PSYCHOTHERAPY PRIMER

Robert E. Matefy, Ph.D.

INTRODUCTION


Mental Health Skills Every Person Should Know

        Floating around my home is a magazine entitled “100 Skills to Make You a Better Gardener”. It offers the very optimistic thought that despite my penchant for killing 50% of the plants I dig into the ground, I hope to learn how to be a more skillful gardener by practicing the strategies outlined in the magazine. I, too, can acquire the proverbial “green thumb” if I follow its practical advice. By improving my gardening attitude and skills, I am not destined by some permanent gardener’s character flaw to live out my life, killing 50% of my plants. A green thumb is not something you either have or don’t have. I have the green thumb skills to raise foxgloves, blueberry bushes, and many other plants. But there are some flowers and shrubs I cannot grow to save my soul. In much the same way, a person’s mental health isn’t an all-or-nothing state. Most people are successful in coping with many life crises, and they may fall apart when faced with life challenges they do not have the particular psychological ability to manage. But we can learn to “fill in the gaps” in those areas of our lives that would benefit from improved coping skills.


         This manual is intended to convey hope and a “can do” attitude to those who want to enhance their mental health. So many people I encounter in my practice are convinced that their mental health fate is sealed, either because of adverse childhood experiences, poor upbringing, traumas, unfortunate life circumstances, genes, bad luck, etc. They view their dysfunctional personality as unalterable, permanent, and pervasive. I certainly do not mean to dismiss the real adverse impact of life misfortunes on mental health. However, I want to provide you with another way to think about mental health. The ability to cope with and resolve the inevitable problems in living is something people can work on. There are skills people can develop to improve their mental health and be prepared for crises in living, just like improving any other skill.
    
         I have included some therapeutic tools and skill-building exercises that help my clients develop and maintain the essential mental health coping skills for a successful and fulfilling life. You are encouraged to try these exercises to enhance your mental health.

         I will update this manual as I think of new ideas, discover new information, or realize better ways to convey what has been written. So, think of it as a “work in progress.”




    
                                            FACTORS FOR SUCCESSFUL THERAPY

Successful therapy depends on three essential factors: a compassionate therapist, the appropriate
therapy, and an engaged client.

The psychotherapist: Research studies and client feedback demonstrate that the successful therapist conveys the following qualities.

• Empathy by conveying to the client a compassionate understanding of their thoughts, feelings, and struggles from their point of view. Empathic understanding is the foundation for successful psychotherapy.

• Genuine interactions as a “real” person, not a distant authority figure. The therapist shows acceptance, and respect for the client.

• Realistic hope and optimism to clients during times of despair.

• A safe and stable place for the client to discover and express powerful and painful emotions. The therapist allows the client to question their undeserving self-criticism and to gain healthy self-acceptance. The client feels supported and nurtured.

• A willingness to switch course if the client does not improve.


The therapy: Next in importance is the particular therapy or combination of therapies employed. The therapist’s job is to provide specific therapeutic strategies to help the client improve coping, managing, and resolving the problem(s) they present to the therapist. Confronting a client about the problem behavior and simply directing the client to stop without offering useful coping tools is not beneficial; it is disrespectful and discouraging.


The client: The client must play an active role if treatment is to be successful. They must be willing to open up and share often difficult thoughts and feelings. The client will be asked to follow through on therapeutic “homework” between sessions, such as keeping a journal, exploring new ways of thinking and behaving in real-life situations, monitoring personal progress, and discovering healthy lifestyle changes. Indeed, those clients who use the insights and coping tools learned in therapy in their daily lives are the ones most satisfied with their therapy. Taking an active role in practicing and applying therapeutic tools has proven to be one of the best predictors of success. Also, the client must be willing to assume a fair share of responsibility for the problematic behavior and not automatically blame others for their difficulties. The ultimate aim of psychotherapy is to encourage the client to take charge of their mental health.

                                   STRATEGIES TO DEVELOP MENTALLY HEALTHY COPING SKILLS

Reexamine Harmful Childhood Experiences
        In the novel The Shadow of the Wind by Carlos R. Zafon, Julian’s father repeatedly calls his son weak and despicable and predicts he will be miserable and a failure all his life. Julian’s poor image of himself as a man reveals how adverse childhood experiences inevitably affect adult life. “Julian spoke about all that as if it didn’t matter to him, as if it were part of a past he had left behind, but these things are never forgotten. The words with which a child’s heart is poisoned, through malice or ignorance, remain branded in his memory, and sooner or later they burn his soul.”

        A recent session with a successful writer client illustrates the impact of harmful childhood experiences that can haunt a person throughout life. “I don’t remember much what happened the day my father deserted us. But I believed I was somehow undeserving and never got what I wanted. This belief has been disproved throughout my life, but I still cling to it. Never do well enough. I grew up thinking I must be invisible. If my father could leave without saying goodbye if my father didn’t want me, how could I make an impression on anyone else? With each book I write, I hope someone will recognize me. It makes me feel like they care, after all. I know I’ve gotten more recognition than I’m willing to see. But I can’t break out of the idea that I’m still a loser. Still yearning for that childhood recognition.”

    
      Our personalities begin forming in childhood. Usually, our earliest experiences, positive or damaging, remain embedded in our psyche throughout life and significantly influence our personality development and mental health by shaping how we relate to others and situations in our adult lives. A child who is loved, cherished, and nurtured grows up with a positive sense of self and a solid foundation for mental health. Unfortunately, many people have not had an idyllic childhood. According to the U.S. Centers for Disease Control and Prevention, almost 60% of American adults say they had difficult childhoods that were harsh, abusive, critical, or unloving, or they suffered family dysfunction due to domestic violence, substance abuse, or they experienced absent parents due to separation, desertion or divorce. Such children are likely to feel insecure, anxious, depressed, or angry as adults. For example, suppose a little boy experiences his parents as punishing, verbally abusive, or overly critical. In that case, he will likely grow up with a self-critical and unworthy sense of self. He will perceive criticism everywhere, even distorting innocent comments and actions of others as hostile and disapproving. Or a young girl who experiences a lack of love and nurturance or grows up believing that a parent abandoned her by divorce or separation may view herself as unlovable, and her lack of self-worth may result in mental health problems and poor relationships throughout her life, especially with intimate partners. Likewise, an adult who experienced neglect or abuse as a child may anticipate similar treatment from others who remind that person of the toxic presence from childhood, often a parent. Abundant research confirms that children raised in disruptive families where they don’t develop secure attachments with parental figures have a tough time forming stable and healthy relationships later in their lives.


