waiting for the check, I told her about my resignation. She was extremely happy and excited for me, but was also a bit shocked and teased, “Next time, when someone asks you what’s new, you lead with that.” She was right. This news was big, exciting, important, but for some reason it took me all of brunch to get to it.

In psychotherapy this is casually referred to as a “doorknob,” a very important statement, fact, or topic that a client brings up right at the end of the session, often literally when their hand is on the doorknob.  The therapy session is almost over, and there isn’t enough time to sufficiently address the topic. There are many practical and theoretical explanations for the doorknob statement. Sometimes the client is embarrassed by the topic and has been trying to relax, get comfortable or gain enough courage to address the issue. Other times the client knows an issue will be important information in their treatment, but might not be ready to dig too deeply, so brings it up at the end. This can be an enormous relief, “Phew, I got that off my chest,” without being too overwhelming. Whether conscious or unconscious, it can even be a way to test the therapist’s reactions and boundaries. “If I think she’s judging me, at least the session is over and I can get out of there.” “Will she extend the session longer than normal if something big comes up with only five minutes left?” “Will she remember this for next time, even if I say it at the very end?” 

This can be exasperating, funny or even scary for the therapist, depending on the statement. While each response needs to be tailored to the client and their needs, when there are no safety issues, I often let my client know that I think it is an important topic, thank them for brining it up, mention that we don’t have enough time to discuss it today, and explain that since it is so important, we should start with it next time. Then I make sure to start with it next time. If this becomes a pattern with a client, I will point this out, see if we can explore why important things don’t come up until the end, and find ways to address it.

In addition to my private practice, I also work at the health and counseling center of a large university. In a college setting the doorknob not only happens at the end of a session, but also to the end of the semester, the December Doorknob. For most of the school, the last few weeks in December are a ghost town. Students hand in final projects, sit for exams and then get the heck out of there. It’s a time for faculty and staff to finish grades, reflect, plan for next semester and maybe clean off their desks, if so inclined. But right until the last day, my colleagues in the  counseling center are humming along, business as usual. We even have intake appointments the week after final exams are over, with students coming to share all the difficulties they’ve been having this semester on the day, or even morning before they head home for a three week break.

The most memorable December Doorknob this year was a client who came in for an intake appointment hours before she would be leaving for home for winter break, and three weeks before she would be leaving for a semester abroad. I could not help but feel frustrated, wondering why she waited until the last minute, wondering what she expected me to do for her in a one-shot appointment. After some reflection, I had to admit that a great deal of my exasperation came from my own sense of helplessness. Knowing that our work together would not continue, and the entire therapeutic relationship would consist of only 45 minutes, I didn’t feel there was anyway I could help her solve her problem, or make any changes. But it was the client herself that helped me remember how therapeutic even getting through the door can be explaining, “I promised myself I would come in and tell someone about this before the end of the semester and  I wanted to keep that promise.” In that moment a December Doorknob takes on a different symbolic meaning, it becomes a fulfilled promise, the start of change, opening a new door.

As the year draws to an end, what are your doorknobs? What it that thing you keep meaning to do? What do you need to say? What is the promise you made to yourself? Instead of waiting for the new year to make resolutions, to put off making changes until the calendar changes, put your hand on the doorknob and turn.

A Case of the Sundays

Recently, a college-aged client who has been dealing with homesickness told me he found a part time job at a small hardware store. He worked at one after school and on weekends throughout high school, and the job is a nice reminder of home. The narrow aisles crowded with lightbulbs, extension chords and paint buckets filled with screws are familiar and comforting. When I expressed concern that he might not have enough time to study, he reassured me. “It’s just one evening a week and on Sundays. You know, because Sunday is the hardest day.”

Sunday is the hardest day.

I’ve heard this sentiment many times from clients, regardless of their demographic or issue we were working on in therapy. Whether unemployed or working, single or partnered off, large social network or isolated, everyone is vulnerable to what I refer to as, “Coming down with a case of the Sundays.” Writing this post on the Sunday at the end of Thanksgiving weekend, I  can feel it a bit myself. It’s is the feeling of dread that the weekend is almost over, even if there is still a full day left of it to enjoy. It can be the self-judgment that you did not get enough done around the house, in the yard, or on your dissertation. It can be as complicated as loneliness exacerbated by the misconception that everyone else is strolling the streets of your city’s trendiest neighborhood, drinking a latte and holding hands with their new lover, or as simple as the anti-climax of a great weekend drawing to a close. A case of the “Sundays” is when your negative emotions, whatever they may be, pull you out of the present, and prevent you from enjoying the end of the weekend.

