Coping as a habit of mind

I hear more and more clinicians and administrators talk about the teaching of “coping skills” as a major goal of treatment. I don’t necessarily disagree with this, but I disagree with what is often meant by “coping skills.” I see people teaching clients to take a time out, think about something else, listen to music, make a phone call. And these things can be sort of useful in certain moments, but I don’t think they really help all that much in the grand scheme of things. Let me explain what I mean:

In treatment, we talk about being provided with “care,” but that’s not actually what we do as treatment providers. What we provide, professionally, as our job, is a service. We perform a prescribed set of actions in exchange for compensation. A service.

Care, on the other hand, as John McKnight & Peter Block describe in their book The Abundant Community, is “the freely given commitment from the heart of one to another.” I care about some of the clients I work with, but not all. How do I choose which ones to care about? I choose to care about the clients who care about themselves — not perfectly, and not all the time, but the ones who present enough curiosity, tenacity, grit, and ambition to at least engage in therapy and see whether they will be able to improve their lives. The ones who won’t engage at all, I don’t care for.

That’s my coping skill. I use that mental habit to cope with the plain fact that I cannot help people who will not allow me to do so. So I disengage from them emotionally. I still do my job — I still provide excellent services. But I don’t let my heart get tangled up in it. I won’t suffer if they don’t succeed.

And then, sometimes, a client surprises me, and begins to change, and I end up caring about them when I didn’t expect to.

Now, this necessitates another coping skill. Because if I went around telling people that I didn’t care about a certain percentage of my clients, people would think of me as being a bad person and a bad clinician. So I cope with that social demand by intentionally empathizing with the people who do care about the clients I don’t care about — I put myself in their shoes and I mention one or two reasons why someone might care about such a person. For example, I might talk about how they really have a lot of potential, or how scared they must be of failure to remain so disengaged. This gives people the feeling that I care, and it helps me provide better and more empathic services, and sometimes it even helps me to care about that person more.

That’s a coping skill.

Not listening to music, not talking on the telephone, not throwing ice. My coping skills are mental habits that enable me to succeed in what I’m doing — not external distractions that simply allow me to ignore my failures.

Applying for internships. Here’s the personal essay I want to submit.

I’m 31 years old now, and I’ve been in school for the last 8 years. For the last six of those, I’ve been focused on becoming a psychologist. That entails a lot of “professionalization,” which is a euphemism for becoming the sort of person that psychologists agree with and would like to be around. At every step through the extensive course of training, would-be psychologists are coerced into expressing particular views about themselves and society that are congruent with the prevailing politics of the field.

Well, I started out in this field because I thought it would allow me to cultivate and express my true self. I thought that was the ideal outcome for patients too – for them become the best and freest possible versions of themselves and learn to create meaning all around them. In my mind then, and still today, the profession of clinical psychology should be bursting with life. We should all be so absorbed into the applications of the incredible knowledge available today that everyone who comes near a psychologist should feel the sting of opportunity. I got into this field because I want to live artfully, and I want to be able to inspire the people around me to do the same. I want to be a psychologist because I want to live in a world that is beautiful and robust, filled with people who are strong, self-possessed, and empathic.

Last year I applied for internships. I did what I was supposed to do: I wrote essays that revealed more of my personal background than I was comfortable with. I submitted to months of excessive, probing interviews. I answered questions diplomatically. I did this because difficult experiences during my training had made me feel that my real self was unacceptable to the field of psychology.

In retrospect, it was foolish to try and present myself so neutrally. I turned my own strengths into weaknesses. My strongest connections in this field have all come to me by way of those same personal traits which alienated me from other potential mentors. I’ve learned my lesson.

The truth about me is that honesty and intellectual integrity are some of my most closely held values, and I’m no longer willing to compromise them for a career field that should love them as much as I do. I’m in this field because I believe that thoughts are worth something. My experiences and beliefs are worth more than this essay. I’m not ashamed of my past; I’m proud enough to save it for people I trust. All I can promise is to treat the experiences and beliefs of my patients with the same respect.

SCEH 2009 in Reno, Nevada

I recently had the great pleasure of attending the 2009 Society for Clinical and Experimental Hypnosis conference in Reno, Nevada. My primary purpose in attending was to serve on the faculty for the Introductory Workshop in Clinical Hypnosis. I had spent the previous weeks helping workshop co-chair Dr. Edward Frischholz in preparing an updated curriculum for the workshop. Dr. Frischholz’ vision for the new training model is to enhance the workshop’s focus on empirically validated methods of assessment, treatment, and training.