“I never bothered to take care of myself or defend myself when people criticized me. I felt I wasn’t deserving, so I just let myself go and took the abuse.”(Female client, 44 years old)

     Early harmful experiences often haunt a person into adulthood. The person often struggles with feelings of unworthiness, poor self-esteem, pessimism, and feelings of inferiority. However, some people go the other way. To compensate for feelings of inferiority (inferiority complex), the person may create a false sense of superiority and devote their life to material wealth, social success, and power or controlling others rather than developing a true sense of competence and self-esteem. The bottom line is that, as adults, how we view ourselves, others, our relationships, and the world are usually shaped by earlier childhood interactions, good or bad.


     The solution here is to revisit these destructive early experiences to put them into perspective. Suppose a client’s mental health problem seems to be due to harmful childhood experiences. In that case, the therapist might encourage the client to discuss childhood traumas to understand how early history influences present behavior, thinking, and emotions. The goal is for the client to be able to release the pent-up childhood emotions from these harmful experiences and, therefore, find relief from present-day depression, anxiety, anger, addictions, etc., before these emotions and actions cause further deterioration of mental health. I have found over and over again that clients find great relief in realizing that their mental health problems were not their fault and that there was a reason for their psychological troubles due to circumstances beyond their control. Once they understand this, they are ready to do the work to learn mentally healthier ways to cope with life problems and manage their depression, anxiety, anger, etc. To be clear, the aim of this form of psychotherapy is not to blame one’s parents or early life circumstances. Exploring early childhood traumas offers insights into the historical origins of later mental health problems, not excuses to continue reacting maladaptively.

Alter Erroneous Beliefs


     As we have seen, beginning in childhood and persisting into adulthood, people develop habitual ways of thinking about themselves and the world. These beliefs automatically enter a person’s mind without questioning their validity or truth. If a person’s life experiences are toxic, these thoughts tend to be distorted, unrealistic, disparaging, self-defeating, and damaging to mental health. In general, anxious people overestimate the possibility of unfavorable and disappointing events. Depressed people tend to overreact to setbacks and adversity by feeling hopeless and blaming themselves. Some common distorted ways of thinking about oneself and the world are:


Polarization: Perceiving everything in extremes, good or bad, all or nothing, black or white. There is no room for a middle ground.

Catastrophizing: Turning the most minor setbacks into calamities. Thinking the worst and believing it most likely will happen

Excessive self-blame: Assuming you are responsible for all bad things and misfortunes. (See next for the opposite false belief)

Fault-finding: Looking to blame someone else when problems occur.

Pessimism: Ignoring the positives in life and magnifying the negative (the glass is always ½ empty),

Feeling Responsible for Changing Others: Believing that it is your responsibility to make another
(usually a loved one) change, to improve life for everyone for their “own good.” This fallacy is the basis for co-dependency.

Shoulds: Strict and rigid rules dictate how you and others should act. Such rules include in it words like “should,” “ought,” and “must.”

Being right: The need to justify and insist on your opinion or behavior without appreciating any other point of view.

Self-sacrifice: The belief that it is your job to put others first, even if it means setting aside your own needs or sacrificing your happiness.

Defective: The idea that you are flawed in some way (“shameful,” “ugly,” “stupid,”
“incompetent,” “a loser,” etc.) and therefore not worthy of being accepted, loved, or cherished.

Perfectionist standards and unrelenting self-criticism: Setting impossibly high life goals (that are bound to end in failure and self-disappointment).

The therapist teaches the client to identify, question, and eventually alter these entrenched erroneous beliefs to reverse this destructive process. There are two phases to this process.

1. The therapist helps the client recognize and question the false beliefs that have, up to this point, created or fed the depression, anxiety, and other toxic emotions interfering with a mentally healthy life. The therapist teaches “critical thinking” (realistic and logical, NOT judgmental or disparaging).

2. The client is taught to substitute distorted or erroneous beliefs with realistic and positive thoughts and actions. Realizing how harmful life experiences, often starting in childhood, gave rise to the negative beliefs that have interfered with one's relationships and life, new insights are gained that allow old emotional wounds to heal. Eventually, the client will stop depending on unhealthy patterns of coping and replace them with realistically based positive attitudes about self and the world


       Typically, the client is assigned specific homework tasks to enhance the therapy. The client may be asked to keep a “thought log.” Between sessions, the client records thoughts, feelings, and beliefs that are reviewed in the next session. For example, as a result of excessive worry and anxiety, the client may record, “I can’t do anything right.” They are asked to give examples to support or contradict the negative beliefs. The goal is to gently challenge the client to realize the irrationality of their beliefs and replace them with more balanced thoughts and reality-based conclusions, as did this client after critically evaluating his self-defeating perfectionist thoughts: “I may not do everything perfectly, but who does and besides I’m beginning to realize it is unrealistic. I usually do things well enough most of the time.” Therapy provides safe opportunities to learn healthy problem-solving skills and stop the dysfunctional thoughts and actions that interfere with one’s life and relationships.

Acquire a Positive Mindset


The greatest discovery of our generation is that human beings can alter their lives by altering their attitudes of mind. As you think, so shall you be.” (William James)


      Positive thinking strengthens mental health because an optimistic mindset alters brain chemistry by releasing endorphins such as serotonin and dopamine, resulting in an uplifted mood. Positive thinking is also a powerful safeguard against diseases and other health problems by strengthening the immune system. We especially realize the benefits of an optimistic mindset in times of crisis and personal misery.


