Every few weeks, I will post my thoughts from various books, articles, and discussions – as an extension of my desire to understand better the relationship between human behavioral health and counseling/psychotherapy. This blog is NOT intended to diagnose, treat, or replace person-to-person psychological, medical, or legal professional consultation.

COVID-19 and Psychological Stress

Posted by augmentin headache on Apr 5, 2020 in tramadol paracetamol | 0 comments

I am completing this blog while “sheltered in place” on Palm Sunday, April 5, 2020, in the midst of the COVID-19 PANDEMIC. When I began the blog yesterday around 2:00 p.m. (MT), news stations (using Johns Hopkins University as their source), were reporting coronavirus numbers as follows:

GLOBALLY:  Total Cases: 1,181,825;  Deaths: 63,902

IN THE UNITED STATES:  Total Cases: 300,915; Deaths: 8,162

As of this morning, less than 24 hours later, those numbers had been updated to read:

GLOBALLY:  Total Cases: 1,221,396; Deaths: 66,485

IN THE UNITED STATES:  Total Cases: 319,205; Deaths: 9,038

A dire freeze frame of ever-changing, exponentially increasing numbers of human suffering.

A couple of days ago, I viewed a live stream webcast from Dr. Bessel van der Kolk, leading trauma expert and author of the New York Times bestselling book, The Body Keeps the Score (2014).  Dr. Van Der Kolk is Professor of Psychiatry at Boston University School of Medicine, and pioneer researcher in the area of post-traumatic stress. The webcast specifically addressed the coronavirus crisis from the psychological toll of absolutely needing to “socially distance” ourselves from others, and “shelter in place.” Dr. Van Der Kolk was quick to point out however, that our “primary” concern is peoples’ physical safety and illness; and, “secondarily,” the economic fallout. Specifically addressing the psychological impact of the crisis, he identified several “Preconditions for Trauma” as follows: lack of predictability, immobility, loss of connection, numbing, loss of sense of time and sequences, loss of safety, and loss of sense of purpose.

It is not my intent to reproduce Dr. Van Der Kolk’s webcast in this blog, except to underscore the psychological (pre-traumatic) impact of COVID-19. Readers might consider brainstorming feasible strategies for each aforementioned “Precondition,” given the limitations of this crisis.

In the following paragraphs, I only wish to offer a few considerations for the current crisis, informed by my recent professional thoughts.

A few weeks prior to the COVID-19 outbreak globally, or at least hearing about it in the news media, I had been reading a new book by Marc Brackett, PhD, entitled Permission to Feel (2019). Reading from portions of the book’s jacket cover, “Marc Brackett, PhD, is the founding director of the Yale Center for Emotional Intelligence and a professor in the Child Study Center at Yale University….He is the lead developer of RULER, an evidence-based, systematic approach to social and emotional learning that has been adopted by more than two thousand pre-K to high schools across the United States and in other countries….Marc consults regularly with corporations like Facebook, Microsoft, and Google on how to integrate emotional intelligence principles into employee training and product design.”

The 5 “emotion skills” identified by the acronym RULER, are as follows:

Recognize Emotions

Understand Emotions

Label Emotions

Express Emotions

Regulate Emotions

Although Brackett cites “subtle and important distinctions” between the words “emotions” and “feelings,” he uses the two words more or less interchangeably, as do most people.

While there is much to glean from Dr. Brackett’s book (perhaps the subject of a future blog?), I use it now to mention two heightened emotions during this pandemic: ANXIETY and FEAR. From the book’s discussion of “Understanding Emotions,” we most certainly understand that ANXIETY involves “uncertainty and unpredictability,” while FEAR involves “threat and danger.”

At a time when it would be easy to ignore, deny, suppress, even numb our feelings through substances and/or behaviors, we can begin to generate our own strategies, and/or borrow from the strategies of other people, using the acronym RULER as a guide. For example, in the section on Regulating Emotions, Dr. Brackett discusses the importance of “co-regulation.”He writes “Originally, co-regulation was a term used to describe the back-and-forth between a caregiver and infant to support a baby’s stress regulation….A caregiver who reliably provides physical and verbal comfort and reassures the infant, teaches that emotional distress is manageable. A caregiver who does not provide such support teaches the infant that he or she may be at the mercy of their emotions. In this way, co-regulation is the precursor to healthy self-regulation” (italics mine).

Our relational need for co-regulation does not end with childhood. It continues throughout the life cycle. “In adult relationships,” writes Brackett, “co-regulation can be intentional, as when we speak soothingly to someone who’s upset, or try to inspire someone into action….We’re all constantly affecting each other’s emotional state.” Psychologist Sue Johnson, PhD similarly writes “In attachment terms, co-regulation is the baseline from which self-regulation emerges.”

While it may sound contradictory to talk about co-regulation during a time of social distancing and sheltering-in-place, I think we must accept the challenge–and limitations–of seeing, hearing, and speaking reassuringly to those we’re sheltering-in-place with, and through social media. The result? A possible mitigation of psychological stress; the kind of self-regulation psychiatrist Dan Siegel calls “feeling felt.”

One final observation. In his landmark book, Religious Thought & the Modern Psychologies (2004), the late Professor of Ethics and Social Sciences at the University of Chicago, Don S. Browning, PhD makes an observation that some people may find helpful at this difficult time. He distinguishes between two kinds of anxiety; one kind of anxiety that arises from everyday stressors, and another kind of anxiety that arises from being humanly finite; the latter being “the anxiety that emerges from realizing we cannot possibly have ultimate control over our lives.” Dr. Browning is addressing the issue of spirituality.

Because the COVID-19 pandemic threatens our very existence, we are necessarily afforded the opportunity to reexamine what’s important in our lives, and what’s not; what the 20th century philosopher and theologian Paul Tillich called matters of “ultimate concern.” Relationship specialist John Gottman similarly writes: “If you find yourself asking, ‘Is that all there is?’….What may be missing is a deeper sense of shared meaning. Marriage isn’t just about raising kids, splitting chores, and making love. It can also have a spiritual dimension that has to do with creating an inner life together.”

The issue of spirituality may well be the ultimate response to the illusion that we have ultimate control over our lives. COVID-19 seems to be making this illusion very clear.

Bill Bray, Colorado Springs, CO

No Therapy is Absolute or Final. However…

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In November 2011, I attended an extremely helpful workshop entitled “The Lost Art of Psychotherapy.” The presenter was Barry J. Koch, PhD psychologist, professor, and author at Newman University’s Master of Social Work program in Colorado Springs.  What may come as a surprise to clients in counseling and psychotherapy (perhaps even some therapists), Dr. Koch ended the workshop with the following caveat:

“There is no such thing as doing a ‘complete’ job in psychotherapy.” 

Although research has consistently shown the efficacy of counseling and psychotherapy, I have never forgotten Dr. Koch’s words. Attempting to briefly qualify that caveat is the subject of this blog.