For some the “Sundays” are a product of anxiety, and start creeping in just before bed, the “Oh God!” feeling as you are running down the to-do list for Monday morning. For others it is a depressed feeling right when they wake up Sunday morning, that the day will drag on, that there will be no one to share it with. Whether it is a day dedicated to church, rest, brunch, football, or dinner at grandma’s, Sunday is supposed to be different, special. There is a great deal of external pressure to enjoy Sunday, and when we don’t we feel even worse. We judge ourselves, saying things like “What’s wrong with me? Why can’t I just relax? Why don’t I have anyone to spend the day with? How did I let the weekend slip by?”

If you’re lucky, this feeling only comes up once in awhile, but if it’s every Sunday, it warrants some exploration. Do you have unrealistic expectations of your weekend that you need to let go? Are there Sunday traditions, like watching your daughter’s soccer games, that need to be replaced or reworked because your children are grown up?  Were you raised going to church every Sunday and now don’t know how to replace that sense of community you felt every week? What is it about the upcoming week that is bringing up the dread? Can you make it go away? If not, can you make it have less power over you? There are so many areas you can explore to help you learn how to take back Sunday.

I used to refuse all invitations for Sunday evening activities, even if it was something I really wanted to do or with people I really wanted to see. My rationale was, that with my busy and stressful work week, I wanted to “start the week off on the right foot.” My plan for Sunday evening was to pack a healthy lunch, plan my outfit in advance, and get a good night’s sleep. But after a few months of feeling anxious starting around 7:30 PM, tossing and turning the whole night, spending most Monday mornings sleep-deprived, and wearing an outfit I really didn’t feel like putting on that morning, I realized planning the perfect Monday morning had too much power over me, and was giving me a bad case of the “Sundays.” I was wasting too much time planning and was missing out on being. Now whenever possible, I meet friends and play trivia Sunday nights. It’s not a monumental change and it doesn’t make my work week any less busy, but it keeps Monday morning to Monday morning, where it belongs.

Just Because You Can, Doesn’t Mean You Should

In a recent session a client expressed both concern and frustration with her social life. With a history of depression, she was worried that her lack of motivation to go out on weekends, her decreased interest in partying, and resulting social isolation might be warning signs that another depressive episode was starting. After going over details of her day-to-day functioning, trying to find recent changes, or identify any red flags, she reminded me that she is working 30 hours week and taking a full-time student course load of four classes. She is spending twelve or more hours a day out of the house, schlepping from home, to work, to class, to the library and back home, to wake up and do it again the next morning. Rinse and repeat.

By the time the weekend arrives she is exhausted, looking forward to lounging around in sweat pants, catching up on chores, and sleeping in. However, she expressed concern that she isn’t living the vibrant social life expected of an early twenty something. When I remarked that her schedule didn’t sound sustainable or healthy, let alone enjoyable, and that I thought the lack of motivation to socialize could simply be because she is tired, not depressed, she was skeptical. Initially she hadn’t even thought of mentioning her schedule because it was nothing new, and since it was something she was used to, she didn’t think it should be a problem. “I have been doing this for the past two years. It’s not like I can’t do it.”

Fair enough. She has been getting good grades and positive feedback from her work supervisors. Nothing is falling through the cracks officially, but she’s cranky, tired and doesn’t feel like her life is any fun. Surviving is not the same as thriving. Which is why my response was, “Just because you can, doesn’t mean you should.”

I think we all do this at some point – we put ourselves on a treadmill that we don’t know how to get off of, or push ourselves past a healthy limit because we don’t know how to say “no”. Sometimes we don’t know something will be bad for us until we are knee deep in it, and then it’s hard to get out without a “real” reason. Don’t get me wrong, at times it is good to test our limits, to push ourselves to see what he can accomplish. It’s not always a bad thing to see what you can do, rather than stick with a terrible status quo simply because the unknown is too scary.

The important thing when deciding between a can or a should is to ask yourself why. Are you trying to prove something to yourself? Trying to get someone to like you? Do you have an unhealthy need for a thrill? Did your parents teach you that it’s important to see something through to the finish and that’s a value you won’t abandon, no matter what? Are you afraid that if you change something, you’ll feel like a failure? Trying to keep your schedule so busy so that you don’t have time to notice you’re unhappy in your relationship? I could go on all night.

