tag:blogger.com,1999:blog-87342277459961821452024-03-27T19:53:33.047-04:00Practice WisdomA collection of reflections for those learning and practicing psychotherapy, and clinical social work more generallyNatalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.comBlogger236125tag:blogger.com,1999:blog-8734227745996182145.post-68730390708248862542013-10-17T17:21:00.002-04:002013-12-18T23:34:16.857-05:00Layers of Thoughts<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7kqcTOE6MC2AwHurtoSzxqzE934g0J9gryydjesGZnQySxqpuDKaTQvHr5EBHyjv2uwmZET1OMTTJtL5MBi0usf0kqE-ukAQOpmTIdfsII2RGsEGqYALkpGK1N54J3qnTfTempOv_3y4W/s1600/onion.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7kqcTOE6MC2AwHurtoSzxqzE934g0J9gryydjesGZnQySxqpuDKaTQvHr5EBHyjv2uwmZET1OMTTJtL5MBi0usf0kqE-ukAQOpmTIdfsII2RGsEGqYALkpGK1N54J3qnTfTempOv_3y4W/s320/onion.jpg" width="320" /></a>In CBT, identifying, questioning, and challenging your thoughts is complicated by the fact that a lot of thinking happens below the surface of conscious awareness. In fact, the cognitive model describes layers of cognition that are sometimes compared to the layers on an onion: peeling back the outer layers reveals the layers underneath. Using this metaphor, your conscious thoughts make up the skin on the outside of the onion. These are the thoughts you are most aware of at any particular moment – the thoughts in the forefront of your mind that make up your ongoing stream of consciousness. They include things that you are paying attention to, focusing on, or choosing to think about. <br />
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Just underneath your conscious thoughts is a layer of what are known as “automatic thoughts.” As the name implies, these thoughts happen automatically – without conscious deliberation. They are typically judgments or evaluations, and are generally brief – sometimes only a few words or a mental image. Automatic thoughts happen so quickly that we are barely aware of them; however, they are relatively easy to bring into conscious awareness because they often produce a shift in mood or emotion. You can become aware of your automatic thoughts by noticing changes in how you feel, and asking yourself: “What was just going through my mind?” <br />
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Automatic thoughts, in turn, give us clues about the interior layers of the onion – our intermediate and core beliefs. Beginning in early childhood, we develop beliefs about ourselves, other people, and the world we live in. Some of these beliefs are so fundamental to how we view everything that we see them as absolute truths. We call these "core beliefs." Core beliefs are the basic assumptions that determine to what degree you see yourself as worthy/unworthy, safe/threatened, competent/incompetent, powerful/vulnerable, independent/dependently, and loved/unlovable. They also establish your sense of belonging and how you expect to be treated by others. <br />
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Although we are often not consciously aware of our core beliefs, they have a significant impact on us: situations in daily life activate core beliefs, which then shape our perception and interpretation of the situation. The way that core beliefs influence our perception, interpretation, and response to a situation is through what are called "intermediate beliefs." These include our attitudes, assumptions, and rules. Attitudes are evaluative statements (e.g., "It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "should" (or must, or ought) statements. Intermediate beliefs arise from core beliefs, either as logical extensions of them, or as attempts to cope or compensate for what we believe is true, for example: “I am inadequate so I need to work harder than everyone else.” “I am unlovable, so I should expect rejection.” <br />
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Core beliefs can be combined in patterns called “schemas,” along with associated intermediate beliefs, and the emotions, body sensations, and behaviors they produce. Schemas serve as templates for processing and understanding life experiences, filtering incoming information so that we take in information that fits our existing core beliefs, while screening out anything that contradicts our beliefs. Schemas also shape the content of conscious and automatic thoughts. Automatic thoughts, in turn, strengthen and reinforce beliefs: the more you “hear” yourself think something, the more convinced you are that it is true. These processes together make core beliefs difficult to change. However, the time and effort needed to change them has a significant payoff: the resulting changes to intermediate beliefs and automatic thoughts can produce lasting emotional and behavioral benefits.Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com20tag:blogger.com,1999:blog-8734227745996182145.post-81127776915566423412013-10-09T10:50:00.001-04:002013-10-09T10:50:37.961-04:00Core Beliefs and Schemas<span style="font-family: inherit;"><span style="color: black;">We all develop beliefs about
ourselves, other people, and the world we live in, beginning in early
childhood. Some of these beliefs are so fundamental to how we
view...everything...that we see them as absolute truths. We call these
"core beliefs." </span>Core beliefs are your basic assumptions about
your value in the world. Core beliefs determine to what degree you see yourself
as worthy, safe, competent, powerful, independent, and loved. They also
establish your sense of belonging and basic picture of how you are treated by
others. <span style="font-size: 8pt; line-height: 115%;"><o:p></o:p></span></span><br />
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<span style="color: black; font-family: inherit;">We may not be consciously aware of
our core beliefs - they are kind of like the water fish swim in. However, they
have a significant impact (like water does for fish): situations can activate
core beliefs, which then shape our perception and interpretation of the
situation. In fact, we tend to filter incoming information to accept
information that fits the core belief, while discounting anything that
contradicts our belief.<br />
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The way that core beliefs influence our perception, interpretation, and
response to a situation is through what is called "intermediate
beliefs." This category includes our attitudes, assumptions, and rules.
Attitudes are evaluative statements ("It would be terrible if..."),
assumptions tend to be "if...then..." statements, and rules are
"shoulds" (or musts, or oughts). These intermediate beliefs arise
from core beliefs, either as logical extensions thereof, or as attempts to cope
with a painful core belief (often that one is inadequate and/or unlovable): I
am inadequate so I need to work harder than everyone else. I am unlovable, so I
should expect rejection. Etc. </span><span style="color: black; font-size: 8pt; line-height: 115%;"><o:p></o:p></span></div>
<span style="font-family: inherit;"><span style="color: black;">Both kinds of beliefs shape the
content of your thoughts from moment to moment – your internal monologue, or
“automatic thoughts.” Automatic thoughts, in turn, strengthen and reinforce
your beliefs.</span> For example, when you tell yourself constantly that you’re
stupid, you convince yourself that this is true. By the same token, if your
self-statements reflect a basic faith in your intelligence, this core belief
will be confirmed and solidified. <o:p></o:p></span><br />
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<span style="font-family: inherit;">As you can see, core beliefs are the very foundation of your
self-image: they largely dictate what you may and may not do (your rules), how
you present yourself (your attitude) and how you interpret events in your world
(your assumptions and automatic thoughts). Therefore, holding negative beliefs
takes a significant toll on your mood, relationships, and overall functioning.
