Mood, disposition and disorder

In a previous post I referred to suicide as a “mood-specific” behavior, and I feel the need to clarify this statement. I wrote that nobody suicides when they’re in a happy mood, suggesting that if people in a depressed mood can “ride out” the mood without doing something lethal, the urge to end their lives will pass when their mood changes. Moods are transient emotional states that can be prolonged by irrational thinking and by ruminating.

Thoughts such as “My life is my problem; the only way to solve my problem is to end my life” can seem logical to a person in a depressed mood. When the mood passes, the person will likely recognize the thought as irrational – or at least as one that doesn’t have to be acted on immediately. Suicide hotlines have prevented many impulsive (mood specific) suicides by helping people to not act on suicidal impulses and to ride out the depressed mood – or to sober up. This principle doesn’t apply to suicidal people who experience chronic depression.

While moods aren’t enduring emotional states, dispositions are. We each have a unique disposition or set of dispositions. For instance, we’re each disposed to be somewhere on the continuum between optimism and pessimism – glass half full vs. glass half empty. I don’t know whether one’s disposition is a result of nature or nurture, or some combination of the two. Other adjectives I’ve heard used to describe disposition include gloomy, chipper, pushy, cranky, generous, stingy, passive and aggressive. They are a component of our personality. As a psychological construct, disposition has so many variables that it’s hard to precisely define or to measure, so these are just my opinions. Dispositions tend to be enduring traits, but that’s not to say that they can’t change over the course of one’s life. For instance, I think that people who’ve tended to be distrustful of others can learn to be more trusting, given enough positive experiences with trustworthy people.

When anxiety and depression are chronic emotional states that seriously affect our functioning, they’re diagnosable as psychiatric disorders. There’s considerable scientific evidence that there’s a biological basis for such disorders, although irrational thinking patterns can exacerbate them. The key to distinguishing  pathological states of anxiety and depression is impairment. Even during the saddest times in my life, my sleep and appetite weren’t seriously affected, and I was able to function adequately. I cried but didn’t have crying spells, and have never come close to attempting suicide. (I’m  not taking credit for this; I consider myself very fortunate.) During my year-long employment in an extremely stressful job, I suffered sleep loss; but my sleep improved immediately after I quit the job.

People who suffer from chronic anxiety and depression often get blamed for their symptoms, because they’re not understood as the symptoms of a chronic mental disorder. Because of the widespread stigma attached to mental illness, many people don’t feel the empathy they might feel for someone with a debilitating physical disorder. And people who suffer from these mental illnesses often blame themselves, telling themselves they “should be” able to control their symptoms. Others self-medicate with alcohol and other drugs that might give them short-term symptom relief, but only add drug dependency to their list of problems.

It’s hard enough to have a mental illness and to have to deal with societal stigma; but in addition, mentally ill persons are increasingly neglected in this country. The mental health system is shamefully under-funded, which explains why so many people with mental illnesses are homeless, why hospital Emergency Departments all over the country are swamped with people who are experiencing a psychiatric crisis, and why jails and prisons have become major providers of mental health services.

Everybody experiences anxiety and depression, and most of us learn how to cope with these transient conditions, because they’re not overwhelming or disabling. But some people with chronic anxiety and/or depression can’t cope without help from social support systems, whether in the form of professional services or community resources – family and otherwise – that recognize mental illnesses as treatable conditions, and provide needed help.

I’m taking a break for a couple of weeks, but will be back with a new post in early June. In the meantime, you can access other things I’ve written at my website: jeffkoob.com. It features links to my books, samples of my artwork, and a short story, “Demon Radio.”

It’s only Monday if you think it is

This post is one of my occasional philosophical departures from my usual subject matter. Although it isn’t specifically about rational thinking (which I’ve written about in previous posts), it is about mental habits and how they can shape our experience. I even intend to examine what “is” is.

