“Why do I feel scared even when I’m not in danger?”

This question, or something approximating it, is one of the most commonly asked by people seeking treatment for trauma, many of whom describe an intense fear when they encounter something that isn’t, in reality, a threat to their safety. These people are aware of this fact cognitively. They can articulate the truth of the situation, but it doesn’t take away the intense symptoms that are experienced.

There is a very good reason for this—and it lies within the structure of the brain and nervous system.

First, let’s talk about fear and its function. Fear is a hard-wired emotion in the brain. We are born with it, and thank goodness. Think of fear like an alarm system. It alerts us to threats in our environment so we can respond effectively and keep ourselves safe. This comes in handy when there is an actual threat. When there is a risk to our safety, the fear circuit is naturally engaged to alert to danger.

Under normal circumstances, we are able to check in with the situation to determine if there is a real threat. For example, if you are walking down the street and hear a loud sound that startles you, your body responds and you look around to see what made the sound. If you discover it was a car backfiring, you see there is no threat and you are able to continue on, recognizing that your safety is not compromised. If it is something truly threatening, such as someone with a gun, you go into survival mode of flight, fight, or freeze. Once the threat has passed, ideally you would be able to talk about what happened, process through it, and know that even if you weren’t safe at the time, you are safe now that the threat is gone.

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Although the fear response is normal and key to survival, the fear circuit can get stuck in a type of feedback loop and over-coupling with danger, which tends to cause a person to experience the common symptoms associated with trauma. When a traumatic event is experienced, certain structures of the brain go offline because traumas are intense and the brain goes into survival mode. As a result, the traumatic memory is not stored like a normal memory. It is instead stored in an isolated, fragmented, and frozen way. Because it is isolated from other memory and knowledge, when one is triggered by something that reminds the brain or nervous system of the memory, that information does not have the ability to readily connect with other information in the brain, which makes the nervous system believe the person is in danger.

When a traumatic event is experienced, certain structures of the brain go offline because traumas are intense and the brain goes into survival mode. As a result, the traumatic memory is not stored like a normal memory.

The nervous system then does its job very well, trying to alert the person to danger, even if there is none. Keep in mind this process in entirely unconscious. We can’t think ourselves out of the nervous system’s automatic response.

It is common, post-trauma, to see an over-linking between fear and danger because of the brain process described above: the person has frozen fragments of the trauma that are maladaptively stored in the brain, which means there are also maladaptive linkages. The brain does not know it is safe because parts of it are frozen in time. The over-coupling of fear and danger is even more severe when a person has experienced pervasive trauma throughout life.

Once people understand this process, it is usually relieving to know they are not “crazy” and their nervous systems are simply trying to promote survival. Understanding the dynamic that is happening in the body is the first step to uncoupling fear and danger. Some of the work in uncoupling is done with specific interventions such as EMDR (eye movement desensitization and reprocessing) therapy, somatic experiencing, and/or ego state therapy. However, between sessions a person can aid this process by simply paying attention to the moment. Paying attention to body sensations, emotions, reactions, and the environment is a big part of the work. Periodically checking the environment for safety can be especially helpful. Noticing what it’s like to be triggered, have fear, and still notice you are safe takes it to another level and can advance the uncoupling process.

A colleague of mine, a psychiatric nurse, was working alongside a psychiatrist who would often be insistent about his intention to change a patient’s medication regimen before they even had an opportunity to see the patient together. She recalled that on one such occasion, she boldly interrupted the psychiatrist as he reported his clinical perspective and intentions. “No, doctor,” she urged. “Just because he’s had an increase in psychotic symptoms does not mean we need to increase his risperidone. He’s been on meth all week. We need to prioritize getting him off of the drugs he’s been using before we start changing his meds!”

The psychiatrist hadn’t seen the bigger picture, had been operating with a kind of clinical tunnel vision out of habit, and her boldness to voice her perspective broadened his, ultimately increasing the quality of the care for the patient. The doctor, for his part, was responsive and did not change the patient’s medication regimen as he had intended.

What Does It Look Like to Promote a Collaborative Care Environment?

Collaborative care involves the sharing of perspective, not necessarily an agreement of perspective. While collaboration in treatment between a nurse and a psychiatrist may in some ways look different than that between a psychotherapist and a psychiatrist, the spirit of the collaboration is necessarily the same—that in our work with people, we naturally and inevitably bring with us our own toolbox of experience, perspective, knowledge, and skills. And to the extent we resign ourselves to treatment in a vacuum, we neglect the person’s treatment, as collaboration is essential, not elective. We each naturally and necessarily engage in our work with people from different angles.

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When the therapist shares the angle of the therapist, the psychiatrist’s perspective widens. When the psychiatrist shares the angle of the psychiatrist, the therapist’s perspective widens.

Think of perspective as standing in a place and looking out over a horizon. As we move about, so changes our available horizon and, thus, our perspective, and yet we are able to take the previously seen horizons with us, aren’t we? In our mind’s eye, in our understanding, we integrate them into our inner map. To acquire a horizon means that one learns to look beyond what is close at hand—not in order to look away from it, but to see it better within a larger whole and in truer proportion.

Therapists, therapeutic case managers, psychologists, psychiatrists, and other mental health clinicians best serve people when they share perspective and responsibility in meeting people’s needs and ensuring therapeutic progress toward established treatment goals.

The horizon of the present is being continually formed, in that, as the philosopher Hans-George Gadamer contended, “we have continually to test our prejudices, and in so doing, adjust our understanding.” This sort of humility is fundamental to good psychotherapeutic and medical treatment.

The purpose of clinical staffing is to aid in service planning, consult on issues of safety and risk, discuss developmental concerns, collaborate on behavior and mental health assessment, address concerning family and social dynamics, consider referral options, and share critical case updates.

Each case presented will typically either qualify as a “consultation” or an “update.” Clinicians usually have only about 15 minutes to staff cases. Here’s how I encourage clinicians to approach clinical staffing and, essentially, all forms of collaborative care:

1. Tell the story (brief): Just as the case record documentation should provide a narrative of services rendered, the introduction of a person in a clinical staffing should similarly provide context. Facilitate talk about engagement in services, home and social dynamics, relevant historical considerations, psychological profile, academic, vocational, and/or behavioral functioning, and recent events that may be relevant to any concern.
2. Identify concerns (robust): Share clear and present concerns. Use clarifying statements, such as, “I am concerned because __________.” Express particular observations, such as, “I have noticed __________.” Ask specific questions, such as, “Why do you think __________?” Strike a tension between curiosity and clarity. If you fail to bring clarity and direction to a consult, time will waste away.
3. Tie services together (summary): It is your responsibility to end discussion about a person by providing specific feedback. Try to summarize any recommendations and clarify the who and what of any follow-up to result from the staffing.