Changing your core beliefs requires time and effort; and yet changing them will
fundamentally alter your view of yourself and your environment. <o:p></o:p></span></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><span style="font-family: inherit;">Schemas<o:p></o:p></span></span></b><br />
<span style="font-family: inherit;"></span><br />
<span style="font-size: 12pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><span style="font-family: inherit;">Core beliefs are also combined in patterns that are referred
to as schemas. Schemas include beliefs about yourself, the future, other people
and the world, along with associated intermediate beliefs (now called schema
processes), which produce emotions, body sensations, and behaviors. Schemas
form templates for processing and interpreting life experiences.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<span style="font-size: 12pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><span style="font-family: inherit;">Dr. Young and his colleagues have identified 18 “early
maladaptive schemas:” schemas that develop very early in life and can produce
distress and difficulties throughout one’s life. Read through their list of
schemas and rate how strongly you think each one applies to you, from 0-100%.<o:p></o:p></span></span></div>
<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Emotional Deprivation<o:p></o:p></span></span></b><br />
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one’s
primary emotional needs will never be met by others. These needs can be
described in three categories: Nurturance – needs for affection, closeness and
love; Empathy – needs to be listened to and understood; and Protection – needs
for advice, guidance and direction. Generally parents were cold or removed and
didn’t consistently care for the child in ways that would adequately meet the
above needs.<o:p></o:p></span></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Abandonment/Instability<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the expectation that
one will soon lose anyone with whom an emotional attachment is formed. The
person believes that, one way or another, close relationships will end imminently.
As children, they may have experienced the divorce or death of parents. This
schema can also arise when parents have been inconsistent in attending to the child’s
needs; for instance, there may have been frequent occasions on which the child
was left alone or unattended to for extended periods.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Mistrust/Abuse<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the expectation that
others will intentionally take advantage in some way. People with this schema
expect others to hurt, cheat, or put them down. They often think in terms of
attacking first or getting revenge afterwards. In childhood, these people were
often abused or treated unfairly by parents, siblings, or peers.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Defectiveness/Shame<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
is internally flawed, and that, if others get close, they will realize this and
withdraw from the relationship. This feeling of being flawed and inadequate
often leads to a strong sense of shame. Generally parents were very critical
and made them feel as if they were not worthy of being loved.<o:p></o:p></span></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Social
Isolation/Alienation<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
is isolated from the world, different from other people, and/or not part of any
community. This belief is usually caused by early experiences in which children
see that either they, or their families, are different from other people.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Dependence/Incompetence<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
is not capable of handling day-to-day responsibilities competently and
independently. People with this schema often rely on others excessively for
help in areas such as decision-making and initiating new tasks. Generally,
parents did not encourage children to act independently and develop confidence
in their ability to take care of themselves.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Vulnerability to Harm and
Illness<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
is always on the verge of experiencing a major catastrophe (financial, natural,
medical, criminal, etc.). It may lead to taking excessive precautions to
protect oneself. Usually there was an extremely fearful parent who passed on
the idea that the world is a dangerous place.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Enmeshment/Undeveloped
Self<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to a pattern in which a
person experiences too much emotional involvement with others – usually parents
or romantic partners. It may also include the sense that one has too little
individual identity or inner direction, causing a feeling of emptiness or of
floundering. This schema is often brought on by parents who are so controlling,
abusive, or overprotective that the child is discouraged from developing a separate
sense of self.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Failure<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
is incapable of performing as well as one’s peers in areas such as career,
school or sports. These clients may feel stupid, inept or untalented. People
with this schema often do not try to achieve because they believe that they
will fail. This schema may develop if children are put down and treated as if they
are a failure in school and other spheres of accomplishment. Usually the
parents did not give enough support, discipline, and encouragement for the
child to persist and succeed in areas of achievement, such as schoolwork or
sport.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Subjugation<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
must submit to the control of others in order to avoid negative consequences.
Often these people fear that, unless they submit, others will get angry or
reject them. They therefore ignore their own desires and feelings. In childhood
there was generally a very controlling parent.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Self-Sacrifice<o:p></o:p></span></span></b></div>
<span style="font-family: inherit;"><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;">This schema refers to the excessive
sacrifice of one’s own needs in order to help others. </span><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;">When these people pay attention to their
own needs, they often feel guilty. To avoid this guilt, they put others’ needs
ahead of their own. Often people who self-sacrifice gain a feeling of increased
self-esteem or a sense of meaning from helping others. In childhood the person
may have been made to feel overly responsible for the wellbeing of one or both
parents.<o:p></o:p></span></span><br />
<span style="font-family: inherit;"></span><br />
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<b><span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">Emotional Inhibition<o:p></o:p></span></span></b></div>
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that one
must suppress spontaneous emotions and impulses, especially anger, because any
expression of feelings would harm others or lead to loss of self-esteem,
embarrassment, retaliation or abandonment. These people may lack spontaneity, or be viewed as uptight. This schema is often brought on by parents who discourage the expression of feelings.<br /> <br /><strong>Approval-Seeking/Recognition-Seeking</strong></span></span><br />
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the placing of too much emphasis on gaining the approval and recognition of others at the expense of one’s genuine needs and sense of self. It can also include excessive emphasis on status and appearance as a means of gaining recognition and approval. People with this schema are generally extremely sensitive to rejections by others and try hard to fit in. Usually they did not have their needs for unconditional love and acceptance met by their parents in their early years.<br /><br /><strong>Unrelenting Standards/Hyper-criticalness</strong></span></span><br />
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the belief that whatever you do is not good enough, that you must always strive harder. The motivation for this belief is the desire to meet extremely high internal demands for competence, usually to avoid internal criticism. People with this schema show impairments in important life areas, such as health, pleasure or self-esteem. Usually these clients’ parents were never satisfied and gave their children love that was conditional on outstanding achievement.<br /><br /><strong>Entitlement/Grandiosity</strong><br />This schema refers to the belief that one should be able to do, say, or have whatever one wants immediately, regardless of whether that hurts others or seems reasonable to them. These people are not interested in what other people need, nor are they aware of the long-term costs of alienating others. Parents who overindulge their children and who do not set limits about what is socially appropriate may foster the development of this schema. Alternatively, some children develop this schema to compensate for feelings of emotional deprivation or defectiveness.<br /><br /><strong>Insufficient Self-Control/Self-Discipline</strong></span></span><br />
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to the inability to tolerate any frustration in reaching one’s goals, as well as an inability to restrain expression of one’s impulses or feelings. When lack of self-control is extreme, it may lead to criminal or addictive behaviors. Parents who did not model self-control, or who did not adequately discipline their children, may predispose them to this schema as adults.<br /><br /><strong>Negativity/Pessimism</strong></span></span><br />
