Toward an Integrative Psychotherapy

Over the years of being with clients in my office, I have become aware that therapy can help on 3 different levels. Usually, the level of help provided is not necessarily dictated by the patient but more by the level of training and expertise of the helping professional. I have broken these levels down as follows: First, is what I will call the Straight Line approach; second, the Underbelly approach; and third, the Overview approach. Any of these can be helpful to the patient, but most helpful would be to integrate all 3 levels of approach. Let’s look at this more closely.

The Straight Line approach is the most frequently used approach. It is the frontline approach for resolution of presenting symptomatology and is mandated by medical insurance companies. It is also what is most expected by our patients when they present in our offices. What is the chief complaint? What are the manifesting symptoms? How long have they been dealing with their problems? How are they managing their symptoms? Are they treating/masking their symptoms with substances? What are the treatment goals? How quickly can these symptoms be abated, treatment goals be achieved, and the patient be sent on their way? We all know how to work within these restrictive limits and we do it. Obviously, it is important to address the presenting symptoms and the treatment goals. We do this through various cognitive and behavioral methods depending on the needs of the patient and our preferred treatment frame.  However, working only from within that frame, we may miss opportunities to help the patient in deeper, more meaningful ways. It is like putting a band aide on a wound, which requires sutures.  A patient may leave feeling better since the wound is clean and has a bandage covering it however, it is likely to rupture again, given similar circumstances, as the underlying issues have not been identified or repaired. In other words, each time we sit with a patient, we have an opportunity to connect and understand the patient in a way in which no one has ever connected or understood that individual before. If we allow ourselves to be dictated solely by the guidelines of insurance mandates, and DSM guidelines, we may miss this opportunity.  However, if we are open to the challenges of deeply understanding our patients, a new and exciting relationship can begin with each patient.

The second approach, or what I will call the Underbelly Approach, challenges the therapist to understand each patient more deeply, in other words what propels the patient, how he perceives the world within which he lives, and how he continues to make the same mistakes repeatedly throughout his life to the point at which he seeks psychotherapy. So while paying attention to the patient’s chief complaints, understanding his symptoms and goals, the therapist is also listening for the roots of mis-learning or what Control Mastery Theory refers to as pathogenic beliefs. These roots usually develop early in life and are reinforced throughout childhood and repeated again and again in adult experiences.  Until these issues emerge, are understood and consciously worked through, the patient is likely to continue to reenact the same dysfunctional relationships and make the same mistakes over and over.  In part, this is what Freud described as the Repetition Compulsion, i.e. humans repeat what was done to them until it is brought to consciousness and worked through.  In other words, infants learn brain maps of their world, including how they perceive themselves and others, based on interactions learned within their family relationships. This brain-map dictates behavior until an individual recognizes it may not produce beneficial results.  

How does the therapist determine what the Pathogenic beliefs are? As we listen to the patient’s story, we inquire about his past. If we only listen to the present, we are only picking up on the current strand of his life. Each life is made up of multiple strands of experience. Most patients who walk into our office do not have a cohesive, well-woven fabric. Their lives are strands that are frayed and even knotted. We inquire about the past because we are wondering how they got to this point in which they are so distressed, anxious, or depressed that they seek help. We are looking for the telltale signs of being harshly criticized, ignored or even abused. If for example, the patient is in an abusive relationship now, the therapist might wonder if he had been criticized, ignored, overly controlled, or abused as a child. On a more unconscious level, he may feel unworthy of feeling valued, respected and appreciated. In this situation, the therapist might even speculate to the patient that perhaps he has never felt worthy of a better relationship.  If the intervention is on target, the patient may recall memories or relate the unfolding story of his past. On the other hand, if he gives you a blank stare and says he doesn’t know what you mean, this may be an indication that the interpretation is off base, or simply that the patient is not ready to explore this. The patient is always giving the therapist information. It is our job to use it as the patient can use it. The idea is to help the patient learn the patterns that have kept him drawing in and repeating unhappiness, to unlearn or stop doing the same patterns and to relearn new, healthier, and more functional ways of relating.  In the process, the patient is leaning new skill but perhaps most importantly, he is learning to become the overseer of his behaviors and relationships.

 The final approach is what I call the Overview Approach.  From the start of each therapy, and as the therapy progresses, I wonder what this patient really wants out of his life while here on this planet. Sometimes, if you ask a patient early on, what he wants to accomplish in this lifetime, he may look at you as if you are crazy. No one may have ever seriously ever asked most of our clients this question. Many have never seriously pondered this question. Often, patients don’t feel much is possible. Some have lost the passion to dream or to actualize their visions. So in this Overview Approach, the therapist is beginning to think with the patient about his life on a much grander view.  Quantum Physics tells us that for any given situation, there are an infinite number of outcomes possible. All that has to happen is an idea formulates, germinates into thoughts, develops into more thoughts, and becomes a plan. Eventually, that kernel of an idea actualizes into reality. Most of us do not know this, or believe it is possible. However, this can be extraordinarily liberating for our patients and even for us.  