In her groundbreaking classic, Trauma and Recovery (1992, 1997, 2015), professor of clinical psychiatry, emerita, at Harvard University Medical School, Judith Herman, MD offers a fitting response. Although addressing the issue of trauma specifically, Dr. Herman speaks insight into the nature of counseling and psychotherapy generally:

“Resolution of the trauma is never final; recovery is never complete. The impact of a traumatic event continues to reverberate throughout the…lifecycle. Issues that were sufficiently resolved at one stage of recovery may be reawakened as (one) reaches new milestones in her development.  Marriage or divorce, a birth or death in the family, illness or retirement, are frequent occasions for a resurgence of traumatic memories….

(A) patient was humiliated by her need to return to psychotherapy. She feared that the return of symptoms meant that her earlier therapy had been a failure and proved she was ‘incurable.’ To avert such needless disappointment and humiliation, patients should be advised as they complete a course of treatment that post-traumatic symptoms are likely to recur under stress….The patient should not be led to expect that any treatment is absolute or final (italics mine). When a course of treatment comes to its natural conclusion, the door should be left open for the possibility of a return at some point in the future.

Though resolution is never complete, it is often sufficient for the (person) to turn her attention from the tasks of recovery to the tasks of ordinary life. The best indices of resolution are the (person’s) restored capacity to take pleasure in her life and to engage fully in relationships with others. She has become more interested in the present and the future than in the past, more apt to approach the world with praise and awe than with fear” (pp. 211-12).

“Though resolution is never complete, it is often sufficient for the (person) to turn her attention…to the tasks of ordinary life.”

A few pages earlier, Dr. Herman similarly writes:

“…the moment comes when the telling of the trauma story no longer arouses quite such intense feeling. It has become a part of (one’s) experience, but only one part of it. The story is a memory like other memories, and it begins to fade as other memories do. (It) begins to lose its vividness….

At first these thoughts may seem almost heretical….And yet she finds her attention wandering back to ordinary life. She need not worry. She will never forget….But the time comes when the trauma no longer commands the central place in her life. (A) rape survivor…recalls a surprising moment in the midst of addressing a class on rape awareness: ‘Someone asked what’s the worst thing about being raped. Suddenly I looked at them all and said, the thing I hate the most about it is that it’s boring. And they all looked very shocked and I said, don’t get me wrong. It was a terrible thing. I’m not saying it was boring that it happened, it’s just that it’s been years and I’m not interested in it any more. It’s very interesting the first 50 times or the first 500 times when you have the same phobias and fears. Now I can’t get so worked up any more.

The reconstruction of the trauma is never entirely completed; new conflicts and challenges at each new stage of the lifecycle will inevitably reawaken the trauma and bring some new aspect of the experience to light. The major work of (therapy) is accomplished, however, when the (person) reclaims her own history and feels renewed hope and energy for engagement with life. Time starts to move again” (p. 195).

That 2011 workshop did conclude on a similar note. Quoting Dr. Koch: “The goal of psychotherapy is to help (one) get to the point where he or she feels (some control) over what has previously threatened to overwhelm them.” And when that happens, therapy may not be absolute or final, but “time starts to move again.” 

Bill Bray, Colorado Springs, CO

Welcome to Holland

Posted by augmentin headache on May 29, 2019 in tramadol paracetamol | 0 comments

I recently purchased the most delightful book, which I’m currently in the process of reading. The eminent and emeritus Stanford University professor of psychiatry, Irvin Yalom, MD says about it, “I’ve been reading books about psychotherapy for over a half century, but never have I encountered a book like this one: so bold and brassy, so pack with good stories, so honest, deep, and riveting. The book is Maybe You Should Talk to Someone (2019) written by psychotherapist and New York Times best-selling author, Lori Gottlieb; a book in which she talks about her life as a therapist, her own therapy, and life in general. In a chapter titled “Welcome to Holland, “Gottlieb includes an essay by the same name–“Welcome to Holland”–written by Emily Perl Kingsley, the parent of a child with Down syndrome. The essay poignantly describes “the experience of having your life’s expectations turned upside down.” The essays reads as follows:

“When you’re going to have a baby, it’s like planning a fabulous vacation trip – to Italy. You buy a bunch of guide books and make your wonderful plans. The Coliseum. The Michelangelo David. The gondolas in Venice. You may even learn some handy phrases in Italian. It’s all very exciting.

After months of eager anticipation, the day finally arrives. You pack your bags and off you go. Several hours later, the plane lands. The flight attendant comes in and says, ‘Welcome to Holland.’

‘Holland?!?’ you say. ‘What do you mean Holland?? I signed up for Italy! I’m supposed to be in Italy. All my life I’ve dreamed of going to Italy.’

But there’s been a change in the flight plan. They’ve landed in Holland and there you must stay.

The important thing is that they haven’t taken you to a horrible, disgusting, filthy place, full of pestilence, famine, and disease. It’s just a different place.

So you must go out and buy new guide books. And you must learn a whole new language. And you will meet a whole new group of people you would never have met.

It’s just a different place. It’s slower-paced than Italy, less flashy than Italy. But after you’ve been there for a while and you catch your breath, you look around . . . and you begin to notice that Holland has windmills . . . and Holland has tulips. Holland even has Rembrandts.

But everyone you know is busy coming and going from Italy . . . and they’re bragging about what a wonderful time they had there. And for the rest of your life, you will say ‘Yes, that’s where I was supposed to go. That’s what I had planned.’

And the pain of that will never, ever, ever, ever go away . . . because the loss of that is a very, very significant loss.

But . . . if you spend your life mourning the fact that you didn’t get to Italy, you may never be free to enjoy the very special, the very lovely things . . . about Holland.”

Was I wrong? Is “Welcome to Holland” not a “poignant” essay about “having your life’s expectations turned upside down”? Lori Gottlieb adds an additional comment later in the chapter: “(Truth is) ‘we’re all in Holland, because most people don’t have lives that go exactly as planned.'”

Like Lori Gottlieb, we think about ”Talking to Someone,” but with one goal in mind: CHANGE! Change me! Change him! Change her! Change us! Change the situation! We overlook another strategy which the professor-psychologist, Marsha Linehan, PhD calls “dialectical”, meaning complementary, not contradictory. Both/and. Not either/or. It’s the same strategy so brilliantly articulated in “Welcome to Holland”: ACCEPTANCE!

The developer of Acceptance and Commitment Therapy (ACT), Steven C. Hayes, PhD (2012) writes about the wisdom of acceptance:

“Almost everyone has read or heard the famous serenity prayer commonly used in 12-step programs:

‘God grant me the serenity to accept the things I cannot change,

the courage to change the things I can,

and the wisdom to know the difference.’

The reason this simple prayer is so widely known is that it addresses a basic conundrum of our daily existence. What do we do when life delivers us the ‘slings and arrows of outrageous fortune?’ How do we deal with the pain of birth, death, divorce, rejection, illness, and myriad other life events we have no control over? How to proceed in the face of such pain is an important question that each of us faces over and over again in the process of pursuing a vital life. This prayer says it takes a certain kind of ‘wisdom’ to live life well.”