A Caution to All Clinical Professionals

Psychological knowledge and jargon are dangerous, often standing between well-intentioned clinicians and effective mental health treatment. Curiosity always runs the risk of gossip. Clinical case consult groups scattered across our fair land meet frequently and are filled with far too much clutter, too often driven by curiosity rather than care. Jargon and gossip increase tone deafness in clinicians.

We all have our blind spots, and we all get stuck in ruts of routine and habit. And details learned about people’s lives ever tempt therapists, psychiatrists, and the like toward distraction. There is a distinct difference between a personality and a person, a diagnosis and a destiny. It is our responsibility to stir hope and catalyze strengths rather than to stew history and analyze at length.

Effective mental health treatment should always aim to treat the person—the whole person. A collaborative mental health treatment approach should enhance communication of relevant evaluative and ongoing therapeutic feedback, increase clinicians’ adherence to a person’s treatment plan, and reduce risk, frequency of crises, and unnecessary emergency room visits and inpatient stays.

It is important for all mental health providers to be well connected to and collaboratively engaged with multidisciplinary networks to ensure the most effective and integrated treatment that can occur does occur. Therapists, therapeutic case managers, psychologists, psychiatrists, and other mental health clinicians best serve people when they share perspective and responsibility in meeting people’s needs and ensuring therapeutic progress toward established treatment goals.

Anger is a misunderstood emotion.

Some people believe they’re not supposed to get angry. They think they should go to therapy to get rid of it. Often, a partner or parent has told them their anger is a problem.

Anger is something many people feel like they have to control. Yet so much of life is set up to blunt a free expression of feeling—from sitting in a regimented circle in preschool, to not crying too loudly at a funeral—and the only response that often makes sense is to feel angry. Why do we need to control that, too?

Anger can sometimes just be the loudest thing in the room. If there are other issues going on (spoiler alert: there are almost always other issues going on), these can be conveniently drowned out by the destructiveness and imperativeness of the anger. I say “conveniently” because anger is often the easiest emotion to notice and to deal with.

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It’s also perhaps the scariest. Anger can lead to uncontrollable, destructive actions. People go to jail or prison for such actions. People stay away from other people because of anger. Actions that typically present as anger are unacceptable in school, in the workplace, in church, and in many other settings.

Anger Can Be Healthy, Too

But anger can also be healthy. There are a lot of things in the world people should be angry about, things worthy of anger. In such cases, we seem to not want to call it anger, though. I remember learning the phrase “righteous indignation” as a child, as if people were so concerned we’d learn to be okay with anger that we had to create a new term to distance ourselves from it.

Anger can emerge in different forms. Some people, the ones sent to anger management, are typically destructive or otherwise problematic with their anger. They may punch walls, kick things, or get in fights. To many of them, their anger feels uncontrollable—they say things such as, “I saw red,” or, “I couldn’t stop myself.”

We often fixate on how negative anger can be—how it can take hold of us, how it can hurt others and ourselves. We talk about wanting to get rid of it. The thing is, it’s not going anywhere.

Others turn their anger inward. They are self-destructive, whether physically or emotionally, and beat themselves up. Depression, among other mental health issues, can look like this.

We often fixate on how negative anger can be—how it can take hold of us, how it can hurt others and ourselves. We talk about wanting to get rid of it. The thing is, it’s not going anywhere.

Anger is here to stay, no matter how happy you are, no matter how much you are in sync with the universe, no matter how much enlightenment has touched you. You are going to get angry.

And thank goodness for that. Because anger can point the way. It can spring us to action; many forces of change are motivated by anger. If it were the only motivation, we’d be like 2-year-olds, but combine anger with a conscience and a sense of justice and you have the makings of a social movement.

It’s especially important to get in touch with your anger if you tend to turn it all inward and it brings about self-hatred. It’s important to find healthier ways to express it if you are someone who physicalizes it. But it is also important to not feed it all the time.

Letting Go of Anger

Anger can be intoxicating. Think of a time you replayed an incident over and over in your mind. Perhaps something happened during your morning commute. You texted your girlfriend about it, called your mom, emailed your friend, and talked about it over lunch, yet you’re still thinking about it as you try to go to sleep. You’re not letting it go. You’re practicing it.

You’re just getting better at being angry. It’s not propelling you to change a social ill. It’s not allowing you to move on by expressing it. It is keeping you stuck, perhaps nursing your own self-righteousness.

You are suddenly at the mercy of a powerful and misunderstood emotion—one that gains more energy the more wood you throw on its fire.

So what does this mean for you? What can you do differently?

The idea is to feel the anger and let it go. Don’t deny it; you need to recognize it within you. (Many people I work with are unaware when they feel anger.) You can also learn to express it in a non-destructive manner—write it out, meditate, cry, draw, let someone know, etc.—and leave it there.

If that seems impossible, it may help to explore the themes stopping you from letting it go. Are you angry when you feel misunderstood or feel like you’re being taken advantage of? Do you respond with anger when you are shamed or when you feel helpless?

Spending some time exploring the themes around your anger, looking deeply at the topics that “get your goat,” will likely be helpful in finding productive ways to express your anger. It won’t stop you from getting angry, but it may help you stop staying there.

Self-compassion is one of those terms that has gained popularity of late but remains misunderstood by many. Self-compassion comes down to treating yourself as you would treat someone else you care about—with kindness, understanding, and the awareness that everyone is human, imperfect, but still inherently worthy.

Dr. Kristin Neff at the University of Texas at Austin was the first person to operationalize, or create a way to define and measure, the idea of self-compassion. She and other researchers since have found three essential components to self-compassion. These are self-kindness, common humanity—which refers to understanding the things we criticize ourselves about are both universal and part of being human—and mindfulness.

