Dragging your teenager to therapy

I have a word for those of you who are concerned about your adolescent’s moods or behavior, and are thinking of insisting that they see a counselor. Two words, actually:

Please don’t.

The reason is simple and self-explanatory: remember what you were like as a teenager when your parents made you do anything? There’s your answer. But in case your own adolescent memories are a bit hazy, let me spell it out for you.

First, it doesn’t work. Good therapy never happens at the point of a gun. Explore one’s feelings and strategizing new behaviors needs the kind of conscious, willing effort that no one can ever be talked into.

Second, it is miserable for your kid. Even when people want and need it, psychotherapy usually ranks pretty low on most people’s lists of fun things to do. Add in the punitive atmosphere of being “sent” to counseling, and it becomes almost impossible for positive change to happen.

Third, it is miserable for the therapist. Ever heard of a “shruggie”? That’s what we call an adolescent client who sits there for the whole hour and responds to every statement with a shrug. Good therapists are usually gentle and kind with shruggies, but in terms of any real benefits taking place, you would be better off bringing a potted plant.

My biggest concern is that when sullen teenagers are dragged to therapy, they learn to associate counseling with resistance, stigma, and parental pressure. Which makes it that much less attractive to them in the future, even if they might want or need the help.

Here is an analogy: when I was growing up, my father always tried to get me to read great literature. Was it effective? You bet. Despite being a prodigious non-fiction author for nearly all my adult life, to this day I neither read nor write a word of fiction.

So what can you do when you are worried about your adolescent?

1. Talk with your kids – and more important, listen to them. Listening without judgment and taking their feelings seriously – even when you might not agree with them – starts building the new adult relationship you are both headed toward, and helps them open up to you when they really need help.

2. Make them a free trial offer. If you think your teen isn’t wild about therapy, but really needs the help, suggest what we therapists often propose: go for three sessions, and then let *them* decide whether it is helping them or not. (And then be sure to pick a great therapist who really “gets” adolescents.)

3. Go to therapy yourself. “But I’m not the problem, my kid is!” Fair enough. But therapy is fundamentally a skill-building process, and if you learn skills for how to deal with your teenagers and bring them home, that may be the most effective way to help them. Besides, you might be surprised to learn how many of your adolescent’s problems are actually a dance with two partners.

4. Know when intervention is needed. Some situations do call for counseling, whether or not your teen is willing. The threat of self-harm, suicide, severe mental illness, or risk to others are good examples of this. A good social service agency or crisisline should be able to guide you in situations like these.

Finally, there is the best reason of all to send your son or daughter to therapy: when they ask for help themselves. When it is their independent decision to get counseling, you can become part of their support team – and in the process, start building an adult partnership for good mental health.

A practical guide to keeping yourself alive

Like everyone, I am shocked and saddened by the death of Robin Williams – someone whom I honestly felt was the most brilliant funnyman of our era. While it was no secret that he suffered from depression and alcoholism for much of his life, I will not try to analyze what led him to make this choice – only pray for him and his surviving family.

But I do want to say something to an equally important person: you. You are still alive and reading this. And if you are feeling desperate, hopeless, or unloved, I would like to chat with you for a minute.

If the thought of suicide has crossed your mind, then more than anything, you are probably feeling overwhelmingly alone. You may be thinking thoughts like these:

-“This pain is never going to end.”

-“I have struggled for so long with (mental illness, substance abuse, disability, or whatever) things will never get better.”

-“I feel so humiliated by something I did – or failed to accomplish – or that happened to me – that I can’t face the judgment of others.”

-“Because I am (unemployed, poor, divorced, retired, flunked out, or whatever) my life has no value.”

-“People would be better off without me.”

I would love to talk you out of these thoughts. And it would be tempting to try, because they often turn out to be untrue in the long run. But I probably can’t. So instead, I would like to try and share a little behavioral science with you. Here are just three simple things I would like you to remember:

1) Realize that you are feeling alone. Which has a simple and proven antidote: DON’T BE ALONE. Don’t try to figure out your thoughts quite yet. Just share them with someone. Perhaps someone who cares about you, or perhaps a crisisline or mental health professional. (Incidentally, calling a crisisline is one of the most effective public health interventions in existence.) Whatever you do, please bring other people in on your situation. This one simple guideline is more likely to keep you alive than any other.

2) You need a safety plan. Willpower is the worst thing you can depend on to do anything, including staying alive. Instead, you need a plan that will always be there for you. Know who you will call, where you will go, and whom you will stay with when life gets overwhelming. And then make a contract with yourself and others that you will always execute that plan.