     Positive thinkers have a “can do” attitude about life. Setbacks are seen as temporary and fixable. Because they expect good things to happen to them, optimists tend to roll up their sleeves and work toward solving their problems. They are resilient and hopeful. On the other hand, a pessimistic mindset increases the risk of poor health and a shorter and unhappier life. Pessimists view even ordinary life setbacks as permanent and unchangeable. They often feel helpless and adopt the attitude that their efforts to improve their lives are futile and hopeless. (“Why bother trying? I’m going to fail anyway”). A negative attitude only increases stress, anxiety, and depression. Harmful body chemicals are released (e.g.cortisol), and beneficial chemicals are suppressed to impair physical and mental health.


      The therapist can suggest simple daily tasks to strengthen a client’s positive outlook and help pessimists avoid negative thinking. These include telling someone you appreciate that person’s help or keeping a daily journal of three positive things that happened to you and writing down how paying attention to the positives in your life makes you feel better over time.


     Here is one coping strategy that works with my clients. The purpose is to retrain their brain to convert defeatist and pessimistic thoughts into positive ideas.


1. Identify your negative thinking. Carry a small notepad with you. Step back and pay attention to how often you trash talk to yourself. Jot down all those negative thoughts that pop into your mind. Don’t change anything. Write down even the most trivial remarks. Note the circumstances in which you had the thought. Soon, that silent, disparaging self-talk will become loud and clear.

2. Substitute a positive thought. Ask yourself what different ways you can see the situation or yourself. Write an affirming message to yourself opposite that negative thought in your notepad. Just telling yourself to stop being self-critical or pessimistic about life doesn’t work. It would be best to consciously replace the negative attitude with positive thoughts. (Instead of “I’m a real loser.” write something like: “I’m a good person who needs to work on some shortcomings.”) If you can’t think of any immediate affirmations, focus on what you will become with this new positive mentality. (“From now on, I will be a better listener and not cut off people during conversation.”).

I am not asking you to ignore your shortcomings. We have to know what needs fixing. But you are not being dishonest, selfish, phony, or vain if you also focus on your more positive qualities. Nobody is always “uncoordinated” or always “screwing up.” Even in situations that seem impossible to redeem, train yourself to discover your redeeming qualities. Instead of insisting that you messed up totally, pay attention to what you did well or what lessons can be learned for the future. The secret is to focus on your potential. Don‘t get bogged down obsessing about your limitations. Look for opportunities to change and evolve. (See next section on “Learn and Grow from Mistakes”.)

3. Set reasonable goals. Changing a lifetime of negative thinking takes practice and dedication. Be patient. Over time, your positive messages will begin to make an impact. What stops most people from replacing their old self-messages with optimistic, healthier ones is expecting results in a few days or weeks. The challenge is to focus on the little progress, the increased optimism, and the good feelings as you become more content, confident, successful, healthier, and happier. We’re talking about baby steps here, minor progress each day.

4. Don’t allow despair to stall progress. It takes time and persistence to get over years of feeling that you are “worthless” and a “loser.” All these suggestions to retrain your brain with positive affirmations may sometimes seem impossible to fulfill. Overcoming years of pessimistic thinking is not an easy task. Please don’t lose hope; it can be done.

Learn and Grow from Mistakes


         "Good people are good because they’ve come to wisdom through failure. We get very little wisdom from success, you know.” William Saroyan


A client once declared: “Instead of being embarrassed by how I f-----up my life and my family, I need to take the offensive and take a close look at my screwed-up thinking and just say to myself that I must start over. Actually, I did feel better after that. As you helped me understand, everyone makes mistakes, and wallowing in the guilt instead of taking a hard look at myself doesn’t help anyone. What makes me think I’m so special that I could waste all this time feeling depressed and useless? Much easier now that I forgave myself, learn from this, and move on to better my life.”

    
        When a person suffers a life crisis (divorce, love break-up, financial peril, legal difficulty, etc.) because of foolish actions or personal “failures,” the persistent and often ruthless stream of self-critical and condemning inner thoughts often leads to overwhelming and unproductive guilt, anxiety and depression. The least helpful way to cope with emotional pain is to deny, avoid, or suppress remorse, misery, sadness, and stress. Refusing to think about the problem or trying to escape the pain through alcohol, other drugs, gambling, compulsive shopping, affairs, etc., in the long run, only intensifies the emotional agony and interferes with supportive relationships that could help heal the pain.


        Utilizing an idea inspired by Zen Buddhism philosophy, psychotherapy can provide a much healthier way to cope with pain by focusing the client on the idea that acknowledgment and acceptance can lead to change. The client is taught that suppressing the problem or running away from it by rash and self-destructive actions does not work in the long run and only makes life more complicated and distressing. The client is encouraged to acknowledge the emotional pain by taking an honest inventory of their dysfunctional and irresponsible ways while being more forgiving of their “humanness” and accepting personal shortcomings. Coping strategies are taught that will bring about healthy and life-improving changes in thinking and actions.


        It is often said that wise men and women and fools make mistakes. But the wise learn from their errors. Failures can be compelling teaching opportunities. Ultimately, we must choose how to address our “flaws.” Will we view “failures” as threats to our self-worth and deny or otherwise avoid them, or will we see our imperfections as challenges to draw important life lessons and opportunities to grow and learn?

Practice Relaxation Techniques


        When a person is anxious, nervous, frightened, or just plain stressed, there is a predictable pattern of physical changes caused by the body’s sympathetic nervous system. Hands and feet get cold and clammy, heart rate increases, muscles tense, breathing intensifies, and brain activity becomes erratic and unstable. These changes are automatic reactions to survive danger. A situation does not have to be life-threatening to trigger this same nervous reaction. Confronting daily stressors, worrying about the future, or remembering painful memories activate the sympathetic nervous system. Monitoring and controlling these sympathetic reactions and gaining control over them is the aim of relaxation training. These techniques work especially well for clients who want to participate actively in their treatment and are willing to practice relaxation skills.


