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.

Dialectical Behavior Therapy, Part 2

Working in a DBT program requires strict adherence to the treatment model, which is why all clinicians are members of the consultation team. The idea is that nobody should have to work with this challenging population without peer supervision and support. I won’t get into the dialectical framework here, except to say that there are strategies that facilitate balance – the synthesis between opposites. Hegel wrote about how the dialectic between thesis and antithesis leads to synthesis. Similarly, wise mind is a synthesis of reasonable mind and emotion mind. A good DBT therapist has to think dialectically, and DBT is a highly strategic therapy.

My education in the model introduced me to the concept of parasuicidal behaviors: non-lethal self-destructive behaviors that are the result of the same impulses that lead to suicide attempts. These behaviors include the abuse of alcohol and/or illegal drugs, abuse of prescription drugs, self-mutilation, and other self-destructive acts. People who perceive themselves as living in Hell often have a profound ambivalence around the issue of living v. dying. If you define your life as “the problem,” then suicide can seem to be “the solution.” Many preventable suicides occur as a mood-specific behavior (i.e. nobody attempts suicide in a happy mood), because of such irrational formulations.

Being a therapist isn’t a one-way street. If I’ve helped some people to improve their lives, my own life has been enriched by working with quietly heroic people who have striven mightily to change themselves. This is true of people across the diagnostic spectrum; but I felt privileged to work in a DBT program, and to watch emotionally unbalanced people learn balance, and learn to build lives worth living. It’s some of the most difficult work I’ve ever done, intellectually, and some of the most rewarding. People diagnosed with BPD used to be regarded as untreatable by many in the mental health field. DBT is an empirically validated cognitive-behavioral therapy. That means there’s scientific evidence that it works.

Marsha Linehan has courageously revealed that DBT came from her own journey out of Hell. She started her career studying highly suicidal people, and coming up with survival tactics and strategies for emotionally volatile people who are trying to finds reasons to go on living. Another feature of BPD – or having “borderline traits” – is being extremely judgmental, both of self and others. That’s why an important component of DBT mindfulness training is learning to notice details in your here-and-now experience without making judgments. People with the BPD diagnosis tend to frequently attribute their emotions and behaviors to external things (relationships, circumstances), and the DBT program teaches skills that help clients to own their own choices, and learn to make better ones.

With DBT clients at high risk of suicide, the primary goal of treatment is to keep her alive until the benefits of the program start to rick in, and suicide risk diminishes. Sly humor is sometimes appropriate in individual therapy sessions, and I remember saying to a client, with a straight face, “One thing that’s clear from the research is that this therapy can’t work if you’re dead.” Suicide prevention is where some of the treatment agreement contingencies come in. With what I knew about mental health clients with the BPD diagnosis early in my career, I never could have imagined that someday I’d give one my home phone number in case of emergencies. But I did, and never regretted having done so.

People with the BPD diagnosis often have long histories of suicide attempts, and for putting crisis line workers in a difficult position, threatening suicide unless _____ happens. As a DBT therapist, I was available at home to my individual therapy clients on evenings and weekends – but I got to set my own boundaries. Mine were not before nine in the morning and not after nine in the evening, and my clients never once abused their contact privilege. DBT clients know that the processing of details (therapy on the phone) wouldn’t be tolerated, that the call would only last five-to-ten minutes, and that the focus would be on skills: What skills have you already tried? What skill has worked for you in this kind of situation before? What skill do you plan to try next? Just knowing that their therapist was available to them in times of crisis, if only for a brief consultation, was helpful in itself. They understood that if they attempted any “suicide blackmail” games, their therapist would call 911.

One built-in contingency was that the client could call her therapist at home only if she hadn’t already engaged in parasuicidal or suicidal behavior prior to calling. Once she had cut herself or taken an overdose, she lost her privilege of calling for help. This was a highly effective contingency. Another contingency had to do with the weekly individual therapy session. Most DBT clients value their limited time with their individual therapist, and often have specific issues they want to talk about in session. But individual therapy sessions generally begin with a review of the week’s diary cards. For the client to get to select the topic of discussion was contingent on not having engaged in suicidal or parasuicidal behaviors during the prior week. Any self-destructive incident would be the automatic focus of the therapy hour. In that instance the client knew that her therapist would engage with her in a detailed “behavior chain analysis” of thoughts, feelings and actions that led up to the self-harm. These therapeutic contingencies help clients to resist impulses to harm themselves. Impulse control is a learnable skill set for most people. It saves lives.