Dabney Ewin presents on the treatment of warts, hives, herpes, and asthma

As a faculty member I was in the esteemed company of Dolores Bjorkman, Dabney Ewin, Ed Frischholz, Hedy Howard, Steve Kahn, Rick Kluft, Dave Patterson, Steve Pauker, and Eric Willmarth. My role as a faculty member was to provide supervision during each of the five supervised small group practice sessions, and to assist in the scheduled demonstrations of hypnotic induction and hypnotic phenomena.

As the least experienced member of the faculty, I did not present any didactic material. However, I received 22 CEU credit for my attendance at these workshop sessions and am now competent in the provision of introductory clinical hypnosis training. There are plans for the Chicago Society of Clinical Hypnosis to offer a basic workshop this winter, and I will be on faculty for this event as well.

Ed Frischholz, Steve Kahn, Tom Nagy, & Rick Kluft

Outside of workshop hours, I also had an opportunity to attend a few presentations and one scientific paper session. I was excited to see Dave Wark present on alert, eyes-open hypnosis. I am very interested in the potential use of alert hypnosis, particularly in performance-enhancement and coaching scenarios.

I also has the pleasure of seeing Ron Pekala present his ideas on the conceptualization and measurement of the phenomenology of consciousness. I was trained in provision of the Phenomenology of Consciousness Inventory Hypnotic Assessment Procedure (PCI-HAP) during my own introductory hypnosis training under Dr. Ian Wickramesekera II.

Completed My Doctoral Psychotherapy Practicum

As of Wednesday evening my psychotherapy practicum is complete!

I spent the year externing on the Valeo Intensive Outpatient Unit at Chicago Lakeshore Hospital. Lakeshore is a freestanding psychiatric hospital, and the IOP unit is located a couple blocks away in a separate building. Many of the patients I saw there were transitioning from inpatient care, some were going back and forth between inpatient and outpatient, and some were admitted solely for intensive outpatient treatment.

Valeo is a specialty program that serves gay, lesbian, bisexual, and transgender (GLBT) individuals, and patients come from a wide range of socio-economic, cultural, and personal backgrounds. Nearly all patients were dually diagnosed mentally ill substance abusers (MISA), with a few patients being treated solely for mental illness and others presenting with primary addictions.

The bulk of my experience there was in providing group psychotherapy and group substance abuse counseling, and one of the major challenges of the practicum was in balancing groups between the needs of highly diverse patients presenting with a wide variety of complaints and levels of functioning. I was also able to work with a number of patients individually in addition to my time with them in group. This allowed for the rapid expression of some fairly powerful dynamics, and offered unique treatment opportunities.

Over the course of the year I was able to do a great deal of individual and group psychotherapy work with patients suffering from severe anxiety and personality disorders. I used this opportunity to develop my skill in the use of techniques such as relaxation, mindfulness training, and visualization. In my final review, my supervisor reported that my work in this area had made a substantial contribution to the program.

I also gained experience in administrative aspects of the intensive outpatient program, particularly in planning and executive treatment groups. As a final project, I designed and administered a series of therapy groups focusing on attachment styles. I provided psychoeducation on the early formation and adult manifestation of various attachment styles, and relating these ideas to recovery concepts such as codependency. Next I provided cognitive-behavioral group psychotherapy aimed at helping patients to recognize the ways that their own styles of attachment impacted their relationships and to begin to approach those relationships in ways that promote increased feelings of security. Finally, I engaged the group in a visualization exercise designed to access and amplify existing experiences of security and adequacy.

I will be receiving my Master’s degree in Counseling after the summer term, and plan on sitting for the Licensed Professional Counselor license. I have only a few classes left to take, so over the next year I will be finishing those up, writing my doctoral dissertation, and hopefully working as a counselor. If you know of any job opportunities in Chicago, please let me know!

Chicago GLBT Behavioral Health Training Consortium

My doctoral psychotherapy practicum on the Valeo Intensive Outpatient Unit at Chicago Lakeshore Hospital focused on the treatment of mentally ill substance abusers within the gay, lesbian, bisexual, and transgender (GLBT) community. Valeo is one of three GLBT-focused treatment programs in the Chicago area, along with Howard Brown and The Center on Halsted.

These three sites collaborate to provide their externs with weekly didactic sessions on issues specific to individuals within the GLBT community. So, over the past year I gained a very broad base of knowledge about the clinical issues and approaches recognized within this field, while simultaneously working with gay, lesbian, bisexual, and transgendered clients. This provided an integrative experience that definitely improved my understanding of the interactions between social and psychological factors for minority groups.

