Extremes and how they are detrimental

I have been pondering my next blog for several weeks and thanks to recent sessions, I realized that this subject has been part of my counseling consistently.
When I started getting interested in counseling, my mother purchased a book that I continue to use to this day: "Feeling Good: The New Mood Therapy" by David Burns. It's pretty thick and kind of long to read but the 10 cognitive distortions that Burns discusses in this book have become my bread and butter for most of my counselling career.
One of the distortions that he discusses at length is "all or nothing" thinking.  I don't want to go thru the whole theory but the short version of this faulty thinking process is when an individual thinks in extremes, making statements with words such as "always", "never", "all the time", and such.
Why do we do this? I think that is a very complicated yet logical explanation.  In fact, I can think of 3 good explanations. The first one is that it simplifies our analysis of a situation. If you can classify it in two boxes, it makes it easy to remember, as well as simplify our emotional understanding of a situation. Think about the last time a misfortune happened to you at a restaurant. How did you react? It is so much easier to say it "always" happens to you instead of thinking of exceptions. This simplifies your emotional response instead of thinking of other factors happening such as a new staff, a busy night, shortage of certain ingredients, or even your own role in this situation. This last sentence complicates your emotional reaction and " gut instinct". No one likes to complicate their lives like that, do they?
Secondly, it can also be what I have nicknamed the "us versus the world" mentality. If "everyone" is against you and "no one" understands because it has "always" been that way, doesn't this type of thinking simplify things for you? I also have dubbed it the narcistic response. I am special, unique, one of a kind. Do you recognize other all or nothing statements there? And frankly, are we that special?
Finally, it distracts you from the true issues. When you think this way, you don't  have to look at yourself and you can blame others, faith, the world, the situation, your upbringing. And change will be "impossible".
How do you change this? It is both easy and hard. You must be able to accept to challenge yourself and your thoughts. And this is a lifetime challenge. You have to learn that black and white does not work. Life belongs in the middle, in shades of gray. If you learn to do this regularly, the extremes will fade. It will not disappear but it will get easier to reach.
In my practice, it is a common subject of treatment. But it is not always discussed...

Chris Herren and his powerful message

I  usually do not blog about something I read, something I attended, or something I saw. I think that experiencing anything in life is usually personal and may not be what others have experienced. I also feel that my interpretation may be wrong and never want to write anything, in case I missed an important point or my misunderstanding affects the person who made the presentation.
In this case, I want to make an exception. I went to a supper this Thursday and the guess of honor was Chris Herren, the former Boston College, Fresno State, Denver Nugget, and Boston Celtic who discussed very frankly about his past issues with addiction. Now, I will not pretend I am a basketball fan, as I am a fair weather fan. I am a lifelong Celtic supporter but to say I am a fan would be a lie. So when I attended, I had only limited knowledge about Chris.
Chris arrived early and shook hands with everyone. I joked with him prior to him speaking and he was very humble and laughed politely at my bad joke. As he started to speak, I learned more about him but more importantly, I learned how bad your decision making gets when substances such as opiates take over your life. Chris is a local kid who got many chances to play basketball, but alcohol and drugs got in his way so many times, he let many opportunities pass him by and it almost costed him his family and his life.
Many things struck me: when he discussed how his college opportunities were wasted away when he had a choice between successes (being a 1st round pick) and his own demons (cocaine, alcohol). Even when he got to the NBA, he was offered many opportunities, including playing with his hometown team, or completing the summer league, getting a golden contract, or restarting his career in Europe but at every turn, he chose his demons instead of career success. He was brutally honest about it and did not pull punches, which I admire.
What really struck me though is how honest he was about the impact on his family and friends. I was particularly touched by his description of the impact on his children and how he felt about it. I had tears in my eyes several times when he spoke about them. The other thing is his honesty about his ODs, as well as his desires to end his life. This is such a hard thing to admit. I rarely hear that. He told us about his homelessness, the places he ended up, the loss of his wife and kids, and how he wished it could end...How many people are willing to discuss that? He also talked about one of the most impactful counselor he ever had: he was brutal, he was honest, and it made a great positive impact on Chris.
He let us know how he got out of it too: Treatment and AA. It saved his life. He talked about his sobriety since August 2008 and how he has been since then. He has been featured on ESPN "Unguarded" and has written a book. I have never bought a book at these type of talks: without hesitation, I bought one and he signed it. He was very humble, very nice, and talked with everyone who spoke to him. Can't wait to read it. I am now a huge fan of his. He also made me feel that my style of counseling may impact someone one day. If you ever have a chance to hear him speak, I strongly encourage you to go.
Thanks Chris, count me as a huge lifelong fan!

Results Of Most Important Treatment Issue

Interesting findings on this non-scientific poll: Short-term treatment and experience of therapist tied for first place. I also found it interesting that no one voted for confidentiality. Most people who come through my door make sure who I can and cannot speak to.

All comments are welcome.

Taking the Stigma Out of Counseling

Recently, a very prominent former football player died of an apparent suicide at a very young age. I will not be discussing his case, as I feel it is disrespectful due to not knowing all the details, nor what happened or what was happening in their life.

