‘Grounding’ and Other Complicated Words

This is a personal reference list for me, but perhaps it will help others. Overall I find quieting my mind or paying attention to my body (common suggestions for self-soothing) to be very unpleasant. At some point I would like to increase my tolerance for things on the second list, but exposure therapy is not how you relax.

Grounding:

1. weighted blanket
2. back breathing
3. fidgets, especially cold or heavy ones
4. hard hugs
5. hot showers/baths
6. square breathing

Triggering:

1. ‘body scan’ meditations
2. okay, really any meditation billed as ‘grounding’ [Example]
3. diaphragmatic breathing
4. mindful movement

A Short Guide to People Who Can Help With Your Mental Health

[Written by an American. Generalities probably apply to Canada and UK, specifics certainly do not]

Psychiatrist
>Can prescribe medicine related to mental health concerns
In the U.S., virtually all psychiatrists do not do psychotherapy on a long term basis. They’re expensive, usually have long waiting lists—I’m told it’s something like an expected three month wait to see a psychiatrist in my city—and specialize in medication.

If you are making an appointment to see a psychiatrist, this is frequently considered evidence that you are looking for medication. This can cause weird misunderstandings when people think of a psychiatrist and a psychologist as identical and psychiatrists anticipate that people who come to see them are coming to see them for their specialty. Patients can (and do!) occasionally get the impression that they’re hopeless and must go on medication or that the entire mental health establishment is focused on pushing drugs.

Psychiatric Nurse Practitioner/Mental Health Nurse Practitioner
>Can prescribe medication related to mental health concerns.
I’ve only run across these in hospitals, but this article suggests they also operate in private practice. In my experience they do slightly more therapy than the psychiatrists I know and work with, though their primary focus does seem to be medication management.*

Clinical Psychologist
>Cannot prescribe medicine.
Has a Ph.D or a Psy.D. Worked a variety of successive internships to collect enough hours (1,500 to 6,000, varied by state) to become a licensed psychologist. Almost always have specialized training in administration of specific kinds of therapies, like Cognitive Behavioral Therapy or Motivational Interviewing.

My impression is that psychologists are low variance in terms of skill at administering one-to-one therapy and diagnostic work. They’ve all received lots of hours of practice before being licensed, and while there are many ways to be a clinical psychologist who does therapy, there aren’t as many ways as say, a social worker. Psychologists are also more likely to be able to sort out a diagnostic label, if that’s relevant or important for you. Others on this list could, but might not use diagnostic labels as frequently or be as comfortable getting a really specific, precise diagnosis.

Social Worker
>Cannot prescribe medicine.
Most social workers who are providing one-on-one therapy have a Master’s degree**. Social work is weird because the list of things a social worker could be doing as their job is…….very long.
Some:

  • being available to talk when someone is in hospice
  • working in school with kids who are struggling (behaviorally, emotionally, academically)
  • doing therapy in a standard couch + office + “and how does that make you feel” setting
  • investigating reports of abuse or neglect
  • coordinating other therapists and psychiatrists for clients
  • talking to people who recently were diagnosed with a terminal or chronic illness
  • helping people get into detox programs by making a lot of phone calls
  • doing assessments of children entering juvenile detention
  • helping new immigrants or refugees adapt and find services
  • going to people’s homes to assist with counseling
  • helping people deal with other bureaucracies
  • accompanying clients to appointments (such as Social Security offices)
  • leading groups (support, therapy, social skills, etc)

The main differences I notice between social workers and psychologists are:

Variance: social workers are high-variance; I happened to spend both of my training internships doing individual therapy and training in Cognitive Behavioral Therapy. It would have been equally possible for me to graduate having never done one-on-one therapy and without specialized training in a single modality.

Advocacy & Case Management: Part of the reason for the high-variance nature of training is that some social workers never particularly want to do one-on-one therapy. They might prefer ‘case-management’. Ever needed to figure out how to get into a treatment center and also have follow-up services when you left? A case manager might coordinate all the people at the treatment center plus follow-up appointments, plus check in on your progress. It’s always been an expected part of my non-case manager role that I do some of this. Sometimes therapy is put on hold to figure out how a client is getting treatment for their health concerns, or sorting out billing. This seems to be a cultural difference between social work and the rest of the list.

Mental Health Counselor
>Cannot prescribe medicine (seeing a theme, yeah?)
Like a social worker, has a master’s level degree, plus two more years of work in the field to get an independent (not-requiring supervision) license. I usually see the license called an LMHC or CMHC. Can do similar roles as any of the non-prescribers listed above. Less of an advocacy focus than social work.