Things that we know and experience through our senses are phenomena: rain, wind, temperature, the day/night cycle, seasons, etc. Mental concepts – noumena – such as justice, authority, honor, nationality and race don’t exist in the same way rain exists. For one thing, they’re not Absolutes; they mean different things to different people. And yet we often act as if certain noumena were as real as rain. Race used to be thought of as a biologically-based reality. Now we know that it’s a social construct based on culture and tradition. All homo sapiens belong to the human race, despite variations in outward appearances.

Days, months and years are all phenomenal, based on planetary rotation, the lunar cycle, and the earth’s orbit around the sun, respectively. The convention of the week, however is noumenal – it isn’t based on any natural phenomenon. The seven-day week has long been the standard way of sub-dividing months throughout the industrialized world, and most of us organize how we spend our time using this noumenal convention.  “Monday” (for instance) is a social construct.  But it’s only Monday if you think it is.

Try this thought experiment: Imagine waking up on the beach, alone, on a desert island. You’ve been delirious with a fever and don’t know how long you were “out of it,” so you’ve lost track of what day it “is.” You have no sensory way of determining it, and it doesn’t even matter in any practical way whether it “is” Monday or Tuesday, because you’re not on anybody’s schedule. Will you arbitrarily choose a day of the week as your baseline and keep track of what day it “is”? Or will you adopt a different mode of thinking and just live each day on the island, without having to give it a name?

Even though it’s just a mental construct that most of us buy into, the day of the week may control our actions and thoughts, and even our moods. You might hear someone who works Monday through Friday complain about having the blues “because it’s Monday.” He’ll predictably perk up five days later because it “is” Friday, the start of the weekend (another noumenal concept). Which brings us to the question of what “is” is.

“Is” can be used to cite a phenomenal reality (it is raining), a noumenal belief (it is Monday), or to state a quality or property of a thing (the apple is red) – the Aristotelean “is of equivalency.” In the first instance, regardless of what I may believe, I’ll get wet if I step outside when it’s raining. As regards the second instance, wars have been fought over where, exactly, the border between two countries “is.” In the third instance, if one person in a room says “It is hot in here” and another person in the room says “No, it’s not,” one of them has to be wrong. What “is” is the basis of many a dispute, whether interpersonal or international. Such disputes can be avoided by dropping the pretense of objective truth implied by an “is of equivalency,” and “subjectivising” the statements: “I’m hot.”/ “I’m not.” No conflict about what “is.” Whether or not Sally “is” pretty can be viewed as a matter of subjective opinion, not of objective fact. Beauty is, after all, in the eye of the beholder.

E-prime – English that omits all forms of “is” – is a tool for learning about the linguistic traps that can be set by its use. Nobody has ever suggested that E-prime should replace English. (It’s often more precise than English, but doesn’t lend itself to poetic word formulations.) But try writing without using is/am/are/were etc. and it will help you to appreciate how much you tend to unconsciously objectivise things you believe to be true or important.

Here are some translations of English sentences into E-prime: English – She is pretty. E-prime – I find her attractive/pretty. English – This is really difficult.  E-prime – I really have a hard time doing this. English – Look, it’s a UFO! E-prime – I can’t identify that flying object. English – Time is money. E-prime – Earning money correlates to a high degree with the way you spend your time. English – This is Monday. E-prime – Because of the social convention of the seven-day week, most people think of today as Monday. English – He is a liar. E-prime – He lies a lot. English – God is love. E-prime – I believe in God as the embodiment of love.

There’s some overlap in the ideas I’ve written about here and my previous posts on rational thinking and cognitive behavior therapy. Linguistic conventions can make us prisoners of language. Wittgenstein wrote, “The limits of my language are the limits of my universe.”

Some irrational self-talk involves the “is of equivalency.” The thought “I am a Loser” presupposes that people are either Winners or Losers and might mean any of several things to different people. It might mean “I think that I lose more often than I should” or it might mean “I’m destined to fail, no matter what I do.” In either case it’s an irrational simplification that can’t help anyone to achieve their goals. “Being a Loser” is a self-limiting noumenal notion.

It’s only Monday (or Tuesday, etc.) if you think it is. Monday isn’t real in the same way that rain is real.

