Questioning Ourselves

What did you believe in five years ago that you no longer believe in today?

This is a question Peter Attia, MD, frequently asks his podcast interviewees. 

I believe this question is vital to ask ourselves on a regular basis. 

The scientific method never proves a belief, we can only see it as not yet wrong. As our understanding of the world grows, both individually and within the research communities, it’s valuable to recognize the changes and incorporate them into our world views. 

Some things I believed five years ago that have changed include…

  • Previously I believed: SSRIs are unlikely to have negative effects and may be helpful. 
    • Now I believe: SSRI’s are likely to have negative effects for most people. While they may still be beneficial for some people, it’s important to support clients in treatment methods with minimal risk first. 
  • Previously: CBT is highly effective and can be used in many circumstances. 
    • Now: CBT may have been subjected to an amplification of benefit and overgeneralization in usefulness. It’s still useful in some areas, yet not as many as I used to believe in.
  • Previously: Clients in emotional distress need psychological counseling interventions, and if not improving a referral to a psychiatrist. 
    • Now: Clients in emotional distress may be due to cause that’s not physiological. Wellbeing may be found though a combination of interventions including psychological, nutritional, medical, lifestyle, spiritual, physical, social, or another area.

What are things you believed in five years ago that you now have new beliefs around?

Explicit vs. Veiled Self-Care

When you’re practicing self-care in session, you may wonder if it’s beneficial to be explicit about the practice or discreet, and I would say the answer is – it depends. When I’m experiencing emotional challenges from a client interaction, it’s likely there are other group members who could benefit from regulation practices, so I will guide the group in regulating while allowing my nervous system to reset. There’s been a few times when the stimuli has come from an outside source, such as an earthquake or the example below, where I will explicit speak to what’s happened for me, eg I noticed my stomach tighten as the building shook, and guide clients’ to check in what’s happened for them.

There was one time when I was in session only a month after I had graduated. I was doing my best to be completely present in session and provide significant value to the client. Though for about 10 minutes I had been noticing this light touch on my calf; I assumed it was the draw string of my capris in the breeze. The sensation doesn’t stop and it’s been about ten minutes, I finally look down at my calf and can just glimpse a part of a very large cane spider crawling up my leg and underneath my capris. At this point in my life I still had a very active fear of spiders, and I don’t remember the next few seconds.

What I do remember is dancing around on top of the coach shaking the spider from out of my capri. This is quite an odd position to be in, especially as the therapist, during a session. What I was able to conjure up from standing on the couch, is explicitly walking through some regulation processes and describe what was happening and what to do about it. This went something along these lines:

  • I’m in the flight stage now. I’m going to shake my limbs to support in discharging the adrenaline.
  • Now that I’m slightly calmer, I’m going to step off the couch and will focus on taking deep breaths.
  • Lastly I’m going to stretch and check in with my body.

This experience turned out to be a significant gift to the client. In each case when you’re looking at guiding grounding exercise in groups and wondering about being explicit about your state, consider what’s best for all of the client/s.

Self Care of the Therapist in Session


I’m guessing most of you are familiar with self care for therapists, yet have you thought about self care during sessions and what that could look like. If you’re sitting in a room with a client who is hunched, the neurons that fire in your brain when you hunch over are likely activated, even if you’re sitting up right. This is due to mirror neurons; neuroscientist Vittorio Gallese, MD, PhD, describes “this neural mechanism (as) involuntary and automatic.” When you are feeling a little stressed, nervous, depressed, or emotionally off kilter, it’s likely the client is feeling similar or worse. When this happens in session, I suggest guiding the client/s through regulation exercises. These could be some of the ones listed in Grounding exercises, or something completely different.

