Wednesday, February 11, 2015

What is my therapist?

On any given day, the annuncitator panel (that sign with lights you click to tell your therapist you've arrived) is filled with incomprehensible acronyms. How can there be this many kinds of therapists and what does it mean?

I'm sporting a Psy.D. after my name. That's a Doctorate in Clinical Psychology. This kind of doctorate is awarded after completion of a dissertation that was a case study of a patient seen while working in a training clinic. The focus of the dissertation is an exploration of current clinical theories integrated and explained in the process with a patient in treatment. It's then reviewed by teachers/ defended by the author and accepted or rejected. My dissertation was about an adult child of holocaust survivors, and in a more subtle sense, non-verbal trans-generational transmission of trauma, and the theoretical-process in the room with the patient. It demonstrated an understanding of clinical process, theory, practice, and critical thinking.  In simple terms a Psy.D. is a doctorate in clinical practice. It does not make me a specialists in holocaust survivor children, rather it demonstrates a competency in clinical thinking.

In order to have a docotorate, you also have to complete a Masters Degree (MA). So, when you see a Psy.D after a therapist's name it means they have a doctorate of clinical psychology built on top of a masters degree, and have finished school. Same with Ph.D.

A Ph.D is a Doctorate of Philosophy. The difference between this doctorate and a Psy.D. is the Ph.D's additional emphasis on research. Ph.D' s spend time conducting research along their degree path. Psy.D's study research concepts in order to understand research, but do not conduct research. In simple terms a Ph.D is a doctorate in clinical practice and research. The dissertation is generally a piece of research done by the practitioner.

The post grad clinical training for therapists with PsyD's and PhD's is the same. It's the focus of document that is approved at school that is the essential difference. The differences between the 2 degrees are subtle and minimal. Both degrees are doctorates, and in practice both are referred to as psychologists.

MFT is a Marriage and Family Therapist.The degree has a lot in common with Psy.D and Ph.D but is completed at the masters level. In a general sense it's a 2 year degree versus a 4 or 5 year degree. It's not by defnition a lesser clinician (MFT's are psychotherapists but not psychologists), rather a background with less depth of study. They also have several thousand hours of post grad work and are highly trained.

An LCSW is a Licensed Clinical Social Worker.  This is a masters degree in social work. They also share an overlap of thought and study with MFT, Psy.D, and Ph.D, with a different focus (they are also called psychotherapists).

An MA denotes a Masters in counseling en route to but not yet awarded a doctorate.

A psychiatrist is a Medical Doctor. They're the ones working from a medical model and writing prescritpions. Some psychiatrists also practice psychology in addition to the medical process. They are skilled diagnostitions, and have a deeper understanding of nuerobiology, medicine, and science.

To make this really confusing. The degree is not the caregiver. There are excellent, average, transcendent, gifted, and awful at every degree level. It's important to pick your caregiver based on who they are and how they practice more than the degree itself.

Personal opinion is that sometimes there are situations that require a skilled hand with regards to diagnosis and pathology that do well to see someone with a more advanced degree. In practice, I've seen sometimes diagnostic opportunities missed (a mixed episode overlooked, a personality disorder diagnosis thrust upon someone for the wrong reasons, etc). But these are rare exceptions. I refer to clincians who's work I believe in, and who are ethical and talented... and these traits have little to do with their acronyms. One of the therapists I look up to and hold in the highest regard has an LCSW degree.

Writing this gave me a headache, I can only imagine what its like for the unitiatied and seeking relief. I like the ten-thousand hour rule... I tend to think folks doing things with ten thousand hours between them and the task... allows a deeper  more excellent process (that or it's an invitation to laziness). Headache indeed.


Monday, February 2, 2015

The beginning, the middle, and where is the end?