Mindfulness, at its most basic level, refers to present-moment, nonjudgmental awareness. The practice of mindfulness has been linked to numerous mind-body benefits, including the ability to notice the thoughts and feelings that tend to cause us suffering—without holding them close, pushing them away, or automatically identifying with them.

Although many of us could identify people we believe would benefit from taking a closer and perhaps more constructively critical look at themselves, there is a large subgroup of people who tend to be overly self-critical. This can come in the form of unfair comparisons, such as, “I’ll never be as good as so-and-so,” to frequent catastrophizing (“I’ve really messed up, and now my life is ruined for good!”), to conditional self-worth (“I’ll be okay/worth something/lovable only when I am [insert criterion here]”).

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Why We Self-Criticize

I’ve noticed a tendency toward chronic or constant self-criticism in those whose parents praised only exceptional behavior (leading to the belief, “If I’m not the best, I am the worst”), spent a lot of time fault-finding, or, in extreme cases, were abusive. If the inner stream of criticism sounds uncannily like the critical statements someone else used to tell you, take note. That’s useful information if you decide to pursue therapy.

Among the many downsides to constant self-criticism: it can leave one either overly vulnerable to feeling criticized—even in response to constructive feedback—and can also lead to projecting self-criticism onto others (and becoming hyper-critical in general). In addition, self-criticism erodes self-esteem and can leave one feeling depressed, anxious, or hopeless.

Why We Resist Self-Compassion

Often people resist the idea of self-compassion because they believe self-criticism is a necessary tool that protects them from “slacking off,” being a “bad” person, or otherwise becoming something they associate with personal failure (“fat,” “alone,” “lazy,” “unlovable,” etc.). People may also feel counter-identified with a parent or other family member who exhibited undesirable qualities, and thus, the self-critical voice may feel necessary to avoid winding up like that person. Similarly, they may worry that without being self-critical, they will fail to take responsibility for the things they do, and perhaps will lack compassion for others (because of the self-indulgence they associate with self-compassion).

The good news is the research on self-compassion has found that the practice is associated with being more compassionate with others, greater altruism, and greater likelihood to forgive others.

The good news is the research on self-compassion has found the practice is associated with being more compassionate with others, greater altruism, and greater likelihood to forgive others. In addition, self-compassion has been linked to being more likely to take responsibility for one’s own actions, greater happiness, increased motivation, and greater self-worth.

Some simple ways to enhance self-compassion include the following:

1. Ask yourself, “Is the way I am thinking about myself the way I would respond to a close friend or other loved one?” If the answer is no, imagine how you would treat others who found themselves in a similar situation. What would you say? What recommendations would you make? How would you offer comfort? How would you help this person reframe their take on things?
2. Write down the answers to the above questions. Now, viewing yourself from the perspective of the observer, speak to yourself in the same compassionate tone, using the language you would use with someone you care about.
3. Remember you, like everyone else, are human. Humans are imperfect, yet born with inherent worth. Most of the things you have suffered over are universal in some way.
4. Remind yourself of the truisms. Mistakes are one of the ways in which we learn. Challenges present opportunities to grow stronger. No one is perfect.
5. Practice mindfulness daily. Set aside time for formal practice, such as breath awareness, and strive to be present for your life in general—however it is in this moment.

References:

1. Breines, J. G., & Chen, S. (2012). Self-compassion increases self-improvement motivation. Social Psychology Bulletin, 38, 1133-1143.
2. Germer, G. K., & Neff, K. D. (2013). Self-compassion in clinical practice. Journal of Clinical Psychology: In Session, 69, 856–867. Retrieved from http://self-compassion.org/wp-content/uploads/publications/germer.neff.pdf
3. Neff, K. D., & Pommier, E. (2012). The Relationship between Self-compassion and Other-focused Concern among College Undergraduates, Community Adults, and Practicing Meditators. Self and Identity, 1-17 (iFirst article). Retrieved from http://self-compassion.org/wp-content/uploads/publications/Neff.Pommier.pdf

The death of a parent is a loss like no other. Our relationships with our parents shape the fiber of who we are. Without them in our lives, a significant piece of our identity may irrevocably change. When unresolved feelings or even estrangement remains, the loss of one’s parents can be even more complicated.

Becoming an adult orphan can be one of the hardest life transitions a person can experience. For me, the loss of my dad felt like the end of an era and the loss of my moral anchor. It was as if I had entered a new level of adulthood. A new path needed to be forged, and all of the familiar guideposts had suddenly shifted.

I often felt adrift and lost. My father’s presence in my life was enormous, and in his absence I struggled to fill the void. I often felt anxious and afraid. Whom would I go to now for the unconditional love only my father could provide? Who could answer my questions about the past? I did not feel ready to be the keeper of the family wisdom; that was his job. Ready or not, in many cases the death of a parent forces you to assume a new role or responsibility within the family.

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Losing your parents can cause you to question your identity. One woman I work with in the therapy room whose father had recently died wondered aloud if she was still a daughter. The answer was and is yes, but in a different way. Our relationships with our parents live on in our hearts, minds, and memories.

Our parents live on in the way we honor their impact on our lives, traditions, and family rituals. For some adult orphans, the transition may mean the loss of a family home, mementos, and other treasured things. The responsibility to manage final tasks, as painful as they may be, can also be an important part of the mourning process.

Our parents live on in the way we honor their impact on our lives, traditions, and family rituals.

For many, losing our parents means losing a sense of safety and security. It may mean losing people—perhaps even the only people—who loved you unconditionally, who were your biggest supporters, and who occupied the greatest space in your life. Their presence in your life may be matched only by their absence. The loss can feel overwhelming.

Navigating this loss may take time, support, and patience. It may redefine your life and reshape it, perhaps even changing your priorities. You may find yourself suddenly more aware of the importance of documenting family gatherings and traditions. You may also have a deeper appreciation for the things that create these traditions, such as family photos, recipes for special occasions, or assembling holiday decorations.

There’s no “right way” to cope with the loss of one’s parents. However, the following suggestions and reminders can be helpful as you navigate this unfamiliar emotional landscape.