After a hard time in your life, it can be difficult to admit that you may need some help. I don't want to pretend that counseling is the only solution. After all, you have friends, family, neighbors, people you trust that can be open to listening to you, help you out, give you a sense of direction, and make you feel good. I think that some of you can name one or two people in our lives that are like that. If you can, you are lucky. It is a great gift and you keep these people close to you.

However, sometimes, the best intentions do not help you. We can also all remember a time that we reached out to a trusted person about something and we kind of left scratching our heads, angrier, more upset, and/or more confused. It is not because their intentions were not good (although, it can happen that the intentions weren't that great) but it may not be what you were looking for. Or maybe they took another person's side and didn't get your point of view. Or you were unable to open up about stuff that can be hard to discuss.
If I have to say it, I will: "I am cheating on my partner"; "I am not sure if I am gay, straight, or bisexual"; "I am stealing from others"; "I've been addicted to a substance and cannot stop"; "I sometimes think of ending it all"; "I have a plan to get rid of my problems"; "I don't know what to do: I am in serious debt"; "I hate not working anymore"; "I sometimes just don't want to be a parent anymore". Think about it: How easy are any of those subjects to discuss with someone, even someone you trust? I know most people do not have those thoughts...or do they? I really think the issue is not talking about it, it is finding a person to talk about these things.
I think most of the questions I mentioned have something in common: Stigma. I mean those subjects are pretty taboo. It is not cool, it is not OK, it is not acceptable to think these things, never mind say them out loud. A strong person, particularly men, don't have these problems. And if you are a celebrity or a sports figure, what gives you the right to think these things? You have the whole world in your hand, don't think these things!
Of course, reality is that EVERYBODY has a right to think these things. And if you recognize that they are wrong, why wouldn't you reach out? Shame, of course comes to mind, as well as pride. And if you are in the limelight, it is hard to get help, as reaching out can be in the public eye. And sometimes, people don't understand HIPPA and go to the wrong people. And if you are a man, deal with your problems as a man.
Reaching out is a brave act but unfortunately, it is not always recognize as such, especially by the person who does reach out. Other people also will find ways to use these problems as a psychological edge on others, which is especially true in sports or celebrity circles. But guess what? After celebrity and your sports career is over, you still may have these problems. Then what? Reaching out and having the public support it is the key to start the reaching out of troubled thoughts. It is also a safe, effective way to deal with your issues. And maybe, just maybe, you get the right treatment, the right time and your future gets better.
It may be brain injury related, it may be inherited, but frankly the Social setting (particularly changing public perception) is the key to avoid future tragedies. Now, do you have the testicular fortitude to support this?

Substance Abuse

This subject can be controversial. Treatment for substance abuse is generally: "Wait until they hit rock bottom (jail, OD, hospitalization, losing everything, etc.), use motivational interviewing until then, send them to detox, do some counseling and send them to AA". I know it is not everyone's opinion, but I am looking at the general view of the treatment.
Let's address this one by one. Let's get one thing out of the way: AA (Alcoholics Anonymous), NA, CA, or __A is NOT treatment. Do I believe in AA? Well, let me put it this way: I have seen it work for some people, I have seen people hate going there for various reasons (triggering, boring, too Higher Power oriented, steps are too complicated), I have seen it grow on people. I believe that AA has good intentions and it has help many people, but to put all individuals in the same boat is wrong. Think about it this way: When you have diabetes, there are several options for treatment, from diet change, to regular insulin, and everything in between. Self-help groups can be part of treatment, but it cannot be the only way a person remains sober.
Motivational interviewing is based on stages of change and meeting the person where they are at. The 6 stages of change, and yes there are 6, are: pre-contemplative, contemplative, preparation, action, maintenance, and relapse. At anytime, the theory is the individual is at one part of these stages. I work with stages, not cycles. I think that an individual can jump stages, fall back, stay "stuck" at one point or the other. Again, meeting as person where they are currently and making sure they get information they need at that time is the best practice. Oh, and yes, relapse is part of it. Relapse may bring you to a different stage, including maintenance. But to assume relapse brings you back to pre-contemplative is shaming.
Shame: what a powerful emotion. I think that most individuals who have a substance use issue have been through shame most of the time they have been using. Using shame in counseling is probably the worse thing you can do, unless, of course, you want the person to really fall back to pre-contemplative. A person goes through enough shame when this happen, why add to it? I think we need to work on looking for the strengths and how they can be used in order to get the sobriety goal met again.
The rock bottom theory: while in principal that is great, I believe that if you wait until then, you might not be able to help that person. Think about it: an overdose can be fatal or even cause permanent damage, a crime can lead to a lifelong conviction, etc. Why wait until then? Will they change before that? Who knows. But giving up  is not always the solution. I have worked with people who told me that I was the first person in a long time that actually asked them how they are doing and why they are still using. The "why" is usually the key. Some people believe some drugs are "harmless" (FYI, none are like that if consumed daily), some are too addicted and don't want to go through withdrawals or even detox, some don't know how to ask and others are tired of being told to "hit a meeting". Rock bottom is not good the answer.
As for detox, only certain "drugs" can be a reason for admission to detox (good luck getting a detox for marijuana) but most drugs lead to detox symptoms. Most of them do not lead to death but not being able to smoke may lead to increase anxiety, panic attacks, and feeling helpless. No physical addiction does not equate no detox symptoms. Most people feel misunderstood and also do not want to deal with these symptoms. Acknowledging those symptoms and finding ways to address them is the key when a person is stopping their drug.
As for maintenance, the use of medication assisted treatment (MAT) (suboxone, methadone) are extremely controversial. I believe again that you have to use a personal fit when thinking about these solution. Some people believe it is a legal high. Others see it as a crutch. And others swear by it. Again, you need to explore what will best work for you. If you are going to use MATs, I strongly encourage counseling (most doctors who prescribe these meds actually expect it). The doctor, the counselor, and the person using MAT should have open communication with no BS. And this is where I also differ: MATs were originally prescribed to help individuals get completely off all drugs, including these meds. But there is no money in that. The manufacturers of these meds, in collaboration with the doctors, now push a lifetime use of these meds. I strongly suggest that, if you use MATs, you should have an exit strategy, off the meds. These meds should not be substitute, they should be just a part of a long term plan.
Is counseling the only solution? Of course not. It is one of the solutions. But most experts agree that a combination of motivational interviewing with cognitive behavioral treatment is probably the optimal way to address these issues. However, it is not the only solution...Hope you get my drift.