I recommend making at least one professional part of your plan, whether it is a therapist, a crisisline, the police, or your local hospital. Why? Because of another fact that may surprise you: friends and family are often your worst resources in a mental health crisis. Unless they have been trained, you may get pat answers, pep talks or awkward silences when what you really need is competent help and support. So if possible, make the right professional(s) AND the right loved ones part of your plan.

(P.S. If you are wondering what to say to a loved one who is at risk of suicide, I have written a detailed blog on this, linked here.)

3) Don’t wait until you are in crisis. I often suggest that therapy clients call a crisisline for fun, just to see what the experience is like – and as a former crisisline volunteer, I can tell you that they will welcome the call. Knowing that there are *always* people who will listen and talk with you, 24 hours a day, about anything that bothers you is powerful and strengthening.

Another reason not to wait until you are in crisis is that professionals vary like anyone. (You’ve probably heard the joke about what they call the person who graduates last in medical school: “Doctor.”) If you don’t feel you connect with a therapist, prescriber or care facility, try another one. You deserve to have the very best people on your team when you need them.

I am by no means implying that these three steps might have saved Robin Williams. That would be horribly unfair to him and his surviving family, because we will never know what happened. Instead, I mourn his passing and wish them peace. But for many of you who feel desperate and hopeless right now, these steps will give you a much stronger chance of staying alive: don’t be alone, have a safety plan, and don’t wait until a crisis erupts. Good luck and be well.

The joy of being second best

Do you ever feel like a failure? Then congratulations, you have lots of company! Feelings of failure are like the common cold of psychotherapy nowadays.

So what can you do about these feelings? Here's a trick question I sometimes use:

“Let’s switch places and have you do a little therapy for me. I am almost 60 years old, and have come to realize I will always be a ‘B-list’ author and speaker. No one will ever stop me in airports for an autograph, and I will probably I never keynote the big conferences. So tell me, how should I feel about being doomed to the B-list?”

People usually walk right into my trap. They empathize with how frustrated I must be, or say they understand my plight. Or give me a pep talk about how I could still do better.

My answer? I break into a huge smile and say, “I love being on the B-list! It’s like winning a game show! Getting paid to write books and being flown all over the country to speak is fantastic! Being on the B-list is totally awesome!”

Which leads to my real point. We falsely connect winning with being happy. We feel we must be unsatisfied with our current performance – and therefore emotionally unhappy – to goad ourselves to succeed.

Instead, this makes us emotionally constipated. Being critical and self-judging is never the road to success. Top athletes, for example, generally learn to shake off failure and keep improving. Which means, by corollary, that they always like themselves in the moment. If you really want to be the best – your best – you must like yourself right now, exactly as you are.

So be proud of being second best. Notice I didn't say settle for second best - improving yourself is always awesome. But psychology says that your best hope of winning lies in being present wherever you are - second, third, or whatever - with a smile.

I am actually no slouch as an author and speaker. I’ve had a couple of national bestsellers, make a nice living speaking, and lifetime gross sales of my books recently topped a million dollars. But I got there by being happy and proud of myself at every point of a decades-long journey. I keep getting better because I like myself and love my craft – not because I grimly put my nose to the grindstone harder.

Finally, your self-worth affects your relationships with others. A few years ago I spoke at a conference following a keynote by Dan Thurmon, a rock-star speaker who combines acrobatics, juggling and breathtaking risk to enthrall the audience. I will never be Dan Thurmon. In fact, my back hurts just watching him! But seeing better writers, speakers or therapists in action delights me - which in turn leads to authentic and satisfying relationships with my community of peers.

Dr. David Burns, perhaps the best selling self-help author in history, made this same point nearly a quarter-century ago in his book Feeling Good, in a delightful chapter entitled “Dare to be Average!” He talks about how perfectionism always leads to a brick wall, and being average leads to a magic garden of joy and success. This point is more than just good advice – it is also sound behavioral science.

So embrace the B-list. Go out there and do your very best crappy job at whatever you are doing. And be proud of it. My guess is that you will become happier and more successful than you ever imagined!

Five things therapists get asked by their friends

Many people get asked about their careers. But since I became a psychotherapist later in life, it has been fascinating to see what people ask me about it - especially, say, versus my other careers such as being a software engineer or a writer. Here are some of the things that well-meaning friends and relatives have asked me:

1. Are you analyzing me?

No, I am not analyzing you. I am not that smart.

I realize where this misconception comes from. We are trained to listen and pay attention to people more closely than most professions. And we do assess and treat people based on what we observe. But that doesn't mean we've suddenly gained some kind of X-ray vision about your psyche. So do I make assumptions about you based on, say, how you hold your fork? I wouldn't worry.