• Be gentle with yourself. The death of a parent is hard. If possible, give yourself as much time to grieve as needed without the additional stress of work or other life demands.
• Pace yourself. The tasks associated with arranging services, sorting through possessions, and handling the estate can be emotionally exhausting and simultaneously healing. Do what you can, focus on the things that must be done, ask for help when needed, and accept the support of loved ones and friends.
• Prioritize rest and eating well. Sleep might be difficult to come by, but without proper rest and nourishment, your body and mind cannot function well.
• Make time for self-care. Exercise and activities such as yoga or meditation can help manage the stress that comes with grief and loss.
• Reach out to others who are also grieving. Connect with other family members affected by the loss, or consider joining a local support group. The support of others who have recently experienced loss may help you feel less alone.
• Use your loss to help others. You may find comfort, for example, in donating a parent’s clothing or belongings to charity.
• Keep the past present. Consider reinstating a tradition of your parents as a way to honor and remember them.
• Contact a therapist. If the pain of grieving becomes too great, seek the support of a compassionate mental health professional. Many therapists and counselors specialize in supporting the bereaved.

The process of psychotherapy is an unpredictable journey into the unconscious, one that offers surprising gifts and unexpected obstacles. The gifts are many: greater access to creativity, insight, tools to address difficult emotions, and increased intimacy, to name a few.

One of the primary obstacles to these gifts, however, is the “cautionary tale”—the primary unconscious story of hurt, imprinted from childhood, which you carry to each relationship. This tale underlies the therapeutic process and, if not understood and addressed, can undermine it.

Mixed Feelings in Therapy

Although you may be earnest in your pursuit of therapy, you may have mixed feelings about looking at the causes of your suffering. This is part of being human. Who WANTS to re-experience pain?

Inevitably, you will bring your mixed feelings in the door with you at the outset of therapy. These mixed feelings show themselves in a variety of ways in session: in the anxiety felt in the room, in the various stories shared with the therapist, in the tensions felt, in the fluctuations between stuck-ness and progress, in a feeling of push-pull.

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It is as if you are taking a trip while simultaneously unsure you want to go or, if you do, where you are headed.

And so you bring in your luggage (filled with conflicts, emotions, thoughts, and memories), drop the bags down in the room, and then, with the help of the therapist, hope (and possibly dread) to sort through them.

If you are unable or unwilling to sort through the bags, they can come out in unconscious ways and stall the process.

What Do We Mean by Cautionary Tale?

One term for these unconscious mixed feelings is the cautionary tale. Thomas Ogden, a major contributor to contemporary psychoanalytic thought, said the following about how the therapist must keep the cautionary tale in mind:

I am listening from the outset for the patient’s “cautionary tales,” i.e., the patient’s unconscious explanations of why he feels the analysis is a dangerous undertaking and his reasons for feeling the analysis is certain to fail …

The patient unconsciously holds a fierce conviction (which he has no way of articulating) that his early childhood experience has taught him about the specific ways in which each of his (object) relationships will inevitably become painful …

Ogden is suggesting here that the so-called cautionary tale is not just mixed feelings but a hidden conviction that therapy will fail. This is important to be aware of, for therapists and people in therapy alike.

Origins of the Cautionary Tale

But where, exactly, does this come from? Simply, a cautionary tale is born when a child’s first love relationships cause pain, either through the experience of abuse, disappointment, misattunement, overstimulation, unreliability, neglect, or something else. Because these early experiences are so painful, the child unconsciously weaves a tale about how this pain will inevitably occur in EVERY relationship, as protection from that same pain.

As the child develops and matures, the tale that was once protective becomes destructive: The adult will act out unconsciously to prove the present relationship is like all the others.

As the child develops and matures, the tale that was once protective becomes destructive: The adult will act out unconsciously to prove the present relationship is like all the others.

Developing a New Pathway

One of the great things about therapy is that this tale can be studied and updated. If you and your therapist keep an eye on your cautionary tale and how it might manifest in the therapeutic relationship, you have the chance to uncover the pain behind it.

If you are in therapy or thinking about starting therapy, pay attention to the thoughts and feelings you have about the process and your therapist’s role in it. Pay particular attention to any anxiety, skepticism, doubt, fear, or paranoia about the process. Then talk about it. There is sure to be a treasure trove of old feelings, packed away underneath, that could hold the key to the gifts you seek.

Reference:

Ogden, T. (1992). Comments on Transference and Countertransference in the Initial Analytic Meeting. Psychoanalytic Inquiry, 12:225-247.

In a previous article, we looked at the role initiation ceremonies play in a culture, and how they help us detach from an outgrown identity and move into one more highly adapted to the present.

In traditional cultures, these ceremonies follow a strict protocol. First communion uses a basic format, and so do bat/bar mitzvahs. Even a bachelor stag party follows a certain sequence of ideas.

For most of us, the transition from midlife into old age isn’t provided with much structure. On the downside, this means it might not be observed or navigated. But on the upside, this leaves a lot of room for an individual experience of initiation. Psychotherapy is a practice in our culture that focuses on the individual. In what follows, we’re going to look at one man’s initiation from midlife to old age. (Names have been changed.)

Howard comes to therapy for relief from depression. He’s in his 70s, burly but fit and well-dressed. During the initial interview, he describes feelings of hopelessness, loss of pleasure, and irritability. His affect—the rise and fall of emotion as he speaks—is mild, but his mood (the “background” feeling) is irritable, not bitter so much as sour, with a sense of disappointment. I ask him if there have been any changes in his life recently. For instance, has he lost anyone? No, he says, not lately, though in the 1980s and ’90s his circle was hit pretty hard by HIV/AIDS. Then he laughs humorlessly and says, “I wouldn’t mind a change, though, to tell you the truth.”

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He tells me he neither recognizes nor appreciates the old man he sees in the mirror. He describes his distaste at noticing age spots, at the continuing loss of skin tone. “I know I’m not a kid anymore,” he asserts, as if I’d accused him of this. “But I still feel like I’m in my 50s.” What are his 50s, I ask. “Like I should still be able to do things. Get up and get out. Meet someone new. But whenever I go out, it’s like I’m invisible.”

When Howard says he can’t believe he’s old, he seems to really internalize it. My impulse is to say, “You’re only as old as you feel,” but I don’t. Instead I sit with curiosity about why I would feel impelled to “rescue” him from old age. I ask him what “old” is. He tells me. It’s material I’ve heard before, and perhaps you have, too: old people can’t, old people don’t.