Dialectical Behavior Therapy, Part 1

For two years I worked in a Dialectical Behavior Therapy (DBT) program at Columbia Area Mental Health Center. The program director was Dr. Sherri Manning, trained by Dr. Marsha Linehan, who had devised DBT for people (mostly women) diagnosed with Borderline Personality Disorder (BPD). People with that diagnosis are notoriously difficult to treat, and DBT provided the first effective, empirically validated therapy for that disorder.  Working in a DBT program requires the study of Dr. Linehan’s groundbreaking textbook, Cognitive-behavioral Treatment of Borderline Personality Disorder and the accompanying Skills Training Manual for  Treating Borderline Personality Disorder.  Every clinician in a DBT program is a member of the “consultation team,” which supports the team members in their challenging work.

Borderline Personality Disorder is characterized by extreme emotional dysregulation, or imbalance. Personality disorders are  diagnosed on Axis II of the DSM (the “Bible” of psychodiagnosis), apart from Axis I diagnoses like depression, anxiety disorders and schizophrenia. According to Dr. Linehan, all people with BPD have an underlying Axis I pathology, but have also experienced trauma that has shaped their behavior in persistent, dysfunctional ways. People with the disorder are often suicidal, and frequently engage in self-destructive behavior, including drug abuse and/or self-mutilation. They go to extremes in over-valuing and then rejecting significant others – sometimes in the same day. Dr. Linehan describes them as living in Hell and not knowing there’s a way out.

In order to be accepted in a DBT program, the client has to sign a year-long treatment agreement, to be renewed at year’s end if the client wants to stay in the program. She agrees to keep a daily diary card, charting moods, thoughts, and behaviors; and agrees to keep individual and group therapy appointments. Participation in the program is contingent on living up to the terms of the treatment agreement, and the client also agrees to other specified contingencies, which I’ll write about later. In the DBT program I worked in, patients were seen once a week for individual therapy and twice a week for skills training group sessions. Although individual therapy plays an important role in DBT, the skills training groups are at its heart. There’s no processing of issues in these sessions, but rather the presentation of skills by the group leaders, and coaching in their use.

One of the skills taught to DBT therapists is radical validation. Whereas I might equivocate if someone said I’d yelled at them, under normal circumstances (i.e. “I didn’t yell, I raised my voice because I felt frustrated.”), if a client in the program accused me of yelling at her, I’d validate her perception and immediately apologize for yelling. People with the BPD diagnosis are frequently blamed for things they can’t control. Many have never heard validating messages like, “You didn’t choose to be like this. If you knew better ways of  dealing with your pain, you’d use them. I believe in you and your ability to create a better life for yourself.”

Four modules are taught in DBT skills training groups: Core Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Group leaders are trained in specific techniques to facilitate skill acquisition, strengthening and generalization. There are a lot of handouts and homework assignments. The groups reinforce what the clients are learning by keeping their daily diary cards. DBT is a cognitive-behavioral therapy in that it helps clients to learn the connections between emotions, thoughts and behaviors, and to apply that knowledge. A primary goal of the therapy is to help the clients achieve balance in their lives.

Marsha Linehan studied meditation with a Buddhist roshi (master) and a contemplative Catholic priest, and mindfulness is at the core of DBT skills training. Group members are taught that there are three primary states of mind: reasonable mind, emotion mind, and wise mind -the last of which is an integration of the first two. That they have a wise mind is a revelation to most clients. Being in the state of wise mind adds intuitive knowing to emotional experiencing and logical analysis. It’s explained as, “learning to be in control of your mind, instead of letting your mind control you.” One of the skills taught in the Core Mindfulness module is how to be mindful without judging.

The Interpersonal Effectiveness module helps clients to learn how to ask for things they want and how to say “no.”  It teaches them to prioritize and self-validate in setting relationship boundaries. It teaches “what” and “how’ skills for getting reasonable things you want and not caving-in to pressure to do things you don’t want to do. The Emotion Regulation module helps clients to learn the role of emotions, positive and negative, and to deal with them in a balanced manner. It teaches them how to build positive experiences and avoid negative experiences, and to feel a sense of agency in their reactions to emotions. The Distress Tolerance module teaches such skills as distraction, self-soothing, and improving the moment. It includes thinking skills and physical techniques for tolerating stress without responding in extreme, self-destructive ways. It teaches the concept of “radical acceptance” of things that can’t be changed.

After finishing the Distress Tolerance module, the group starts on Core Mindfulness again; so group members get multiple exposures to all four modules. I personally think that the skills taught in DBT groups can also help people with other diagnoses. I’ll continue to write about DBT in my next post.