It can be helpful to have several exercises that you know will benefit the group that also allow you to step out of the room for a minute so you can take a breather, get a drink of water, or take a shake. An exercise I commonly use for this purpose is a listening exercise. I prompt the group to list the traits of their ideal listener. The group usually comes up with characteristics like accepting, patient, loving, kind, fully present, etc. Before creating the list, I ask the group if they would prefer the list to be what it is, not what it’s not. Usually the group wants this, so if non-judgmental is suggested, you can respond with a yes, and ask the group a way to describe what that would mean to them, so usually accepting or open minded may be used instead. Pair up all participants, and instruct them to select who wants to be the first listener. The other person will then speak for 4 minutes about something they want to explore in their life. The listener only listens and doesn’t speak, yet practices embodying the characteristics of the ideal listener. You can then step out of the room for a couple minutes, say if you need to change your shirt as someone spilled coffee on it as they were coming to group or if you just need a two minute breather to reset. You showed up as the professional, even though you may not have felt like starting group with coffee on your shirt. You role modeled what it’s like to maintain a commitment even when it was challenging for you, and you are still able to care for yourself and change your shirt out during the break you created for yourself.

Especially in the substance abuse treatment center I work with, it’s important for the clinical team to model showing up. Clients could be struggling with much more difficult challenges than the treatment team, such as detoxing and not feeling so great. Clients monitored our behavior closely to see if we were walking our talk.

At the end of the four minutes, guide a discussion for the both the listeners and speakers about what was challenging about the exercise, what beliefs came up, and what was easy about the exercise. Common things that come up are:

  • Difficulty in listening and not offering suggestions
    • Ask how else this applies to their lives, eg do they have the ability to sit with the discomfort of their own experiences or are they constantly trying to fix something so they don’t have to feel discomfort? What is it like to bear witness to the pain of another? What would it be like to be present to their own discomfort?
  • Beliefs around boring the other (underlying of not being good enough) – How else does this apply to their lives? In what ways do they dismiss their concerns and focus on another?
  • “It was easy, no challenge whatsoever on both listening and speaking”
    • Evaluate for dissociation, people pleasing, ability to connect with others, or maybe this was easy for them. The questions for follow up would be tailored to what you believe may be happening.

You’ll begin to see different patterns based on your theoretical lens and develop questions that will support the clients in recognizing patterns, seeing how these patterns affect their lives, and ways to operate differently. There’s frequently the desire to want to be able to offer this type of present listening more often to others and also to themselves. I would frequently pair this exercise with a assignment to do outside of listening to practice this style of listening of others and themselves a couple times a day for the next week.

Speech & Debate – Empathy for the Unknown

Speech and Debate, a play performed by students at Western Oregon University, showed me a glimpse of the emotional experience of a teenage male coming out in high school. In the production, the school’s Gay Straight Alliance only had three members. The students that are gay demonstrated their difficulties in finding self acceptance, the challenges in finding partners, and desire for connection

When I was in high school, I was completely oblivious to the challenges faced by a friend. I wanted to impose on them the values and fears I was raised with. I didn’t stop to think about the vast differences in challenges we faced. I’m guessing back then I offered a whole lot of advise. While I’m much better at seeking to understand first, I still find it beneficial to expose myself to different experiences. I’m thankful for the students for portraying these life experiences.   

Who is a person in your like that you can seek to understand more?

Parts of a Group Therapy Session, Part 2 – The Warm Up

After your clients have mentally arrived through the grounding exercises, it’s time to begin the warm-up. The warm up is a time for clients to start thinking about what’s most important for them to work on, while fostering internal and external connections. It can be a time to awaken both sides of the brain through metaphorical thinking. I was taught by an amazing facilitator at Onsite, that there’s no such thing as resistance, only not enough warm-up. The following are some possible warm-up exercises, with an emphasis on metaphors:

The Keys

Ask the clients, “Think about the most meaningful thing you could unlock for yourself today. What is it that you want to unlock? What key unlocks this for you and why?” Inspired from workshop on Onsite.

Stature or Movement

Guide participants to think about what they want to achieve or work on today, and how that would translate into a feeling in their body, and how this feeling would lead into either their stature or in their movement. Each participant will have a turn expressing what they would like to work on today, and how working on that would be evident in their body through their stature or movement.