Didactic sessions I attended included:

  • Boundaries & Self Disclosure
  • Internalized Devaluation & the Coming Out Process
  • Substance Abuse Assessment Issues
  • Assessment Issues with Transgender Clients
  • Domestic Violence Assessment Issues
  • GLBT Youth
  • Midlife Issues for GLBT Clients
  • Issues in Older Adult GLBT Populations
  • GLBT Sexual Assault: Barriers to Care, Recovery, & Survivorship
  • Work with the BDSM/Kink/Leather Communities
  • GLBT Issues in Higher Levels of Care
  • Spirituality Issues in the GLBT Community
  • Termination Issues
  • HIV Grief & Loss Issues
  • Legal Issues in HIV/AIDS Clinical Work
  • Ethnic Minority GLBT Clients: African American
  • Ethnic Minority GLBT Clients: Hispanic/Latino
  • The Gay/Straight Divide in Therapy
  • Children of Same-Sex Parenting
  • Working with Female Couples
  • Working with Male Couples

While many very specific issues were covered during the course of these training sessions, I found that ultimately it is the similarities between people that are the most useful as a psychotherapist. I do think that it can be valuable to learn about a specific minority population in-depth in order to be able to be more conversant in their culture. However, for me the main takeaway message has been that ultimately the diversity one finds within any group tends to be equal to the diversity between groups.

If a therapist enters the therapy ready to try to understand the individual clients’ specific worldview, I think they will tend to be more successful than even a better-informed therapist who has it in mind that a client should fit into a particular type of category. Having worked with clients from a tremendous variety of backgrounds over this past year, I have found that openness and candor are two of the most important prerequisites of successful therapy, regardless of the client’s race, ethnicity, gender, sexual orientation, socio-economic status, or any other demographic factor.

Finishing Psychodiagnostic Practicum

At this point in my clinical training, I have spent nearly a year on what is called the psychodiagnostic practicum. What that means is that my main job for the last year, as a psychodiagnostic extern at the Diamond Headache Clinic inpatient unit, has been to figure out what psychological factors are playing a role in our patients’ headache pain.

This is a tricky thing to do, for a number of reasons:

  • It’s tricky to figure out what’s going on with anybody, psychologically. People are pretty complicated; when things go wrong, they rarely go wrong for just one reason. Typically any psychological problem will have some genetic components, some environmental components, some relational components, and some intrapsychic components. You don’t really get the luxury of pointing to one thing in someone’s past and saying you’ve found the answer.
  • These people tend to be especially complicated. There’s some research to suggest that chronic pain patients are more likely to meet criteria for personality disorders than other types of patients. In my experiences, I’ve found that even those who don’t meet criteria for those diagnoses usually have pretty deep-seated ways of interacting with the world that unintentionally serve to maintain their pain status.
  • Headache patients, in particular, are usually pretty resistant to psychological asssessment. This is mostly because they have gotten used to being told that the very real pain that they experience on a daily basis is “all in their head.” Usually they hear this from physicians who are simply frustrated that none of their tests come back positive and nothing they do seems to change anything. The same goes for any other type of chronic pain patient, and probably many people with IBS as well.

So what I do currently is I go into each patient’s hospital room and spend about 30-60 minutes finding out how they feel, what their life is like, what it was like growing up, what kinds of relationships they have, and what kinds of stress they experience. From this, I try to draw connections between all of the different factors, in order to figure out what kinds of psychological treatments might be effective in reducing their headache pain. If a case is particularly complicated, and if we have the time, I will administer the patient an intensive 8-hour battery of psychological tests which help me to pin-point exactly what kinds of cognitive and personality issues they face.

It’s actually quite beautiful: my entire job is to find out how people are put together and what makes them tick. What I’m especially looking for, when I conduct a psychological interview, are the parts that the patients themselves cannot possibly allow themselves to know. And when I say this, I want you to know that I am not only talking about chronic pain patients. We all have parts of ourselves and our lives that we cannot know, that we must defend against at all costs.

For now, I’d like to announce a new clinical practicum! After I finish up at Diamond Headache in June, I’ll begin a new one-year psychotherapy externship at Chicago Lakeshore Hospital’s Valeo Program, which is Chicago’s only inpatient and intensive outpatient therapy for GLBT individuals. About 50% of my patients there will be HIV positive, and about 50% of them will suffer from substance abuse disorders in addition to their other psychological troubles, which will run the gamut from anxiety and depression, to eating disorders, to identity disturbances, to personality disorders. I’ll be taking on anywhere from 4 to 8 individual patients per week, and doing 2 or 3 therapy groups each week as well.

The Valeo program is a very competitive training site, and I was selected from more than 60 applicants!