<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"><span style="font-family: inherit;">This schema refers to a pervasive pattern of focusing on the negative aspects of life while minimizing the positive aspects. Clients with this schema are unable to enjoy things that are going well in their lives because they are so concerned with negative details or potential future problems. They worry about possible failures no matter how well things are going for them. Usually these people had a parent who worried excessively.<br /><br /><strong>Punitiveness</strong></span></span><br />
<span style="font-family: inherit; font-size: 12pt; mso-bidi-font-family: Tahoma;">This schema refers to the belief that people deserve to be harshly punished for making mistakes. People with this schema are critical and unforgiving of both themselves and others. They tend to be angry about imperfect behaviors much of the time. In childhood these clients usually had at least one parent who put too much emphasis on performance and had a punitive style of controlling behavior.</span><br />
<span style="font-family: inherit; font-size: 12pt; mso-bidi-font-family: Tahoma;"></span><br />
<span style="font-family: inherit; font-size: 12pt; mso-bidi-font-family: Tahoma;">Based on:</span><br />
<div style="text-align: center;">
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<span style="font-size: 12pt; mso-bidi-font-family: Tahoma;"></span>Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com1tag:blogger.com,1999:blog-8734227745996182145.post-35991356469511610642013-09-12T08:00:00.000-04:002013-12-18T23:35:50.505-05:00The Therapeutic Paradox of Self-InvalidationIf validation is one of the core skills for fostering a therapeutic alliance, it may be even more important for clients who grew up in an invalidating environment, may have little prior experience of validation, and habitually invalidate themselves. However, it's also important to consider and plan for how a particular client is likely to experience and react to validation. Some respond positively: validation improves rapport, diffuses pain, and over time helps clients become better able to self-validate and self-regulate. Others find validation itself to be distressing.<br />
<br />
While such a reaction may seem counterintuitive, it makes sense in the context of the client's experience. For someone who has been chronically invalidated, the experience of validation is foreign and uncomfortable. The client may feel thrown off balance by the unexpected response.<br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjk4D9DC74VDKixlsKdVaebDgDsfcuSEazViCFoZkbQkYzkI2TRUR7kNCNl_ekuzi25TpukT9Sy-0aMk4iYgUMkHepR4AcFKXHQm44LV88wb5y2VdM8PdczoAVIVS089yOeVdlsAoMBD_Yj/s1600/cognitive+validation.gif" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="171" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjk4D9DC74VDKixlsKdVaebDgDsfcuSEazViCFoZkbQkYzkI2TRUR7kNCNl_ekuzi25TpukT9Sy-0aMk4iYgUMkHepR4AcFKXHQm44LV88wb5y2VdM8PdczoAVIVS089yOeVdlsAoMBD_Yj/s200/cognitive+validation.gif" width="200" /></a>At a more complex level, a client who habitually self-invalidates may find validation itself...invalidating. This presents quite the therapeutic paradox: I can validate my client's experience, which invalidates their self-invalidation of that experience; or I can validate the self-invalidation, which invalidates the experience.<br />
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Both of these options are likely to dysregulate the client. Perhaps this is why clients with Borderline Personality Disorder are so often labeled "difficult clients." However, that's also invalidating of the genuine and understandable distress these clients experience living inside this paradox day in and day out.<br />
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The challenge for therapists is to find a way to lessen a client's suffering by gradually lessening the internal dissonance of self-invalidation - which happens in part through the experience of validation. How, then, can we make validation less invalidating?<br />
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I believe the answer is that validation itself must be dialectical. We need to name and reflect both the client's initial internal experience, and their self-invalidation of this experience. In this way, by simultaneously validating the experience of invalidation, and the experience that is invalidated, the client may finally be able to experience genuine validation.Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com1tag:blogger.com,1999:blog-8734227745996182145.post-12281107737277459432013-08-26T21:39:00.003-04:002013-08-26T21:39:55.114-04:00Two Kinds of SupervisionSupervision is at the heart of teaching and learning how to be a mental health professional. Therapy brings about change through a special kind of "helping" relationship, and we learn to foster and harness that kind of relationship through our relationships with supervisors.<br />
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We all receive supervision throughout our training, in graduate school, and leading up to licensure. However, ethical guidelines require that we continue to make use of supervision - or consultation, supervision's less hierarchical cousin - throughout our careers. Unfortunately, not all agencies that employ mental health professionals make supervision a priority, and not all supervision is created equal.<br />
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Indeed, there are two main categories of supervision that professionals receive once they have graduate and are out in the field:<br />
<br />
1) Administrative Supervision<br />
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Administrative supervision is perhaps the most readily-available kind of supervision. It focuses on ensuring that workers are meeting requisite standards and following established protocols. An administrative supervisor is concerned with how programs are operating, whether workers are showing up on time, presenting themselves professionally, and completing all the paperwork needed to keep the agency in business. Administrative supervisors are also typically responsible for things like performance evaluations.<br />
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2) Clinical Supervision<br />
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Clinical supervision is what most of us think of when we think about supervision. This is the kind of supervision that focuses on the clinical work: how we understand what is going on for our clients, how we can connect with and help them, and what might be getting in the way. It helps us recognize and think about what may be going on underneath the surface of our clinical encounters. It gives us a place to express our own feelings, identify our own biases and issues that may be triggered in our work, so that these things don't "leak out" when we're with a client. It may help us recognize a need for more self-care, or our own therapy. It helps us develop a deeper understanding of theory and practice so that we can intervene more skillfully.<br />
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Most agencies provide administrative supervision as a matter of course. Whoever is your "boss" is probably technically providing administrative supervision. When licensed supervisors are available, many agencies will provide clinical supervision for employees working toward licensure. After all, agencies typically benefit from this arrangement, both because they are more competitive when vying for the best new graduates, and because they stand to receive added reimbursement for services provided by licensed professionals. Of course, there is not always a supervisor available who has the kind of license an employee needs for their own licensure. When this happens, the employee may be able to negotiate with their employer for an appropriate supervisor to be found in another program, department, or even outside the agency. However, sometimes it is necessary for newer graduates to find and pay for their own outside clinical supervision.<br />
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Logistically, it is easiest when your administrative supervisor (your "boss") also provides clinical supervision. Practically, however, this is not always possible...or even desirable. It may be that your boss has a different kind of license than you need, or that the agency does not prioritize clinical supervision, or that your boss's area of expertise is not quite what you need. You may have reservations about revealing difficulties to the person who will be completing your performance evaluation. Or you may benefit from the perspective of someone who has a little more distance from the program or agency setting.<br />
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I was grateful in my early years of practice to have a clinical supervisor who was removed from the program where I worked, who could stand outside the politics, and who was supportive of me, rather than another agenda. I left a different job because my supervisor took expression of emotion during supervision as a reflection of my sessions with clients, rather than as a healthy way of ensuring my emotions did not enter into my work with clients. Currently, I have a supervisor who is better able to blend administrative and clinical. Thus, my experience suggests that much depends on the supervisor, and the setting.<br />
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What has your experience been? How have you experienced supervision at its best and at its worst? How have administrative and clinical supervision been combined or separated for you? What recommendations would you make to agencies and the profession as a whole?Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com4tag:blogger.com,1999:blog-8734227745996182145.post-17886069104330945322013-07-22T22:51:00.002-04:002013-07-22T22:51:47.171-04:00Breadth or Depth?Working at a partial hospital program, I spend time thinking about program development - specifically, how to best structure a psychoeducational curriculum. Since we opened 18 months ago, we've generally organized the weekly schedule on what I'll call a "breadth" model. Groups are generally offered once a week. Each group tends to go through a rotation of material, and may build on what is covered in previous weeks, but don't typically tie into other groups happening in the same week.<br />