Getting to the why is the important part, where the therapy truly begins. Getting insight into behaviors, decisions, and emotions is what the work is all about. It makes the difference between surviving and thriving, and answering that one word question completely and  honestly can help you decide if something is a can do or a should do.

To Skype or Not to Skype- Part Three: My Reflections

I was pleased to see the article, “When your Therapist is Only a Click Away,” in the style section of The New York Times this week, highlighting clients and clinicians who use video chat for therapy sessions. I was excited because it made me feel trendy and cool, but more importantly because it shows that there are people out there thinking and talking about the issue.

In my last post I was able to share what I learned about the legality of video chatting a therapy session, explaining what I can and can’t do according to the law. While learning the law was the vital first step (that took about twenty sub-steps), I also did a great deal of additional reading and reflecting. Knowing what I can do got me thinking about what I should do, which got me thinking about what I would want to do.

Here’s What I Think:

Skype or other forms of video chatting can be a great way to provide individual or group psychotherapy to people in rural or remote areas, where access to clinicians is very limited, or where weather can make travel unsafe or impossible. Video chat can also be an ideal way to reach a client whose diagnosis, like Agoraphobia or PTSD make leaving the house or traveling to your office too anxiety provoking.

However, I don’t think video chatting should replace therapy sessions just because it would be more convenient. One could argue that the client is a consumer and we should cater to their needs, it’s their hour to use how they wish, or that for a busy client it’s better to have an on-line session than no session at all. But what about self-care, prioritizing yourself and that one hour a week you designate for therapy? What about having a time and place where you can get a break from the outside world, stop multitasking and dig deep into yourself to reflect, discuss and develop insight into your mood, personality and behaviors? In my opinion, for psychotherapy to be as successful and helpful as possible, both clinician and client need to be giving the session their 100%.

In the Times article they highlight a client sitting in a lounge chair by the pool and sipping a cocktail during a session. The same client discusses how great it is that she can take a break from a shopping trip to have a session. For me these scenarios raise red flags. First there is the boundary issue. If you are drinking cocktails, cooking dinner, or shopping during our session, there is a very high chance that you are going to forget my real role in your life. We are not friends or drinking buddies. I don’t give you advice, compare your experiences to mine, or share my personal issues with you like I do when I am out to dinner with my friends. Those choices are intentional, with the goal of allowing you to feel comfortable sharing your concerns without feeling like I will judge you, without worrying how your problems will impact me, and without wondering if my comments have an ulterior motive. In my work, I like to be accessible and approachable to my clients while maintaining boundaries.

Here are a few ways I conceptualize Skype’s place in individual therapy: Two feet of snow last night and the city hasn’t yet plowed your street? Yes. Raining and you don’t want to go outside and ruin your blow-out? No. Stuck in at the office because you left the lights on in your car all day, the battery is dead and you need to wait for Triple AAA? Yes. Stuck at work for the fifth session in a row because you don’t know how say no when your supervisor asks you if tonight is an okay night for you to stay late at work? No.

How I Plan to Translate My Reflections into Practice:

I plan on using Skype as an adjunct service available to clients I already see for in-person sessions. For example, if a client would like an urgent appointment for support or to discuss an unexpected issue, like a break-up, getting into a car accident, or a family member having unexpected surgery, and we can’t find a time at my office that works for us, I am comfortable using Skype. I will also be using Skype as an alternative to last minute cancellations, when getting to the session is just not possible, but a client still has the availability to meet privately for an hour. For example, if a nor’easter blows into Boston and it would be unsafe for the client or myself to travel I would use Skype. I would also consider using it for short term support while a client was dealing with a health issue, such as home recuperating from surgery, and unable to walk or drive.

Before I roll out this feature, I need to purchase a high-quality webcam for my desktop, if possible, one with enough resolution to allow me to recognize details such as blushing, sweating or shaking hands. I also plan on creating a separate informed consent document and treatment contract for clients who work with me in this way. I see the need for us to sign an agreement including things like, “I will never sign off or abruptly end the session intentionally,” and “I agree that neither party will record the session,” and to decide together how we will negotiate “eye contact” whether we will look at the camera or at the other person’s face on screen.

I will not work with anyone exclusively over Skype, nor will I use Skype sessions  with people who are currently having thoughts of self harm or have any history of suicide attempts or psychiatric hospitalizations. There is just too much risk that a client in distress could log off before I am able to act to keep them safe.