It’s a description of aging that’s prevalent in our culture, almost cartoon-like because it seems to flatten people out so they’re not quite real. Old age is adjacent to death, so it seems. And even though we don’t know what death is, our fear of it informs all of our other fears. No wonder so many of us avoid recognizing ourselves as old, and feel distress when we do. In a culture characterized by a fear of death, old age can be seen as a stigma—a sign that an individual has beliefs, qualities, or behaviors counter to the culture, and therefore threatening to it. Which might account for Howard’s experience of feeling invisible.

We begin by addressing some of the myths of aging. The first one we tackle is about declining sexuality in both men and women. In Geriatric Mental Health Care, Gary J. Kennedy, MD, notes that “the continuance of sexual activity into late age depends on the life pattern of each person.” Acceptance of a perceived inevitability of loss is linked to both loss of libido and even bodily changes. In How We Die, Anne Karpf cites a study on memory function in aging American and Chinese subjects. The study findings indicate that not only did the Chinese subjects do better on memory testing than their American counterparts, but they performed better than young Chinese adults. The researchers associate these findings to the fact ageism is less prevalent in China than in the United States. Howard and I discuss the idea of self-fulfilling prophecies.

Ageism is the idea that old age will be a mirror image of infancy. In the first stages of development, we acquire skills in sequence—language, mobility, continence, to name a few. Ageism suggests that all of us will, sometime before the end of life, lose those skills along with many others, and that anyone displaying signs of age is experiencing this loss of integrity. I find that Howard has a history of resisting prejudices, including internalized prejudices. I enlist this in our work together.

I ask him about meaningful experiences. This starts a life review—piecemeal at first, but gradually we get a chronology established. We don’t hear about the violent disagreements with his father when he was in his mid-teens, and that were the reason he left Illinois for the west coast, right away. Instead we start with his career as a counselor in a parole office that is both a source of pride and loss for him now in retirement. But eventually we come to his partnership with Don, which ended with Don’s death a decade ago, and to his marriage with Karen when they were both in their 20s, and their two children. Over many sessions, we put together a narrative that extends through seven decades, and that despite having some unsolved mysteries to it—what life doesn’t?—holds together so that meaning can be clearly observed.

One of the effects of such a review is that Howard becomes more grounded in his life—not just its events but its duration. There’s not so much of a disconnect between his actual age and his ownership of that age. He’s just a little bit less inclined to wish it away. For better and for worse, he’s related a history that requires 70-plus years for its unfolding.

As well, this life review places Howard’s own life into the context of his age cohort, and the events which shaped them and which they shaped in turn. Some of these he participated in literally, such as protests against the Vietnam war and his advocacy for ACT UP. His participation in others events is more symbolic but no less real, such as the moon landing and reunification of Germany. We find resources of accomplishment and pride here. In Identity and the Life Cycle, Erik Erikson describes the developmental tasks of later adult life as shifting allegiance from self and our small group to a larger field (“mankind, my kind”). As Howard considers the impact on history of his age cohort—whose accomplishments both include and extend beyond his personal ones—he has the opportunity to locate himself inside and identify with larger movements of life.

Old age is adjacent to death, so it seems. And even though we don’t know what death is, our fear of it informs all of our other fears. No wonder so many of us avoid recognizing ourselves as old, and feel distress when we do. In a culture characterized by a fear of death, old age can be seen as a stigma—a sign that an individual has beliefs, qualities, or behaviors counter to the culture, and therefore threatening to it.

During this stage, I encourage Howard to bring in photographs of meaningful others, and especially of his younger selves. As the conversation grows more intimate, we give names to the earlier versions of Howard. The slim, long-haired teenager is the Poet. The mustached thirty-something exploring a new sexual identity is Robert Redford. The bearded man demonstrating with his younger colleagues at an ACT UP protest is Papa. We marvel at the way one identity succeeded another, taking its turn to be lived. We open up and sit with the interesting problem that even though these identities are no longer the case, they will always be true. Howard is no longer the Poet, and yet Howard carries the Poet and all that identity’s youth and passion within him.

We also look at the fact Howard knows the answers to the questions that puzzled each of his “earlier selves.” He knows, for instance, how the struggle to come to terms with his own sexuality turned out—that struggle was difficult but ultimately rewarding—though the 29-year-old in the photo with Karen doesn’t. As he considers this odd fact, I take the opportunity to wonder out loud if there is an older Howard “up ahead” who knows how Howard resolves his conflicts about old age.

I introduce Howard to Carl Jung’s concept of Self. This is the organizing principle of the psyche, one that initially operates on an unconscious level but with which a conscious relationship can be formed. To illustrate this, I tell Howard a person can have a set of values he lives by without stopping to think about them, but if he becomes aware of what his values are he’s able to live them more effectively, relating to them as he would a blueprint or a compass.

The Self is often personified in fairy tales as the wise old man or woman—think Cinderella’s fairy godmother or Obi-Wan Kenobi of Star Wars. In a rational sense, this combination of wisdom and age speaks to our having lived the earlier stages of our lives and learned through them who we are and what the world is. In an intuitive sense, who I am now and how I’ve lived or not lived so far implies who I will be. That “future self” is implicit in who I am now.

Howard is intrigued by this image of an older self, or Self, from whose point of view his present issues are all resolved one way or another. “I don’t feel so lost,” he says. “In a funny kind of a way, it’s like I already know the answers. It’s just a matter of remembering them.” He’s also interested to think that compared to this image of the Self, he’s the younger of the two. That if the Self is the cumulative image of his full life span, Howard is not there yet.

We look at the fact that if Howard had refused to go on to have new and further experience when he was the Poet, then Robert Redford, Papa, and the others wouldn’t have had their times to be lived. He says about the Self, “I feel like he’s waiting his turn. Like he’s depending on me to live him. I don’t want to let him down.” I reflect the positive nature of such a relationship to the Self. Erikson describes “the acceptance of one’s own and only life cycle,” and Jung refers to participating in “the ego/Self axis.” Both ideas act as guideposts to the same fact, that it’s possible to experience old age with integrity and hope.

In The Measure of My Days, a book of reflections written when she was in her 80s, Florida Scott-Maxwell notes, “Personal immortality may not matter at all. Perhaps our long insistence on it has been our need of spiritual value, and a groping conviction that is our central truth; that we have a share in impersonal greatness.”