 

On supervision and treatment teams

Throughout most of my career as a public sector psychologist, working in a variety of settings, I was blessed with good supervision. The few times I either didn’t have a clinical supervisor (as in Jamaica) or didn’t get adequate supervision, I felt like I was walking a tightrope without a net. A good supervisor will listen to you as carefully as you listen to your clients, and give you feedback on how you’re doing.  Positive feedback validates your work and increases your confidence that you’re on the right track, and negative feedback teaches you humility and provides valuable instruction.

As in therapy, a good supervisor asks the right questions. (When the person you’re talking to asks spot-on follow-up questions, you know she’s listening and understands you, whether it’s a friend, therapist, or supervisor.) As your supervisor gets to know you, he will validate your competencies and strengths, be part of your continuing education as a clinician, and insure that you know the appropriate scope of your practice. He will offer constructive criticism when necessary, and may suggest resources for your professional development. He will alert you to possible ethical issues.

At  the beginning of individual supervision, the therapist being supervised might have to staff each case in some detail, until the supervisor gets to know her strengths and limitations. Later in supervision, the therapist might provide brief updates on the progress in cases already staffed and spend more time on new, or challenging, cases. In group supervision, participating clinicians may be asked to prepare case presentations, usually on their most challenging cases.

The other group setting where clinicians might be asked to present cases is in treatment team, which is a kind of group supervision. In community mental health centers (CMHCs) and other treatment facilities, each new case has to be staffed,  and the treatment plan has to be approved by a multidisciplinary treatment team. Not only do treatment teams insure that all treatment is reviewed by colleagues on an ongoing basis, they also serve a professional development function. The ideal treatment team consists of one-or-more psychiatrists, psychiatric nurses (or nurse practitioners), psychologists, social workers, counselors, and possibly specialists such as art therapists or activity therapists. Each discipline represented on a treatment team brings a different area of expertise to the table. In the best treatment teams a kind of cross-pollination of ideas occurs, as treatment plans are generated and reviewed.

I’ve been a treatment team member at CMHCs, juvenile and adult prisons, and hospitals. The smallest, at a rural satellite office of a CMHC, consisted of only a psychiatrist, a psychiatric nurse (my supervisor), and me. The largest consisted of something like fifteen members, with people from all or most of the helping professions listed above. Some treatment teams might give assignments to its members, such as  asking a psychologist to do some psychological testing for a client on someone else’s caseload. In facilities run on the medical model, treatment teams are headed by psychiatrists. In a well-run treatment team, everybody has a voice.

I’ve not only appreciated, but enjoyed most of my treatment team experiences. Working with colleagues from a variety of disciplines has broadened my knowledge and increased my appreciation of the unique contributions offered by each profession. The highest goal of both clinical supervision and treatment team staffing is to insure that clients receive effective treatment, tailored to their unique needs. I have fond memories of interactions I’ve had with a number of my clinical supervisors over the years and – full disclosure – I fell in love with one of them. We’ve been married for almost thirty years.

Maria, a psychiatric nurse, was my third clinical supervisor, and I admired her before I fell in love with her. I had the silly notion – grounded in my own insecurities as a young therapist – that group therapy wasn’t effective with chronically mentally ill clients. She set me straight, telling me that I’d be leading  a weekly group with some of my most challenging clients, and offering to co-lead the group with me until I felt competent to lead it on my own. She was my first role model for doing group therapy.

We felt awkward at first when we started dating, but Maria did the right thing and talked to her supervisor about it. He reassured her: These things happen. You know what you’re doing.

The rest is history.

 

Relapse Prevention, Part 2

In my last post I wrote about triggers for relapse and the importance of having a relapse prevention plan, if you’re trying to establish and maintain a clean-and-sober lifestyle. The relapse prevention curriculum I developed in at the University Hospital of the West Indies in Jamaica included modules on stress  management, anger management, and rational thinking – all topics I’ve covered in previous posts. In this post I’ll be writing about other aspects of recovery from addiction.