        Here is how practicing relaxation techniques helped a young girl in distress. The parents of a fifth grader recently sought treatment for their honors student daughter because she was having anxiety attacks before going to school. The initial interview uncovered the source of her anxieties. She was a victim of bullying in school. Even after the bullying situation was resolved, she still suffered from anxiety that ultimately interfered with her school work and social interactions. To help her gain control over her anxiety reactions, she was taught relaxation techniques. She practiced her relaxation before going to school and during the day when she felt the slightest bit anxious. After five sessions, the young client reported no noteworthy symptoms and enjoyed school again. Her parents happily agreed with her optimistic reports.


        Meditation therapy is another form of relaxation training that specifically applies age-old meditation techniques to help the client become free from unproductive thoughts, feelings, and worries that cause emotional misery. Clearing one’s mind of distressing thoughts and feelings takes practice. The benefit is that the client gets better at reacting to the immediate problematic situations in a mentally healthy way rather than falling back to past dysfunctional reactions. Research shows that clients who regularly practice meditation gain a multitude of mental health benefits. Tolerance for stressful events, an increase in overall relaxation and calmness, a more productive problem-solving mentality such as improved concentration and increased memory, effective coping skills, less judgmental attitude toward oneself and others, reduction in pessimistic thinking, more restful sleep and reduced anxiety, anger, and depression are among the benefits. Neuroscientists studying long-time meditators find that the part of their brain associated with positive feelings and thoughts is notably more active than in non-meditators brains. Meditation is not a mysterious or complicated technique, although it takes practice to achieve the best results, like any other skill. Also, modern meditation isn’t about contorting oneself into various yoga positions or embracing Buddhist philosophy. Meditation therapy aims to clear one’s mind of stressful thoughts and distractions so one can become absorbed in the present moment of experiencing a tranquil and uncluttered state of mind and body.


        Stress-reducing relaxation techniques are employed when a client learns to be anxious about a situation due to a stressful or traumatic event. The client is encouraged to confront the stressful situation gradually rather than avoid it. This form of therapy teaches new coping skills to people troubled by phobias, panic attacks, post-traumatic stress reactions, and obsessive-compulsive reactions. In safe, gradual steps (“baby steps”) and within one’s comfort level, the client is exposed first to the least fearful, then gradually to more threatening situations, until they realize that nothing bad will happen... Using this systematic relaxation technique, stress-related reactions become manageable and, in most cases, disappear.


       A middle-school student became visibly sick in front of her classmates and consequently was too embarrassed and self-conscious to return to school. After she was taught to relax, inducing deep breathing, she was asked to recall an image of the traumatizing event and the embarrassing and self-conscious feelings that arose. Then, while retaining the very relaxed state, the client was instructed to let go of the traumatic memory and focus on positive and tranquil images (a favorite is lying on the beach and listening to the waves gently roll onto shore). Then, the whole process was repeated until she was utterly desensitized from the emotional pain associated with the traumatizing event. In the final stage of therapy, the client replaced the painful thoughts and feelings with positive ones that encouraged her triumphant return to school.


        When working with children, I often find that mentally unhealthy behavior (temper tantrums, disrespect, behavioral acting out, etc.) is learned for attention or “getting one’s way.” In these cases, the therapist’s job is to help the child unlearn the dysfunctional actions and replace them with healthier behaviors. When a child is referred for psychological treatment, it is essential, in my opinion, to also include the parents.
(and other family members) to modify their approach to parenting. Suppose a child’s problematic behavior is learned by having it unintentionally encouraged through attention or other forms of unproductive rewards. In that case, significant people in the child’s life (parents, siblings, and teachers) are taught to reinforce healthy behaviors through praise, positive recognition, and other suitable rewards. The family’s well-intended parenting practices are reviewed to ensure that the family provides the proper incentives for positive behavior and workable and effective consequences for problematic behaviors. Common but unproductive parenting habits are discouraged, including empty threats, shouting matches, nagging, imposing excessive guilt, shaming, and belittling.

Take Charge of your Mental Health

      “Until now, I always believed I couldn’t help getting angry. I was always this way. That’s all I knew. I still get angry sometimes, but now I see it coming and know what to do. As you say all the time, it’s especially helpful when I can stop it before it gets out of control.”

    A significant theme in psychotherapy is to encourage clients to:
1. take responsibility for their actions and choices in life and
2. make the necessary life changes that they may have been avoiding up to this point.
    
        Many people resist accepting that they have a choice regarding how their life will turn out. They prefer to believe that what happens to them is due to forces outside their control, such as their upbringing, life traumas, social environment, etc., and that they can’t do anything about it. Anxiety, depression, alcoholism, anger, and all the other unhealthy emotions and dysfunctional behaviors are inevitable. A goal of therapy is to inspire the client to adopt healthier choices to meet basic human needs and take control of their mental health by learning the coping skills to meet basic needs for a successful, fulfilling life.

Manage Anger

        The inability to manage anger is a common reason people seek psychological help. Many clients were never taught self-control or were raised in a home where anger was the reaction of choice for most conflictful situations. People with anger management problems have a history of explosive outbursts toward others or destructive acts toward property that are out of proportion to the reality of the situation. They will overreact angrily to insignificant irritants. Their body language emits hostility (e.g., tense muscles, clenched jaw or fist, glaring looks, no eye contact, etc.). They often use indirect behavior patterns (“passive-aggressive”) to show their anger. Passive-aggressive actions include giving the “silent treatment”, refusing to cooperate to frustrate the other person, embarrassing the other person in public, and criticizing others behind their backs. They persistently challenge or disrespect authority figures. They often employ verbally offensive language to control others.

        The therapist helps the client become aware of the many ways they express anger by first confronting the hostile behaviors and, as therapy progresses, having the client identify their aggressive acts during the week. Then, the therapist and client review alternative socially acceptable and non-self-defeating ways to address angry feelings, perhaps role-playing healthy reactions. Psychotherapy may take the form of identifying past hurt and pain going back to childhood, as well as current life situations that may be fueling excessive anger. Teaching empathy or putting oneself in the other’s shoes increases the chances that the client can forgive and forget his unreasonable anger. The client may have their erroneous beliefs about anger challenged and then be encouraged to replace them with more reasonable and logical thoughts. (“The only reason I come home so angry is the first thing I see is all the kids’ toys everywhere.” versus “Yes, seeing all those toys laying around frustrates me, but that is no reason to blow a gasket. It’s time to fix up the basement so the kids have a place to play. It’s unfair to blame my wife and get angry at her and the kids. The kids need to play, and I probably was the same way when I was a kid. Besides, I now realize that I’m angry about a lot of things and often take it out on my wife and kids.”)