 

Mindfulness and meditation

Mindfulness has become a buzzword, not only in psychotherapy, but in the mass media. Mindfulness is when you “stop and smell the roses.” Some people are making a lot of money marketing mindfulness training, but learning to practice it costs nothing beyond an investment of your time. An age-old Asian aphorism is that the mind is like a drunken monkey bitten by a scorpion. One of the benefits of this time investment is learning to tame your monkey mind.

Fritz Perls said that past and future are fictions: our lives are spent exclusively in the here-and-now. Buddhism teaches that all suffering arises from attachments, and in that regard it correlates to cognitive behavioral therapy. Self-talk is like a constant mental radio broadcast that most people don’t know how to turn off, as much as they might wish to sometimes. In my career I’ve had many clients who lived their lives in thrall to their frequent or constant irrational thoughts. Learning meditation gives you a way to turn off the mental radio at will.

Mindfulness is a kind of meditation that’s always available to us. It doesn’t require silence, or sitting in the lotus position, or chanting, or concentrating on a mandala, or doing yoga breathing – although all of these practices are valid methods  for learning to meditate.  Mindfulness simply means getting out of your head and being fully present in the here-and-now, the only time there is, without letting your mind wander and without making judgments.

Before I specifically get into mindfulness further, I’ll first share my understanding of meditation in general. I learned to meditate in grad school, and found that there are many methods for learning to stay in a meditative state of consciousness, some of which I listed above. I’ve experienced two distinct levels of meditation. I started out with what I call single-pointed meditation, which means learning to focus on a single thing – a candle flame in a darkened room, a mantra (chant), focusing on your breathing to the exclusion of all other thought. Unrelated thoughts will inevitably intrude, but with practice you can learn to ignore them, let them go, and return your focus to the single point. At first it’s a balancing act, like walking a mental tightrope. When you first realize that you’ve achieved a meditative state, you think “I’m meditating!”, but the instant you think that, you’re not – you’re thinking again. With sufficient practice you can lengthen the time you stay in the meditative state, and develop confidence in your ability to meditate whenever you choose to.

Once I’d learned to stay focused on one thing exclusively, without letting my mind wander to other things, I was able to move on to a new level of meditation – pure awareness. I learned that it’s possible to be awake and aware, without being aware of any thing. Learning to suspend object-consciousness and judgement is a liberation. You can tame your monkey mind, turn off the mental radio. The silence is golden. It’s a distinct state of consciousness that teaches you what thinking cannot teach. It calms the body and the mind.

Mindfulness is a kind of single-pointed meditative state. You can be mindful while performing a task, taking a walk, taking a bath, having a conversation, doing Tai Chi, or standing in a crowd. You can be mindful of your self-talk. Mindfulness means staying focused on your here-and-now experience, to the exclusion of extraneous thoughts and without making judgments like good/bad, beautiful/ugly, or right/wrong.

Many times in public I’ve played a mindful game with myself, a game that teaches me things about my ordinary (non-mindful) consciousness and my monkey  mind. Normally when I’m in public, people-watching, I’m constantly categorizing and judging and speculating about all the people I see: whether or not I find them attractive, whether they’re fat or thin, graceful or clumsy, whether  they seem smart or dumb, likeable or unlikeable, etc.  Sometimes when I catch myself making these instant evaluations, I decide to play “the Buddha game.” I mindfully suspend my monkey mind and imagine that everybody I see is a Buddha – perfect, God in disguise. Just as I believe that meditation has changed my ordinary consciousness over time, I believe that playing the Buddha game has helped me to be less judgmental and more compassionate.

Mindfulness training is at the core of Dialectical Behavior Therapy (DBT), a highly effective therapy developed by Dr. Marsha Linehan to treat people who meet the diagnostic criteria for Borderline Personality Disorder. While she was devising the core strategies of DBT, Dr. Linehan studied meditation with a Catholic priest in a contemplative order and with a zen master. The people for whom DBT was designed tend to be extremely judgmental (of themselves and others) and emotionally volatile. Dr. Linehan became convinced that practicing mindfulness would help them to find balance in their deeply conflicted lives. Having co-led DBT skills training groups and seeing first-hand the effectiveness of mindfulness training, I believe that it’s beneficial for mentally ill people with other diagnoses, too. But as I’ve said many times, you don’t have to be sick to get better. Mindfulness is a learnable practice that can improve your life, if you invest some time in it.