Emily Perl Kingsley clearly understood this wisdom, and expressed it accordingly: “Welcome to Holland”

Bill Bray, Colorado Springs, CO

Distressing Events, REM Sleep, & EMDR Therapy

Posted by augmentin headache on Sep 21, 2018 in tramadol paracetamol | 0 comments

Several weeks ago, strolling through our local Barnes & Noble, a book title caught my eye. Why We Sleep; Unlocking the Power of Sleep and Dreams (2017) by Matthew Walker, PhD. Little did I know in that moment, it would become a most interesting and informative read. Dr. Walker is a professor of neuroscience and psychology at the University of California, Berkeley, and the director of the Center for Human Sleep Science. He is also a former professor of psychiatry at Harvard University. I was particularly interested in reading about the stage of REM (Rapid Eye Movement) sleep, and its possible implications for EMDR (Eye Movement Desensitization & Reprocessing) therapy – which I will say more about later.

In Chapter 10 called “Dreaming as Overnight Therapy, Dr. Walker writes:

“It is said that time heals all wounds. Several years ago I decided to scientifically test this age-old wisdom….Perhaps it was not time that heals all wounds, but rather time spent in dream sleep. I had been developing a theory based on the combined patterns of brain activity and brain neurochemistry of REM sleep, and from this theory came a specific prediction: REM-sleep dreaming offers a form of overnight therapy. That is, REM-sleep dreaming takes the painful sting out of the difficult, even traumatic, emotional episodes you have experienced during the day, offering emotional resolution when you awake the next morning.

At the heart of the theory was an astonishing change in the chemical cocktail of your brain that takes place during REM sleep. Concentrations of a key stress-related chemical called noradrenaline are completely shut off within your brain when you enter this dreaming sleep state. In fact, REM sleep is the only time during the twenty-four hour period when your brain is completely devoid of this anxiety-triggering molecule. Noradrenaline, also known as norepinephrine, is the brain equivalent to a body chemical you already know and have felt the effects of: adrenaline (epinephrine).

Previous MRI studies established that key emotion- and memory-related structures of the brain are all reactivated during REM sleep, as we dream….(N)ow we understood that this emotional memory reactivation was occurring in a brain free of a key stress chemical. I therefore wondered whether the brain during REM sleep was reprocessing upsetting memory experiences and themes in this neurochemically calm (low noradrenaline), ‘safe’ dreaming environment. Is the REM-sleep dreaming state a perfectly designed nocturnal soothing balm – one that removes the sharp edges of our daily lives? It seemed so from everything neurobiology and neurophysiology was telling us (me). If so, we should awake feeling better about distressing events of the day(s) prior.

This was the theory of overnight therapy….Think back to your childhood and try to recall some of the strongest memories you have. What you will notice is that almost all of them will be memories of an emotional nature: perhaps a particularly frightening experience of being separated from your parents, or almost being hit by a car on the street. Also notice, however, that your recall of these detailed memories is no longer accompanied by the same degree of emotion that was present at the time of the experience. You have not forgotten the memory, but you have cast off the emotional charge, or at least a significant amount of it. You can accurately relive the memory, but you do not regurgitate the same visceral reaction that was present and imprinted at the time of the episode.”

(Note: An exception to the soothing balm of REM sleep dreaming is the condition of post-traumatic stress disorder [PTSD], which Dr. Walker discusses later in the chapter. REM sleep dreaming is important to the reduction of PTSD symptoms, but additional factors are involved, which will not be addressed in this blog). 

Continuing this lengthy, but necessary excerpt, Dr. Walker writes:

“The theory argued that we have REM-sleep dreaming to thank for this palliative dissolving of emotion from experience. Through its therapeutic work at night, REM sleep performed the elegant trick of divorcing the bitter emotional rind from the information-rich fruit. We can therefore learn and usefully recall salient life events without being crippled by the emotional baggage that those painful experiences originally carried….That was the theory, those were the predictions; next came experimental test, the results of which would take a first step toward falsifying or supporting both.

We recruited a collection of healthy young adults and randomly assigned them to two groups. Each group viewed a set of emotional images while inside an MRI scanner as we measured their emotional brain reactivity. Then, twelve hours later, the participants were placed back inside the MRI scanner and we again presented those same emotional images…During these two exposure sessions, separated by twelve hours, participants also rated how emotional they felt in response to each image.

Importantly, however, half of the participants viewed the images in the morning and again in the evening, being awake between the two viewings. The other half of the participants viewed the images in the evening and again in the morning after a full night of sleep….

Those who slept in between the two sessions reported a significant decrease in how emotional they were feeling in response to seeing those images again. In addition, results of the MRI scans showed a large and significant reduction in reactivity in the amygdala, that emotional center of the brain that creates painful feelings. Moreover, there was a reengagement of the rational prefrontal cortex of the brain after sleep that was helping maintain a dampening brake influence on emotional reactions. In contrast, those who remained awake across the day without the chance to sleep and digest those experiences showed no such dissolving of emotional reactivity over time. Their deep emotional brain reactions were just as strong and negative, if not more so, at the second viewing compared with the first, and they reported a similarly powerful reexperiencing of painful feelings to boot….

As the theory predicted, it was the dreaming state of REM sleep–and specific patterns of electrical activity that reflected the drop in stress-related brain chemistry during the dream state–that determined the success of overnight therapy from one individual to the next. It was not time, therefore, time per se that healed all wounds, but instead it was time spent in dream sleep that was providing emotional convalescence.”

One, final important caveat. Citing the exquisite dream research of Dr. Rosalind Cartwright at Rush University in Chicago, Dr. Walker adds: “it (is) not enough to have REM sleep, or even generic dreaming, when it comes to resolving our emotional past….,but dreaming of a very specific kind: that which expressly (involves) dreaming about the emotional themes and sentiments of the waking trauma. It (is) only that content-specific form of dreaming that (allows movement) forward into a new emotional future, and not be enslaved by a traumatic past.”

So, what might be the possible implications of REM sleep dreaming, (if any) to Eye Movement Desensitization & Reprocessing (EMDR) therapy?

My website is replete with information about EMDR therapy; from a separate web page, to official websites, to specific blog posts. Borrowing an excerpt from my May 1, 2016 post:

“(EMDR therapy) was developed in the 1980s by psychologist Francine Shapiro, PhD. As with many discoveries, Dr. Shapiro made the chance observation that eye movements can reduce the intensity of disturbing thoughts, under certain conditions. This humble beginning launched years of experimental and clinical research, and has now evolved into one of the leading and most recognized treatments for trauma throughout the world. My succinct description of EMDR to clients goes something like this: ‘Research suggests that when distressing events are paired with bilateral stimulation—visual, tactile, and/or auditory—there is the potential that those events will be desensitized and reprocessed.’ Although no one knows how any form of psychotherapy works neurobiologically in the brain, EMDR appears to be similar to what occurs naturally during dream or REM (rapid eye movement) sleep. Therefore, EMDR therapy can be thought of as a physiologically based therapy that helps a person see disturbing material in a new and less disturbing way.”

Now, 30 years later, independent sleep studies—like Matthew Walker–offer support for Shapiro’s ideas: that directed eye movements can stimulate the same processes that occur in REM sleep. Dr. Shapiro (2018) writes:

“Despite this evidence that REM can support forms of memory and emotional processing critical for trauma recovery, there is currently no direct evidence that EMDR induces similar processing during the waking state. However, Strickgold (2002) has posited direct neurobiological correlates between EMDR- and REM-state functions and has also posited appropriate tests of this hypothesis….Strickgold (2002) proposed that the repetitive redirection of attention in EMDR processing induces changes in regional brain activation and neuromodulation similar to those produced during REM sleep. Activation of these systems may simultaneously shift the brain into a memory-processing mode similar to that of REM sleep, facilitating the integration of traumatic memories into associative cortical networks.”