        No matter the origin of the anger, the client is also taught to use meditation, exercise, and other relaxation techniques to “chill” and make time to reflect on whatever makes them angry at that moment. As with other psychological issues, a qualified psychotherapist will integrate various therapeutic approaches to help the client achieve lasting success in managing and reducing their unwarranted anger and developing healthier ways to express legitimate resentments and concerns.

Improve Communication Skills

        Often, the problem also lies with how an individual deals with others, such as spouses, children, friends, and co-workers. Interpersonal difficulties may arise during significant stress points and transitions in one’s life, such as the birth of a child, child leaving home, divorce, job loss, or death of a family member. In such cases, psychotherapy focuses on improving the client’s communication skills to minimize needless misunderstanding and hurt, especially as the client relates to family and friends during times of distress.

        Love, Marriage, and Family: A person’s mental health problems can have an impact on their love relationships, marriage, and family. And the reverse is true. Relationships, marital, or family issues can adversely affect a person’s mental health. Besides treating the “identified client,” the therapist may invite into treatment the client’s spouse, love mate, or other family members who are also suffering or who are somehow contributing to the problem. Communication difficulties between marital partners or among family members are addressed. Hidden feelings of hurt, confusion, resentment, anxiety, and anger often surface that negatively affect the relationship. How inevitable fights, conflicts, and disagreements are resolved can bring people closer or further apart. Usually, marital, family, and individual issues are intertwined. In these cases, the relationship, marriage, or family is also “the client.” Success in therapy is greatly enhanced when one’s spouse or family members take part in the therapy. A primary focus of family therapy is not to determine which family member is to blame for the family problems. Instead, it is to uncover the dysfunctional communication patterns and help members learn better ways to resolve family conflicts by encouraging support and closeness.

        The Couple: Couple’s therapy aims to help each partner take charge of the mental health of their relationship and resolve the problems between them. Couples therapy is not a vehicle to force change in their partner, although that is often the stated or unstated reason many people enter couples therapy. It is the therapist’s job to point out how each partner’s actions and styles of communication impact the other. Research has shown that couples in healthy relationships communicate in ways that inspire mutual compassion and acceptance. In contrast, couples in problematic relationships communicate in ways that increase hostility, disrespect, and pessimism about their relationship. The therapist will help the dysfunctional couple discover better ways to communicate so that each partner can be attentive to their own and the other’s legitimate needs and be engaged and emotionally responsive. The therapist will also help each partner address the anger, pain, and other negative emotions that often accompany or underlie poor communication. Finally, the therapist may need to clarify and help correct false beliefs and assumptions about what to expect in a marriage, often based on the marriage of each partner’s parents.
    
        One therapeutic strategy is to ask the couple to recount typical contentious scenarios and use these interactions as teaching tools to enhance effective communication, listening skills, and problem-solving approaches. The couple will be encouraged to initiate positive communication and acts of kindness at home between sessions. For example, after rehearsing good communication skills in session, the couple's homework assignment may be to set aside some uninterrupted time to discuss troublesome topics needing resolution.
The couple will be reminded to use “I” statements (“When you do that, I feel hurt.”) and avoid “you” statements (“There you go again, making me feel hurt by your stupid comments.”)

        Another strategy is to ask the couple to keep a journal throughout the day indicating when they feel appreciated, angry, fearful, happy, hurt, sad, ashamed, surprised, etc. The couple is asked what actions by the partner triggered these positive and negative feelings and to identify how they expressed these emotions in the relationship (anger, “shut down,” moody, etc.) and how their expressions affected the relationship. The therapist suggests how each partner can obtain their legitimate needs healthily and respectfully instead of being angry and controlling.

        Sometimes, the emotions and behaviors that hinder couple communication are deeply entrenched in the personality of one or both partners. The kinds of childhood relationships they had, especially with parents, often set the stage for how people relate with loved ones as adults. Many of these childhood patterns, healthy and unhealthy, are internalized without the person’s conscious awareness. Treatment aims to bring these unconscious relationship “blueprints” out of the darkness so that the couple can alter the dysfunctional patterns that interfere with emotional (and often sexual) intimacy.
    
                                                                           HEALTHY HABITS

Developing healthy life habits is as essential for one’s mental health as participating in psychotherapy. Yoga, stress-reducing deep breathing, meditation, exercise, good diet, spending time outdoors around nature, going for a hike or just working in your yard, random acts of kindness to oneself and others, good friendships, reading engaging books, prayer and church attendance for the religiously inclined are a few suggestions that might be recommended in conjunction with psychotherapy to renew one’s mental health. In my opinion, a psychotherapist would be remiss not to remind his clients of the importance of these activities for strong mental health.

Exercise

        Besides being good for general health, physical exercise also benefits mental health. More and more evidence shows that regular cardio exercise enhances stress reduction, decreases symptoms of depression and anxiety, lowers the risk of serious illness, and adds to overall well-being. And the benefits extend to older adults. Walking for at least 30 minutes three or more times a week stops cognitive decline in adults in their mid-60s and improves such functions as memory. Increasingly, physical exercise has become an essential addition to psychotherapy. The therapist may identify what exercises the client currently or previously participated in and enjoyed. Then, the client is asked to exercise consistently and note the prevailing mood daily. The client will likely acknowledge a clear connection between exercise and overall positive mood.

Diet        

        A balanced diet that is low in fat, junk food, and sugar products, high in fiber content, and includes five servings of fruits and vegetables is essential for a healthy body and mind. Good nutrition also means not skipping meals, leading to mood swings and low energy. Caffeine, which exists in coffee, tea, sodas, energy drinks, and chocolate, if ingested in excessive amounts, can make things worse for an anxious person or trigger anxiety reactions in previously calm individuals. Clients are often surprised at their poor nutritional habits when asked to list everything they ate over the week. They discover the lack of sufficient fruits and vegetables, the excessive amounts of fat, sugar, and caffeine in their diet, and their neglect to eat regularly.