Therapeutic Goals

It is usually one of the first questions I will ask or it will be one of the first statements of the person seeking therapy: the goal of counseling. As far as I'm concern, if this is not discussed right away, the first session can be a terrible disappointment  to both the client and the therapist.
Some people mistake the goals with the "why" of counseling. Stating that you are in counseling because of x/y/z really is not as important as "what do you want to accomplish?". Let me explain: someone may come to counseling because of others saying they are ______. Frankly, being in counseling for that reason is probably a) not a good reason to be in counseling and b)not the goal of the person seeking services.
If a person is coming to see you to confirm or infirm that statement, now we have a goal. Sometimes, however, they come to you for a total different reason. They may have noticed other things relates to that reason. A substance user may originally come to counseling because of others saying they have a problem but really, they feel misunderstood, have a short fuse, etc. Hence you can finally identify the goal of them seeking counseling.
It is not unusual that the original reason does not end up being the goal of the therapy. And that's ok. Most people can identify the why of counseling but, to many people, the goal is really the key to a successful first session and therapeutic relationship long-term.

Treatment Philosophy, Part 2

I wanted to add a few notes about my treatment. I believe that you got to meet people where they are at. What I mean by this is that if a person is motivated for change, we are going to talk about ways to change right now. If a person is unsure, then you work on  motivating them and see if they do want to change. The one thing I will not address immediately is past trauma. Why? I think it is irresponsible to work on it right away. You must develop skills and be sure that a person is ready to go there and have the tools to recuperate from discussing trauma. Therapy is only an hour a week but dealing with past trauma goes beyond the hour meeting. Give skills in order for the person to deal with possible thoughts about the trauma when the therapist is not there.
One of the first lessons I got from one of my favorite clients is that you must be real. People have been lied to, told stories, made promises, and had guarantees made to them in the past. Most of them turned out to be untrue or filled with conditions or "but"s. I think being as real as possible is what makes therapeutic alliances last. I am who I am and that is OK. I have some faults and I will always say that if I make only one or two mistakes in a day, that is an awesome day. We all make mistakes and we need to be honest about it. I expect that you will not come in perfect and I got to admit my mistakes when I make them. One of my favorite quotes from that same client is the following: "We can smell a phony a mile away". For the record, I still see this client in counseling.
If you read my blog, I disclose some information. I don't mind you knowing that. I also don't mind personal questions. I think they can be appropriate at times. I always remember the statement of one of my favorite singer. She said: "There is a difference between secrecy and privacy". Secrecy implies you have something to hide. Privacy is just normal stuff that is not kept secret, just some information that are private. If you ask me if I have a cat, why would that be secret or private? If you ask me where I live, well that is private. It's a line that can be blurry but I think that showing transparency improves the relationship with the clients. Making it about me, well that is wrong. I don't think everything about me should be secret but there are certain things that are private.
I also believe in the expression of emotions. Most people avoid certain emotions, especially some that are perceive as negative. I tell people to live their emotions, every one of them, as long as they do it appropriately. What I find is I have to facilitate the expression of these emotions. I think that if you live your emotions, you will feel more fulfill, more complete, and less repressed. I also like to make people feel uncomfortable. If you are having therapy and you are comfortable and you feel your therapist is on your side, you may not be getting everything you can from your therapist. I challenge, ask difficult questions, and make you feel like this is hard work. I think you need to challenge every client in order to earn your keep so to speak. Most of my clients appreciate it...eventually.