I’ve met people with serious substance abuse problems who were too  proud to admit that they needed help in their recovery. (“I’m man enough to do it on my own!”) I’ve also known drug abusers who couldn’t imagine talking to other people – especially strangers – about addiction-related things they’d done and were ashamed of. But I’ve never met a recovering addict who got and stayed clean-and-sober without help from others, either in the form of professional help, or peer support groups such as AA. The road to recovery isn’t a road to walk alone.

Although I never saw him staggering drunk, my own father was an alcoholic. A military man who prided himself on his self-control, he once went for a year without drinking, to “prove” his ability to control his drinking. He went for exactly 365 days without a drink, but he hated every day of his self-imposed sobriety. It’s a condition known in the recovery community as “dry drunk.” As planned, on Day 366 he resumed drinking, moderately at first. But within weeks he was back to hiding bottles and drinking at the level he’d been drinking before his year of “white knuckle” sobriety.

There are individuals, I’m told, who’ve regained control of their excessive drinking and become moderate “social drinkers” – but I’ve never met one. “Someday I’ll be able to drink again” is a dangerous thought for people in recovery. Addicts are notorious for irrational thinking and self-deception. Many a relapse starts with thoughts like “I’ll allow myself one beer on my birthday” or “I can still shoot pool with my drinking buddies at the bar, and just drink sodas.” One of the arguments for attending Twelve Step meetings is that in time you’ll come to recognize your own rationalizations, by listening to other addicts who’ve come to recognize their own bullshit. Twelve Step meetings are all about getting real with other addicts who they know won’t judge them, because they’ve been there, done that, themselves.

Some friends and family of addicts don’t want to support their recovery, for a variety of reasons. Other well-meaning people who care about an addicted friend of family member become enablers. With the best of intentions, they try to shield their friends or  loved ones from the natural consequences of their addictions. They think they’re being helpful, but they’re simply enabling the person to continue drinking or using. In order to truly help, enablers need to learn to practice tough love – to stop attempting to rescue the person, and to let them suffer the natural consequences of their substance abuse. A mother practicing tough love won’t bail her son out of jail, because she knows from experience that if she does, he’ll be shooting up again within hours of his release.

Most recovering addicts come to the realization at some point in their recovery that they not only have to stop their drug-of-choice, but all intoxicating substances. I’ve known a number of crack and opioid addicts who initially believed that they could substitute alcohol and/or cannabis for their drug-of-choice, only to find that it was just a bridge back to their preferred drug. Cravings are one of the most common triggers for relapse, and getting high or intoxicated doesn’t improve anyone’s judgment or ability to resist cravings.

In my last post I mentioned euphoric recall (addicts dwelling on memories of the good times they’d had drinking and drugging, before getting addicted) as a trigger. This is one form of rumination, but addicts can also ruminate about how much they’d like to get high right now. This kind of thinking activates cravings that lead to relapses.

I’ve had some personal experience with this, as a recovering nicotine addict. What I found was that when I ruminated on how good it would feel to light up a cigarette, I relapsed time and again. Eventually I was able to identify my ruminations as a predictable relapse trigger, and to stop dwelling on thoughts about how I’d like to have a smoke. I still have occasional situation-specific cravings for tobacco, but I no longer feed the initial thought with more thoughts, and the cravings only last for a few seconds. After years of being  nicotine-free, the long-term rewards of being a non-smoker outweigh any momentary cravings I might have to light up again.

Relapse prevention, Part 1

I’ve written about my two years (1991-93) as a ward psychologist on the fledgling Detox/Rehab Ward of the University Hospital of the West Indies (UHWI), in Kingston Jamaica. When I started my Peace Corps tour of service, the ward had no treatment model other than the medical model, supported by Twelve Step meetings (Alcoholics Anonymous, Narcotics Anonymous). I introduced a relapse prevention curriculum that was adopted by the ward staff. When I recently checked out the UHWI Detox/Rehab Ward (now called the Addiction Treatment Services Unit) online, I was delighted to see that it’s still using a relapse prevention model. My Peace Corps legacy was a relapse prevention manual that I wrote for use on the ward. A Returned Peace Corps Volunteer who’d served at UHWI years after my departure told me that the manual had still been in use  when he was there.