Yeses and Nos

Have all group members pair up, while one person only says yes, one person only says no for 30 seconds to a minute, then have participants switch roles. Ask each member what they were saying “Yes” to. Then ask each member what they were saying “No” to. Lastly, ask if anything else came up for them around their reactions to the exercise. Group member with specific explanation of who or what they were saying Yes or No to are warmed up and ready to do work. Inspired from workshop on Onsite.  

The participants answers will guide the experiential work done in session. With practice, as you listen to their responses, you will be be able to pair meaningful exercises with each response. These are just a few of the hundreds of possibilities. You will be able to determine what warm-up best suites the group’s needs. The group could be very low energy, so a movement grounding and warm-up can support them in energizing while connecting with their bodies.

Finding Compassion for a Broken Man, Part 2

What did you take away from the story?

One of the reasons I shared it was to speak to the importance of offering compassion to those you might have difficulty at first offering compassion towards. My experience of working with people is they can share their worst with you first. They will share with you how they yelled at their elderly mother and everything else they have done wrong. They hate themselves and want to make sure you hate them too. It’s what they know, so it’s actually feels safer for you to feel disgust towards them, than to offer them compassion.

They might say they had a perfect childhood, and that can make it more difficult for people to have compassion for them when they had this “great upbringing”. When I hear “perfect childhood” I begin assessing for intense childhood trauma, dissociation, and/or black and white thinking. It’s my belief that no one had a “perfect childhood”, they may have had an amazing childhood, yet also some loss, small challenges, or discomfort. When people are able to speak to both sides, that’s usually speaks to healthier more adaptive world view. When I hear “perfect childhood”, it’s time to assess for trauma.

I commonly see processes as both inwards and outwards. As you work on offering yourself compassion in areas which it’s been difficult, it will become easier to offer others compassion. As you offer challenging others compassion, it will become easier to offer yourself compassion.

What’s a way you can implement this understanding of compassion right now?If you came up with something, awesome. If not, no worries. Check out one of my favorite practices, which is exercise #2: Self Compassion Break by Dr. Kristen Neff. Implementing the knowledge right now will likely support you in integrating it on a deeper level.

Finding Compassion for a Broken Man

He didn’t imagine this for my life. He’s in his 40’s and walking back to his halfway house, after working a long day of construction framing. His body aches and his mind is screaming at him. He uses alcohol and drugs when he can, it quiets his mind. Yet he knows he will likely be drug tested tomorrow, so he walks past the liquor store with what little strength he has left. He gets back to his dingy room, the cockroaches hiding from the light. He swallows a couple sleeping pills and waits for sleep to come. Sleep has always been hard for him. It’s been 40 years and he still hasn’t figured out how to sleep, what type of man can’t fall asleep.

He’s being hard on himself again, that’s really the only way he knows how to speak to himself. While he remembers his past, he isn’t yet able to offer himself any compassion or forgiveness about why he can’t sleep now. When he was a toddler, the youngest of the bunch, he wasn’t able to protect his older sisters. He laid in bed hearing the repeated sound of a belt as it hit his sister’s flesh. His oldest sister would bawl so loudly, yet that seemed to end her punishments sooner. Then his mother would begin to belt the younger sister, and she never made a noise. Her beltings would last the longest. He would finally wet the bed and cry out. His mother would leave his sisters alone, now he was the one to face her pain.

Towards the end of her life, he would get to know his mother. She was a depression child, the middle of seven. After her father left the family, her mother had to try to keep seven children feed, which seemed like an impossible task. She gave her middle child away, to be a maid, for a household that had plenty of food. Over her entire life, she would only share one story of her time in that household, so what happened there would mainly be a mystery. Yet it’s evident to see, she carried a lot of pain, and it would leak out and effect those she loved the most.