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Since the length of stay in partial is relatively short (3-4 weeks is average, but some patients can be there much longer, or leave right away), and admissions and discharges happen on a rolling basis, the population is always in flux. In practice, that means it's hard to build upon previous weeks. If groups do build on a prior week's group, it's necessary to start with a recap for those who weren't present for the prior group. Each group session has to function, in some respects as a stand-alone, single-session intervention.<br />
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The primary rationale for the breadth model is to provide clients with a range of basic information and coping skills. Since not every skill works for every client, nor in every situation, it is hoped that a breadth of options will allow everyone will find something beneficial.<br />
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Recently, however, we've been thinking about a different approach, which I'll call a "depth" model. In contrast to the breadth model, the depth model would include sequences of groups that build on each other within the same week, focusing in depth on a particular skill before moving on to a new skill. There would still be some breadth (not every group in the week would address the same topic - that would be overkill!), but not to the same degree.<br />
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The rationale for the depth model is that coping skills are <i>skills</i>, requiring practice and repetition to reach the point of truly being useful. Providing only a superficial overview of a skill may not make it accessible to clients, and if a client does try to use a skill to cope, the skill may not be well-developed enough to be helpful. The client may then reach the unfortunate conclusion that the skill "doesn't work" (and maybe none of them work!).<br />
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DBT can serve as a useful illustration of breadth vs. depth. DBT includes four skill modules (mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance). The breadth model would be to have one group each week for each module, and cover the material in each module sequentially over several weeks. Thus, a client would be exposed to all four modules and would learn some, but likely not all, of the material from all of the modules. In contrast, the depth model would devote all four weekly groups to the same module until all of the material has been covered, and then move on to the next module. A client would likely learn most or all of the information in at least one module, but may only learn about one or two modules during the length of their stay.<br />
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So, what do you think: is it better to focus on breadth or depth? Is it better for clients at this level of care to be introduced to a wider range of possible skills (and perhaps learn more in individual or outpatient therapy about the particular skills they find helpful), or to become more comfortable and skillful at one or two skills (which may not be the most useful to them, or may leave them without skills for some situations they face)?<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com1tag:blogger.com,1999:blog-8734227745996182145.post-87234038720435542392013-07-20T22:51:00.001-04:002013-07-20T22:51:39.794-04:003 Steps to Improving Self-EsteemPart of developing self-esteem is reframing and restructuring negative thoughts and beliefs about ourselves. However, at the same time, it's important to increase our awareness and attention to positive things about ourselves - to not only decrease negative thoughts and beliefs, but also to actually increase positive thoughts and beliefs.<br /><br />This can be pretty challenging for people who have low self-esteem, because our minds naturally filter information through our existing beliefs and expectations. If we have negative beliefs and expectations, we are likely to notice and remember everything that might support these beliefs and expectations, but we probably don't even notice all the things that contradict our negative beliefs and expectations. In other words, the positive things exist, but we may not see them because we don't expect them to be there!<br /><br />To help you become more aware of your positive aspects, follow these three steps:<br /><br /><b>Step 1: Make a List of Positive Qualities</b><br /><br />Because it's hard to notice the positives, it is important to start writing them down. This first step is the most difficult of the three. Make a list of positive aspects of yourself, including all your good characteristics, strengths, talents, and achievements. Set aside a specific time to do this, and write the list somewhere you will be able to find it again. <br /><br />Write as many positive things about yourself as you can think of…there is no limit. Include everything no matter how small, insignificant, modest, or unimportant they are! Exhaust all avenues and brainstorm as many ideas as possible (there are some suggestions below to help). If you run out of ideas, take a break. Come back to it over the course of a few days, until you have a substantial list of your positives.<br /><br />Some questions that might help you come up with things include:<br /><ul>
<li>What do I like about who I am?</li>
<li>What characteristics do I have that are positive?</li>
<li>What are some of my achievements?</li>
<li>What are some challenges I have overcome?</li>
<li>What are some skills or talents that I have?</li>
<li>What do others say they like about me? What do people say my strengths are?</li>
<li>What are some attributes I like in others that I also have in common with?</li>
<li>If someone shared my identical characteristics, what would I admire in them?</li>
<li>How might someone who cared about me describe me?</li>
<li>What do I think are bad qualities? What bad qualities do I not have?</li>
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Enlist the help of a trusted friend or family member – someone you know would be supportive of you doing this, rather than someone who may be critical or contribute to lowering your self-esteem. Two heads are better than one and an outsider might have a more objective perspective of you than you do of yourself. Who knows what nice things you might discover about yourself with their help? <br /> <br />Watch out for negative self-evaluations or discounting positives as “small” or “no big deal” or “not worth writing.” You tend to remember detailed negative things about yourself, therefore do the same with the positives – it is only fair! Also remember, you don’t have to do these positive things absolutely perfectly or 100% of the time – that is impossible. So be realistic about what you write down - something that you generally are or do is a true positive, even though there will always be exceptions to any positive - for all of us!<br /><br /><div>
Once you have a list, re-read the things you write, over and over. Reflect on what you have written - and resist critical or doubtful thoughts about it. Let the positive qualities pile up and ‘sink in.’ This is important so that you learn to notice these things and feel more comfortable acknowledging them, rather than just giving them lip-service.<br /><br /><b> Step 2: Identify Past Examples of Your Positive Qualities</b></div>
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<br />Once you have a list of your positive qualities, the next step is to recall specific examples of how you have demonstrated each of the positive attributes you listed. Fold a piece of paper in half. On the left, write the first item on your positive qualities list. On the right, list as many examples as you can come up with to provide evidence of that positive quality. Consider events, experiences, successes, achievements, feedback you've gotten, etc., both recently and throughout your life up to this point.</div>
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Leave plenty of space to add examples as you remember them, then move on to the second item on your list, and so on, until you have examples for each of your positive qualities. By doing so, you will make each attribute more than just meaningless words on a page. Instead, each attribute will become a real, specific, and detailed memory of something that actually happened. In the process, you may also recognize additional positive qualities that your examples suggest. Add those to your first list, too!</div>
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<br />This process will take some time, but is worth the effort. Remembering specific incidents that illustrate your positive qualities will allow the list to have an impact on your self-esteem. <br /><br /><b>Step 3: Notice Examples of Positive As They Happen</b></div>
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After spending time recalling past examples of your positive qualities, it's time to recognize examples of your positive attributes on a daily basis. This should be an ongoing exercise – something to do every day. Each day, try to record three examples from your day that illustrate certain positive qualities you have. Write exactly what you did and identify what positive attribute it shows in you. Start with noticing three a day if you can (you can always start with fewer if necessary), but try to build from there, increasing it to 4, or 5 or 6. By doing this, you will not only be acknowledging your positive qualities as things you did in the past, but also acknowledging them as things you are every day. <div>