Marriage and Family Therapist
>Cannot prescribe medicine.
Though all previous listed professionals could do couples’ counseling, this category specializes in it, and other family work. Master’s level degree plus two years of training to get a license for independent (non-supervised) work.

*Know more? Feel free to add in the comments.

**It’s possible to be a social worker with a Bachelor’s degree, but this generally involves more case management and very little direct therapy.  Except in my state, where you do not have to have a degree at all.

Empowerment Exhaustion

[CN: brief mention of self harm, anorexia, alcoholism]

Empowerment as a social service model holds that….well, it holds a lot of mostly-overlapping things actually. A handful of the places I’ve worked with have had empowerment models, which get summarized into catchphrases like “the client is the expert on what’s going on with them” and “we provide information; we don’t tell clients what to do.”

And I can almost hear the grumbling over here, so let me make a defense.

Lots of people who end up needing social services haven’t got many feelings of control over their lives. A feeling that you have control over your life (i.e. internal locus of control) is associated with lots of excellent mental health outcomes (Maltby, Day, McAskill, 2007)*. Empowerment might be teaching the client to have a sense of control and choice in their lives, which is a powerful lesson.

Empowerment models meet the client where they are. If Jimmy shows up in our office because a teacher reported that he was self-harming, and our response is that nobody should ever self harm ever again, well then Jimmy can reasonably conclude that we aren’t helpful or interested in why he self-harms, and proceed to dismiss us.

While we continue to suggest that he just stop doing that, Jimmy can go on his merry way ignoring us. We’ve missed the opportunity to reduce the harm to Jimmy at all (is he using clean razors? does he care for his cuts?) or figure out why Jimmy is using self-injury as a coping mechanism (is he depressed? are there interpersonal problems going on? Can we help with any of that?).

The empowerment model avoids pattern-matching to everyone else who tells the client what they should have done/aren’t smart enough to do/should be doing next. If Bob the Alcoholic shows up because his wife pressured him into seeing a substance abuse counselor and the counselor says something that sounds like “You drink too much!”…well.

Now the counselor just sounds like Bob’s wife. And Bob’s wife has been bugging him about drinking too much for a while—he’s gotten practice at ignoring people who say that! Besides, now it seems like the counselor is on his wife’s side, and people are not all that calm and thoughtful when they feel as though they’re being ganged up on. Feeling as though you and your therapist are on the same side is the best predictor of immediate outcome and roughly 8% percent of the outcome four years later.

You’ll notice that in both Bob and Jimmy’s cases, the client-as-expert framing isn’t meant to cause the conversation to stop when the client says they’re happy with the current state of affairs. (So, not: “The client says she’s happy getting high every afternoon—guess I’d better pack it in then!”) But instead, it assumes that the client is doing the current behavior because it feels adaptive…and might currently be adaptive.

A personal example: for most of the time I’ve had an eating disorder, up until a few years ago, eating a whole meal caused me to be panicky and anxious, unable to focus or sit still to work. At this point in recovery, I was able to usually force myself to do it, deal with being panicky for a while, and then go about my normal life. But, during midterms and final term papers, I needed to be working and focused almost all of the time. In the choice between skipping a few meals here and there and failing, I did the one that wouldn’t mean paying extra tuition to repeat whole classes.

One model for responding could have pointed out that this is known as anorexia, and it is not good for your health, Kate. I tried this! For a while I was chronically panicky during finals: freaking out when I ate food and tried to focus, feeling overwhelmingly guilty (I was failing at recovery!) when I didn’t. I had even more meltdowns, I was able to focus even less.

The other option pointed out that I did have some interest in continuing to eat food, but that this was harder to do during final exams. Sometimes the most adaptive option I had at hand, given my anorexia-brain was to eat very little food when I needed to focus for a long period of time. An empowerment model might point out that this is sometimes the only adaptive choice I have at hand…and then looks for  ways to decrease the instances where this is the only adaptive choice. Can I figure out what things make food the least stressful? Can I work on my midterms beginning much earlier, therefore allowing me to focus less each given day?

And this worked! It’s worked so well that it’s still my strategy: as soon as mid-semester rolls around I switch to having lots of enticing, low stress food around and I’m willing to settle for a lower grade if it means I have to force myself to focus a little less frequently each day.