If he was the Poet when he was in his 20s and Papa in his 50s, I ask Howard who is he now. He thinks about it, then grins and says, “Well, I guess I’m the Traveler now.” On the spur of the moment he asks if I’ll take a picture of him using his Android phone. I do, and Howard has his first photograph of the Traveler, evidence that he passed this way.

References:

1. Erikson, E. (1980). Identity and the Life Cycle. New York: Norton.
2. Jung, C.G. (1966). The Practice of Psychotherapy: Essays on the Psychology of the Transference and other Subjects (Collected Works Vol. 16). Princeton, N.J.: Princeton University Press.
3. Karpf, A. (2014). How to Age. London: Picador.
4. Kennedy, G. J. (2000). Geriatric Mental Health Care. New York: Guilford Press.
5. Scott-Maxwell, F. (1968). The Measure of My Days. New York: Penguin Books.

If I asked whether you spend most of your day feeling cool and confident, you’d probably laugh at me, right? We’re all constantly working on knowing who we are and feeling OK about ourselves. And too much of the time we’re looking for this feedback from the outside—other people, accomplishments, a number on the scale—instead of looking inside ourselves.

There’s a metaphor I love to describe this phenomenon. I liken people to beautiful, old oak trees. Our trunk is where our strength and sense of self is. It’s literally grounded, connected to the earth through a network of roots, and it’s solid, hefty, and multilayered. Up higher are the branches, and at their ends lay the leaves, constantly blown around by wind or rain. If we think of other people’s opinions (or traffic, or problems at work, or financial worries, etc.) as the weather, and our sense of self as the leaves, we can see how quickly and often we get battered.

When we “live” up in our leaves, we feel that we’re easily swayed or, worse, hammered by outside influences. If we can work on “living” in our trunks, we feel solid, unable to be knocked down.

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So how do we get out of our leaves? First, we recognize what we’re doing. For instance, if you’re feeling a lot of anxiety and depression, this could be a clue that you’re worried about how other people see you. Anxiety commonly carries a message of “I have to be perfect or other people will feel let down.” Depression often sounds like “I’m not good enough.” Both of those statements, and the hundreds of other, similar ways we beat up on ourselves, lose track of how we feel about ourselves, and instead are all about the way we think we come across to others.

When you recognize that you’re being hard on yourself because you’re worried how others will perceive you, label that: I’m doing it again—I’m in my leaves. Then turn your attention to your trunk.

Your idea of your trunk will take some time to develop, but it can be a fun project. First, come up with an image. You can look online for a lovely photograph of a tree, remember one you grew up with, or create your own fantasy picture. Next, think about the qualities that make you unique, and that you feel good about. Your values, strengths, and dreams are a good place to start. By making lists and spending some time considering these characteristics, you may come up with a stronger sense of who you really are and what you like about yourself.

When we “live” up in our leaves, we feel that we’re easily swayed or, worse, hammered by outside influences. If we can work on “living” in our trunks, we feel solid, unable to be knocked down.

Values are how we decide what’s important to spend our time on, and if our lives fill us with a sense of purpose. If we’re not clear on where our values lie, that can make us feel lonely, alienated, or confused, and open us up more to being manipulated. Thinking about your values can get you in touch with your spiritual beliefs, lessons from relatives or mentors you admired, or books or movies you’ve felt inspired by. You can use a worksheet, such as this one, to calculate how you prioritize aspects of life.

Listing strengths can be really challenging for people battling low self-esteem. If you’re one of them, this exercise may take some time. You can use an online tool like the ones at the Institute on Character, or you can just sit and try to list 15 things you like about yourself. Fifteen is an important number. Many people can list five pretty easily, and then can strain to come up with 10. Fifteen takes thought, creativity, and commitment, and the mere act of investing the time often makes people feel better. If you truly can’t finish the list, ask relatives, friends, or coworkers to help.

Finally, look into your dreams. What did you want to be when you were a kid? Was there anything you felt passionate about as a young adult? For many of us, we tend to be our most idealistic in our teens and twenties. We find causes or have goals that are lofty and principled. By looking at those, or remembering them, we can get in touch with what fires us up and makes us feel committed—and passion and commitment are two of the most important qualities shared by happy people, according to the field of positive psychology.

By turning our attention from our leaves (the outside judgments of other people, the annoyances of daily life) to our trunk (the inside assets and standards we appreciate about ourselves), we can worry less about what other people think of us and concentrate more clearly on who we know ourselves to be. Which is the very definition of self-esteem.

On February 16, 2016, police in West Palm Beach, Florida arrested Malachi Love-Robinson, 18, for allegedly setting up a medical practice, posing as a doctor, and examining patients without a medical license. Amazingly, this was not the first time the teen had been arrested for operating without a medical license. On his website, Love-Robinson listed his qualifications to provide psychotherapy, phototherapy, electrotherapy, and physiotherapy, among many other professional services; however, licenses or certifications to provide such services were never disclosed.

It is frightening to consider that the person you turn to for physical or mental health care may not be who they say they are, let alone able to safely and effectively perform the procedures they say they can.

This sensational story sounds like just that, a story; however, stories of actual health professionals acting outside of their scope of competence occur only too often. As can be seen on popular cosmetic surgery shows such as E!’s Botched and Lifetime’s Atlanta Plastic, it is not uncommon for individuals to discover their health professional was incompetent or unqualified to perform a medical procedure. Unfortunately, this discovery typically happens after a surgical or cosmetic procedure has taken place and the person is left with a physical or psychological issue. Afterward, the person discovers their doctor was not a specialist, not licensed, or worse yet, not a doctor at all.

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On reality television and with the Love-Robinson case, it is easy to blame victims for placing themselves in situations that caused physical or mental harm. In regard to Love-Robinson, social media posts have commented, “They (patients) should have known he wasn’t a real doctor by how young he looked” and “I congratulate the young man; it’s the patients’ own faults if they fell for it.” In hindsight, it is always easier to judge things differently, to believe all the information we know now was obvious in the beginning. But the reality is, when people visit health professionals, they typically trust them to be credible, vetted, and experts.

Many (perhaps even most) of us do not take time to really explore who our health professionals are. How much time did you spend investigating your primary care doctor before your first visit? When you were referred to a specialist, how much effort did you expend in reviewing their credentials? When you found a therapist, did you ask questions to determine the best fit or did you schedule with the first person who returned your phone call?