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This process will take time. Don't try to rush through it. Instead, give yourself time to actually experience and come to believe the things you are writing down. Over time, taking these steps will help you develop a positive self-image that is connected to your past, embedded in the present, and carries forward into the future.</div>
Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com1tag:blogger.com,1999:blog-8734227745996182145.post-70939198273761568762013-07-14T21:55:00.001-04:002013-07-14T21:55:59.957-04:00The Pursuit of HappinessAs therapists, we spend a lot of time talking with people about the things contributing to unhappiness. After all, people who are happy don't often come to therapy. However, research in the field of Positive Psychology comes at things from a different perspective. Instead of the clinical lens, which focuses on trying to decrease negatives, Positive Psychology focuses on trying to increase positives. High on the list of positives is happiness.<br />
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Happiness is something most of us wish for, and yet all too often find elusive. Happiness is often thought of as an emotion - that warm and fuzzy feeling - but true happiness is actually a much more complex human experience. Perhaps that's why people who go to great lengths to experience an emotional high continue to find genuine happiness beyond their grasp.<br />
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Indeed, research supports an understanding of happiness as a mixture of: positive emotion, occasional negative emotion, autonomy, mastery, purpose, belonging, playfulness, and psychological flexibility. Furthermore, it is not necessary to experience all of these, or to experience them in particular proportions. Indeed, different people experience happiness through different combinations, and the combinations are likely to change with life circumstances from moment to moment.<br />
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Some of the variables that contribute to happiness are within our control, while others seem to be innate. Indeed, genetics that influence brain chemistry, personality and temperament contribute to am emotional "set point." Like body temperature, our emotional "temperature" may have short-term ups and downs, but tends to return to our own natural baseline. This innate set point contributes about 60% of our happiness (or lack thereof). The good news for those of us with a lower set point for mood is that we have more control over the remaining 40%.<br />
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So, what can we do to boost our happiness?<br />
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1) Work on increasing <a href="http://practicewisdom.blogspot.com/2011/10/flexible-thinkinglets-streeeetttch.html">psychological flexibility</a>. People who are happy are able to modify their expectations and ideals, and therefore accept reality without readily succumbing to dissatisfaction. They are able to use uncomfortable emotions as information to guide behavior, rather than trying to avoid such emotions, or allowing the emotions to overwhelm them. Moreover, they can modify their behavior to fit each situation, and tolerate the discomfort of sitting with and containing emotional reactions when necessary.<br />
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2) Don't sweat the small stuff. While attention to detail can be helpful at times, being too detail-oriented lends itself to perfectionism, which only leads to dissatisfaction and disappointment. People who are happy tend to be less skeptical, less analytical, and less achievement-oriented. In contrast, people who are depressed are more observant, realistic, self-reflective, conscientious and performance-driven...but at a significant cost.<br />
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3) Step out of your comfort zone. While doing things that are comfortable and enjoyable can be fulfilling, life is richer for those who take some risks. Curiosity is correlated with satisfaction and happiness, and curiosity emerges through exploration. Trying new things produces short-term discomfort, but is energizing and contributes to longer-term growth.<br />
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4) Celebrate and share in other people's joys and successes. Unhappy people respond to other people's good news with envy. Happy people feel happy for others, and therefore experience a boost in mood after talking with others about their accomplishments.<br />
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5) Develop a sense of purpose. Working toward goals, and finding sources of fulfillment and meaning in life contribute to overall happiness, even when doing so involves challenges and set-backs. However, it's important to include things that genuinely feel fulfilling, rather than things we simply think "should" be fulfilling.<br />
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6) Take time for self-care. Relaxing, pampering, and indulging ourselves from time to time, and making time each day for some pleasure, is crucial to maintaining happiness and energizing us to take on life's challenges.<br />
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However, all that said, it's also true that striving for happiness can paradoxically produce unhappiness. This occurs because striving for happiness leads us to do the opposite of several of the things that produce happiness. It erodes psychological flexibility, heightening the distance between real and ideal, and raising our expectations of how life "should" be. It makes people unwilling to accept and tolerate negative emotions, and therefore reluctant to step out of their comfort zones. It makes it hard to share other people's happiness because such happiness triggers comparisons and dissatisfaction with one's own life circumstances. Lastly, it turns happiness itself into the driving goal or purpose, detracting time and attention from pursuits that offer meaningful fulfillment.<br />
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In other words, the best approach is to act in ways that can contribute to happiness, but not spend too much time focusing on whether or not you've achieved happiness as an outcome, since doing so only makes happiness more elusive.<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com6tag:blogger.com,1999:blog-8734227745996182145.post-9941205859807937442013-07-04T20:36:00.000-04:002013-07-04T20:36:53.126-04:00Declaration of Independence: A Narrative InterventionPeople have been using documents to mark important events and decisions ever since writing was invented millenia ago. It is said that the ten commandments were documents carved into stone tablets, and carried around by the Israelites as representations of their covenant with God. Similarly, every religious tradition has some form of sacred text. Documents play a pivotal role in human relationships as well, both political and domestic. The Declaration of Independence is a political example, along with innumerable other famous documents (the Declaration of Independence, the Magna Carta, the Bill of Rights, and many others). Domestic examples include marriage licenses, contracts, restraining orders, among other things.<br />
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Narrative Therapy draws on this human tendency to create documents signifying important moments, decisions, and changes. Documents serve as a symbol - a visible manifestation to clients and to others - of what clients have achieved, decisions and changes they have made, and preferences they have for their future vis-a-vis the problem(s) that brought them to therapy. The documents used in Narrative Therapy may be modeled after various documents, social, political, religious, or otherwise. Contracts, letters, certificates and diplomas are some common examples. Often the problem, <a href="http://practicewisdom.blogspot.com/2012/06/why-i-believe-in-externalizing-problem.html">externalized</a> and sometimes personified, is addressed in the document (for example, a letter can be addressed to or from the problem, and contracts may be drawn up between the client and the problem).<br />
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An illustration of this kind of intervention that is particularly fitting for today, Independence Day in the U.S., is a Declaration of Independence from the problem. The format I've used is as follows:<br />
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Choose an area or issue in your own life from which you would like to declare independence. Write your own Personal Declaration of Independence following the five-part structure of the U.S. Declaration of Independence, develop each as thoroughly and as creatively as you can.<br />
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I. Introduction (Preamble)<br />
Why are you writing this document? From what are you declaring independence? What are the conditions causing the desire to separate?<br />
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II. Philosophical Foundation<br />
What human rights and privileges support your right to declare your independence?<br />
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III. Nature of the Complaint<br />
Describe the actual situation, including three or four specific grievances detailing how your rights have been violated.<br />
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IV. Explanation of Previous Actions<br />
Describe what the ideal or tolerable situation would be. Specify what remedy is needed to correct the complaint, and detail what efforts have already been made to address the problem and achieve the ideal or tolerable state.<br />