….but actually, I don’t often enjoy when I’m on the receiving end of empowerment-based interventions. And this is probably because I’m not a good fit for them! By the time I end up on the client side of the couch, I’ve gotten to the point where I don’t think I’m currently making the best choices for myself on my own steam (that is, I’m decision fatigued).  Therefore, I’ve called in the therapist to help. And the conversations can feel like this:

Therapist: “I’m allowing you to determine what’s best for you, and give you control in a way that will empower you to make decisions in the future. Some options you have include, Options A, B, and C. ”

Me: “I’m here because you are trained to be the expert! I’m not able to currently trust decisions I make! None of the list of options seem obviously bad, but you have more knowledge about what happens in each scenario! Now I feel like I’m trying to read between the lines, when you could just tell me what tends to work for people with my particular issue.”

In fact, when I’m particularly anxious and decision fatigued, this resolves in irritation: “I do NOT care what my list of options are, I want an ANSWER about the BEST option right now.”

But I live in a world where I get to (mostly) make all of my own choices and (mostly) have everyone assume I am deserving of autonomy. It’s cool and interesting and ‘powerful’ when I am open about mental illness, rather than unavoidable or ‘gross’ or ‘disturbing’. I get to make my own choices…so much so that it’s sometimes exhausting! Empowerment approaches feel like they add to the mental work of choosing when I’m at my least capable. But if I never got treated as though I were capable of making my own choices? Or I stated my choices, and then people nodded a bit and said those were silly decisions that indicated I was clearly incapable? The empowerment style would probably feel incredible.

It reminds me a little of picking a restaurant with your friends. If you have three friends who never ever ask you where you’d like to go out to eat, or take into account the fact that you hate Thai food, the first time they say “Hey, Joe, where should we eat tonight?” it’ll be great! But if the four of you always trade off on picking restaurants, and one night, everyone says “Nah, I don’t care, I’ll eat whatever” and nobody picks a place to eat?  You’re going to be annoyed. (And hungry.)

Related, on both food and empowerment grounds: poverty and the marshmellow test


*there’s a mediating effect of coping skills, but the short version is that having an internal sense of control seems to be related to a large number of positive health and mental health outcomes.

Lesbians and the Parable of the Late Client

In social work classes (and also in my undergraduate clinical psychology/counseling psychology classes) there is the Parable of The Late Client.* It looks something like this:

There’s a therapist whose client is always late. Not five minutes late, but fifteen or twenty minutes late to the majority of sessions. The therapist finds this disrespectful and resistant, and in the grand tradition of Freud, decides to address with the client what this means about how the client views the therapist-client relationship. What is the client’s relationship to authority? What things do they believe about the therapeutic process? Does the client need to push away everyone who tries to help her? What does that mean? So the next time the client walks in late, the therapist brings it up.

And….

…the bus is late. The client cannot afford to travel except by public transportation, and the bus is often late. She could catch the much earlier bus, but that would mean leaving work early each day she had therapy, and she can’t afford that either.

The first point of the parable is to pay attention to environmental factors** and to be extraordinarily careful in attributing fault to the client. Client appears to be ‘resistant’ to medication? Can they afford them? Client is late—do they have control over their ability to arrive?

The second point is about—at least, in the tellings I’ve heard—making sure to look around at what’s leading to the client’s concern…and what risks and strengths could shape the future of the client’s life. So, I spend a lot of time looking at case studies And it seems like there are two kinds of risk factors: the Intrinsically Risky and the Societally Risky.

Take lead.

Lead exposure is bad. It’s near impossible to bend and twist ‘has lead exposure’ into anything but a risk factor for future health. Exposure to toxic metals is not good for you, and will probably measurably impact your life. Also bad: domestic violence, iodine shortages, not being able to afford food, really, poverty of all kinds, and a bunch of other things. These are not putting you at risk purely because society thinks they’re bad and then treats you poorly, they are things that will harm you no matter how people feel you experiencing them.

Okay, but take being a lesbian.***

In theory, being a cis lesbian should be….probably a protective factor. Lesbians are less likely to contract HIV/AIDS, significantly less likely to have an unintentional pregnancy, less likely to be killed by a partner.

But right now, lesbians are more likely to be suicidal, more likely to self harm, and experience a lack of social support than their heterosexual counterparts, and all of that makes the reaction to ‘in case study, client is a lesbian’ be ‘risk factor’

Just taking a wild, speculative, swing at things, I’m going to guess this is not a feature of ‘wanting to sleep with women’ and possibly more a feature of discrimination, lack of acceptance, and ambiguous attribution issues. (In fact, this study, linked to previously, suggests that lesbian and bisexual women had slightly lower levels of depressive symptomatology than their heterosexual counterparts.)

And I’m sure there are other qualities that are like that: risks only because we make them out to be. I’d love to arrive a place where orientation isn’t one of those—it feels likely that that will happen within my lifetime. And then we’ll move on to the next Societally Risky, but not Intrinsically Risky feature.