Back to him though, he’s lying in bed with his noisy brain. Even in prison, he had better access to alcohol to calm his brain. Within a year in prison, he was a bootlegger, sneaking juices from the cafeteria and fermenting them in his cell. He was able to trade his moonshine for a little more safety in prison, and the alcohol allowed him to get some rest. Rest might be an overstatement, it allowed him to black out, more of a respite from his mind and his physical cell. He didn’t have alcohol in this moment, so all the memories of how he messed up everything in his life flooded his mind. How he and his wife were both been sent to prison for being marijuana farmers. His kids were in their early teens and drifted among family members, each suffering from their own trauma and not being able to provide his kids a home. By the time he got out of prison, his kids were adults, thus no longer needed and no longer spoke to him.

He had a temper, he knew that, he was far from the perfect man. When he was born, the trauma of his mother, already impacted his epigenetics. His DNA was methylated, which is actually a protective factor, if a human was born into a warring tribe, it was safer for us to think less and react more, this piece played into his temper. He spent his entire life reacting, no one had showed him a different way. The traumas of his prison life added on to the traumas of childhood meant he had a highly activated amygdala. His amygdala would take input anyone else would sense as beneigning and send him into fight of flight. What happens in fight or flight, is blood flow to the prefrontal cortex almost stops, this prevents the ability to empathize with another or even yourself (another reason he frequently speaks so harshly to himself) and shuts down logical thinking. It floods his body with stress hormones, so he’s ready to take out the threat in front of him, even when the threat is someone he loves. He has no way of sensing this, he’s flooded with cortisol and lacks blood flow to his prefrontal cortex. While it’s possible to demethylate his DNA, he didn’t know to search out for this, he keeps blaming, ridiculing, and torturing himself for not being able to act differently.

************************

This is my portrayal of a small part of my uncle’s story. A few months after this point, I’m 19 and visiting my grandmother and see him viciously lashing out at my grandmother. She got down on her hands and knees crying. He began yelling racial epithets, I never knew existed, at two of my friends. I held a bitterness and fear towards him for this event.

My uncle’s story does change. After his third DUI, his life begins to change with the support of his mandated counselor. He praises her frequently for altering the course of his life. He becomes the only family member of that generation who encourages me to take care of myself. He appears to release the manipulative traits he picked up as a child to obtain safety. He rebuilds the relationships with both of his sons. He’s in intense, chronic pain. He chooses to spend his money on their college education, instead of obtaining medical insurance and addressing his needs. They both get their associate’s degree and walk for their graduation on the same day. He then allows his son and myself to help him get insurance and begin to have doctor’s visits. They discover he’s already stage four cancer. He’s surrounded by his sons, nephews, and niece during the last year of his life. He’s healed many of his wounds, and supported us in beginning to do our own healing. I believe he became the man he wanted to be.


Group Therapy Session Parts, #1 – The Grounding

Your clients have just arrived for their group therapy session, and, likely, they have dozens of topics on their mind and very few of these thoughts might actually be about where they are now. I find it beneficial to open each group and individual session, with a grounding, resourcing, or mindfulness exercises. This supports clients in practicing these tools, while supporting them in landing in the here and now. The following are some suggestions:

Breathing Exercises

I like using a Hoberman Sphere when demonstrating breathing techniques, to represent inhales, holds, and exhales. You can pass the sphere in a circle allowing each client to be able to guide the group in breathing.

Senses Exercises

  • 5 Senses Mindfulness Exercise
    • An augment I made to the 5 sense, is in explaining the exercise I will either que the group to focus on sensations far away and then bring it closer or even internally, or to start close and then allow the awareness to expand further and further away. The way I choose depends on what the group needs more, are they scattered and need help focusing inwards or are they too internally focused and need support in expanding their focus.
  • Safe Place Exercise
  • Silly LIttle Questions
    • This helps increase activation of the pre-frontal cortex for clients that may be more stressed upon arrival to group. Examples of Silly Little questions include:
      • How many yellow items can you see?
      • How many different scents can you notice?
      • How many shades of green can you currently see?
      • How many textures can you feel?
  • Taking in the Good

Movement Exercises

Take your time introducing and explaining exercises. Let the clients know about the physiological and neurological benefits. After you have lead clients through the exercises a couple times, empower them to co-lead the exercise with you, then to lead the exercise on their own. Encourage clients to practice these exercises every day. If they are able to repeat these exercises for 20-30 seconds 8-10 times a day, it can support increasingly being able to access calm states when under stress. Ways to incorporate regular practice could include setting a phone alarm or through marking, such as every time one walks through a door or washes their hands.

