Last week, after 3 years of practice, I closed the doors to my Palo Alto office location. Over the last year, I have gradually been transitioning to a full time practice in Sacramento, where I recently moved. As much as I am excited to be fully grounded in the Sacramento community, and to be able to stop the weekly commute between the two locations, there is also a sadness as I have had to say farewell to many clients who I have been working with for some time.
Final sessions (or terminations, in therapist jargon) in therapy come for many different reasons. Sometimes the client’s goals have been met and the therapy in no longer necessary. Sometimes scheduling conflicts, financial constraints, or other practical issues interfere with therapy continuing. Then there are times when either the therapist’s or client’s life changes (moving, new jobs, having children, etc) lead to an end of the therapy. What ever brings about that final session, when it arrives, it may come with a mix of emotions.
In the final sessions, I typically try to reflect with the client on the initial goals that brought them in, and where they feel they are with accomplishing those goals. We discuss what the client has learned about themselves, and themes that were important in the therapy. We also take time to consider areas where the client would like to continue to grow and how they would like to pursue this growth. If it is necessary, we discuss referrals or ways that the client can continue to grow on their own. Relapse prevention and considering what to do if relapse does occur are also topics to examine. Finally, we take time to discuss our relationship, how we have felt about each other during the work, and how it feels to be ending our time together. The therapeutic relationship is unusual as it is one in which great intimacy is shared and yet it has a clear and definite ending. In other close relationships, we say goodbye and expect to speak with the person again at some point in the future, but in the therapeutic relationship you may never have contact again. Clients sometimes experience feelings of sadness about this ending, while other times they feel it is a relief to be done and moving forward without the therapist’s support.
People often ask me how ending with clients is for the therapist. Do therapists feel a loss with an ending? In my case, the answer is absolutely. While the length of time we have worked together and the kind of work we have done, certainly affects how close I feel to a client, I almost always feel some sadness when saying goodbye. I feel honored that they have trusted me with their thoughts and feelings over the time we have spent together and while I experience joy at their successes that lead to them no longer needing my support, I know that I will miss them. I often find memories of my past clients will be triggered and make me smile or wonder what has become of them. Therefore, even when therapy has come to a close, both the client and I carry the shared memories with us as we go forward on our own.
In March, I opened the doors to a new office location in Sacramento, California. I found a lovely sunlit office in a beautifully restored Victorian on J Street in Midtown Sacramento and am enjoying getting to know this very welcoming and vibrant neighborhood. With beautiful architecture, incredible dining options, and friendly neighbors I have found it to be an easy place to be excited about. I am looking forward to growing my practice in this new city and connecting with the local community.
Mindfulness is purposeful and non-judgmental awareness of the present moment. It increases your awareness of sensory impressions, thoughts, emotions, imagery, urges and impulses. It enables you to become freer to observe your mind without being immersed in the workings of it. You can watch the waves of your thoughts and emotions crashing from the shore rather than being knocked around in the surf. The skills of mindfulness are quite simple, and will be outlined below, but because our minds typically behave so differently, learning them can take patience and practice.
How is Mindfulness Useful?
So much of the time we are lost in thoughts about what has happened in the past, or worries about what we need to do tomorrow, that we lose the present moment in the shuffle. You may take a shower, drive to work, and go through your day on “automatic pilot,” without real awareness of what you are doing. This common experience of losing touch with the present can cause a variety of problems. On autopilot, you are more likely to be triggered by events around you to react out of habit in ways that may be unhelpful. You may succumb more easily to urges and impulses. By increasing awareness of your thoughts, feelings, and body sensations without being completely immersed in them, you can give yourself greater freedom and choice. This can help you to get out of “mental ruts” or habitual reactions, that may have caused you problems in the past, and enable you to make healthy choices for yourself in the present. It can also help you to feel more engaged in your life, reduce worry about the past and future, experience deeper connections with others, and savor the positive moments when you come upon them.
Not all moments are positive though. We often are facing experiences that include pain, anxiety, sadness and other difficult emotions. Mindfulness can help in these circumstances too as you learn to increase awareness of feelings, you can learn to become more of an observer of them rather than being reactive to them. Even the most disturbing experiences can be viewed as passing experiences rather than as part of you. You can listen to distressing thoughts mindfully, recognizing them as mere thoughts. When the distress is too overwhelming, you can also move your attention to your body, breath, or other sensory experiences.