2. You work with crazy people all day, right?

First, the vast majority of my clients are extremely normal (and very nice) people who suffer with issues many of us share: anxiety, depression, loss, relationship problems, etcetera. And they have the good judgment to seek out new skills for dealing with them - skills that would benefit everyone. Second, people who suffer from what we call "severe or persistent mental illness" are more likely to be treated in agency or hospital settings versus a private therapist. Many of them are not "crazy" either.

My clients, however, often do work with crazy people all day. Or so they tell me.

3. You must be a “paid friend”

I certainly hope not, because friends are often the worst possible resources for mental health care.

Say, for example, a kid is acting out in school. That family's friends will probably have no lack of input on how to “motivate” this kid, when the real answer may involve doing a psych eval and uncovering a treatable neurological problem. Likewise, if someone has a fear, most friends would recommend mindless bravery (which doesn't work) instead of cognitive-behavioral therapy (which does). I am constantly being reminded that training and expertise really do matter.

4. Do you make people do uncomfortable things?

You've been watching too much reality TV. We never force people to do things they don’t want to. Even the most challenging forms of therapy, such as exposure therapy for fears or OCD, always take place at a rate that *they* choose, with lots of safety and support. In my experience getting well is normally a lot easier than staying ill, and most people emerge from therapy sessions feeling better than when they came in.

5. My last therapist was cold and distant. Or talked too much. Or asked me too many questions. Or whatever. Are you like that?

Our personalities vary like any random group of people. For example, I tend to be humorous and outgoing. Many clients like this, while others are more comfortable with a quiet listener. Some people prefer a counselor who has a step-by-step game plan for getting well (me again), while others prefer someone who can “hold space” for complex feelings. There is no right or wrong when it comes to people's preferences.

Which leads me to perhaps the most important point of all about this profession: we provide a service for people, like painters and barbers and lots of others. We do something that we are highly trained for, that hopefully makes most people feel a lot better. More than anything else I've ever done, serving them has been one of my greatest privileges. So keep asking away, I don't mind at all!

Creating a virtual therapy office

Many therapists have at least dipped their toe into doing online sessions with clients nowadays. I have always embraced it wholeheartedly: I am an alpha geek who was an early adopter for webcasting, long before my own therapy days. Online counseling is often ideal for clients who travel, leave the area, need urgent sessions outside of office hours, or are housebound. At any given time, two or three of my 15 or so weekly sessions are virtual ones.

Online sessions are generally easy to do with a laptop with a webcam and a headset, but my project this Thanksgiving holiday was to take this a big step further: to have a real virtual “office” for online psychotherapy. A space that is warm, inviting, and feels more like a live session than a web chat. And I was fortunate to have the perfect setting: my home’s glass-enclosed living room overlooking the hills outside of Ithaca, NY, with great views and lots of natural light.

My view of the office

The client's view of the office

The results far exceeded my expectations: after investing less than $200 in equipment (in addition to my existing wide-screen HDTV and laptop computer), I now have a real therapy office where my client is visible at close to actual size on the television monitor, we hear each other at a normal voice volume, and I am sitting across from him or her in a comfortable chair taking notes. It now feels a lot like a real therapy session, for everything except the parting handshake. Here is a summary of what I did, as a recipe for creating your own virtual therapy space.

1. Interfacing your computer and TV

It helps a great deal here to have a recent-model laptop computer with an HDMI interface. Most modern wide-screen televisions have HDMI interfaces, which normally give you the highest quality picture. Equally important, HDMI cables carry both video and sound, eliminating the need for a separate audio interface.

I had HDMI at both ends, so all I needed to do was hook up a standard HDMI cable between my laptop and the HDMI 2 input on my 42-inch HDTV. Now, switching between TV and therapy is as simple as toggling between HDMI 1 and HDMI 2 on my television’s remote. If you don’t have HDMI on your computer, you may need to purchase an interface box and cables to convert from your computer’s VGA video and analog audio to HDMI, or to composite video plus audio input. Unfortunately, given the cost (often $150-200), it may make more sense to simply invest $350 or more in a basic HDMI laptop.

2. Webcam

Instead of using my laptop’s low-res webcam, whose narrow viewing angle requires sitting in front of the laptop itself, I installed a Logitech HD webcam - their top-of-the-line Pro Webcam C920 model, costing roughly $75 - that mounts on top of my HDTV and connects to my computer via a USB interface. Its wide-angle view allows me to sit anywhere in my “office,” just like a regular therapy session, and gives the client a great view of the hills outside.