A relapse prevention approach to recovery works well within the medical model, which – like Twelve Step programs – regards addiction as a disease. I introduced the patients on the ward to the relapse prevention model in my psycho-educational groups. Addiction, I said, is a chronic, progressive, relapsing disease that is ultimately fatal, if the disease progression isn’t arrested. Chronic means it doesn’t just go away at some point. Progressive means it gets worse over time. Relapsing means that most addicts will relapse multiple times before establishing long-term sobriety – if they ever succeed in doing that.

One of the advantages of the medical (or disease) model of addiction is that it helps some alcoholics/addicts to understand why they can’t control their drinking and/or drugging: they have a disease. Guilt and self-blame don’t generally help people to come to terms with their addiction. The medical model tells addicts that while they can never be “cured” of their chronic disease, they can halt its progression and stay in long-term recovery. This is why alcoholics in AA programs still refer to themselves as alcoholics, even if they haven’t had a drink in many years. They’re not ex-alcoholics, they’re in recovery. They may have stopped the disease progression, but they remain at risk of relapse. As any recovering addict will tell you, recovery happens one day at a time.

If you’re an addict, relapse prevention means learning what puts you at risk of relapsing. There are myriad ways that people who are struggling to stay in recovery unconsciously set themselves up for relapse. The first step in creating a personalized relapse prevention plan is to identify your triggers for relapse. Triggers can be people, places, things, activities, attitudes, emotions or thoughts. Different people have different triggers.

Recovering alcoholics may have to sever relationships with their old drinking buddies and stay away from bars and parties where alcohol is served, at least in early recovery, possibly permanently. If a lover is still drinking/using, a person in recovery may have to end the relationship. A recovering crack cocaine addict may need to stay away from the places he used to score and use, and might be triggered by the sight of a crack pipe or the smell of cocaine being smoked. Stress, anger, anxiety and depression might trigger a relapse. Thoughts like, “I’ll never drink again unless ________” can be a set-up for relapse, as can euphoric recall – dwelling on thoughts about the good times you used to have getting high, before you became addicted.

The second step in creating a relapse prevention plan is knowing in advance what you’re going to do instead of using, once you’ve been triggered. That might be going to a Twelve Step meeting, calling your sponsor, or checking yourself into Rehab. If you don’t have a plan for what you’ll do when you’re triggered, you’re probably going to relapse. A slip – defined as a single episode using your drug of choice or a bridge drug – need not become a relapse, if you have a plan and act on it. All too often, when an alcoholic gives in to temptation and drinks a six-pack after an extended period of sobriety, she thinks “I blew my recovery! I may as well go to the liquor store.” If, instead, she goes to an AA meeting or calls her sponsor, and admits what she’s done, she may prevent the slip from becoming a full-blown relapse. I used to quote an African proverb I’d heard somewhere: “If you want to avoid falling where you have fallen before, don’t examine where you fell, but where you slipped.”

I don’t mean to suggest that everyone with an addiction problem has to join a Twelve Step program and go to meetings for the rest of their lives, although for  some that may be exactly what they need to do. I’m convinced that there’s more than one road to recovery. I’ll write more about relapse prevention in another post.

Psychological learning theory

I briefly covered behavior modification in a prior post. In this post I’ll explain classical and operant conditioning in more detail, with examples to illustrate the concepts. The principles of behaviorism, or learning theory, are fundamental to the science of psychology. Two of the names most commonly associated with behavioral psychology are J. B. Watson and B.F. Skinner. Two key words in learning theory are stimulus and response.

Classical conditioning is also known as Pavlovian conditioning, based on Ivan Pavlov’s famous experiments with drooling dogs. Salivation is what behaviorists call an unconditioned response to an unconditioned stimulus – the presentation of food. In other words, neither dogs nor humans have to be taught to salivate when we see and smell food that appeals to us. A bell is initially a neutral stimulus, having nothing to do with food or salivation. But when a bell is rung every time food is presented, it becomes a conditioning stimulus, as the brain learns to associate it with mealtime. Eventually the ringing of the bell alone, without the presentation of food, will stimulate salivation – a conditioned response.