How much time did you spend investigating your primary care doctor before your first visit? When you were referred to a specialist, how much effort did you expend in reviewing their credentials? When you found a therapist, did you ask questions to determine the best fit or did you schedule with the first person who returned your phone call?

Additionally, unethical health professionals may target vulnerable populations, including individuals with low socioeconomic status, ethnic minorities, sexual and gender minorities, children, the elderly, and people with disabilities. We have seen this with the U.S. Public Health Service (USPHS) Syphilis Study at Tuskegee in which African-American research participants were purposely left untreated for syphilis despite there being a cure for the disease (Northridge, 2011); the continued practice in some states of conversion therapy, which attempts to change the sexual orientation or gender identity of gay, lesbian, bisexual, and transgender individuals, even with research indicating such practices cause psychological harm (APA, 2015); or the St. Louis Veterans Affairs dental clinic exposing more than 1,800 veterans to HIV and hepatitis. Subjugation to societal discrimination or biases can leave vulnerable populations feeling powerless to assert their rights or question those in positions of power.

It is not helpful to blame the victims when health-related crimes or injustices occur, as it is possible that any of us could be misled by a seemingly legitimate professional. Having said that, there are steps we can take to educate ourselves as consumers and to investigate the credentials of health professionals.

Consider the following:

• State licensure boards license health care professionals. A simple web search of your state’s licensure board can provide you with information regarding the status of a health professional’s license. Seeking a psychologist? Visit The Association of State and Provincial Psychology Boards to find your state’s licensure board.
• Health care professionals may be members of national or state associations. For example, your medical doctor may be a member of the American Medical Association, or your psychologist a member of the American Psychological Association. Membership can lend greater credibility and can alert you to ethical standards your health professional is expected to maintain.
• Complaints regarding ethical violations, misconduct, or fraud can be filed through your health professional’s state licensure board or professional membership organization. You can also review any previous complaints regarding your health care professional by contacting state licensure and professional membership bodies.
• If your health professional has certifications, you can check with the certifying organization to verify the certificate. For example, if it is important that your couples counselor is Gottman-trained, you can review therapists through the Gottman Institute website.
• Research and publications are not necessary for a health professional to be skilled and competent in their field. In fact, many health professionals are so involved with their clinical work that they do not have the time or interest to engage in research. For those health professionals who do, exploring their research and publications can help gauge your health professional’s level of expertise in a particular area.
• Don’t wait for health professionals to reveal themselves to you. Ask your provider questions to ensure they are the best match for you. This includes asking questions about the provider’s education, expertise, and training. If you don’t feel comfortable with the provider’s answers, find someone else.

References:

1. American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832-864.
2. Northridge, M. (2011). Toward the ethical conduct of science and a socially just world. In R. Katz & R. Warren (Eds.), The search for the legacy of the USPHS Syphilis Study at Tuskegee (pp. 49–58). New York, NY: Lexington.

Assertive communication is a style of speaking in which the goal is to take care of your needs while also showing the other party mutual respect. An important form of assertive communication is known as “I” messages or “I” statements. “I” messages clearly state what you want in a way that someone will understand and, more importantly, not get defensive. When people are defensive, they may get angry, accusatory, or ignore parts of what you are saying.

When you use “I” messages, you focus on your personal interpretation. Your experience is harder to argue with because it’s yours and yours alone. Someone might not agree with how you interpreted a behavior, but they are less likely to feel personally attacked by you expressing the experience as your own. As a result, “I” messages tend to reduce the likelihood of someone feeling criticized and may increase their likelihood of changing a behavior.

Roll your cursor over the text below (or click if you’re using a mobile device) to see examples of complete “I” messages:

How ‘I’ Messages Work

An emotion is one word. If you say, “I feel like you aren’t listening to me,” that’s not a feeling. Feelings may include: anger, frustration, confusion, guilt, encouragement, gratitude, happiness—you get the point. When you begin a conversation with “I feel” and then express an emotion, you are putting your perspective first. This reminds the person you are talking to that this is how you feel and not about what they did to you.

[fat_widget_left]Once you have expressed the emotion you are feeling, describe what happened. Try to avoid saying “you” whenever possible. Again, this is about keeping the other person’s defenses down. Instead of saying, “I feel frustrated when you leave the dishes in the sink,” say, “I feel frustrated when I see dishes in the sink.” As another example, instead of, “I feel left out when you make plans without asking me,” try, “I feel left out when I’m not included in plan making.”

After you get the feeling and specific behavior down, you will want to explain why the behavior made you feel that way. This helps the person you are speaking to better understand why it’s so important. It might sound something like this: “I feel left out when I’m not included in plan making because I like to be aware of the schedule.”

Finally, provide a suggestion to take the guesswork out of what you need in the future. Using the last example, a replacement behavior might sound like, “I feel left out when I’m not included in plan making because I like to be aware of the schedule. I would prefer if you could send me an email before committing to our friends.” Sometimes there might not be an immediate solution, but even saying, “Can we talk about this further?” can be a good start.

The opposite of an “I” message is a “you” message. “You” messages often sound accusatory and tend to put people on the defensive. As soon as someone hears “you,” preparing for an attack is a common reaction. The goal of “I” messages is to diffuse that possibility, and instead enable a more meaningful discussion.

Here are some examples of “you” messages versus “I” messages:

“You” message: “You are always making me late for the movies!”
“I” message: “I feel anxious when I’m late for the movies because I want to make sure we get a good seat. Is there something I can help with to get us out earlier?”

“You” message: “You never remember to pick up the mail when you come in.”
“I” message: “I feel worried when we don’t have the mail at night because I want to make sure we don’t miss anything important. Could you please grab it when you come in tomorrow?”

Finally, it is important to remember that when using assertive communication there is no guarantee you will “I” messages will only increase the chances of getting something you want, but they often won’t get you everything you want.actually get the new behavior from the other person. “I” messages will only increase the chances of getting something you want, but they often won’t get you everything you want. In that last example, the person could easily say, “My hands are full when I come home so I tend to forget the mail. Could you get it instead?” That response is presumably preferable to the “Get off my back. I’m tired after work!” that you might be used to.