Research has demonstrated that developing mindfulness skills can be helpful for general well being as well as in the treatment of a variety of mental health concerns including depression, anxiety, substance abuse, eating disorders and couples’ conflicts. In addition to these mental health benefits, mindfulness has also been shown to improve physical health by relieving stress, treating heart disease, lowering blood pressure, reducing chronic pain, improving sleep, and alleviating gastrointestinal difficulties.
How Do I Get Started?
There are a lot of different ways to practice mindfulness, and not all of them involve sitting quietly with your eyes closed in meditation, but often this is a good place to start as you are developing skills.
Exercise: Mindful Awareness of the Breath
Sit quietly and focus on your natural breathing. Allow yourself to notice the sensations of air rushing in and out of your body without trying to control it. As you sit, focused on your breath, your mind is sure to wander. When this happens, gently bring your attention back to your breath without criticism or struggle. There is nothing wrong with your mind wandering, it is giving you the opportunity to notice a wandering mind and return your attention back to your breath. Noticing, without judgment, is part of what you are practicing. You can start with doing this for 5 minutes a day, squeezing it in wherever you can, gradually lengthening the time as you become more comfortable with these skills. The important thing is that you don’t base the practice on whether you feel like doing it or not, instead it needs to be established as a good habit like brushing your teeth.
You may find it helpful to begin practicing mindfulness with the help of guided exercises. Audio files can be found on this site to help you develop your skills.
To learn more about mindfulness, check out this video where Jon Kabat-Zinn, defines “What is mindfulness?” and discusses the hard work and rewards of practicing mindfulness. If you like it, you can read more in his book, Wherever You Go, There You Are.
Therapists will sometimes talk about “dual relationships” as a reason that they cannot work with a particular client, but what is a dual relationship and why is it a problem?
A dual relationship is when you have a relationship with someone within two or more contexts. For example, if your therapist was also your cousin, your next door neighbor or your client at work, you would have a dual relationship with them. A dual relationship can also occur within the professional domain. For instance, if a therapist was your individual support, working to help you overcome some challenge and support you, but was also asked to assess whether you or someone else should have custody of a child, this would also be a dual relationship because there would be two different purposes to their relationship with you.
Not all dual relationships are harmful. You and your therapist might go to the same gym, or perhaps your therapist occasionally has gone to the coffee shop at which you work. These types of dual relationships, of seeing one another in two different contexts, may not affect the work you do together and therefore may not be a problem. However, there are several reasons that therapists are often concerned about the way that a dual relationship could affect your therapeutic work together. One reason that therapy is different from other relationships is that the therapist is more objective than a friend or family member. By not knowing much about your therapist’s personal life, it can also free you up to be able to speak without concern about how what you say might affect the therapist – you don’t have to take their personal life into account and can be more open. Also, some dual relationships can create a power differential that could affect the therapy. For example, if you were a teacher and your therapist had a child in your class, the therapist might be uncomfortable giving you the kind of feedback they normally would if they were concerned it might affect your teaching relationship with their child. You also might feel uncomfortable sharing openly with your therapist if you feared it might affect their opinion of you as a teacher and thus affect your job in some way. Basically, having two different relationships with your therapist can at times result in conflicts of interest, and therefore dual relationships are typically avoided by therapists. In fact, the American Psychological Association’s Code of Ethics for Psychologists prohibits psychologists from engaging in harmful dual relationships.
These kinds of concerns are the reason that therapists will avoid engaging with you outside of their office. In most situations, they will decline invitations to your parties, and turn down your offers to provide your own occupational services to them. It is not because they wish to reject you or do not wish to spend time with you socially. In fact, I have often heard therapists say, “I wish I could be friends with this client – they are such a wonderful person.” However, the ethics code that therapists follow does not allow for these kinds of interactions and therapists therefore need to maintain strict professional boundaries.
Last week, I guest blogged at Cardinal Education’s Blog. Cardinal Education provides personalized educational consulting, tutoring, and admissions preparation to Bay Area Students. I’m reposting the article on how students can navigate performance anxiety in the classroom or on the field below. Hope you enjoy it!