Robert Strickgold, PhD (cited above) is not only Professor of Psychology at Harvard Medical School, and Director of the Center for Sleep and Cognition in Boston, Massachusetts, he is also Matthew Walker’s “mentor…longtime collaborator and friend” at Harvard Medical School.

Conclusion? Independent sleep research suggests that the most common form of bilateral stimulation used in EMDR therapy—side-to-side eye movements—can stimulate the same processes that occur in REM sleep.

Bill Bray, Colorado Springs, CO

Feeling Our Feelings: Revisited

Posted by augmentin headache on Apr 29, 2018 in tramadol paracetamol | 0 comments

A year ago, March, I posted a blog called “Feeling My Feelings” (3/5/17), occasioned by the decision to put our beloved 14-year-old dog, “Mia,” a Papillon, to sleep. My wife and I agonized for weeks over Mia’s failing condition. I said in that blog that my intent was “not to subvert the purpose of the blog, or even memorialize our ‘furry, quirky, little dog,'” as my wife called her, but to…emphasize the importance of ‘feeling our feelings.'” Even now as I write this, I feel that same, old familiar ache in my stomach. Five months later, my wife declared that she was ready for another dog; but, I was not ready. She revealed that she had been researching a very different dog. Different breed. Different size.  Different background. And, because I was not interested, I reluctantly agreed to go with her to a rescue shelter. Not asking my wife, nor caring about another dog, you can imagine my shock when in trots a large, white and tan-coated – greyhound; a six-year-old racer from the Midwest. I’m sure my stunned silence and demeanor spoke volumes. I’ll spare you the details of the next few hours and days, but a week later, we loaded this large (but very beautiful) dog in our vehicle and took her home. Identified only by a number tattooed in her ear, and not liking the temporary name given her by the shelter, we renamed her “Lilly.” Simply put, I’ve had to recant all my negative thoughts and resistance. Lilly has turned out to be the sweetest dog I could ever imagine. Although my heart still aches when I think about Mia, my “sad” has become “glad” when I think about Lilly.

The reason I’m revisiting the theme of “feelings” in this blog is largely due to an article in the current edition (May/June 2018) of “Psychology Today” magazine. Written by a psychologist and professor at James Madison University, Gregg Henriques, PhD addresses the “neurotic feedback loop of negative reactions to negative feelings.” He begins the article by telling about Hannah (name changed), a college junior he had been counseling for depression and anxiety. Of particular clinical interest to Dr. Henriques was Hannah’s closing statement in one session: “I need to stop acting like a (expletive) child, cut these feelings off, and just grow up.” He writes:

“I guided her to take a moment to locate the root of this feeling. ‘Take a deep breath. Close your eyes. Do you recall a time when you felt vulnerable or needy and then hated yourself for that?'” Tears welling up, she did remember a time: ‘I was about 10. I liked drawing horses and dogs and stuff like that. I always shared them with my dad. One day, I brought a new drawing to him, asking if he would put it with the other drawings I’d given him. He said, in his usual calm, matter-of-fact tone, that he had thrown them out because I could draw so much better now. I knew my dad loved me and did not mean to hurt me, so I didn’t say anything. But I started to feel all those sensitive feelings I would always have. I ran to my room to cry. I remember thinking, ‘What is wrong with me? I am such a freak! My dad loves me. What can’t I have normal reactions like everyone else?’

I pointed out that she was punishing herself for her negative feelings so that she could stay close to her dad. This process of turning against oneself is the root of much pain in life. Yet there are alternative ways of relating to negative feelings….(T)he root of much long-term suffering takes hold when individuals battle with themselves by developing negative reactions to their negative feelings….(T)his  secondary reaction to the original negative feelings often creates a vicious cycle that results in major depression and generalized anxiety disorder….Many cases of depression and anxiety have their root in negative reactions to negative feelings. It is hard to overstate the importance of this fact. Depression and anxiety disorders are the biggest drivers of mental illness, and they get continually worse in modern society. This increase may be occurring because people are taught that they should be afraid of their negative feelings, or that they should not have to feel them, or that they are ‘disease states’….Instead we too often seem to reinforce the idea that negative emotions are, well, negative. This is a mistake because all emotions are essential to human living.

Early on, Hannah developed the idea that she felt things she should not feel. She learned from her mother, who coped with her own distress through avoidance, that she should put on a happy face. She learned from her father, who was kind but also analytical and not as attuned to her feelings as he could have been, that her sensitivity was a weakness. She learned as a child that she ought not to have strong negative feelings, that such feelings were a problem and she should control herself by whatever means necessary to crush them. By doing this, Hannah could imagine maintaining a justifiable image of herself in the eyes of her parents. Unfortunately, she ended up turning against herself.”

Henriques’ discussion, thus far, reminds me of reading about “an early Buddhist teaching…parable of a person pierced by two arrows in rapid succession….The first arrow  is the objective pain and distress felt when encountering an adversary, trauma, or loss. The second is the extent to which the pain challenges tightly held, albeit inaccurate, expectations, needs, worldviews, resulting in resistance, avoidance,…suffering” (Briere, 2015). Neuropsychologist Rick Hanson, PhD (2009) similarly writes: “(I)nescapable physical or mental discomfort is the ‘first dart’ of existence. As long as you live and love, some of those darts will come your way. First darts are unpleasant to be sure. But then we add our reactions to them. These reactions are ‘second darts’ – the ones we throw at ourselves. Most of our suffering comes from second darts.”

Basically, Hannah’s negative reactions to her negative feelings is a classic example of first and second arrows, or darts. Hannah’s negative reactions (second dart) only exacerbated and complicated her negative feelings (first dart).

So, how does Hannah–how do we–close this neurotic loop? Henriques writes:

“Attempting to regulate our feelings does make good sense. However, the crucial point is how that regulation is achieved. If a person uses a critical, controlling voice, he can set in motion a downward spiral of feelings that get harder to control. As he grows increasingly frustrated with his own negative feelings, he can become conflicted and vulnerable. The criticism leads to more and more negative emotions, which leads to more and more frustration and harsher and harsher attacks from the inner critic….What we need to do, both intrapsychically and interpersonally, is create a different kind of attitude toward bad feelings. Rather than seeking to avoid them or control them or engage in self-attack, we should listen to what our feelings are telling us and to learn how to use them to guide us toward long-term valued states of being.” Did you catch that?

“What we need to do . . . . is create a different kind of attitude toward bad feelings.”

Henriques concludes: “Over time, Hannah learned….a different way of being….Eventually she learned to become curious about what her feelings mean, to accept them for what they are, and to use them to inform herself about who she wants to be going forward. By breaking the loop created by her negative feelings, she set herself on a path to a much freer and more fulfilling way of being.”