These approaches do not have to happen one step at a time, although they might, depending on the individual patient. If you ask a patient on his first visit, what his lifetime plan is, he may likely think you totally missed the boat on his current suffering.  Like the fabric of each person’s life, the treatment also has a fabric. Initially, the therapist may simply be trying to help pick up the threads of a broken past in order to weave an understanding of how thoughts and behaviors create past and present and by changing thoughts and behaviors the patient can create a limitless future. The therapist always keeps in mind pathogenic beliefs, the presence of symptoms, disruptive relationships, etc. while the patient progresses. Every treatment is unique just as every individual is unique. This model of treatment requires much more than a prescriptive understanding of the DSM.  It requires the therapist to think about patients individually, and within the frame of his life, his history, his relationships and his behaviors.   The curative factor in psychotherapy is always in the relationship between the patient and the therapist. The therapist understands the patient in ways he has never understood himself, which expands not only self-knowledge but also knowledge of others as well. When the therapist is open to this level of work, everyday is a learning experience.

This article was originally published in the Spring, 2017 edition of The Clinical Page of the Georgia Society for Clinical Social Work under the title “How We Help”. All rights reserved.  Alva S. McGovern, LCSW

Stress Management:
From Distress to Eustress

Pervasive, persistent, and intense stress can be overwhelming and debilitating.  It can lead to distress, anxiety, frustration, withdrawal, depression, and even the development of diseases such as ulcers, stroke and heart attack.   On the other hand, under some conditions, stress can be a positive experience facilitating challenge and motivation. In this manner, stress is a positively perceived experience referred to as eustress. In other words, your perceptions of yourself and the problems you encounter, are determining factors in your ability to cope with stress. With a solid emotional and psychological foundation, much stress can be transformed from distress to eustress. While distress is characterized by the development of psychological and physical symptoms, eustress is characterized by hope and active engagement. This article will not address the time-honored practical tools of stress management like setting priorities, time management and saying no, to name a few, but rather it will address on a deeper level tools to build a stronger mental and emotional foundation from within. Through a stronger foundation, you will not only manage stress better but will function better throughout all areas of your life. Let’s look closer at some of the core underlying tools you can develop to help you better handle stress, become more stable, pursue your life’s purpose, and enjoy yourself.  

Grounding: Being Fully Present

An essential beginning is being fully present and grounded in the moment. This means that your brain is not reliving a past moment or creating a future moment, but rather being fully engaged and present in the current moment.  In part, this requires having the ability to observe your thoughts, to detach from the clutter in your brain, and to develop a healthy skepticism of your brain’s activity. The Buddhists call the constant brain chatter ‘monkey brain’. Your brain jumps from one thought to another sometimes without seeming connection.  But wait there is more. Not only does your brain jump around all day long, it also can hijacks you by keeping you stuck in old ideas and patterns of behaviors, prohibiting new thoughts, new ideas, new actions, new behaviors, and ultimately from growth and expansion. Believing every thought you have is risky business. It can prevent you from being open to greater truths. 

A highly effective tool to learning the skill of being present is mindfulness meditation. In a recent article published in the Wall Street Journal, Robert Wright sighted Mindfulness Meditation was a vital tool for stress management. Meditation can help you consider the thoughts in your brain less seriously. Meditation can help you be more grounded in the moment by allowing moments in which you push thoughts away. I heard someone recently say they enjoyed mediation because it allowed them a few minutes away from their self. It certainly can provide a pause in the chatter and the recognition that thoughts are transient, they come and they go.

Self Observation

Einstein once said that no problem can be solved from the level of the problem, but rather one must rise above the problem to find a solution.  The same is true with your life. To solve your problems and overcome the stresses of life, you must rise above the habitual thoughts and behaviors that got you into the mess you currently find yourself. In other words, you become a self-observer. Through self-observation you learn not to react based on your usual brain chatter or on kneejerk emotional responses.  Instead, self-observation helps you develop a curiosity about your thoughts, your attitudes, your feelings, and your kneejerk reactions.  You might begin to question yourself. Why do you have these reactions? Where did your attitudes come from?  Why do you react so strongly in certain situations? Then you might notice that your thoughts are transient, your feelings also come and go, and that you don’t need to take things so seriously.  

Inside you, there is always a calm, inner presence. This calm inner presence always has the answers and always knows the truth. Trusting yourself to find your own answers can require patience, discipline and confidence. How many times have you done something that you intuitively knew was not right and then of course the outcome was poor? Perhaps you can start paying attention to your gut instinct more often. After all, your gut doesn’t have thoughts to mess you up. Take a step back and wait until you have more clarity before making an important decision. Rising above the problem, stepping back, even sleeping on it are tools that can help you get a better perspective and begin the journey to greater emotional stability. 