Stress Reduction in Everyday Life

        Stress reduction techniques are a vital part of some therapeutic approaches discussed earlier and should be essential to all discussions about improving one’s mental health. Simple ways to reduce stress and boost a positive mood include regular exercise, practicing meditation and mindfulness each day, a peaceful walk, a hike in the woods, reading a book, listening to music, attending a yoga class regularly, etc. Whatever stress-reducing activities a person uses, they should become a natural and consistent part of their life.

Prayer, Church Attendance, and Secular Coping Practices

        Participation in one’s religion isn’t recommended often enough for good mental (or physical) health. Recent studies reveal the health benefits of a rich religious and spiritual life. This is especially true for religious people who view their God, or “higher power,” as forgiving and inspiring hope as opposed to a God viewed as unforgiving and punishing.
For those not religiously inclined, don’t fret. Studies also show that secular and religious individuals can achieve similar mental and physical health benefits if they exercise, meditate, walk in the woods, perform random acts of kindness, take good care of themselves, and consistently engage in similar serenity-enhancing activities.

Positive Relationships

        The importance of solid mental health in close friendships and emotionally and sexually intimate relationships cannot be emphasized enough. Having happy thoughts about someone you like has benefits by releasing certain chemicals in your body (e.g., oxytocin) to neutralize the harmful stress-related cortisol hormone that interferes with your body and mind to handle life stresses.

                                                                                      MEDICATION

        Which works best, psychotherapy or drug therapy? As a general rule, psychotherapy alone is most effective for the milder to moderate disorders. For clients with moderate to severe disturbances, psychotherapy combined with drug therapies may work best. The personality of the client also determines which is best. If a client is not very motivated to help him or herself through psychotherapy or their maladaptive emotions and behaviors are so deeply entrenched that they cannot detach from their feelings and actions, drug therapy may be necessary to enhance psychotherapy success. Medication relieves disturbing symptoms (e.g., debilitating anxiety and depression, severe mood swings, etc.). Still, only psychotherapy helps the client develop the coping skills to resolve problems and improve relationships, make healthy life decisions, and provide the empathic bond and acceptance to inspire the client to continue working on their mental health.

        Combining psychotherapy and medication works like this. Once the disturbing thoughts, feelings, and behaviors are stabilized, the client can take full advantage of the insights and coping strategies introduced in psychotherapy. Many clients who are compliant about taking their medication and continuing psychotherapy may be able to stop taking medication within six months to a year. However, studies have found that without psychotherapy, the client’s symptoms often return when they go off their medication, even after the prescribed period. That is why many physicians will only prescribe psychotropic medication under the condition that the client follows up with psychological treatment.

        Potential side effects, especially for the commonly prescribed antidepressants and anti-anxiety medications, tend to be relatively mild and temporary for most clients. Side effects of antipsychotic medications can indeed be disturbing and enduring. The following summary of drugs and their effects is no substitute for consultation with your primary care physician, medical professional, or psychiatrist. Ultimately, the best treatment occurs when medical and psychological professionals coordinate their care of the client.

Antidepressants

        This commonly prescribed group of medications increases the available amount of particular chemicals called neurotransmitters (serotonin, norepinephrine) in your brain to improve mood. The release of neurotransmitters in one’s brain limits a specific neurological function called reuptake that hinders mental health. In reuptake, a cell releases serotonin and norepinephrine into the brain, which is good. But these chemicals often reabsorb in the body before they can work. Antidepressants increase the time the neurotransmitters can function in the brain to improve mood. In a few words, they correct the imbalance in a depressed person’s brain chemistry. Although commonly called anti-depressants, they also effectively reduce anxiety and excessive worry.

       Clients taking antidepressants should notice a more optimistic mental outlook, a decrease in anxiety, anger, and depression, reduced feelings of hopelessness, guilt, and confusion, as well as a return to normal sleep and eating habits. Clients consistently tell me that the medication “takes the edge off” or that they feel like their old self. It takes between two and four weeks to feel better. To answer the common concerns of many clients, antidepressants are not addictive, and they will not stimulate, intoxicate, or cause a person to be “high.” However, they will boost one’s “psychological immune system” so that the natural neurological functions can work to maintain a healthy mood.

Anti-anxiety

        Commonly called tranquilizers, this type of psychotropic medicine decreases overall anxiety levels. Antianxiety medications enhance sleep and relax tense muscles. As discussed above, anti-depressants are also prescribed to alleviate anxiety symptoms.

Mood Stabilizers

        This group of medications lessens the mood swings characteristic of bipolar disorders. Some mood stabilizers were initially used as an anti-seizure medication and are also shown to be effective for the treatment of bipolar disorders.

Antipsychotic Medications

        These medications are for the treatment of schizophrenia and other psychotic disorders. The aim is to provide a soothing effect on clients as well as to reduce the severity of any hallucinations, delusions, and other psychotic thinking. They all work by reducing the level of the brain's chemical dopamine, and some of the newer medications also lower the amount of serotonin released into the brain. Besides reducing typical psychotic symptoms, this latter group may be used to decrease symptoms of low energy and lack of emotional expressiveness and increase general participation in life for non-psychotic clients as well.

                    MENTAL HEALTH DISORDERS COMMONLY SEEN IN OUT-PATIENT SETTINGS

Anxiety Disorders

        It is the most common mental health problem. NIMH statistics indicate that about 18% of adults suffer from anxiety problems every year; that’s 40 million Americans. About 29% of adults are affected by an anxiety disorder sometime during their lives.  

        • Generalized Anxiety Disorder (GAD) refers to intense and persistent worries and fears that may or may not have a realistic basis to them.

        • Panic Disorder is characterized by overwhelming fears and anxieties that peak at about 10 minutes and usually last no more than half an hour. The person reports no apparent warning and can find no cause. Some typical symptoms during a panic episode include trembling fear, shortness of breath, a smothering feeling, rapid heartbeat, dizziness, abdominal cramping, headache and the belief they are dying, often of a heart attack or having a nervous breakdown. A fear of leaving one’s house (agoraphobia) may complicate the problem.