One final word. In addition to Henriques’ focus on depression and anxiety, Robert Weiss, MSW, LCSW, CSAT-S (2015) adds the addictive consequence of inhibiting feelings. He writes: “In the world of addiction treatment, there are two main areas of concern – addiction to substances, and addiction to patterns of behavior….So whatever the addictive substance or behavior, the drive is the same – addicts want to feel better, which usually means feeling less, and they know their addiction is the easiest way to (temporarily) disconnect, numb out, and not have to experience the difficulties of life….This is a sure sign of addiction.” Reminds me of one of my professors who similarly observed: “Addiction is the inability to feel.” To repeat the sage admonition of Dr. Henriques:

“What we need to do . . . . is create a different kind of attitude toward bad feelings.”

Bill Bray, Colorado Springs, CO

Relationship Conflict and the Transformative Power of Feeling Safe

Posted by augmentin headache on Jan 28, 2018 in tramadol paracetamol | 0 comments

Emotional flooding. Psychologist John Gottman, PhD, explains what it means:

“(Your body mobilizes) so that it can effectively cope with emergencies that might injure you. The way this works is that in situations you perceive as ‘dangerous’…a series of things happen in your body. It can even happen without your awareness.

For example, suppose you are driving down the highway at night and suddenly see headlights in your lane coming right at you. You swerve onto the shoulder and narrowly avert a collision. If we were to examine your physiology at the moment, we would find your heart was beating fast and contracting hard, that your blood pressure was up, that you were secreting adrenaline, that blood flow had shut down to ‘nonessential services’ (your gut and kidney), that your liver had changed some of its supply of glycogen to glucose (sugar) in your blood, that the reninangiotensin system was conserving blood volume in anticipation of hemorrhage, and that you were sweating, particularly on your palms and the soles of your feet. You would be in a state of high alertness and arousal as well, a state psychologists call ‘tunnel vision.’ Your limbic system…would have been activated. Your blood pressure would be up, and blood would have been drawn in from your arms and legs into your trunk.

We call this state ‘diffuse physiological arousal’ (DPA) because many systems are simultaneously activated….You would feel what we call ‘flooded’….

The amazing thing is that all these things can, and do, happen during relationship conflict. But whereas the DPA response can be adaptive in dealing with emergencies, in relationship conflict it has consequences that are quite negative. With DPA there is a reduced ability to process information. It is harder to attend to what your partner is saying. Peripheral vision and hearing may actually be compromised. As much as you want to listen, you just cannot do it….Fight and flight routines become more accessible so you can enjoy with your romantic partner maybe even using a rabbit vibrator if you feel adventurous. The sad result for relationship conflict is that creative problem-solving, active listening, empathy, and your sense of humor go out the window” (2011).

Gottman adds: “We also know that men become more flooded during conflict than women. That’s just an empirical fact.”

Gottman’s discussion of emotional flooding (during couple conflict) meshes with another emotionally-focused psychologist, Susan Johnson, PhD. In her emotion-focused couple therapy (EFT), Johnson uses attachment theory to help couples deal with what she calls “attachment injuries.” Attachment theory broadly defines attachment in terms of secure and insecure. Johnson writes: “Attachment theory is essentially a theory of trauma, (where) distressed partners tend to adopt stances of fight, flight, or freeze that characterize responses to traumatic stress” (2004).

Which brings me to my primary reading interest of 2017; the research of Stephen W. Porges, PhD, and his “polyvagal theory.” Dr. Porges is Distinguished University Scientist at Indiana University where he directs the Trauma Research Center within the Kinsey Institute. Having plowed through his initial, groundbreaking book in 2011, I was delighted to learn he had published a more user-friendly Pocket Guide to the Polyvagal Theory in 2017. This book now ranks among my top five most “marked up, written in, and highlighted” books – ever. I could never sell it back to someone else; or, even loan it for someone else to read. Heck, I can barely read it now because of my notations. Let’s just say that I earnestly tried to digest its contents.

Specifically, Porges’ research targets the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). While the SNS mobilizes us to take action, for example when threatened (“fight or flight”), the PNS calms us down; one being the accelerator, the other being the brake, so to speak. Both systems are part of the autonomic nervous system (ANS) which operates, as the name suggest, more automatically or involuntarily. Whereas the traditional view has been twofold (SNS and PNS), Porges’ research has subdivided the PNS to make three subsystems. This subdivision of the PNS focuses on the vagus nerve, which is the tenth cranial nerve, and the largest nerve in our body. This nerve with its many (poly) fibers sends and receives messages between the brain and the rest of the body. The ventral vagal nerve generates and interprets positive responses (called the “social engagement system). The body perceives safety, as when someones smiles at us, calming us down in a positive way. The dorsal vagal nerve does the opposite, and is considered a second “defense” system along with the SNS (“fight or “flight”). When one cannot handle a perceived threat by addressing it, or getting away from it (namely, “helplessness”), then there is an “immobilzation” or “freeze” response. This numbs the pain associated with the threat. Porges coined  the term “neuroception” to mean that the nervous system evaluates threat apart from conscious awareness. In other words, our nervous system is already defending us before we’re even aware of it. Porges writes:

“When people are defensive–feeling bad about themselves, feeling angry at someone else–they are recruiting (these) neural structures. There is an overlap between defensive responses and responses to evaluation… Whenever we are evaluated, we are already recruiting the physiology of defense….These feelings of danger would produce a chronic state of defense that would negatively bias perception of others.” This “neuroception” is not always accurate; for example, the body might detect risk when there is no risk. Nevertheless, one’s physiology is already on the defensive. Is it any wonder why Porges subtitles his 2017 book “The Transformative Power of Feeling Safe.” Secure attachment is all about safety.

Now, let’s connect this back to “emotional flooding” and relationship conflict. Couples who are genuinely and earnestly intent on improving their relationship need to change their interactional patterns (versus overpowering each other with “fire and fury,” even logic). We can change interactions during conflict by mindfully respecting physiology! We can work with the nervous system, not against it. We can do this by helping ourselves and each other feel “safe.” In other words, “I’m here for you. I’m not going anywhere. Talk to me. I will do my best to listen, affirm, apologize, and validate your feelings – even if we don’t agree. You can trust me.”

In that 2011 book I cited earlier, The Science of Trust; Emotional Attunement for Couples, Gottman makes an admission and correction to his Seven Principles for Making Marriage Work (1999; 2015). Read for yourself:

“(The) implicit suggestion…was that by following (the) seven principles, any two people in the world could create a stable, happy relationship. We had misgivings about those implications….(So) as we worked with couples in therapy, we found that indeed something might have been missing in the seven principles conceptualization….I therefore began searching for the missing ingredient for these couples….The answer came during the course of building a program for lower-income couples expecting a baby. What we found was that all the couples talked about the importance of ‘trust.’ (Many) told us that the central missing ingredient was the ability to build and maintain trust with each other. Many distressed couples complained that their partners simply couldn’t be counted on to ‘be there’ for them when they needed them most. Over time, they said, the emotional injuries they sustained from a lack of trust built a huge gulf of emotional distance between them, leading to eventual  betrayal or the quiet whimper of the demise of love….So it appeared that the missing ingredients…were all about trust and betrayal. After all, trust and safety in a relationship are the theoretical pillars of…attachment theory.”