Do you ever find it difficult to speak up in class, even when you are pretty sure you know the answer? Maybe you feel overwhelmed when you have to give a presentation – your voice shakes, it seems like your heart is beating out of your chest, and you have trouble remembering what you were planning to say. Do you find that no matter how hard you study for an exam, when sitting down to take it, you blank out and have difficulty focusing? Or do you find that when playing a sport you have difficulty performing at your best when the pressure is on? Although it can sometimes feel like you are all alone in these experiences, this type of performance anxiety is actually quite common among students.
Many psychologists believe that the problem with anxiety is that it is based in a system that was built to alert us of life threatening situations like woolly mammoths stampeding or saber-toothed tigers attacking. It is an old response to danger that is not always appropriate for what we perceive as current threats. The physical responses of an increased heart rate, sweating and quickened breathing, that many people experience when anxious, is our sympathetic nervous system preparing us for “fight or flight.” This response may have been helpful to early humans who had to defend themselves against physical threats, but seems to have spread to other types of situations where these physical and emotional reactions are no longer useful or appropriate.
The good news is that there are ways to retrain yourself so that the type of stressful situations that you experience at school do not alert either the physical or psychological responses that can interfere with your performance in class or on the field. Here are some tips to keep in mind when combating anxiety in your life:
Avoidance is working against you. The rush of relief that you experience when you escape another class without having had to speak up or decide to put off looking at the exam materials may feel good. However, over time this trains you to escape situations that make you nervous, which makes it much harder to face them in the future. The best way to address this is by pushing yourself to do some of the things that feel scary even though they are uncomfortable. Exposing yourself to situations where you feel anxiety is getting in the way of your success will actually lead to those feelings of nervousness disappearing over time. Sometimes joining groups such as a debate team can help you push yourself to do the things that feel scary and get you used to the anxious responses that may come up.
Practice makes perfect. Practicing the things that make you feel anxious repeatedly is another way of reducing anxiety. If it is an exam or a presentation, you want to practice them in situations where there is some sense of pressure, such as the practice exams offered by Cardinal Education, because it gives you the opportunity to be exposed to and to get used to the feelings of anxiety that are produced. This way, when it counts, those feelings will not be as likely to get in the way.
Learn to relax your body. Deep breathing and progressive muscle relaxation (where you tense and release different muscle groups), can reduce some of the physical symptoms of anxiety. There are many CDs and websites with mp3s for guided relaxation exercises to help you learn these methods of relaxation.
Skip the caffeine. Unfortunately, caffeine produces many of the same physical responses as anxiety. Because you associate these responses with being anxious, your brain often starts going looking for reasons you should be nervous and can end up finding something to be worried about. Therefore, if you experience anxiety, caffeine is not your friend.
Visualize success. We have a tendency to create what our mind imagines. Sports psychologists emphasize that repeated visualization of performing well can result in peak performance, where as imagining yourself failing often results in failing to show true capabilities. This means that imagining yourself missing a field goal or saying something “stupid” in class makes it more likely that you will have difficulty when actually in the situation. Instead, take time to imagine yourself performing at your best and demonstrating your true abilities.
Cut out negative thinking. That voice in your head that criticizes you, tells you you are going to fail, or puts the pressure on is not helping you. Many students worry that if they do not push themselves in this way they will lose motivation to perform well. However, visualizing your goals and success can create the same motivation without introducing the kinds of thoughts that tend to increase anxiety and interfere with performance. If you catch yourself thinking in this way, imagine a big red stop sign and internally say, “Stop!” Then, try to encourage yourself with more positive self-talk, the way you might encourage a friend.
Many of these suggestions are easier said than done. If you need additional support in learning to address this kind of normal anxiety, you should consider meeting with a psychologist. They can help you to develop the kinds of skills that will help you in performance situations throughout your life.
That first phone call to a psychologist or therapist can be pretty nerve wracking. It takes a lot of courage to make the decision to reach out and find some support. Many people put this off for months before finally feeling ready to make the call. Part of the anxiety may be in not knowing what to expect or what to say, so I’m hoping to give you some information on what to expect in that first call and what you may want to ask about.