        • Phobias are powerful and irrational fears of an animal, insect, situation, or place (bridges, closed spaces, heights, etc.). Social Phobia (often called Social Anxiety) is the fear of being humiliated or embarrassed in social situations.

        • Obsessive-Compulsive Disorder (OCD) is characterized by uncontrollable, senseless, intrusive, and distressing thoughts and impulses (obsessions) that trigger anxiety and often compel the client to perform repetitious and ritualistic acts (compulsions) to relieve the anxiety. Typical examples include the uncontrollable urge to check doors and windows for safety or repeatedly washing hands well beyond the requirements for good hygiene. These irresistible habits are dysfunctional attempts to gain some peace of mind.

        • Post Traumatic Stress Disorder (PTSD) is caused by experiencing a life-threatening trauma or one in which the person feels an enormous sense of powerlessness. An accident, a crime, a natural disaster, rape, or war are such traumatic events. The trauma may be recent or experienced many years earlier and blocked from memory until it surfaces as disturbing memories or dreams or triggered by some reminder of the original trauma. Symptoms can include intense anxiety, depression, irritability, avoidance of people or situations that remind of the trauma, vivid and intrusive flashbacks of the traumatic event, hypervigilance, feeling numb or detached from reality, morbid or suicidal thoughts, nightmares, and trouble sleeping.

Mood Disorders

        This group of disorders is the second most common, comprising about 10% of the adult population each year. Approximately 21% of all adults will experience a mood disorder during their lives. (Regarding just depression and not mood disorders in general, the NIMH states that 6.7 % of the American population, or 14.8 million adults, will suffer from depression in any given year.)        

        • Major Depression is the most crippling mental health problem in the world and can last for months or years if not treated correctly. Besides extreme sadness and despair, the person may experience concentration difficulties, insomnia or sleep deprivation, no joy or pleasure in life, limited energy, weight changes, and often strong thoughts of death and suicide.

        • Dysthymia is a chronic, “low-grade” depression that usually starts in the teen years. Typical signs are negativity and pessimism, low self-confidence and feelings of inadequacy, little enthusiasm or motivation, and diminished joy.

        • Grieving a loss, such as the death of a loved one, divorce, or a child going off to college, can be debilitating and emotionally painful and is often experienced as a form of depression.

        • Bipolar Disorder is characterized by extreme mood swings. The symptoms range from severe episodes of mania (irrational exuberance and self-confidence, extra high energy, distractibility, impulsiveness, agitation and irritation, decreased need for sleep, racing thoughts, and speech) to extreme episodes of depression with periods of “normalcy” in between. Without proper treatment, including medication, people with bipolar disorder usually become progressively worse, and the suicide rate is notably high.

Alcohol and Drug Problems

        Approximately 4% of adults annually and 15% of all adults at one time in their lives will suffer from substance abuse or dependence.

        • Substance Abuse is defined as a pattern of alcohol and drug use that 1. Interferes with home life, friendships, school, or work, 2. It is used in situations that can jeopardize the safety of oneself or others (while driving or caring for children), and 3. Persists despite negative consequences (e.g., legal, marital, job problems).

        • Substance Dependence (Addiction) is the more serious diagnosis and is given when the client develops a tolerance to drugs or alcohol that requires more amounts to achieve the desired effect. Also, withdrawal symptoms are evident unless use continues, all control is lost, and the client’s life centers on obtaining and using alcohol or drugs. Psychotherapy is often not enough. The client may need to enter a detoxification program, take medication to block the desired effect of getting high and participate in a 12-step program such as Alcoholics Anonymous or Drugs Anonymous.

Eating Disorders 

Approximately 5% of the adult population, primarily women, will suffer from an eating disorder within their lifetime.

    • Anorexia refers to a fear of gaining weight, an irrational view of being overweight despite being dangerously underweight, binging then purging by laxatives or vomiting, strict dieting, and compulsive exercising.

    • Bulimia also involves persistent and excessive fears of being overweight, uncontrollable binging, and self-induced vomiting. Unlike anorexia, the client’s weight is closer to the normal range and, therefore, may not yet pose a serious health problem. Nevertheless, purging can cause serious disruption to the metabolism process and lead to illnesses of the esophagus and throat.

Childhood and Adolescent Disorders

    • Attention-deficit/hyperactive disorder (ADHD) describes between 7 to 10 % of preschool and school-aged children in the USA. Symptoms include inattention, hyperactivity, and impulsivity. Children with ADHD often suffer from learning disabilities, depression, anxiety, and disruptive behavior. All ADHD children have trouble paying attention, especially to tasks of minimal interest. Many are also hyperactive or impulsive.

    • Tic Disorders and Tourette’s Disorders show symptoms that are involuntary and rapidly recurring movements (“tics”) or vocalizations, such as grunts. Tics can cause significant embarrassment and social anxiety for the child and may be so severe as to interfere with academic, social, and general functioning.

    • Oppositional Defiant Disorder refers to defiant, disobedient, and antagonistic behavior toward authority (not just parents) that is severe and persistent enough to interfere with the child’s general functioning and social adjustment. Children less than ten years of age are seldom diagnosed with this disorder.

    • Conduct Disorder is another form of aggressive and hostile behavior, but with more serious consequences. The client violates social norms and the rights of others by aggressive actions that threaten or cause harm, property damage, deceitfulness, theft, or the violation of rules.

    • Anxiety Disorder of Childhood, like its adult counterpart, refers to physical (nausea, vomiting, etc.) and emotional manifestations of extreme stress that last for a long time and upsets the child’s ability to function at school, socially, and at home. Any situation that requires the child to perform under pressure or threatens the child’s self-esteem, such as school or performing in front of others, can trigger an anxiety reaction. School-related anxiety may be so overwhelming as to cause the child to refuse to attend (school refusal).

    • Separation Anxiety Disorder is indicated if a child shows extreme anxiety or panic when not with parents or in familiar surroundings that is atypical for the child’s age.