I plan on charging the same rate and conducting my Skype sessions exactly like I would an in-person session, and I expect my clients to do the same. I will wear pants, sit in a room where privacy can be maintained, and do nothing else, except attend to the session.Whether or not we are in the same room, our work needs to be the priority for that hour.

Integrating technology into psychotherapy is both exciting and scary. As with any clinical decision I feel I have done my best to explore the clinical, legal and ethical questions, and can make an informed choice for my practice as a result. I may love this approach or I may hate it, but as with anything new, I can’t know unless I try.

To Skype or Not To Skype- Part One

I recently received a phone call from a former client in distress. We met for almost two years and ended our work together a few months ago because he was finishing his graduate program and moving out of state for a fellowship. It was good timing. He had been doing well emotionally for months, had transitioned off of medication with very little trouble and stayed stable, we had been meeting less frequently as a result and the upcoming move involved a great deal of excitement and happiness. He would be doing a prestigious fellowship at a well-known hospital and would be moving in with his partner after six years of long distance. As far as terminations (the therapy word for ending treatment) go, this one was a “web-gem.”

When he called last week, he was a few weeks into his fellowship, feeling very overwhelmed, afraid that he could not “cut it” in his program, was paranoid that he would make a mistake that would hurt a patient, was having trouble falling asleep, was waking up repeatedly throughout the night, and was having ongoing chest tightness. Not his best day. At the start of our conversation he stated he felt like he did when we first met, like all the work we had done flushed down the toilet and that he was back to square one. I disagreed. While he was most definitely having a flare-up of anxiety, which is pretty normal when someone with a history of anxiety makes a major change, he was not at square one. I reminded him that while physical and cognitive anxiety symptoms had returned, the coping skills (taking medication, regular exercise, talk-therapy, positive self-talk) he developed and used in the past were still in there, he just need to be reminded to use them. We discussed options, which included the possibility of finding local providers and resuming medication or talk-therapy. He was open to the medication suggestion, but was reluctant to find a new therapist,  “I’m not sure I want to start over with someone else, that I could connect with someone like I did with you. Maybe we could do phone or video sessions over Skype?”

Hmm… Maybe we could do sessions over Skype? Prior to this phone call, I had met a few clinicians personally and discovered many more on-line who conduct sessions via Skype, using the video conferencing feature. I found the idea interesting, but did not consider trying it myself. When my former client suggested it, I began more actively entertaining the idea. Could we do video sessions via Skype? More importantly, should we?

The issues of ending work with a particular therapist because of moving away or moving on,  client attachment issues, boundaries in the therapeutic relationship, ethical concerns, transference (the unconscious feelings in the client that are brought up and projected onto the therapist) and counter-transference (the unconscious feelings brought up within the therapist) all needed to be considered in this decision. I would do that, but before deciding whether or not I should provide psychotherapy using video-chatting over the internet I  needed to find out if I could. What are the laws for social workers providing therapy via internet video chatting? Are there any? Federal? State? What does my licensing board think?

So I began to research, like the good student that I always was….. and then I fell down a legal and internet rabbit hole, involving MA and VA social work licensing boards, the National Association of Social Workers (NASW) legal counsel, the NASW Massachusetts chapter’s ethics committee, and a non-profit called the Center for Tele-Health and E-Health Law. I got a few answers, still have a few questions unanswered and was left to ask myself even more questions.  I’m going wait for a few more folks to call me back, let all the new information marinate in my brain for a few days, make a decision and then post again. Stay tuned……

It Could Be Worse

Out of pure coincidence I happened to spend my most recent vacation in both north and south New Jersey the same time as Hurricane Irene. Over the course of four days I was at the Jersey Shore, where the ocean and strong winds did less damage than expected, and in Northern New Jersey, where the onslaught of rain caused rivers to crest to record levels, washing out roads and flooding homes. An annual summer-send-off beach weekend turned into hurricane prevention, bringing lawn furniture and potted plants inside, tying down anything loose, evacuating from a barrier island, and keeping fingers crossed. Clean-up involved using a wet vac in the basement and collecting five garbage cans worth of fallen branches. Not the vacation I had planned, but all-in-all not so bad for a hurricane.