3. Audio

Audio will be your biggest challenge in setting up a virtual therapy office. Why? Because of "lag." When a client speaks, there is a lag time before their voice is audible over your speakers, which can cause an echo when they hear their own voice later. The same is true with your voice if the client is using speakers.

When you both use headsets, this solves the problem by definition, because neither of you can hear the other person's audio output - however, this means that you are "tethered" to your equipment. I have found that using a combination of a high-quality microphone and low speaker volume often prevents the need for a headset.

Currently I use the integrated dual microphones included with the Logitech C920 webcam, together with the laptop speaker located off to the left of my HDTV - not the HDTV's speakers themselves. This also has the advantage of combining the webcam and microphones on the same USB port. Previously I had tried a USB-powered Samson Go Mic (a very good condenser mike), however this only worked if the mic was right next to me with a low speaker volume.

Most of the time this setup works well, and I can speak comfortably and naturally with the client while sitting in my chair. In some cases, however - for example, when the client is traveling to a faraway location and lag is an issue - I use an inexpensive Plantronics Audio 326 headset with a long extension cord to prevent lag from being a problem.

4. Cordless mouse and keyboard

Using a quality cordless keyboard and mouse – in my case, a Logitech K360 keyboard and a Logitech M525 mouse – gives me the range to sit across the room from the TV and computer and still control the therapy session from my chair. These both share the same USB controller, only requiring me to take up one additional USB port for both.

This also has the added bonus of allowing me take notes electronically during the session, with the caveat that you must use an encrypted, password protected drive or disk partition for compliance with HIPAA privacy regulations.

5. Software

Therapists often talk about having “Skype sessions,” however in reality Skype is technically no longer legal for therapy use under current HIPAA privacy regulations. (Skype has in fact always discouraged its use for therapy: its video conversations go through their servers, and they understandably don’t want the hassle of meeting HIPAA requirements.) I use a HIPAA-compliant peer-to-peer solution called VSEE that is both high-quality and free. One note: I had to go through VSEE’s settings and change the default sound output, microphone and webcam to use the HDMI channel and USB devices I added – and then it worked great!

Online therapy: the practicalities
Any drawbacks to online therapy? Just two in my case. One, online sessions are generally not reimbursable by insurance, so it is largely for clients who are self-pay or willing to pay for extra sessions out of pocket. Second, online practice is generally only legal (and covered by liability insurance) when you are licensed in your client’s home state, so my practice is currently limited to New York residents. Eventually I plan to obtain reciprocal licensure in at least a couple more places, starting with my family’s home state of Arizona.

There is a third and more subtle drawback as well: online therapy isn't for everyone. *I* think it's great, of course. But many clients have a hard time wrapping their heads around the idea of having a therapist pop up virtually on their computer or smartphone. Some prefer the richness of a real, live human interaction with another person, where you can see subtle cues of facial expression and body language. Others have legitimate privacy concerns at their end, because of the presence of partners, roommates or family members. And for some forms of therapy, such as EMDR or trauma therapy, eye contact is very important.

For my particular brand of therapy (cognitive-behavioral therapy and relationship counseling), which is very practical and skills-based, the online modality seems to work very well. And as a rule, I find younger clients who are already savvy with computers and social media are much more comfortable interacting online. So I expect the use of this approach to continue growing over time.

I strongly feel that online therapy is the wave of the future, as well as a tool to reach people who ordinarily might not obtain counseling. And with the right technology, it is starting to increasingly resemble traditional live psychotherapy. I hope to expand my own online practice in the future, and would encourage more therapists – and clients – to give it a try!

The do-it-yourself family therapy kit

I sometimes joke that when I am not busy defusing angry people on stage as a public speaker, I put myself in the middle of other people's family conflicts. But seriously, I really do enjoy being a marriage and family therapist. It is gratifying work where couples and families often move from a place of anger and pain to re-discovering one another again, with a little guidance.

At the same time, I have to be honest with you: what I do is really pretty simple. There is more science behind it than you might think. And you can do it yourself in your own relationship. Looking back on a couple thousand therapy sessions or so, I could boil many of them down into five simple rules:

1. No criticism. Ever. Really. Before my first session with a family is over, I tell them my mantra: you can never successfully criticize anyone for anything, ever. There are few less successful undertakings than trying to convince someone else they are wrong.

We all have a hard-wired survival instinct to push back against criticism – listen carefully – no matter how right it is. Get this and everything starts changing.

2. Ask for what you want. So now what happens with all those grievances you have with your loved ones: the crumbs in bed, the bad attitude, the affair two years ago? Here's what you do: ask them for something specific and actionable. And remember, NO criticism.