    • Obsessive-Compulsive Disorder in children, as with adults, involves persistent and intrusive thoughts or repetitive and ritualistic patterns of behaviors not typical of children the same age.

    • Social phobia, characterized by avoiding contact with unfamiliar people because of extreme fear of doing something embarrassing or personally humiliating, is prevalent among adolescents.

    • Depressive Disorders of Childhood share many characteristics of adult depression. A significant difference is that children often “act out” their sadness and despair by misbehaving, isolating themselves from family and friends, performing poorly in school, etc.

    • Autism Spectrum refers not to a single disorder but a continuum of closely related disorders with a common core of symptoms. Every child on the autism spectrum has challenges with social skills, empathy, and communication. They exhibit restricted, repetitive, and stereotyped behavior that is not age-appropriate. A child can be placed along a spectrum denoting the severity of developmental challenges. Their symptoms mildly impair some, while others are severely disabled. Autistic disorder, Asperger's disorder, and Pervasive developmental disorder are common terms to describe this spectrum of symptoms.

Personality Disorders

        This group of disorders, from 10 to 15 percent of our adult population, is seldom seen voluntarily in outpatient settings because most people with personality disorders deny they have a problem and are unwilling to change. A loved one can occasionally convince the person to seek help, although reluctantly. People with personality disorders relate to others, think, and perceive themselves and the world in ways that are rigid, socially distressing, and often destructive to themselves and loved ones. Anxiety, depression, mood swings, substance abuse, and anger outbursts are difficult to manage because of the person’s denial and poor insight into their problems. They are often viewed as hostile, detached, needy, antisocial, or obsessive. Consequently, relationships are often chaotic and unstable, and steady employment is difficult to maintain. Diagnosis of personality disorders should wait until at least early adulthood since these patterns are typically part of the growing-up process in younger people. Personality disorders are grouped into three clusters.

1. The Eccentric Thinking and Odd Behavior cluster comprises Schizoid, Paranoid, and Schizotypal Personality Disorders.

2. The Dramatic, Emotional, or Erratic Behavior cluster: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders.

3. The Anxious and Fearful Thinking cluster: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders.

    Treatment is limited by the very nature of personality disorders, which unusually remain relatively constant throughout life. Mood swings and anger associated with specific disorders can be managed by medications, especially if the client sees these symptoms as a “medical problem.” Still, there is no medication specifically to treat the underlying personality disorder. Psychotherapy may allow setting firm boundaries on the most outrageous behaviors. Indeed, the clients loved ones can benefit from support and learning strategies to provide clear limits on unreasonable actions while, at the same time, safeguarding their mental health, which often is threatened by the chaos and toxicity caused by the client with a personality disorder.

            AN INTEGRATED APPROACH TO HELPING CLIENTS ACHIEVE MENTAL HEALTH

        A client of mine recently told me the following, which illustrates the importance of an integrated approach to address the many levels of causes and solutions for his distress. “I used to wonder what was wrong with me. I forgot how I was neglected by busy parents and somehow thought it was my fault. I’m now aware that I still view life through the eyes and mind of a kid once in a while. When I realize it now, I remind myself how ridiculous that is. I got to remember to separate how I saw things as a sad, confused, and nervous kid and think about it as a 50-year-old man. It’s been hard. When I lose focus, that’s when I get into trouble (i.e., depressed and anxious). When I think in small, baby steps and practice every day, I can see the progress. You know, do my meditation, jog every morning to start the day, live in the present, watch my negative thinking, don‘t be so intense and make a big thing out of nothing, work on my marriage by opening up to my wife. If I set my mind on that and not being perfect, I don’t get stressed out or depressed. Trying real hard to get into my head and my heart to be more reasonable and hopeful, you know, that half-full glass”.

        In my opinion, successful psychotherapy requires that the therapist be competent in a range of therapeutic approaches. Often, the client benefits from exposure to a careful mix of several methods, depending on their personality and problem. For example, a client complains of long-term depression and anxiety. He might profit initially from a therapy that focuses on securing trust in the therapist and his ability to achieve psychological potential. Also, very often, depressed clients must overcome a lifelong belief that they are unworthy and undeserving of being successful and happy, so bolstering self-esteem is required before the client will allow themself to be taught better ways to cope or confront their unrealistic and illogical thoughts. Having renewed self-confidence also increases the chances that clients will be motivated to practice healthier thought and behavior patterns and apply these new reactions in their everyday lives. Exploring how childhood experiences set the stage for negative and irrational thinking outlook and examining and reexamining those experiences as an adult, not as a confused and frightened child, could provide important insights and relieve entrenched guilt and feelings of fault and blame. The phrase:” It was not your fault…” said by a trusted and understanding therapist at the right time can be magical and deeply healing. Finally, the impact of the client’s depression, anxiety, or anger on other family members often requires some form of family or couple therapy.

        Regardless of the therapist's approach (psychoanalytic, cognitive, behavioral, humanistic, etc.), if the psychotherapist is genuine, competent, understanding, and compassionate, and a mutual bond is established, therapy is likely to be successful. As mentioned earlier, successful psychotherapy involves teamwork and a good fit between therapist and client. Research has repeatedly shown that the type of therapeutic approach is less important than the therapeutic relationship. The bottom line is that therapy will be successful to the degree that the psychotherapist inspires, encourages, and teaches the client to change and meet their life problems in a mentally healthy way.





SOURCES

Carson, R.C., Butcher, J.C., and Mineka, S., Abnormal psychology and modern life, N.Y.: Harper Collins, 1996
Diagnostic and statistical manual of mental disorders: DSM IV, Washington, D.C.: American Psychiatric Association, 1995
Preston, J., Varzos, N., and Liebert, D., Every session counts: making the most of your brief therapy, San Luis Obispo, CA: Impact Publishers, 2000
Wood, J.C. and Wood, M., Therapy 101: a brief look at modern psychotherapy techniques and how they can help, Oakland, CA. New Harbinger Publications, 2008
Zafon, Carlos Ruiz, The Shadow of the Wind”, The Penguin Press, New York, 2004     

                                                                                                                                               Revised 12/2023 

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