While “trust” may not be synonymous with “safety,” the two are definitely related. Trust creates safety. And, feeling safe is transformative.

Bill Bray, Colorado Springs, CO

Vicarious Traumatization (VT)

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On November 6, 2017, CNN reported that of the 30 deadliest shootings in the US dating back to 1949, 18 have occurred in the last 10 years. Two of the five deadliest have taken place in just the last 35 days.

On Sunday, November 5, 2017, a gunman opened fire inside a small community church in Sutherland Springs, Texas, killing 26 people; the fifth-deadliest shooting in modern US history.

On October 1, 2017, a gunman opened fire from the 32nd floor of the Mandalay Bay Resort and Casino on a crowd of more than 20,000 gathered on the Las Vegas Strip for a music festival. He kills 58 people and injures more than 500; the deadliest shooting in modern US history.

The Las Vegas attack was 10 years removed from the 2007 Virginia Tech massacre (32 killed), and a year removed from the second-deadliest shooting in modern US history–the Orlando nightclub shooting, where 49 were killed and more than 50 injured.

Then, there’s the December 14, 2012 Sandy Hook Elementary School shooting in Newton, Connecticut, where 20 children (ages 6-7) and six adults were gunned down.

Etcetera. Etcetera.

I’ve been thinking a lot lately about the trauma survivors of these horrific events; the lives of their loved ones tragically and swiftly snuffed out. I remember watching a television interview with the bereaved family of the Sandy Hook Elementary Principal, Dawn Hochsprung. One of the daughters was asked the awkward question what she might say to her mom, if she could. The daughter tearfully replied: “Come back”; the precise sentiments of trauma survivors who’ve lost loved ones.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines the three main symptom clusters of posttraumatic stress disorder (PTSD) as: a re-experiencing of the event (for example, intrusive imagery or flashbacks), avoidance of event-related cues, and hyperarousal. While posttraumatic stress (PTS) most certainly threatens the health of trauma survivors, I’m thinking that the ubiquitous and real-time nature of social media exposes every person to a kind of secondary traumatic stress (STS); also known as vicarious traumatization (VT).

Secondary Traumatic Stress/Disorder (STS/D)—a.k.a. Vicarious Traumatization (VT)–is the emotional duress that results from seeing/hearing about the firsthand trauma experiences of others. As such, it primarily targets helping professionals, like myself, who work directly with trauma survivors. Its symptoms mimic those of posttraumatic stress disorder (PTSD). In her book, SecondaryTraumatic Stress; Self Care Issues for Clinicians, Researchers, & Educators (1999), Beth Hudnall Stamm, PhD, now retired research psychologist at Idaho State University, writes:

“Here we define secondary traumatic stress as the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event….It is the stress resulting from helping or wanting to help a traumatized or suffering person.

There is a fundamental difference between the sequela or pattern of response during and following a traumatic event, for people exposed to primary stressors and those exposed to secondary stressors. Moreover, not only are family and friends of people exposed to primary stressors (i.e., ‘victims’) vulnerable to secondary traumatic stress and stress disorders, so are mental health professionals and other helpers.

Therefore, STSD is a syndrome of symptoms nearly identical to PTSD except that the response to a traumatizing event experienced by one person becomes a traumatizing event for the second person….At the same time, we suggest that perhaps PTSD should stand for Primary Traumatic Stress Disorder, rather than Post Traumatic Stress Disorder, since every stress reaction is ‘post’ by definition.”

Dr. Stamm contrasts the symptoms of PTSD with the symptoms of STSD around the same threefold symptom cluster of: re-experiencing the traumatic event, avoidance and numbing of event-related reminders, and persistent arousal (mentioned above). The only difference between the two is the “vicarious” nature of STS/D; that is, hearing what happened to the “primary” trauma survivor.

Stamm observes that a “disrupted frame of reference” is the “hallmark of vicarious traumatization.” By “frame of reference,” she means one’s identity, worldview, and spirituality. While writing primarily to helping professionals, the disruptive nature of trauma on everyone is hard to miss:

“As a result of…trauma, (one) is likely to experience disruptions in their sense of identity (sense of oneself as man/woman, as helper, as mother/father, or one’s customary feeling states), worldview (moral principles, ideas about causality, life philosophy), and spirituality (meaning and hope, sense of connection with something beyond oneself, awareness of all aspects of life, and the sense of the non-material.”

Think about it. Can anyone honestly deny that their “frame of reference” (identity, worldview, spirituality) has been challenged–yet again–by the random violence of the last few days?

Stamm continues: “The other parts of the self impacted by VT are psychological need areas: safety, trust, esteem, intimacy, and control. Everyone possesses all the five needs, but specific areas are more important or central for each individual. One’s most important need areas are those most likely to be disrupted.”

Survey that fivefold list for a moment. Which “need area” has not been “disrupted”–yet again–by the random, violent acts of the past few days? Which “need area” do you personally feel most vulnerable? Safety? Trust? Social connectedness? What about control, or predictability? The Stanford University professor of biology and neurology, Robert Sapolsky, PhD (2004) talks about many of these same psychological variables needed—to some degree–to withstand the stressors of life; especially social connectedness, control, and predictability (See my October 8, 2012 blog).

Given the primary and secondary helplessness of traumatic events, Stamm asks if there’s anything we can do. “What antidotes can we create to these ‘disruptions’?” Citing research where trauma therapists were asked to identify self-care strategies, some of the activities mentioned include: travel, social activities, collegial support, pleasure reading, workday breaks, emotional support from family and friends, time spent with children, listening to music, time spent in nature, physical exercise, community involvement, rest and relaxation, gardening, spiritual life and practice, artistic expression, hobbies, to name just a few.

Perhaps some of these suggestions will prompt you to generate your own “antidotes” to a “disrupted frame of reference.”

This is the second time in six months that the expression, “frame of reference,” has surfaced in one of my blogs. On May 26, I posted thoughts from Irvin Yalom’s book, The Gift of Therapy (2002). The emeritus professor of psychiatry at Stanford University talks about his interpersonal and existential “frame of reference;” which strikes me as particularly apropos for thinking about “antidotes” to vicarious traumatization. Yalom discusses the need for developing and sustaining gratifying relationships (interpersonal frame of reference), as well as the “givens” of human existence (existential frame of reference); especially: death, isolation, meaning in life, and freedom. Yalom’s existentialist orientation reminds me–in the face of random violence and traumatization–that there is no such thing as absolute control or predictability in life. The shootings of the past 35+ days have reminded us of that. Rather, we are confronted with the inexorable “givens” of existence – and, how we choose to live life. There is no freedom to do otherwise.

One last thought. Several months ago, one of my colleagues brought a plaque to our office suite. I found myself mouthing the words on the plaque every time I saw it; a saying attributed to the renowned French painter Claude Monet: “For one’s health, it is necessary to walk in the garden and see the flowers growing.” In a world of primary and vicarious traumatization, that sounds like good advice.