Classical conditioning is one of the most powerful tools used by marketers and advertisers to condition behavior on a mass scale, through the popular media. They systematically condition consumers to associate pleasant or desirable things with symbols such as McDonalds’ golden arches, logos, slogans, jingles, and attractive people giving sales pitches. They use it because it works. You see bikini-clad babes posing at car and boat shows because it increases the sales of the cars and boats  they’re posing in front of.

Where classical conditioning is a passive mode of learning, involving the creation of unconscious associations, operant conditioning involves systematic responses that shape a target behavior, making it occur either more frequently or less frequently. The process starts with recording the baseline frequency of the target behavior, i.e. how frequently it naturally occurs without systematic reinforcements being applied. Things that happen consistently as a consequence of the target behavior will tend to make it occur more frequently, if followed by a rewarding – or positively reinforcing – response (e.g. praise, money, candy, affection, etc.). If an expected reward is withheld – negative reinforcement – or the behavior is somehow punished – aversive reinforcement – the behavior tends to occur less frequently. Negative reinforcement is also used to increase the frequency of the behavior, when an aversive consequence (e.g. pain, shaming) is removed/avoided.

We might go to work even if we don’t really want to, because we know that our behavior will be reinforced by a paycheck. We know that if we stop going to work, the reinforcer will be withheld. Operant conditioning is the way we shape the behavior of our children, and train animals to obey our commands or to learn tricks. It explains the motivation athletes have to spend long hours exercising and practicing their skills.

The other principle to understand about operant conditioning is ratios of reinforcement, which can determine how lasting a conditioned behavior is. A hungry, caged rat can be taught to press a lever relatively quickly, if it’s rewarded with a food pellet every time the lever is pressed – a 1:1 ratio of reinforcement. But if you stop reinforcing the learned behavior with food, it won’t persist. In order to make the new behavior more persistent, you gradually “thin out” the frequency of reinforcement, perhaps starting with a 1:2 ratio. Now the rat only gets food every second time it presses the lever. Then you can go to other fixed ratios (1:3, 1:4); but if the ratio becomes too thin or if the food pellets stop coming, the learned behavior ceases, or in behavioral terms is extinguished.

If you really want a target behavior to persist without reinforcing it at a fixed interval, you move to a variable ratio: you vary the ratio, so the rat doesn’t know how many times it will have to press the lever (1:2, then 1:5, then 1:3, then 1:6, then 1:2, etc.) in order to get the food pellet. A hungry rat will keep pressing the bar, having learned that it will eventually get rewarded with a pellet. A well-fed rat will find better things to do with its time.

To take this to the level of human conditioning, think of the difference between a vending machine (with a 1:1 ratio of reinforcement) and a slot machine (with a variable rate of reinforcement). Every time you feed the required amount of money into a soda machine and press a button, you expect to get a soda. If you don’t and you’re very thirsty, you might try a second time. But if your behavior isn’t reinforced the second time, you certainly won’t keep feeding money to the machine.

But if you’re sitting at a slot machine, you don’t expect to be reinforced every time you put in a quarter and pull the lever. You might  get a sequence like this: nothing, $2, nothing, nothing, $5, nothing, nothing, nothing, $3, nothing, nothing, etc.. The behavior of feeding money to the machine and pulling the lever might persist until you’re out of money. Gambling machines have been called “addictive” because when we get money back from the machine, we get a jolt of the neurotransmitter serotonin ( a positive reinforcer) and persist, anticipating the next jolt – much like a hungry rat conditioned to persist in pressing a lever, knowing it will eventually get a food pellet.