*I don’t know if it’s been named as such, but it’s appeared in a variety of textbooks and classes across more than one university.
**the social work version of this told it as “psychotherapists don’t pay attention to environmental factors, but we do.
*** For the purposes of this discussion, we’re talking cis-lesbians. I know this is frustrating, but the research only looks at cis lesbians, and paragraphs got unwieldy when I did anything else.

Name That Therapy

Or, Therapy Names as Currency

When my client says “Therapy sucks—I tried it and it didn’t work!” there are a number of things this could mean.

“The therapist I had was of a personality that did not mix with my personality well. I felt invaded and condescended to and it was deeply unpleasant.”

“The therapist tried a specific therapy: psychodynamic or DBT or narrative therapy, and it was [not my cup of tea/definitely making it worse/seriously not feasible for my life or personality]”

“Therapy as a modality is not very compatible with me. We should pursue alternate things like medication or structuring parts of my environment to decrease symptoms or finding me a support group.”

I am uncomfortable with you, New Therapist, and expressing it via saying that therapy sucks.

The thing is, I have none of that information, just that the client is not pleased about interacting we me and has low expectations. Though my next question is almost always going to be “can you tell me more about why it sucked for you?” Even presuming they answer and follow that line of questions (and this is not guaranteed), I won’t have a ton of information.

So this is a plea/suggestion/blog post request for therapists to err on the side of telling their clients what the heck they’re doing.* And a second suggestion for clients to ask their therapists what the plan is.

Consider this situation: you, client-named-Jeff, are going to therapy for the first time. You don’t have any prior interaction with psychotherapy, nor do you read blogs like this. Your therapist focuses on cognitive distortions and sends you home with homework, and you just hate it. It feels like being a kid, and you really wanted to figure out why you’re feeling so anxious all the time (you’ve wondered if it comes from having to move around so much when you were growing up).  You never end up with rapport with the therapist, and given that trusting and liking your therapist is an important component of therapeutic success…you decide that the cost of seeing a counselor is ridiculous, and leave.

Two years later, your anxiety is severely impairing your ability to function at work. The company you work for is small, and they offer to pay for therapy instead of asking you to resign, hoping that it will allow them to keep an employee who has a history of loyalty and service. So you end up in my office. “Therapy sucks,” you say. We spend a good deal of time trying to figure out what things you hate and what things I can do that don’t make you feel patronized. Eventually we build some kind of trust, but your opinion remains that most therapists are incompetent. Lots of time is wasted in hit-and-miss appointments.

Or, consider this scenario: you, client-named-Jeff, are going to therapy for the first time. Again, you don’t have prior info about what therapy is like. Your therapist tells you do that they do Cognitive Behavior Therapy. They focus on cognitive distortions and sends you home with homework, and you just hate it. As in the previous story, it feels silly and childish and you’re more interested in discussing how you ended up where you are and building from there.  The therapist hears your complaints, but for some reason doesn’t deviate much from the CBT framework.

Now two years later, I see you. In the course of trying to figure out why you think therapy is hell served in fifty minute portions, you mention that your previous therapist did CBT. Now, I have some pretty damn useful information. I can ask you what things you didn’t like about it. If you’re able to give me concrete answers, I can avoid those things.

If I end up believing that some part of CBT really would make an impact, even if it annoys you, I can convey that! “I know you didn’t like getting homework because it felt childish, but I think I could help you much more if I had a sense of what triggers your anxiety at home, and I wouldn’t be surprised if you learned something about yourself too. Would you be willing to do a trial period of documenting your panic day to day?”**

Even better, you’re getting information that lets you self-advocate in future therapy settings. If your first therapist tells you they were CBT-focused, and I tell you that I’m mainly doing narrative therapy, you get to convey what worked and what didn’t to any future mental health professionals. If you end up needing some immediate help, or can’t afford an appointment, you’ve got a starting point for googling. You’ll know that Feeling Good is less likely to work for you than Retelling Our Stories, because you can read the flyleaf and compare it to your experiences.

But perhaps most importantly, giving clients information about a treatment plan or orientation can prevent them from generalizing one therapeutic orientation to the profession at large. A client knows that you’re doing one thing under the umbrella of therapy. It’s much easier to say to a therapist “this specific thing seems to fail” than “I think the thing that is your profession (therapy) doesn’t work for me”


*I recognize that sometimes telling certain clients (for instance) that you’re trying solution-focused brief therapy is going to derail the crisis work you’re doing, or going to paint you as an ivory tower academic who doesn’t understand.