Bill Bray, Colorado Springs, CO

The Value of Negative Experiences

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February 5 was NOT a good day for me. In the words of the popular children’s writer and psychoanalyst Judith Viorst, it was a “Terrible, Horrible, No Good, Very Bad Day.” My car was broken into while jogging, involving the theft of my wallet, credit cards, and checkbook. I remember the sick feeling in my stomach as I spotted the shattered back window from a distance. Looking immediately into the console of my car–where these items were kept–only confirmed my fears. Everything was gone. Those of you having experienced identity theft know the feeling all too well. Exacerbating my loss was the knowledge that I had no one to blame but myself. Frankly, I had grown complacent; having jogged at this particular park many times, and leaving such valuable information in a securely locked car (or so I thought). Had it not been for locating a police officer who took my report and provided telephone numbers to call, the situation would have been much worse. Quite simply, I was traumatized. 

The financial and emotional fallout from that experience is better now in these 6+ months since, but the trauma still lingers. I still go (force myself to go?) to that same location to jog, but with some definite changes. I no longer leave such valuable information in my car, and my complacency has been replaced with a vigilance; even hypervigilance at times. Call it the school of hard knocks. 

In his book Buddha’s Brain (2009), neuropsychologist Rick Hanson, PhD writes about the value of negative experiences:

“When an event is flagged as negative, the (brain) makes sure it’s stored carefully for future reference. Once burned, twice shy. Your brain is like Velcro for negative experiences and Teflon for positive ones – even though most of your experiences are probably neutral or positive.” I’ve thought of Hanson’s Velcro/Teflon simile often since February 5, and have used it frequently with clients in therapy. Hear it again:

“Your brain is like Velcro for negative experiences,

and Teflon for positive ones.”

This is not to minimize or idealize the negative effects of pain, or to promote suffering. Hanson quickly adds that “emotional pain with no benefit to yourself or others is pointless suffering.” Nevertheless, he underscores what he calls the “negativity bias of memory.” Why? What possible value could there be from negative experiences? In a word? Survival. Hanson continues:

“(The) brain is built more for avoiding than for approaching. That’s because it’s the negative experiences, not the positive ones, that have generally had the most impact on survival….(L)oss open the heart, remorse provides a moral compass, anxiety alerts you to threats, and anger spotlights wrongs that should be righted.” Obviously “survival” means more than the avoidance of human extinction; it enhances quality of life. Hanson continues:

“The remedy is not to suppress negative experiences; when they happen, they happen. Rather, it is to foster positive experiences….Positive experiences can be used to replace negative ones. When two things are held in mind at the same time, they start to connect with each other. That’s one reason why talking about hard things with someone who’s supportive can be so healing; painful feelings and memories get infused with the comfort, encouragement, and closeness you experience with the other person. These mental minglings draw on the neural machinery of memory. When a memory–whether implicit or explicit–is made, only its key features are stored, not every single detail….When your brain retrieves a memory, it does not do it like a computer does, which calls up a complete record of what’s on its hard drive (e.g., document, picture, song). Your brain rebuilds implicit and explicit memories from their key features, drawing on its stimulating capacities to fill in missing details.”

Hanson echos the research of others, including UCLA psychiatrist Dan Siegel, M.D., whose research I’ve referenced extensively throughout my blogs. Basically, writes Siegel, “Memory is not a static thing, but an active set of processes…Remembering is not merely the reactivation of an old (experience); it is the construction of a new (understanding) with features…from other experiences…and present state of mind” (The Developing Mind, 2012). 

Summary. The brain has a bias toward negativity. There is value in negative experiences. Negative experiences need not be the final verdict. Positive experiences can begin to modify negative experiences in the brain. All this I have been reminded of since February 5. I still go to that same park to jog. I still have residual memories of that “terrible, horrible, no good, very bad day.” But, other experiences since are attaching themselves to the old memory. Just the other day, I finished my run and leaned against my car. I watched children playing. I noticed a new dog owner training his chocolate lab puppy. And I wasn’t thinking about February 5 at all. 

Bill Bray, Colorado Springs, CO

Internal Family Systems (IFS)

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Last month, I took a day off from seeing clients to attend an Internal Family Systems Therapy (IFS) seminar. The seminar was led by Frank G. Anderson, M.D. Dr. Anderson completed his residency in Psychiatry at Harvard Medical School, and was a clinical instructor at Harvard. He is currently the chairman of the Foundation for Self Leadership, which is the organization for Internal Family Systems Therapy (IFS). Dr. Anderson maintains a private practice in Concord, Massachusetts, and has maintained a long affiliation with Bessel van der Kolk’s Trauma Center at the Justice Resource Center in Boston. The seminar was well worth the time and money spent.

I have been aware of IFS therapy for several years, as my March 4, 2012 blog post will attest. That post, more than five years old now, reads as follows:


It is not uncommon to describe ourselves in “parts.” For example, “A part of me loves him, and a part of me doesn’t even like him.” Or, “A part of me is mad, and a part of me is sad.” Such is the language of ambivalence that often characterizes human awareness. There is even a biblical reference to such ambivalent “parts”: “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate” (Romans 7:15; NRSV), and vice versa. So “parts” is often how we describe our internal conflicts. Just as families consist of individuals (Mom, Dad, child[ren]), each person contains an internal family of personalities (or, subpersonalities).

In his book, Internal Family Systems Therapy (1995), Richard C. Schwartz, PhD (Northwestern University) organizes these internal “parts” into three groups: Exiles, Managers, and Firefighters. Basically, “exiles”–the most sensitive members of the group–represent internal conflicts (for example, painful memories, feelings, behaviors). “Managers” represent the internal control of exiles, mostly through preventative measures. And, “firefighters” represent our remedial actions when the exiles seriously threaten escape.

Here’s how Schwartz describes each group:

“Commonly, children are taught to fear and hide their pain or terror….They become the exiles, closeted away and enshrouded with burdens of unlovability, shame, or guilt. Like any oppressed group, these exiles become increasingly extreme and desperate, looking for opportunities to break out of their prison and tell their stories….Like abandoned children, many of the exiles desperately want to be cared for and loved. They constantly look for someone who might rescue and redeem them….(Managers) live in fear of the escape of exiles. They try to avoid any interactions or situations that might activate an exile’s attempts to break out or leak feelings, sensations, or memories into consciousness. Different managers adopt different strategies (for example, Controller, Perfectionist, Dependent One, Caretaker, Etc.)….The point (and) primary purpose of all mangers is to keep the exiles exiled….That is, the goal is to keep the feared feelings and thoughts from spilling over the inner walls, so that the system remains safe and the person is able to function in life….(Common managerial manifestations) include: obsessions, compulsions…passivity, emotional detachment…panic attacks, somatic complaints, depressive episodes, hyperalertness, and nightmares….(Sometimes) despite the best efforts of the managers, the exiles are activated and threaten to break out and take over. When this happens, another group of parts leaps into action to try to contain or extinguish the feelings, sensations, or images. I call this group the ‘firefighters’ because they react automatically whenever an exiled part is activated. It is as if an alarm goes off and they frantically mobilize to put out the fire of feelings. They do whatever they believe necessary to help the person (separate from) or douse dreaded exiled feelings, with little regard for the consequences of their methods. The techniques of firefighters often include numbing activities such as self-mutilation, binge eating, drug or alcohol abuse…or promiscuity. When activated, a firefighter will try to take control of the person so thoroughly that he or she feels nothing but an urgent compulsion to engage in (an avoidance behavior) or self-soothing activity….Although firefighters have the same basic goal as managers – to keep the exiles exiled – their roles and strategies are quite different….Managers strive to prevent the activation of exiles by keeping the person in control at all times….Firefighters …usually react after the activation of exiles has occurred.” 