Stability

 An essential tool for maintaining calm through stress and turmoil is the ability to remain emotionally stable. For many of us, this is a life long goal and a worthy one. After all, how wonderful it would be to hold an even keel while navigating life’s most turbulent storms rather than being tossed around like a ragdoll. Earlier, we discussed the importance of becoming an observer of your brain chatter and your emotional reactions.  Interestingly, your thoughts and your body work in tandem to keep you stuck in old habits and behaviors. For example, if you have the thought “I am depressed”, then automatically millions of depressed bio-chemicals are released by your brain, and rush to every cell in your body. Then you say to yourself “Yes! I really am depressed!” * Your body has bio-chemicals which respond directly to your thoughts. Remember we discussed the importance of being skeptical of your thoughts? Perhaps even more importantly, is the power your thoughts hold over your body. For example, if I know that asparagus has powerful antioxidant and anti-inflammatory properties as well as being a natural diuretic but I don’t like the taste, then I have a decision to make: will I allow my taste buds and the thoughts I have about how bad it tastes, to hold my health hostage or will I decide to learn to develop a taste for a vegetable which is nutritious and positive for my health? 

Not only do your brain and body work in tandem to keep you stuck, but your brain is comprised of millions of neural pathways for every thought, every action, every behavior you exhibit. The more frequent you have the same thought or do the same action, the more ingrained and hardwired your brain becomes for those thoughts and actions. If on the other hand you have a new thought, or act in a new way, you are building a new neural pathway. To some extent, this is why new thoughts and behaviors feel a little uneasy at first; there are no neural pathways in your brain for them. It also speaks to why it is difficult to change. If you have been thinking and behaving the same way all of your life, it is hard to start down an unfamiliar path of new thoughts, ideas or behaviors. Literally, your brain has no neural pathway for new thoughts and new behaviors. But then again, the path you are on is resulting in a lot of stress! 

Through the miracle of neuroplasticity, your brain has the capacity to continue building new neural pathways throughout the duration of your life. This means you can learn to observe your thoughts and behaviors, develop new thoughts and behaviors, and grow and expand into a healthier, happier individual throughout your life! Just because you have acted in depressed, and unhappy ways all of your life, you don’t have to continue acting and thinking the same old way. You can actually change!

Opening Up and Letting Go

Each of us has developed a storyline over our lifetime.  This storyline consists of thoughts, attitudes, meanings, and expectations of yourself and others. It defines how you think, how you act, and how you expect others to think and act.  You learned this storyline from your first days on planet Earth. You developed the storyline and the subsequent plots and subplots based on observations in your family of origin; how others related to you and to each other. Unfortunately, most of us did not pick perfect parents (since we all picked human parents!) nor did we pick perfect families in which to grow up. However, some might tell you that you picked those parents and families in order to learn certain lessons in this life. The good news is that you don’t have to act the way people in your family acted and you don’t have to have the same beliefs, thoughts, perspectives, or attitudes of your family or parents. This means you can begin to define yourself in new and more meaningful ways. Just because your parent was a mean, depressed or chronically unhappy person, you don’t have to be the same. 

Opening up means that you have become self-observing and self-reflective.  You have learned to consistently examine your thoughts, attitudes, and behaviors with a more skeptical eye. Your emotions are a guide to deeper self-understanding rather than holding you hostage to emotional reactions. You are more open to new thoughts, new ideas, and new behaviors. You are open to creating a new you!

You can be whomever you desire. By changing your thoughts and attitudes you create a new you. If you are not happy, think about the people you know who are happy. Begin to emulate the attitudes and behaviors of happy people. The Buddhists say that your life is in your mind’s eye. This means that how you view the world defines who you are and what you become. Why not change now. It is never to late.

Loving Yourself: Your Greatest Asset

You are your most beautiful asset. You are unique on this planet. Only you have the unique assets, talents, experiences, and abilities that make up who you are today. You came here with a unique plan and purpose. Only you can recognize those talents, and abilities, and only you can develop them, and actualize yourself to your highest good. This means, honor yourself, respect yourself, believe in yourself, and enjoy yourself. Each morning wake up to a new day to follow your unique path. Examine old attitudes. Discard what is not working. Trust your intuition. Don’t be afraid to fail. You can always change what doesn’t work. Try new things and have new experiences. Laugh. I once heard the Dalai Lama asked what was the purpose of life. He chuckled with his contagious smiling face and replied, “Well of course it is to be happy!”

    Quantum Physics tells us there are an infinite number of possibilities to any situation. This applies to you as well. There are an infinite number of possibilities in front of you. You only have to open yourself up to a new you. Be the person you have always wanted to be. Happiness is not found in the enjoyment of the splendor of our belongings, but rather in the enjoyment of the splendor of our inner wisdom. 

*Pert, Candace, The Molecules of Emotion