People tend to start therapy in some sort of crisis of feelings, loss/anxiety,  change in relationship, or when their coping mechanisms start to wobble. A sense of relief from the presenting-issues generally happens within a few sessions if not immediately after the first session. Research tells us that one of the most powerful tangible experiences in therapy comes from experiencing a sense of hope. Talking to someone with basic skills and a grounded, focused empathy should give the client that sense of hope and a sense that their feelings are contained, the crisis will pass, time will do the work, and perhaps a new narrative is formed that one uses to find higher ground under their own power.

The question that immediately comes up.... Is it time to stop therapy or is this just the beginning?  To simplify... Are you here to seek relief or to try and manufacture a deeper change? Both are valid, both are connected by soft tissue, and both can be foreward and reversed engineered into the clinical process. The thing is, you're here, the hood is up, the engine is right there... so why not?

This tends to be an ambigious endeavor for the patient (it should be crystal clear to the psychologist) and is all grist for the mill. That being said, there's nothing wrong with a quick few months or few sessions of talking. The take-home should be a sense of relief, and a language for what is there but not necessarliy on the table.



Tuesday, August 12, 2014

It's division's fault (sometimes).

When we're injured by the invisible forces of misattuned caregivers during childhood, we develop a genius survival mechanism. We divide and fragment. We divide all the treasures within, (that form self), and divy them up into pieces, and then bury them apart from each other. This ensures that when facing attack, we never lose all of ourselves. Think of a pirate burying his gold all over his island so that no one thief can steal all the loot.

In adulthood, if these treaures are still scattered and buried it creates a situation where you can't love and feel attraction to the same person. You can only feel sexual connection to someone that can't make you feel emotionally intimate and connected. The two primary treaures of love and libido are secreted away in 2 different places, always ever protecting you from losing yourself to intimacy. That's the classic experience of being sexually attracted to unavailable people while feeling repulsed by those most capable to love you back. For some, this is the unconscious energy behind polyamorous relationship(s). The playing with the distinct treaures at the same time.

It's also that this is the case when different intense senses of feeling come up in dystonic random and painful ways. One can be in some kind of basic joy and then completely hopeless with no sense of connection to their surround. You get buried by feelings. Once again, these are the sensations of those disjoined fragments popping up. You merge with pain and it becomes all of you because there is no connection to the rest of self.

The work in adulthood and especially in therapy, is to unbury all the treasures and reuinte them into a unified whole. That's what we refer to as , "integration".  And where one can't muscle into integration, then there's always the idea of consciously unintegrated. The threats we face in development aren't portable to adulthood (we aren't dependant on caregivers for survival and we have coping mechanisms) and so those same primitive defense mechanisms of buring the treasure no longer work. Adulthood is the  time to uncover what's buried away and gather it into one whole, for no other reason than this allows you to self soothe.

The risk of not doing so is that one never receives love and a libidnal connection to the same person, or when you encounter intense feelings, it seems like you merge with them. This so often is the condition that creates the impulse for suicide. This is the fertile soil for suicidal ideation when that impulse to die is simply the lost map to the other buried parts of yourself.

Wednesday, July 2, 2014

Black and White Thinking.

One of the things we look for when we're trying to understand how your defense mechanisms work is your ability to see the good and bad in something (or someone) and hold onto those attributes at the same time. To be able to see wholeness as a integration of good and bad into a cohesive sort of grey, rather than splitting everything into good or bad and going through enormous effort to put those two categories into some sort of tension with each other, and then in that tension the good and the bad can never exist at the same time.

When you're with someone that loves you one minute and hates you the next, its an expression of that kind of thinking. The idea being that we all have personality structures, and depending on the structure, how one organizes the sense of self and sense of other is an indicator or whether or not we're confronting neurosis or a deeper defict like a personality disorder. *Except in children, where this kind of thinking, the "friend/enemy list", is a normal part of their development*

The main problem or side-effect of black and white thinking is that in order to hold onto the division between good and bad, or render everything into those categories, one has to distort reality. And those distortions cause all kinds of problems (as a metaphor, think of a black and white photo instead as a black or white photo and you can see how the absense of the grey scale eliminates information). Or worse, when reality forces good and bad together and one starts to lose a sense of integrated-self (which is the fuel for acting out). That acting-out of emotions is also normal for children, but not a functional coping mechanism for an adult, rather it's a method of quick disposal of difficult feelings and often involves some sort of conflict or drama and suggests an injury or traits of some kind of personality disorder.