One additional observation not included in the original blog post. These “parts,” sometimes called “ego states,” are most often formed when we do something over and over again. This repetitive learning, this over and over again learning, creates a literal, physical neural pathway (circuitry) in the brain. In other words, a “part” or “ego state,” is a physical part of the brain – with its own experiences, emotions, and behaviors. It is to say, in the oft quoted words of Canadian psychologist Donald Hebb: “Neurons (nerve cells) that fire together, wire together.”  And the more they fire, the more they wire. And the more they fire, the more they wire. And the more they . . . .

By the way . . . . The brain can make changes.

Bill Bray, Colorado Springs, CO

The Gift of Therapy: Reasonable Happiness

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The other day I finally purchased a book I had passed by multiple times; each time thinking “I should read that book.” The book is The Gift of Therapy; An Open Letter to a New Generation of Therapists and their Patients (2002). The author is the emeritus professor of psychiatry at Stanford University, Irvin Yalom, M.D. Obviously written to and about a professional reading audience, Yalom calls the book a “nuts-and-bolts collection of favorite interventions or statements…long on technique and short on theory.”

Although Yalom urges therapists to work from a variety of approaches, he writes:

“Still, for the most part, I work from an interpersonal and existential frame of reference. Hence, the bulk of the advice that follows issues from one or the other of these two perspectives. Since first entering the field of psychiatry, I have had two abiding interests: group therapy and existential therapy. These are parallel but separate interests….The two modes are different not only because of the format (group versus individual), but in their fundamental frame of reference. When (I’m in a group setting), I work from an interpersonal frame of reference and make the assumption that (people) fall into despair because of their inability to develop and sustain gratifying interpersonal relationships.”

“(W)hen I operate from an existential frame of reference, I make a very different assumption: (people) fall into despair as a result of a confrontation with harsh facts of the human condition – the ‘givens’ of existence.”

These two frames of reference reminded me that I should have purchased the book much earlier than I did. Indeed, whatever else urges us to talk with a counselor-type, the challenge of relationships, and the inexorable conditions of life are among the primary influences.


Yalom’s first frame of reference: the difficulty of developing and sustaining gratifying relationships.

For all the value of gathering information about a person’s history in therapy, Yalom emphasizes the “here-and-now” importance of the “therapy relationship”; the importance of interpersonal relationships, and the idea of therapy as a social microcosm. This is to say that sometimes the interpersonal problems a person has with others (spouse, partner, parent, friend, coworker) will manifest itself in the “here-and-now” of the therapy relationship. This emphasizes something I’ve written about in earlier blogs; that what we do not or cannot communicate directly, we evoke or (re)enact with others. It’s basically the nonconscious, nonverbal behaviors we communicate unawares.

Yalom tells of a client, Albert, who was “suffused with anger but could find no way to express it.” In one of their sessions, Albert described a frustrating encounter with a girlfriend who, in his view, was “jerking him around,” yet he was afraid to confront her. Yalom writes: “The session felt repetitious to me; we had spent considerable time in many sessions discussing the same material and I always felt I had offered him little help. I could sense his frustration with me…. (So) I tried to speak for him:

‘Albert, let me see if I can guess at what you might be experiencing in this session. You travel an hour to see me and you pay me a good deal of money. Yet we seem to be repeating ourselves. You feel I don’t give you much of value. I say the same things as your friends, who give it to you free. You have got to be disappointed in me, even feeling ripped off and angry at me for giving you so little.’

(Albert) gave a thin smile and acknowledged that my assessment was fairly accurate. I was pretty close. I asked him to repeat it in his own words. He did that with some trepidation, and I responded that, though I couldn’t be happy with not having given him what he wanted, I liked very much his stating these things directly to me. It felt better to be straighter with each other, and he had been indirectly conveying these sentiments anyway. The whole interchange proved useful to Albert. His feelings toward me were an analog of his feelings toward his girlfriend.”

Rather than talk objectively about Albert’s frustration with his girlfriend, Yalom used the therapy relationship to talk directly about Albert’s difficulty with expressing feelings.


Yalom’s second frame of reference: our confrontation with the “givens” of existence.

Yalom writes: “The existential psychotherapy approach posits that the inner conflict bedeviling us issues not only from our struggle with suppressed instinctual strivings or internalized significant adults or shards of forgotten traumatic memories, but also from our confrontation with the ‘givens’ of existence.

And what are these ‘givens’ of existence? If we permit ourselves to screen out…the everyday concerns of life and reflect deeply upon our situation in the world, we inevitably arrive at the deep structures of existence (the ‘ultimate concerns,’ to use theologian Paul Tillich’s term). Four ultimate concerns, to my view, are highly salient to psychotherapy: death, isolation, meaning in life, and freedom.”

That fourth “ultimate concern,” or “given”—freedom—implies responsibility; choice. Hoffman (2007) writes: “The attempt to be free without being responsible is, by nature, pathological, and arguably, immoral. The process of psychotherapy helps people embrace and enhance their freedom (by becoming more responsible).” Freedom, responsibility, and choice – all go together. They are irrevocably linked. Corey (2001) cites the existentialist philosopher Jean-Paul Sartre (1971) in speaking about “bad faith.” Examples of Sartre’s bad faith are: ‘Since that’s the way I’m made, I couldn’t help what I did’ or ‘Naturally I’m this way, because I grew up in an alcoholic family.’ Sartre claims we are constantly confronted with the choice of what kind of person we are becoming, and to exist is never to be finished with this kind of choosing.”

Hoffman (2007) again writes: “This is one of the great paradoxes of existential theory; that people are both necessarily limited in their freedom and at the same time condemned to be free. It is not possible to escape the influences of biology, genetics, and the past. Furthermore, individuals can never become fully aware of the influences lurking in their unconscious. This is what (German philosopher) Heidegger refers to as thrownness. Everyone is thrown into a particular life situation with a particular genetic makeup, with parents they have not chosen, and into a time and culture they are not able to control.”

This second frame of reference—the “givens” of existence—reminds me of theologian Reinhold Niebuhr’s “Serenity Prayer,” (1926) – but not the part you might think. The more familiar part of the prayer begins: “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” A later line in the prayer seems to emphasize the inexorable “givens” of human existence. The petition reads: “That I may be reasonably happy in this life…”

“Reasonable happiness.” Sometimes I read the claims of therapies and therapists and think, “Wow! ‘Banish anxiety forever!’ ‘Live the stress-free life you’ve always dreamed of!'” Obviously, I’m being both facetious and satirical. There’s no question about the potential efficacy of therapy, but “absolute happiness?” No way. We know better.

Thus, the prayerful and realistic petition: “That I may be reasonably happy in this life.” That’s what we’re after. It’s one of the gifts of therapy.

Bill Bray, Colorado Springs, CO