What it takes to be a psychotherapist

These are just my opinions, based on my thirty-plus years as a psychotherapist. I suspect that the first thing it takes to be an effective therapist is to feel a calling to the profession, as in a religious calling, or vocation.  I may be wrong in this belief, but I don’t think many people enter the profession with the goal of becoming wealthy or famous. (I think the same is true of the best teachers.) A basic qualification is that you’re a compassionate person by nature. I grew up thinking I was going to be a career Army officer, like my father and his father; but at the end of my service obligation I resigned my commission and decided to study psychology on the GI Bill. I knew I wanted to be a healer, not a soldier.

One factor in my calling to be a therapist was the gratitude I felt for having been raised by loving parents, in a loving family. I had a happy childhood, and the older I became, the more aware I was of my good fortune. My father felt called to lead men in combat; I felt called to help people who hadn’t been blessed as I had been, to heal and grow.

That’s not to say that a happy childhood is a prerequisite for being a good therapist. Sometimes the compassionate nature that’s a basic requirement for the profession comes from painful personal experience, and empathy for others. Dialectical Behavior Therapy (DBT), a highly effective therapy for people diagnosed with Borderline Personality Disorder, was the brainchild of Dr. Marsha Linehan. It was born from her own struggles with mental illness, and her own painful road to recovery. I’ve known a number of good therapists who were themselves in treatment for a mental illness.

Therapists are flawed human beings, like everyone else, and I’m not saying that your life has to be in anything-like-perfect order for you to be an effective therapist. But in order to be able to separate your own needs from those of your clients, you need to have the kind of self-awareness and insight that come from leading a balanced life, in which your own basic needs are being met. Any blind spots about your own personality and needs will be blind spots in your understanding of your clients’ personalities and needs. (In my opinion all therapists have blind spots; it’s a matter of how many and how big. That’s where good supervision – and an openness to being supervised – comes in.) If you  have significant unresolved conflicts in your own life, you probably need to be in therapy, yourself. Having the experience of being in therapy (some therapist training programs require it) will surely help you to be a better therapist.

You have to have the ability to be present and caring with many people who are in pain, without becoming functionally depressed. This is another reason why you’ll need to have your own psychic house in order, if you’re going to be able to help other people. In most clinical settings, being a psychotherapist carries a lot of responsibility with it. It’s a very stressful profession. If you work with clinically depressed people, you have to be prepared for the possibility that one of your clients may commit suicide. Especially if you work in the public sector, you may also have to work with violent people.

If you have a tendency to be judgmental, you can’t be a good therapist. You’re bound to encounter clients whose values are very different from your own. You have to accept the client as he is in order to help him change. Carl Rogers called this “unconditional positive regard,” and maintaining this radical acceptance may call for frequent attitude adjustments on your part. This requires self-awareness and emotional stability. It’s okay for a therapist to be a flawed human being, as long as you have some awareness of your flaws.

You need to enter the profession with an awareness of your limitations as a helping professional. You’re not there to fix people or to solve their problems. There are people entering therapy who are looking for a rescuer, because they think they need to be rescued and nobody in their social support network has been able to rescue them. (The “rescuer” is a role played by certain people in many dysfunctional families.) All you can do as a therapist is to try your best to establish a helpful relationship with your client(s) and to work with them in good faith on goals that were mutually agreed-upon. Among the appropriate roles you may play as a therapist are teacher, facilitator, coach, and even cheerleader. But you aren’t going to rescue anyone.

Sometimes you’ll fail to be helpful, despite your best efforts. Sometimes a client you thought you had a good relationship with, and were helping, will abruptly drop out of therapy; and you’ll never discover why. Sometimes you’ll feel “in over your head” with a client, not knowing what you should say or do next in your efforts to facilitate positive change. That’s when you need to appreciate the limits of your abilities to help alleviate suffering in a person you’ve come to care about. You may find that you’re not able to help someone you really, really want to help. These are humbling experiences. These are times when you need a good supervisor.

Those are the human qualities I think you need in order to become a psychotherapist. In terms of academic requirements, generally you need to have a graduate degree in psychology, sociology/social work, nursing, counseling, or a related field. If you work in the public sector, you may be “credentialed” to deliver specified clinical services, without having to be licensed in your profession. If you want to work in the private sector or have your own private practice, you’ll have to be licensed.