So, there's that.


Monday, April 7, 2014

Sometimes Someone.

I was just reading about Peaches Geldof and still thinking about LWren Scott... If one suffers from a depressive disorder, is a little over-attuned to what comes in,  and has some kind of narcissistic injury... it's impossible to convey how much not killing oneself is a daily decision, a minute by minute conversation and a kind of unending grind that... no matter how much one is met by love and support, opportunity and freedom... is always there. Some folks are fighting invisible forces every second of their lives.  The thing is wiring. It's subtle, it doesn't care much about rational thought and it's always there whispering at you no matter what you do. It makes a home of you. I hate seeing take anyone... as it so often does. The bad moment always passes but the accumulation of them can kill even the most thriving amongst us in a moment of hopelessness. We don't really (culturally) engage it beneath the surface before we toss it away as selfishness or stupidity. 
There is a way through. There are ways through.




Wednesday, April 2, 2014

Time for a Tolle.

This seems pertinent to a lot of what I've been seeing come up in the office of late:

"Every addiction arises from an unconscious refusal to face and move through your own pain. Every addiction starts with pain and ends with pain. Whatever the substance you're addicted to- alcohol, food, legal or illegal drugs, or a person - you are using something or somebody to cover up your pain" - Eckhart Tolle.

The underlying process in talk therapy is unconvering pain at its root... through the layers to the  original pain, and then finding a way to  feel and move through it, and to make  make narrative meaning of it. That's most often the process for most people. There are a lot of false pains and compartments... the unearthing is an endeavor. But it's ultimately to uncover and then move through pain. Life is many things, all made more difficult by undigested pain. There's that old notion that we create new pain to avoid old pain with the hopes that the old pain is pushed so far down it's made mute. I've yet to see this work for someone. It can never find quiet until it's released. It's fairly easy to identify the pain at it's root... it takes skill to get there. Reading a map and walking through a jungle are very separate endeavors.



Tuesday, May 7, 2013

Trauma (for argument's sake)

My doctoral dissertation was a case study about a then client who's parents survived the Holocaust and unconsciously transmitted their unresolved, untouched, repressed, disavowed, and un-digested trauma into her. Now, some 13 years later.... if I were going to take on the task of rewriting it with this many years of private practice under my belt and this many long walks back up the mountain.... I'd write about "Transmission of Unresolved Trauma in Intimacy". 

Since this is a simple conversational medium and just blog, I'm going to distill it down to a uncomplex thought, opinion, and button pusher... and hopefully a conversation starter. This is entirely subjective.

I often find that people that come in for work around issues related to childhood trauma/abuse will only set about doing so by following  pathways to healing that don't require that they encounter difficult and sometimes unbearable feelings. This is the catch 22... I've yet to see any pain transformed without feeling pain. I do see superfifical improvements and those can be deeply meaningful.

The only way to entice them into the therapy is by talking and yet they fatigue around conversations rather than feel comfort in them. They move towards the black and white and away from the ineffible. And their lives are unconsciously built around this avoidance. And there is this exhaustion because so much has to be orchestrated to keep the undigested feelings at bay and out of consciousness. There is this seeking away from feeling that is so often exploited in so many well-intentioned earnest healing-arts.

There are so many pathways to reduce the intensity of the affective experience... but nothing can happen until you are in the room with them and they are in their trauma. To get to that trauma, all the while not traumatizing them... is no easy endeavor (for both parties). I don't have any stock answer for that one. Nothing happens if they aren't willing, and the arrival of  that willingness lays an expensive tax upon all involved.