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V. Resolution<br />
State in your own words that all other efforts have failed, and describe what you intend to do now (what this Declaration of Independence means).<br />
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Don't forget to sign your document!Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com1tag:blogger.com,1999:blog-8734227745996182145.post-44416858098723153382013-06-30T21:09:00.000-04:002013-06-30T21:09:05.235-04:00America's Racial ParadoxSome - perhaps many - Americans like to think that our nation has entered a "post-racial" era, where racial prejudice and discrimination is just a thing of the past. After all, people of diverse racial and ethnic backgrounds have risen to positions of prominence in government (up to and including the presidency), business, the medical and legal fields, and just about any other position of status you could think of. But does that make us "post-racial?"<br />
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Three news stories of the past week raise the question of exactly how far we have actually come since the civil rights movement. Fifty years is a long time, but is it enough time to erase the preceding centuries of prejudice and discrimination? Is it enough time to truly level the playing field of "White privilege?"<br />
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It seems unlikely, and each of our lived experience is likely enough to tell us that, although we do tend to consider people of varied races and ethnicities "equal" - equally intelligent, equally able, equally moral, equally "human" - we also judge each other according to negative stereotypes. These judgments don't just go in one direction - everyone seems to have them toward racial/ethnic groups other than their own.<br />
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Some folks would like to sweep these judgments under the rug - claim that signs of equality (such as people of color who hold positions of power) represent the absence of prejudice. These folks see this week's Supreme Court decision on the Voting Rights Bill as further evidence that racial injustice is a thing of the past. However, others, including the ACLU and NAACP, warn that the Court's decision poses a risk precisely because of the continued existence of prejudice.<br />
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So, what exactly did the Court say? The Voting Rights Bill was <a href="http://en.wikipedia.org/wiki/Voting_Rights_Act">first passed in 1965</a>, and renewed in 2006. This bill required specific States, counties, and municipalities to have any changes to voting policy, including districting, approved by the Justice Department ahead of time. The Supreme Court threw out the list of places required to obtain this "preclearance," not because targeting certain places is in itself unconstitutional, but because the list was based on evidence gathered in the 1960s. In other words, the Court did NOT say that such oversight is no longer needed. Instead, they said that Congress needs to determine WHERE such oversight is needed on the basis of current evidence, rather than 50-year-old data. The clear implication is that current evidence would indeed show some places in our country where the racial climate warrants judicial oversight to ensure voter rights.<br />
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The Supreme Court is one of the three news stories I mentioned earlier. What about the other two?<br />
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The first illustrates our attempt to repudiate our racial past. Paula Deen, a famous cook, tv personality, and author, lost the vast majority of her contracts (for tv, books, and product endorsements) after admitting in a deposition that she has used the "n-word" in the past. Now, Paula Deen was born in Georgia, in 1947. In other words, she grew up in the deep South prior to the Civil Rights movement. I would have been shocked if she HADN'T even used the "n-word." It is ludicrous to judge her so harshly for being a part of the culture of that time and place. It certainly should not be taken as evidence that her current beliefs and behavior are racist. My psychodynamic side wonders whether we, as a society, are attacking in her what we are trying to deny about ourselves and our own societal history.<br />
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The last of this week's news stories is an illustration of how racial prejudices continue to shape our collective psyche. George Zimmerman, a Florida man who is half-White and half-Latino, has gone on trial for shooting an African American teenager named Trayvon Martin. As a member of the neighborhood watch, George Zimmerman is reported to have followed Trayvon Martin, while calling the police to report a "suspicious" person, before a confrontation during which Zimmerman ended up shooting and killing Martin. While the defense is claiming self-defense, the prosecution claims that Zimmerman racially-profiled Martin, assuming he was a criminal because of his race and gender.<br />
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The outcomes of all three of these news stories are yet to be determined. However, what they demonstrate (at least from my perspective) is that our society is desperate to distance ourselves from any hints of racism, at the same time these hints belie the myth that America is "post-racial." We're just not there, yet; and it's going to be pretty hard to get there if we can't acknowledge and talk about it!<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-32241480439077091782013-06-10T11:54:00.002-04:002013-06-10T11:55:43.030-04:00Self Concept: Self-Image, Ideal Self, and Self-Esteem<div style="text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 18pt; mso-fareast-font-family: "Times New Roman";">Self-Concept</span></b></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The term <i style="mso-bidi-font-style: normal;">self-concept</i> is a general term used to refer to how someone thinks
about or perceives themselves. To be aware of oneself is to have a concept of
oneself. One definition of <span style="mso-bidi-font-style: italic;">self-concept</span>
is: “the individual’s belief about himself or herself, including the person’s
attributes and who and what the self is."</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 0pt; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Self-concept includes two different
experiences of the self:<o:p></o:p></span></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"></span></span></b><br />
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">(1)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The
Existential Self </span></b><br />
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.5in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">This is <i>the
most basic part of the self-scheme or self-concept; the sense of being separate
and distinct from others and the awareness of the constancy of the self”</i>
(Bee, 1992).</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.5in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The child
realizes that they exist as a separate entity from others and that they
continue to exist over time and space. According to Lewis, awareness of the
existential self begins as young as two to three months old and arises in part
due to the relation the child has with the world. For example, the child smiles
and someone smiles back, or the child touches a mobile and sees it move.</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(2) The Categorical Self</span></b></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.5in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Having
realized that he or she exists as a separate experiencing being, the child next
becomes aware that he or she is also an object in the world. Just as other
objects including people have properties that can be experienced (big, small,
red, smooth and so on) so the child is becoming aware of him or her <i style="mso-bidi-font-style: normal;">self</i> as an object which can be
experienced and which has properties. The self too can be put into categories
such as age, gender, size or skill. Two of the first categories to be applied
are age (“I am 3”) and gender (“I am a girl”).</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.5in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">In early
childhood. The categories children apply to themselves are very concrete (e.g.
hair color, height and favorite things). Later, self-description also begins to
include reference to internal psychological traits, comparative evaluations and
to how others see them.<o:p></o:p></span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Beyond these basic ways of
experiencing the self, self-concept encompasses 3 things:<o:p></o:p></span><br />
<br />
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; tab-stops: list .5in;"><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">The
view you have of yourself (<b>Self-image</b>)<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">How much value you place on yourself (<b>Self-esteem </b>or
self-worth)<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">What you wish you were really like (<b>Ideal self</b>)</span></li>
</ul>
<div align="center" class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 18pt; mso-fareast-font-family: "Times New Roman";">Self-Image</span></b></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Your self-image is what you see in
yourself. It does not necessarily have to reflect reality. Indeed a person with
an eating disorder may be thin but have a self-image of being fat. A person's self
image is affected by many factors, such as parental influences, friends, the
media etc.</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 0pt; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Our self-image includes: <o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-indent: 0.25in;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">1)