I can read your mind right now. You are saying, "Look, I've asked my partner over and over and over to stop doing X, and she keeps doing it anyway." No you haven't. You've been complaining to her in a tone of voice that would curdle milk, and she's responded with human nature. So try it again: "Agnes, honey, I see why you do X. It makes perfect sense to me. From my end, I would love to figure out another way that would make us both happy - I might suggest Y. Where could we go with this?"

Maybe the other person will say yes. Maybe they will say no. Maybe the problem is unsolvable, like when she wants children and he doesn't. Either way, you'll be talking productively, instead of watching the other person respond passively or aggressively to your gripes. So ask them to go mountain climbing, see a movie with you every week, or kiss you passionately. Then watch what happens.

3. Ask what they want. What makes your kid happy? What is your partner most worried about? How do they feel about the X that you are asking for? Knowledge is power, and most of us spend too much time wondering what to say to someone and not enough time wondering what to ask.

4. Cheer the other person on. Do you have a rotten kid, or a complaining spouse? Pop quiz – how often do you compliment them, or say things that accept them for who they are, or comfort their mistakes? There is a stronger correlation between these things than you might think. People are capable of amazing transformations when they feel loved and supported.

5. Create your own great life. In grad school, they teach us a spectrum. At one end people are "enmeshed" – highly reactive and dependent on others for their emotional well-being. At the other end they are "differentiated" – loving and secure, but not needy. We want you to be more differentiated and less enmeshed. So start being a great partner or family member by making yourself happy.

Is that all there is to it? Well, not always. But as long as you both care, and aren't beating each other with sticks or recovering from trauma, this is actually a pretty good summary of where a family therapist might lead you. Try it for yourself, and watch some amazing things start to happen with the people you love.

You're stressed - now what?

I recently did a radio interview about the Anxiety Camp group program I run here in Ithaca, and the host asked me a great question: "Everybody feels anxious in certain situations. So what do you do when you first feel that tinge of fear?"

My answer was a correct one, but not a very good one - partly because the real answer is more complex than a short sound bite. So now, with a whole blog to work with, I am going to take another crack at it.

You see, I focus on treating anxiety *disorders* like fears and phobias. They are frankly not the same thing as stress. And there is a clear, well-established approach for treating these issues: understand the self-talk about your fears and make it more rational, create a hierarchy of your fears, expose yourself them gradually, and learn to be fully present as you take these small baby steps, with lots of support and feedback. Easy peazy. That's why these disorders are highly treatable.

But normal stress? Here was my correct-but-not-very-good answer: Be aware that your stress is happening before it boils out of control, change the way you think about the situation (preferably ahead of when your fear starts to mount), and learn to gradually get used to the stressor.

Here is a longer but much better answer. When you feel stressed - right now, in the present moment - what lowers it depends on who you are and what the stress is. For example, one person may be working too hard and needs to relax, while another may be frightened about a health crisis and needs support. So in addition to the basics above, learn what kind of "first aid" works best for you and start using it sooner rather than later. When you feel your anxiety starting to creep up, try one - or more - of these techniques:

Slow down. This is the place I like to start. Why? Because anxiety expresses itself physically through things like shallow breathing, rapid pulse rates, and emotional overload. Amp down your workload if you can, focus on relaxed, natural breathing from your diaphragm, give everything more time, and learn progressive muscle relaxation - try these free resources . All of these will strengthen most people.

Connect. Some people calm down by withdrawing to a quiet space, but for others silence can be maddening - because they gain strength through the fellowship and validation of others. If you're the latter, get out of the house, pick up the phone, or even chat online, and harness the healing power of community.

Get moving. Exercise releases endorphins that improve your mood and your emotional resilience, and even a walk around the block can re-engage you both physically and emotionally.

Be mindful. Mindfulness exercises that engage all of your senses - like this one - are particularly good at dissipating anticipatory anxiety, and help you learn to observe rather than react to your feelings.

Be grateful. What has been clinically proven to be the biggest component of happiness? Showing gratitude to others. Watch this video, and see if making other people happy lifts your mood too.

Most important of all, remember that everyone is different. One person may find calm at a spiritual retreat, and another might find sitting in a white robe and staring at a candle to be like watching broccoli grow - and make them feel more stressed! Gratitude may be a powerful antidote to emptiness in your life, but do nothing at all if you are dreading a final exam. Explore who you are and what works best. And try to stay away from false cures like food or alcohol if you can - they wear off quickly and eventually cause problems of their own.

Finally, if you are chronically anxious or first aid isn't enough, there is no shame in getting a professional involved. Anxiety is very treatable, and talking with a counselor or physician about it is a sign of good judgment and pro-active self care. Good luck and have a stress-free week!