What’s the cause?

Recently on these two podcasts, Found My Fitness and The Drive, medical professionals discuss their new understanding of Alzheimer’s. My simplified summary of these podcasts is that we are now seeing that there are several subtypes of Alzheimer’s. These subtypes are actually unique diseases that all have similar effects, yet a unique cause. The scientific community seems to be aware of the following subtypes: the first is characterized by systemic inflammation, the second type shows reduction in support for synaptogenesis, and the third type characterized by environmental toxin exposure from molds or heavy metals. They even named another type 1.5, as it seems to be a mix of the first and second types. When medical providers thought it was only one disease, then the cures that were being applied were probably unlikely to apply to all types of the disease, as they had different causes. If someone’s Alzheimer’s is related to mold exposure from their homes, then reducing systemic inflammation via dietary intervention may have little impact. I’m wondering if we will see similar discoveries in mental health.

I think it’s likely that we will discover multiple subtypes of depression, anxiety, and other mental health concerns. I think it’s likely there will be overlaps between the subtypes, such as the type 1.5 for Alzheimer’s. When I review studies on the treatment of depression (broccoli sprouts to support neuroimmune system, curcumin, transcranial magnetic stimulation) so many of treatments provide improvement for a portion of the people in the study, yet not one treatment provides benefit for all the people. Is it possible that the reason for this partial effectiveness is that there are many subtypes of depression?

What could be the causes of some of the subtypes of depression? My guesses are:

  • Distressing Beliefs
  • Childhood Trauma
  • Behavioral Patterns
  • Rigid Neuropathways/Default Network
  • Overactivity of Immune System/Inflammation
  • Poor Nutrition
  • Poor Gut Health
  • Sedentary Lifestyle
  • Poor Sleep
  • Social Stress

When counselors are lucky, we see clients that are only suffering from depression that is connected to beliefs, emotions, stress, and traumas. We have the tool set to support clients in these cases. What happens when the client is suffering from multiple subtypes or a subtype that is outside of our professional lane? What if we started with interventions with the highest benefit and least risk, and find ways to keep these affordable for our clients? Could we partner with professionals in other fields and find ways to offer group consultations to keep costs low? A childhood obesity clinic offered parents group informative sessions by a nutritionist on dietary advice for their children. All the parents had a similar concern and they all needed similar support from the nutritionist, and the group information sessions made them more affordable.

As mental health counselors, can we build a network of providers that can affordably support our clients? Maybe a nutritionist, you partner with, offers a monthly class on nutritional recommendations for depression and you offer a class on distress tolerance skills or something else that would be supportive to her clients. These classes can have a fee and be a referral source. We could each have a network of many other providers from different fields.

When we have clients that aren’t responding to our tools, maybe it’s not because they are resistant, maybe it’s because their depression has a different cause.

Comfort vs. Discomfort

Where does your preference lie on the spectrum of comfort to discomfort? And in what areas?

For me, I like workouts, personal challenges, and temperatures (bot and cold exposure) more in the uncomfortable side of the spectrum. My clothes, food, and technology, I prefer in the comfortable side.

Where could it benefit you to move an area to a different area of the spectrum? In example, today I’m traveling, so choosing to fast instead of indulging in the many offerings of food like substances at the airport. Yet. I’m tuning into ways to bring more comfort to my body today, by rubbing my neck and ears, while enjoying the sunrise over Mount Rainier.

What practice of moving more towards comfort or discomfort would you like to try today? Can you engage in this practice 5 times today?