When the rain and heavy winds finally stopped, I practically sprinted out of the house to avoid going stir-crazy. There was a crystal-blue, cloudless sky, a perfect-ten day that almost made you forget about what happened twelve hours before. Walking through the suburban community, we observed the full range of impact. There were large tree branches on top of cars, downed power lines and blown transformers that left a block of neighbors without power for the weekend. Others had piles of belongings, ruined by basement flooding, out on the curb for trash pickup. On our walk we stopped to chat with friends, neighbors and anyone out cleaning up. Stories about the damage were swapped and jokes about my poorly timed beach vacation were made. However, what really stuck with me was that every conversation ended with, “Well, it could be worse.”

Yes, it can always be worse. If your beach vacation was ruined by a hurricane, you can be grateful that you didn’t have to evacuate from your hotel. If you had to evacuate, you can be glad it wasn’t your hometown or city that was hit. If the basement flooded, you can be grateful that your whole house wasn’t destroyed. If your house was destroyed you can be grateful that no one was hurt…. AND ON AND ON AND ON. But when do you get to stop that Look-On-The-Brightside-Pretty-Princess-Routine? Staying healthy emotionally does not mean being happy or staying positive all the time. Being emotionally healthy means having the right feelings, in the right amounts, at the right time. While it’s not good to spend your whole life complaining about your bad luck, feeling that you are being punished for something, or believing that you can’t catch a break, can you at least be allowed a week, a day, or even five minutes? In early sessions of treatment, I often encounter clients who feel embarrassed or ashamed that they are wasting my time with a problem that is “silly” or “not a big deal.” It’s as if their problems are not serious enough, or that they are not allowed to talk to a therapist because “It could be worse.” They censor themselves before our work has even started.

It doesn’t have to be so dichotomous. We can be upset, cry, and shout, “It’s not fair,” while also acknowledging that it could be worse. Yes, you could be homeless, paralyzed from a car accident, a starving orphan in Africa, or a victim of human trafficking. But you’re not. You are only you, and the only pain you can feel is your own. It’s good to have proper perspective, to be able to count your blessings, to feel and show gratitude. However, responding to every negative feeling and comment with “It could be worse” is invalidating. Allow yourself to have a negative emotion, acknowledge your feelings and then start moving on. Try this next time, “I know it could be worse, but this still really sucks.”

Don’t Tell the Point Guard to Hit a Home Run

A friend and I were recently discussing comparative religion on a road trip, a conversation inspired after listening to The Book of Mormon, this year’s Tony Award winning best musical by Trey Parker and Matt Stone of South Park fame. My friend, a PhD candidate, has been doing an excessive amount of academic reading this summer (“excessive” to me, but probably a normal amount for a PhD student) and she shared with me an analogy she loves and has been using all summer, which she came across in the introduction of Stephen Prothero’s God Is Not the One.  From what I gather, Mr. Prothero wants his readers to understand that the major religions are not playing the same game, but very different ones, with different rules, different scoring systems and different outcomes. To compare and communicate between religions one needs to under stand this.

Later that weekend she brought out the analogy when giving another friend advice about how to deal with a family conflict. Our mutual friend was having a hard time figuring how to support her brother through a difficult time, while also dealing with all the mixed feelings that tend to arise when family dynamics are involved, such as frustration, love, resentment and concern. She wanted to help her brother as soon as possible and wanted to know what she could say or do to get him to seek out the help he needs.  But it’s never that simple, and the analogy was fitting. “Right now, the two of you aren’t playing the same game. It’s as if you play baseball and he plays basketball. Your advice, suggestions and encouragement come across to him as if you were telling a basketball player that he should score a lot of runs.”

The analogy really appeals to me. Although the concept is not new in social work or mental health, it’s funny, simple and is a nice replacement to the overused, seventies-cheesy, social work phrase, “Meet the client where they’re at.”  Honestly, it felt like this phrase was tossed out a daily basis in social work school, so over used and groan-worthy that even professors could be caught wincing, making air quotes or practically apologizing for saying it. However the phrase couldn’t be avoided because the concept was so appropriate, important to our training and clinically rich.

As clinicians we have to remind ourselves regularly that the goal of treatment must be the client’s agenda, not our own. It’s not about us and it’s not up to us to decide what is best for someone else. Despite our best intentions, if we don’t understand what matters to the client, how they see the world, how they define success, or what type of changes they think are important, we miss the mark. Ultimately a major goal in my session is not to tell someone what to do, but to help them decide what they want to do and how to get there.  To coach you or cheer you on, I have to understand the game you are playing.