The true goal for utilizing “I” messages is to improve your overall communication to one of mutual respect and increase your confidence when speaking about touchy subjects. “I” messages take practice, so be patient with yourself as you get the hang of it. Over time, you will hopefully notice a reduction in petty arguments, criticism, and defensive reactions.

During a recent therapy session, I had a profound exchange with a man about how, months after the tragic loss of his sister, grief is changing him in ways that feel important and meaningful.

There is a clear delineation of causality within our conversations; there is no sugarcoating the hell he is living or the pain he will always feel. The grief is not a “gift,” and it did not happen “for a reason.” But it did happen. And the ways in which this man is choosing to live with it are giving him a deeper experience in life.

He is motivated to switch careers to something more fulfilling and mission-driven. He wants to move closer in proximity to the people he loves most. And what he organizes his life around on a daily basis is shifting toward quality of experience versus social status or traditional measures of success.

Making changes such as these, while often worth it, can be very difficult. It can be painful, lonely, confusing, filled with uncertainty, and extremely uncomfortable, to name a few. For this particular man, his newfound intentions further rattled a life that has already been turned inside-out.

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Yet after the initial blackout period of grief, a period in which devastation and heartbreak were all he could see, he is now in a place where he is able to come up for air and reassess his life. He is taking inventory of where he has been, where he is now, and where he wants to be.

The grief has given him an understanding of life he never asked for—to know how short it really is. The grief from the loss of his sister forced him to go inside himself, where he found more core truths of who he is and how he wants to live than ever before. While he lost much, he is realizing through his grief journey he found more of himself.

You have to enter into a partnership with the grief. You have to agree to be changed by it. This means acknowledging that the transformative process will be hard, that you will most likely have to let even more things in your life go, but that in the end your voice will be clearer and stronger. Your life will feel more yours—even with the ever-present loss and pain.

These transformative realizations are not always easy to let in or act on. However, if you are willing, grief can change you in a way that leads to greater meaning, freedom, authenticity, and comfort. Pain and beauty can coexist. Grief and joy can both sit at the table.

To have this type of experience, to undergo transformative grief, you have to be willing to be changed by the grief. It is not an automatic process.

You have to enter into a partnership with the grief. You have to agree to be changed by it. This means acknowledging that the transformative process will be hard, that you will most likely have to let even more things in your life go, but that in the end your voice will be clearer and stronger. Your life will feel more yours—even with the ever-present loss and pain.

The point is not for your loss to be softened or minimized. Why should it be? The point is if you are willing to work with this horrible loss, you can allow it to change you in meaningful ways, perhaps with the help of a therapist. Grief and pain can contain an alchemical process that empowers you, points you straight to your truth, and removes old fears.

This does not necessarily mean your life will be better than before. It does not mean the pain goes away. It means you adjust to your new normal and find a life inside of it—a life that still hurts, but that also finds beauty, love, courage, and truth. Transformative grief allows you to live more fully.

In Part II, we will cover how to enact this transformative process—and the pitfalls you may face in excavating joy from within the pain.

When was the last time you saw one of those charts that has a bunch of yellow, circular faces representing a variety of feelings? Elementary school? Perhaps it’s time to refresh yourself. Happy, sad, frustrated, confused, disappointed, surprised … we often identify these and other feelings by examining facial expressions. Feelings are often deeper and more complicated than that, however. Psychotherapy is often about identifying and exploring feelings that might not be apparent on the surface.

Sometimes we might think we feel, say, anger or irritation when talking about an issue, but it may turn out a whole bunch of feelings that are more applicable, interesting, and useful are underneath. For example, a person might come to therapy talking about why her supervisor’s method of running meetings irritates her. Upon further exploration, however, we might find that the irritation is masking a feeling of her feedback being devalued. We can then come up with solutions to process and manage that feeling.

The feeling remains just a feeling. As with a passing rain shower, we get wet or take out an umbrella, or possibly even enjoy the depth of being alive, even if the feeling itself is unpleasant.

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Sometimes a feeling profoundly affects a person’s well-being. Instead of a passing rain shower, it feels more like a tsunami that has swallowed the person up. In the previous example, the feeling of being devalued by the supervisor may extend to coworkers or even people outside of work. This person might be attaching more meaning and weight than is necessary to the feeling. In other words, she may be over-identifying with the feeling to such an extent it has a negative effect on unrelated areas of her life.

A feeling is not an identity that has a mind of its own and gets to run your life.

A feeling is not an identity that has a mind of its own and gets to run your life. When we over-identify with feelings, we may start to feel that they are truth—permanent states, even—that take control and determine our life paths. Feelings are just responses to certain events and people, and while many events have a certain predictability of feelings that follow, they are still just a part of our emotional selves. We likely have many other feelings and experiences even when we are feeling dismissed, sad, or angry. But over-identifying with one sends them all to the background.

Some of us are more emotional than others. If you have strong reactions to the news, for example, you might also ruminate on another’s problem or a small piece of feedback that another person might brush off. There’s nothing wrong with being sensitive and empathetic, but when these feelings become unproductive and affect your well-being, or when you feel that a wave of emotion has swallowed you whole, you might consider the following actions:

• Go back to the chart of “feeling faces.” Visualize those yellow faces with labels underneath them and really identify what it is you are feeling. Then say very clearly, “I am feeling ______.” In the previous example, the person might say, “I am feeling that my feedback at today’s meeting was not valued.” This is very different from saying, “I’m always dismissed at staff meetings” or “Nobody values my opinions.” We have to work hard to not turn feelings into broad statements about ourselves. Clearly labeling something is helpful in keeping it in its place.
• Use self-compassion. Self-compassion is a powerful way of looking at yourself and your behavior so you can better manage stress and bring the best version of yourself to all of your activities. It requires not over-identifying with feelings, but rather acknowledging them and moving on. For example: “I’m feeling disappointed that my phone interview didn’t get me to the next round, but I did the best I could and will focus on the next job now.”
• Try a cognitive therapy exercise. Thought charts and other structured activities can help you counter big-wave feelings and put them in perspective. They take a little practice, but over time you’ll likely be able to do a thought chart rather quickly. Here is one example.

So the next time you’re feeling off-balance because of a feeling, try to see it for what it is—just a feeling that will pass—and let it be. If it sticks around, or if it seems to return again and again, try challenging it with self-compassion and perhaps a thought chart. Comment below if you want some feedback on a thought chart you’ve completed!