 

Effective communication and “fair fighting”

I wrote in my last post that I’d share my “fair fighting rules” for couples in a later post. I’m feeling on a roll with the topic of effective communication, so here goes. Arguments inevitably arise in all long-term committed relationships. They can be constructive or destructive. As a therapist, I coached individuals and couples in communicating effectively and avoiding destructive disputes. The successful use of these guidelines depends on good faith between the persons involved, meaning that neither partner tries to dominate the discussion, and both want there to be a positive outcome, based on honest communication. In honest, good faith disputes between equal partners, there doesn’t have to be a winner and a loser. (In game theory an I win/you lose interaction is known as a “zero sum game.”)  It’s possible to “win all the battles, but lose the war.” If you follow some basic rules, a disagreement is more likely to lead to a win/win outcome.

(1) Be mindful. Stay in the here-and-now and be aware of your emotions. (2) No attacks, threats or generalized judgments. Easy to say, but if you’re both mindful and acting in good faith, you can avoid these traps. (3) Be an active listener, with one person talking at a time. Don’t interrupt. Each of you gets to express yourself, each of you wants to be understood. (4) One topic at a time. Don’t drag in other issues or stuff from the past. (5) Try to express yourself in I-statements. You-statements, especially generalizations, tend to lead to defensiveness and denials. If you say, “I think/feel/want _____,” the other person can’t contradict you, can’t say “No you don’t.” I-statements invite understanding and empathy. (6) Avoid generalizations, often characterized by “always” and “never,” or  “should.” If you’re critical of something about your partner, try to frame it constructively. (7) Be assertive. Clearly state what you want/don’t want, or what you mean. Don’t expect your partner to read your mind. (8) Don’t miss opportunities to validate, or to acknowledge your understanding of, your partners feelings or point of view. What’s your common ground? Try to understand your partner’s position and express any empathy you may feel. (9) Avoid questions-that-aren’t-really-questions. They’re usually characterized by “why”s, such as “Why don’t you ever listen to me?” This is actually a statement (“You never listen to me.”) phrased as if it were a question. There is no answer to this emotionally-loaded pseudo-question that would satisfy the asker, because it’s not really a question. (10) If appropriate, turn the tables. Ask, “What do you think we need to do?”

I had the professional privilege of working in a Dialectical Behavior Therapy (DBT) program for two years. DBT programs are designed to treat people diagnosed with Borderline Personality Disorder. The program I worked in was run by Dr. Shari Manning, who studied with Dr. Marsha Linehan, creator of DBT. I spoke briefly with Dr. Linehan at a professional conference years ago and mentioned that I’d worked in a DBT program under Shari’s supervision, to which she replied, “You’re a lucky man.” And indeed I was. My participation in the DBT program at Columbia Area Mental Health Center was a great opportunity for professional development. Working in a DBT program requires adherence to a model and methodology as precise and rigorous as psychoanalysis. You have to follow fixed protocols and work within a peer consultation team that supports and guides your work with this very challenging population.

I’ll get into DBT in more detail over time, but suffice it to say for now, DBT programs teach specific skills to people who frequently have difficulty with relationships. For two years I co-led DBT skills training groups, and worked individually with clients in the program, coaching them in the use of the skills. One of the skills modules is interpersonal effectiveness. For now I won’t go into the acronym DEAR MAN that DBT uses as a mnemonic device, but will briefly describe the process that it outlines. First, you strive to be mindful and stay in the here-and-now. If necessary, you describe the situation or set the context. You express your feelings and/or opinions, then assert yourself, asking for what you want or saying “no” to something you don’t want. Next you try to say something positive, if only to express your appreciation that you were listened to.

An interpersonally effective communication might go something like this: “We’ve been friends for a while now and you’ve helped me when I needed it. I value your friendship and I hope we stay friends. But I can’t hang out with you when you’re drinking anymore. You know I’m going to meetings and trying to stay clean and sober. It’s not that you get obnoxious when you’re drinking, like some people. You can be lots of fun when you’re high, but I just can’t risk getting triggered and relapsing. You don’t drink during the day, so we can meet for lunch. Or if you want to try quitting again, maybe we can go to meetings together, and hang out over coffee afterward. You’re really a special person and I want you in my life, but my sobriety has got to come first.”

The speaker  here is attempting to preserve the relationship, but setting clear boundaries. She’s specifying the conditions under which they’ll meet in the future, without attacking or judging or blaming. In some interpersonal exchanges, a willingness to compromise is called for, but not in this case. Whether or not the relationship survives, the communication will have been effective. Effective communication is a learnable skill set.