**For the curious, this is the worksheet I was thinking of.

Room in Recovery

Related: A Week

[Content Note: Discussion of eating disorders, some of which might make recovery harder. I don’t actually endorse the feelings here as ones I want to have.] 

I remember when I first started following other people writing about eating disorders how shocked I was that they prided themselves on not being in recovery. They seemed to not want to hit ‘recovered’, and I could not understand. I thought of recovered as necessarily good, a picture in my head of resetting the clock and going back to ‘normal’. And oh god, did I want ‘normal’.

I had friends who had recovered from OCD, depression, anxiety. Their lives were unquestionably better for it. Even a little bit of recovering, a little bit less depression, anxiety that wasn’t quite so debilitating, was wonderful. I wanted that. I expected that.

But I don’t think that’s what most of us get, recovering from an eating disorder. Of course, there’s little things: having more energy, fewer dark circles under my eyes. Less distress at the prospect of picking out clothes in the morning. But on the whole? Eating enough food means beating back the brain demons that think it makes me repulsive, horrible. It means spending willpower to remember that yes, you will eat lunch today. It means deciding to be more stressed and less happy because I’ve forced some bit of myself to remember that depriving isn’t good for me.

This isn’t part of the recovery narrative you hear, right? The part where you decide to pick “less happy, more healthy” over and over?

I want there to be space for hating recovery. For clawing at it with your fingernails, for wishing you hadn’t, for being less happy as a result. For putting on a brave smile to encourage others because it’s wrong (even as it’s also right) to say aloud that sometimes the only way you tolerate recovery is by viewing it as a challenge that will make others happy. And you love challenges.

I want there to be space to discuss the hard questions. The ones that sound like “If I eat, I’ll be too anxious about it to study for this exam. Which matters more?” and “Do I tell him that the things he likes about my body are the same things that make me cry?”

Recovery can look like this too.

In Defense of Inkblots

Rorschach, Blot 10

[This post is partially written to be contrarian. Please do not abandon your nice therapist in favor of getting inkblotted.]

I was recently linked to this part of the Less Wrong Sequences, Schools Proliferating Without Evidence. It contains a bit of the attitude towards psychology I run up against in this community, and I want to talk about it.

“Remember Rorschach ink-blot tests? It’s such an appealing argument: the patient looks at the ink-blot and says what he sees, the psychotherapist interprets their psychological state based on this. There’ve been hundreds of experiments looking for some evidence that it actually works. Since you’re reading this, you can guess the answer is simply “No.” Yet the Rorschach is still in use. It’s just such a good story that psychotherapists just can’t bring themselves to believe the vast mounds of experimental evidence saying it doesn’t work—

—which tells you what sort of field we’re dealing with here.”

But but but…

If I could speak in defense of inkblots (words I never thought I’d say), well, they’re not helpful as predictive tests. We can all fairly well conclude that this is not how to determine risk for depression or somesuch. It’s probably a non-terrible way to determine if someone has a thought disorder like schizophrenia. Give them a thing to construct a story around, and see how they connect thoughts and ideas.

A card from the TAT
A card from the TAT

But projective tests like Rorschach inkblots and the Thematic Apperception Test (“here’s an ambiguous picture, what are the people in it thinking?”) CAN be helpful for getting clients who are uncomfortable in therapy to open up. Client John Doe isn’t sure about this whole “talking about his feelings” stuff, but get him started telling a story about an inkblot and he might relax into conversation more easily than if you ask him to talk about his latest self-harm experience or troubled childhood.

Handing a stranger your feelings, or telling them about trauma or mental experiences that you know are abnormal is hard. People can go months and years in therapy before mentioning that one time they were assaulted, or how yeah, they’re fine now but they were abused as a child. It takes a lot of work to force yourself to share something in a vulnerable place…and it’s all too easy to feel like you’ve let it go too long without sharing…so why not just wait until the next session? Or the session after that? How do you squeeze that information in between explaining how your previous week was and this week’s focus?

Inkblots are a performative way to introduce those discussions. You say how Inkblot #5 looks a bit like a cow chasing a butterfly and the therapist says oh, they remember you saying you grew up on a farm, how was that. And lo, five minutes later you’re talking about your childhood.

Look, inkblots are not going to magically inform the therapist about your chances of being sociopathic, or convey a ton about your personality. It’s a bit ridiculous that some therapists use them for this. On this, the Sequences and I agree. But, this usage is rare. The cards are expensive, at $125 for the ten plates, and all of the blots are now available online for anyone to read about, removing much of the mystery. But for as long as clients keep requesting them, and they keep being an avenue into comfortable discussion, I think inkblots will be hanging around.