Before making a call I would encourage you to consider the following questions:
Do I want to work with someone with a particular kind of educational background or license? Therapists can be psychologists, psychiatrists, marriage and family therapists, social workers, psychiatric nurses, etc. You may want to consider whether there is a reason that you would prefer to work with one kind of practitioner over another. (For more information on different types of providers, see here)
Are you most comfortable talking to someone of a particular gender, culture, religion, sexual orientation, etc?
When in your schedule can you make time for therapy? How much time can you make?
What is your budget for therapy? If you are hoping to use insurance, what does your insurance company cover and do they accept out of network providers?
Often when you call a psychologist, you will have to leave a voicemail message if they have a private practice. Most private practice therapists do not have any administrative help and therefore may be with another client or out of the office when you call. Different therapists handle that first call in different ways. Some want to mostly set up a first appointment so that you can discuss what you are coming in for in person, while others will want to have a lengthier conversation over the phone. They want to ensure that you are a fairly good fit to work together prior to having you come in to the office. They are likely to ask you questions about what is bringing you in at this point in time, but may also ask questions about your psychological history, medications, substance use, eating and sleeping, etc. to determine whether you are a good fit to work with them or might work better with someone who has a particular specialty. It can be uncomfortable to share this kind of personal information with a stranger over the phone, but it is harder when you come in and start to form a relationship with someone, only to find out that another provider would be a better fit for you.
At some point the psychologist is likely to ask you whether you have any questions for them. Many people are uncertain what they should be asking, but here are some ideas of areas you may want to inquire about:
Have you worked with people before who are dealing with the types of concerns I am? How do you typically work with clients with these kinds of concerns?
What type of treatments do you use and how effective are they usually with concerns like mine? If things don’t seem to be working, what do you do?
Do you have areas of expertise?
Does your work in therapy tend to focus more on the past or present? Do you tend to see clients for longer-term therapy or shorter?
What is your rate? Do you take insurance?
Do you take payment at each session or do you bill later?
What is your schedule like? Do our schedules match up? Do I hold a certain time slot in your schedule, or do we schedule from week to week?
What kind of degree and license do you have?
As you talk with the psychologist, both about what is bringing you in and about some of the questions that you have, you will start to be able to get a sense of their personal style and your comfort level in talking to them. Just like in dating, people have different chemistry with one another, and a therapist that is perfect for your friend may not feel quite right for you. It is perfectly okay to say that you are not sure that the therapist is the best fit for you, or that you are speaking with others to see who will be a good match and will let them know which way you decide to go. Only you can determine whether a particular psychologist is the right fit for you.
For many people, going to therapy for the first time is anxiety provoking. It can be intimidating when you don’t know what to expect. In an effort to familiarize new clients with the setting of my office and who I am, I decided to produce a video that serves as a brief introduction to my practice. Check it out!
Learning how to express concerns in a constructive way (as we did in Part I of Couples Communication) is an important part of communicating with a partner. However, it is equally important to learn to listen to what your partner is saying and to show them that you are listening. Sometimes you may be hearing what a partner says but you are not taking actions that let your partner know that you are understanding them. The following steps can help to show your partner that you hear them when they are communicating to you about your relationship or if they are simply trying to share some other experience with you, such as a bad day at work.
Listen to what your partner is saying even if you disagree. Avoid interrupting or preparing your defense while listening.
Body Language: Face your partner, make eye contact, and nod when they say something that makes sense to you.
Reflect: Let them know what you are hearing. Exp: “I see that you are hurting.” “You feel angry when I don’t do what you have asked.” “It sounds like your boss is putting a lot of pressure on you.”
Validate: Let them know that you recognize their feelings are real and valid. This does not mean you have to agree with them, rather you understand how they could feel the way they feel even if you disagree. Try to find the truth in what they are experiencing even if you don’t understand it. “I can understand why you would feel angry with me right now.” “I can see why you would feel hurt when your friend said X.”
Ask Questions: Asking questions lets someone know you are listening and that you want to understand them more fully. “What is it about X that makes you feel I don’t care about you?”
Avoid Advice or Problem Solving: Unless your partner asks you for it, try to just hear and understand your partner’s feelings. If your partner asks for help problem solving you can then take action.