Physical Description</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">: I’m tall, have brown eyes...etc.</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.25in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">2)
Social Roles</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">: We are all social beings whose
behavior is shaped to some extent by the roles we play. Such roles as student,
housewife, or member of the football team not only help others to recognize us
but also help us to know what is expected of us in various situations.</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.25in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">3)
Personal Traits</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">: These are a third dimension of our
self-descriptions. “I’m impulsive...I’m generous...I tend to worry a
lot”...etc.</span></div>
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt 0.25in; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">4)
Existential Statements</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> (abstract
ones): These can range from "I’m a child of the universe" to
"I’m a human being" to "I’m a spiritual being"...etc.<o:p></o:p></span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Typically, young people describe themselves more
in terms of personal traits, whereas older people feel defined to a greater
extent by their social roles.</span><br />
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">
</span><br />
<div align="center" class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 18pt; mso-fareast-font-family: "Times New Roman";">Ideal Self</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Ideal self refers to how you wish
you were, and how you think you should be. It is shaped by your life
experiences, messages you received from other people about how you should be,
cultural values, and things you admired in role models. <o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Where a person’s ideal self and
self-image are consistent or very similar, a state of congruence exists. If
there is a mismatch between how you see yourself (your self-image) and what
you’d like to be (your ideal self), then this is likely to affect how much you
value yourself. Therefore, there is an intimate relationship between
self-image, ideal self, and self-esteem. A person’s ideal self may not be
consistent with their actual experience, or what is even possible. This is
called incongruence.<o:p></o:p></span></div>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0CXdclVU_W-POjtJci-qLF34cn8c7lBcio_FVhoZkXqDzLUkUYpfC0zURxcWfnN-jVrPj-E6XPzOk9QnPIsI3GeGYnOlFOilNRonYOjWDskjg75h64JkyEWRMMsgLc7eHnERkoe1w_ySu/s1600/self+congruence.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0CXdclVU_W-POjtJci-qLF34cn8c7lBcio_FVhoZkXqDzLUkUYpfC0zURxcWfnN-jVrPj-E6XPzOk9QnPIsI3GeGYnOlFOilNRonYOjWDskjg75h64JkyEWRMMsgLc7eHnERkoe1w_ySu/s1600/self+congruence.jpg" /></a><br />
<h2 align="center" style="margin: 0.83em 0in; text-align: center;">
Self-Esteem and Self-Worth<span style="font-size: 12pt;"><o:p></o:p></span></h2>
Self-esteem refers to the extent to which we like, accept, or approve of
ourselves; or how much we value ourselves. Self-esteem always involves a degree
of evaluation, and we may have either a positive or a negative view of
ourselves. <o:p></o:p><br />
<br />
<div style="margin-bottom: 0pt;">
<strong>HIGH SELF-ESTEEM</strong>:
we have a positive view of ourselves. This tends to lead to<o:p></o:p></div>
<br />
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Confidence in our own
abilities<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Self-acceptance<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Not
worrying excessively about what others think<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l1 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Optimism<o:p></o:p></span></li>
</ul>
<strong>LOW SELF-ESTEEM</strong>:
we have a negative view of ourselves. This tends to lead to<o:p></o:p><br />
<br />
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l2 level1 lfo2; mso-margin-bottom-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Lack of confidence<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l2 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Wanting to
be/look like someone else<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l2 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Always
worrying what others might think<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: normal; margin: 0in 0in 10pt; mso-list: l2 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><span style="font-family: Calibri;">Pessimism<o:p></o:p></span></li>
</ul>
However, self-esteem is changeable, and varies from situation to situation.
For example, in one study, participants waiting for a job interview were seated
next to someone they were told was another candidate, but was really working
with the researcher. Some of them sat next to “Mr. Clean,” who was dressed in nice
suit, carrying a briefcase. Others sat next to “Mr. Dirty,” who was dressed in
an old T-shirt and jeans, slouched over a trashy novel.<o:p></o:p><br />
<br />
The self-esteem of participants with Mr. Dirty increased while those with
Mr. Clean decreased! No mention made of how this affected subjects’ performance
in interview. However, other studies have shown that level of self-esteem
affects performance at numerous tasks, so we could expect Mr. Dirty subjects to
perform better than Mr. Clean.<o:p></o:p><br />
<br />
Even though self-esteem might fluctuate, there are times when we continue to
believe things about ourselves even when there is evidence to the contrary.
This is known as the perseverance effect. That means if we believe negative
things about ourselves, we are likely to maintain those beliefs regardless of
what is really true. <o:p></o:p><br />
<br />
Our early experiences, particularly messages we received from our parents,
have a significant influence on our self-esteem. Four aspects of our current
experience also influence self-esteem:<o:p></o:p><br />
<br />
<div style="margin-left: 0.75in; mso-list: l0 level1 lfo3; text-indent: -0.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-list: Ignore;">1)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></b><strong>THE
REACTIONS OF OTHERS</strong>. If people admire us, flatter us, seek out our
company, listen attentively and agree with us we tend to develop a positive
self-image. If they avoid us, neglect us, tell us things about ourselves that
we don’t want to hear, we develop a negative self-image.<o:p></o:p></div>
<br />
<div style="margin-left: 0.75in; mso-list: l0 level1 lfo3; text-indent: -0.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-list: Ignore;">2)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></b><strong>COMPARISON
WITH OTHERS</strong>. If the people we compare ourselves with (our reference
group) appear to be more successful, happier, richer, better looking than (we
think) we are we tend to develop negative self-esteem. BUT if they are less
successful, etc., than we are, our self-esteem will be positive.<o:p></o:p></div>
<br />
<div style="margin-left: 0.75in; mso-list: l0 level1 lfo3; text-indent: -0.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-list: Ignore;">3)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></b><strong>SOCIAL
ROLES</strong>. Some social roles carry prestige, e.g. doctor, TV personality, professional
athlete, and this promotes self-esteem. Other roles carry stigma, e.g. ex-con,
maid, day laborer, garbage collector, and may lower self-esteem<o:p></o:p></div>
<br />
<div style="margin-left: 0.75in; mso-list: l0 level1 lfo3; text-indent: -0.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-list: Ignore;">4)<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></b><strong>IDENTIFICATION</strong>.
Roles aren’t just “out there.” They also become part of our personality i.e. we
identity with the positions we occupy, the roles we play and the groups we
belong to.<o:p></o:p></div>
Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com85tag:blogger.com,1999:blog-8734227745996182145.post-66643940035425154332013-05-10T10:22:00.001-04:002013-12-18T23:37:04.961-05:00DBT's Motivational ApproachWhen we think about ambivalence and motivation, the first approach most of us think of is probably <a href="http://practicewisdom.blogspot.com/search/label/MI">motivational interviewing</a>. However, DBT also includes interventions designed to enhance motivation, and while there are some clear similarities to MI, there are also some differences. <br />
<br />
In particular, DBT addresses motivation by targeting a related but distinct concept: commitment. In fact making a commitment or agreement to do something is a strong predictor of actual future behavior. Therefore, DBT sees eliciting and maintaining commitment as a key therapeutic task. Therapists elicit commitment from clients to participate in therapy, to target particular problems, and implement particular solutions. And it is often not enough to make a commitment once. With longer term choices (e.g., staying in therapy, making ongoing changes), commitments may need to be made and remade many times. <br />
<br />