Conflict is a normal part of being in a relationship. However, couples often struggle to figure out how to talk to one another about relationship concerns and areas of disagreement. It can be hard to determine how to bring up these areas and easy to let related emotions guide you towards expressions that may be hurtful to the relationship. Here are some basic guidelines to keep in mind when having these conversation. Not only will they help you to express feelings in a way that protects the relationship, but they also may help you to be heard, as they are less likely to push your partner to be defensive.
Pick the Right Time and Place: Avoid bringing up concerns when there is little time or if you know your partner is tired or stressed.
Avoid the Blame Game: Take the blaming and criticism out of what you wish to discuss by talking about your feelings and experience but presenting these as your perceptions not absolute truth.
Use I Statements: When you use statements about how you feel or your reactions rather than accusations, people can empathize with you rather than feeling they have to defend themselves. “I feel anxious and worried about you when you come home late and don’t give me a heads up,” is heard a lot better than “You are so selfish! You never think about my feelings and that I might be worried!”
Don’t Label Your Partner: When you talk to your partner keep it specific to the action that bothers you rather than labeling them with a characteristic. Say, “I feel frustrated when the dishes are left for me to do,” not “You are lazy.”
Stay in the Present: As much as it is tempting to bring out a laundry list of offenses to back up your point of view, this often leads the listener to shut down and feel defensive. Try to keep the conversation focused on the specific events that you are trying to address instead. Avoid saying, “you always…” or “you never…” Instead talk about the current situation and your reaction to it.
Empathize: Remember that the person you are speaking to has feelings and reactions to what you are saying and try to recognize their perspective while expressing your own.
Compliment: Don’t forget to give your partner credit for the things they do right and that you appreciate.
Express Needs: Instead of stating things that require your partner to infer what you need, state it explicitly. Instead of “The dining room is a total mess,” say “I’d appreciate it if you could clean off the table.”
Utilizing these guidelines will not necessarily make every conversation go smoothly, but they are a first step in finding healthy ways to communicate with a partner. Another important part is learning how to listen to your partner and to show them that you are listening (which can be two different skills). Stay tuned for Couples Communication Part II, where we will look at these kinds of listening skills.
Every person has values that affect the way in which they interact with the world. These are qualities, goals, life domains, etc. that a person prizes or prioritizes as important to them. Values can be influenced by culture, family beliefs, religion, education, and a variety of other experiences. Often values inform the way you act or decisions you make without you even thinking about it. Unfortunately, people sometimes get off track and start living in ways that are not consistent with their values. They might be making decisions based upon what feels good in the moment or avoidance of something that is uncomfortable. While we all do this from time to time, if you regularly are living in ways that are inconsistent with your values, you may find that you do not feel very good about yourself, that you are feeling stressed, or that you are generally feeling down. It is hard to feel positively about yourself and your life if ultimately you are not living in ways that you believe are right for you.
The following exercise can be useful in thinking about what your values are and whether you are living them as fully as you would like to be. It can also be helpful when you are trying to make decisions in your life, as this prioritizing of values can remind you of what is most important to you. Remember, values can change over the course of your life, as experiences influence you, so something could be important to you now that was not important to you before or vice-verse.
Look at the following list of values. On a piece of paper, make 3 columns: “Very Important To Me”, “Important To Me”, and “Not Important To Me”. Write down the values in the columns according to how important you feel they are to you. You do not have to be currently living the value as though it is very important to you for you to put it in the “Very Important” column. For instance, you may really value physical health, but you find it difficult to get yourself to exercise regularly and eat balanced meals. Still, physical health can be in your “Very Important” column if you really value it. Feel free to add values of your own that are not on the list below.
What do you notice about this process? Is it easy to determine how important to you these values are or did you have difficulty deciding which column they should go into? Were there surprises?
Now look at your “Very Important to Me” column. Circle your top 5 values.
Think about times you have really lived these values fully, how it felt, and how you felt about yourself. Ask yourself am I living this value as fully as I wish to?
Each week pick one of your top 5 values to dedicate more energy towards. Think of new ways to live this value more fully and commit to taking action. For instance, if you rank family as a top value, think of new ways to reach out and show family you care about them or consider what it means to you to be a good family member and try to live this more fully.