According to <a href="http://www.amazon.com/gp/product/0898621836/ref=as_li_ss_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0898621836&linkCode=as2&tag=practwisdo08-20">Linehan</a>, "the therapist is often functioning like a good salfesperson. The product being sold is DBT, new behavior, a renewed effort to change, or sometimes life itself" (p. 286). As a result of this perspective, DBT borrows from social psychology's insights on compliance - the same insights used in sales. Most notably in this category is the "foot-in-the-door/door-in-the-face" technique. These terms refer to door-to-door sales or charity drives. The foot-in-the-door approach begins by making an initial easy request, followed by a more difficult request, based on findings that those who agree to one thing are more likely to agree to subsequent things. The door-in-the-face approach begins by asking for something much larger than what the asker really hopes to get, and then "settling for" something lesser (what the asker was hoping for to begin with). The idea is that people who say no to one thing feel more social obligation to say yes to the next request if it is reasonable.<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi50hM99CoHT5544JW1E-leI2CBYEVSYOM8gaIcmZJDwkSMKRdGxm8Nc0peH-vyYgk-Hq6OtUQqONEmj-4MDa7_JOQ3qEuktMl0aDImRzzThUBRAffxMZ5l_0eTKv-I5Wj4XieKXaQ4IP9T/s1600/foot-in-the-door.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi50hM99CoHT5544JW1E-leI2CBYEVSYOM8gaIcmZJDwkSMKRdGxm8Nc0peH-vyYgk-Hq6OtUQqONEmj-4MDa7_JOQ3qEuktMl0aDImRzzThUBRAffxMZ5l_0eTKv-I5Wj4XieKXaQ4IP9T/s1600/foot-in-the-door.jpg" /></a><br />
While these techniques may seem "manipulative," they are based on a cultural reality, which is that most of us expect to do some negotiating in our social interactions. When we try to go directly for the commitment we are hoping for, the end result is often NOT an agreement from the client (it might be a flat-out refusal, agreement without follow-through, or negotiation to a lesser commitment). Linehan suggests that the "door" techniques can be used instead, to more effectively elicit agreement. <br />
<br />
These techniques can be used separately, or combined. When combining them, either can be used first. In other words, a therapist might start with a very difficult request, followed by a fairly easy request, and finally progress to a moderately challenging request. Alternatively, the therapist might begin with an easy request, move to a very difficult request, and settle somewhere in the middle. An example of a combined approach would be first asking a client not to engage in a problem behavior at all in the coming week, then eliciting a commitment instead to not use the behavior on at least one day that week, and finally asking the client to use the behavior on no more than 4 of the 7 days.<br />
<br />
A variation of the foot-in-the-door approach is to connect new commitments with prior commitments. This approach is particularly useful when the client seems to be losing commitment, or when current behavior is inconsistent with past commitments. Of course, in doing this, it's important to assess whether the client still feels committted to the prior agreement; clarifying, renegotiating, and renewing commitment may be needed.<br />
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Social psychology has also demonstrated that people are more likely to make commitments when they believe they have freedom of choice, and/or when they believe there are no other options consistent with their goals. These two conditions can also be combined, so that the therapist is simultaneously highlighting the client's freedom to choose, and the lack of viable alternatives. How is that possible? There may not be an alternative that would allow the client to reach the goals s/he has, but s/he is free to choose different goals if unwilling to do what is needed. However, the client's choice of goals has natural consequences, which the therapist also highlights.<br />
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Of course, DBT also uses other strategies to elicit commitment. Like MI, DBT therapists help clients evaluate the pros and cons of a particular commitment or change, particularly highlighting the advantages of the commitment, while developing counterarguments for any identified reservations about it. Also like MI, DBT therapists may "play the devil's advocate," arguing against the commitment in order to move the client to the opposite side of the ambivalence (the side in favor of change).<br />
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Have you ever used these, or similar, techniques to "sell" a client on change? Was it helpful/effective? Why or why not?Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com3tag:blogger.com,1999:blog-8734227745996182145.post-59823611710277937472013-04-16T14:23:00.001-04:002013-04-16T14:23:32.890-04:0011 Ways to Be Resilience in the Face of TragedyYesterday, on a beautiful holiday afternoon, my city was rocked - literally - by tragedy when 2 bombs exploded at the finish line of the Boston Marathon. Currently, 3 have died and the number reported injured has climbed to 176; many of these injuries are very serious, including amputations. People around the city, and beyond, are struggling to find ways to make sense of and cope with the shock, grief, and horror.<br />
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In times such as this, I think about resilience - the human capacity to recover from, adjust to, or even grow from adversity. In the past 20 years or so, increasing research attention has focused on understanding what allows some people to be resilient in the face of tragedy and violence. This research has identified several strategies that resilient people use. They may be particularly useful as we face the aftermath of this attack.<br />
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<strong>1) Take Care of Yourself</strong><br />
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Keeping our bodies healthy by getting enough rest, eating a balanced diet, drinking enough water, and getting moderate exercise helps to reduce emotional vulnerability and therefore acts as a foundation for resilience. <br />
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<strong>2) Establish and Maintain Connections</strong><br />
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Our relationships with other people are our biggest resource when it comes to coping wtih traumatic experiences. Giving and receiving support and acceptance helps us to feel grounded and held, regardless of what is happening around us. Accept the help and support of people who care about you. Find ways to be around other people in positive ways. Engage with others in a civic or spiritual community. This may be one reason why people find ways to gather together in the aftermath of traumatic experiences. Find solidarity. <br />
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<strong>3) Find Meaning</strong><br />
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Connect to a sense of purpose for your life. Focus on something that feels meaningful. Turning our attention to what is meaningful instead of what is senseless helps orient us beyond the tragedy. It is also easier to sit with painful feelings if we can identify something meaningful that transcends them. News stories focusing on transcendent values such as bravery, sacrifice, and generosity help connect us to a narrative of meaning beyond terror and tragedy.<br />
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<strong>4) Work Toward a Goal</strong><br />
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Identify small things you can accomplish today that move you a step closer toward a goal. Feeling like you're accomplishing something helps you feel competent and productive. Working toward a goal helps you feel hopeful and orients you toward a better future.<br />
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<strong>5) Laugh</strong><br />
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People often feel like it would be a sign of denial, or dishonor the victims of a tragedy to express humor. However, humor is a helpful coping skill, particularly in the most challenging of circumstances. Being able to find a glimmer of humor, or taking time to exposure yourself to finny media (youtube, comics, comedic movies and tv shows, comedy routines, etc.) provides a needed break from the stress and distress. Furthermore, laughing produces a chemical reaction in the body that neutralizes the negative effects of stress. <br />
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<strong>6) Learn from Experience</strong><br />
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Think back on how you've coped with past hardships. Build on things that have been helpful, and avoid things that have not been helpful. Not all coping skills work for all people. Go with what you know works for you!<br />
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<strong>7) Remain Hopeful</strong><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8uj4tGMlM3CrH8dRKmktMFFrviJUcwHFDIJK5BKgjrblE41DrJXBr-BfXzjfMtS-dK1GR4w5kzc5NBYp9exO3Icv7m5L733eJaxl6zEpxodPWNNaTCYJtE2W_yQGZMoLoCbinDor6LeQ9/s1600/boston.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="222" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8uj4tGMlM3CrH8dRKmktMFFrviJUcwHFDIJK5BKgjrblE41DrJXBr-BfXzjfMtS-dK1GR4w5kzc5NBYp9exO3Icv7m5L733eJaxl6zEpxodPWNNaTCYJtE2W_yQGZMoLoCbinDor6LeQ9/s320/boston.jpg" width="320" /></a>Instead of engaging in "what if" thinking, and dwelling on the past, focus on the future. Look for signs of hope - indications that things can change for the better. Again, this often means looking for those positive values and strengths that shine through a tragedy: the ways people come together in solidarity and generosity, people's courage in facing danger to help others, etc. In some ways, the best qualities of humanity seem to be brought out by the worst. <br />
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<strong>8) Take Action</strong><br />
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We often feel better when we feel like we're doing something to contribute or address the problem at hand. Many people have come forward to donate blood. Staff at all the local hospitals jumped into action, and those who were not scheduled to work got there as fast as they could. People want to DO something when there is a tragedy. Unfortunately, there is not always something that can be done right away. They don't need blood right now, but they may later in the week. However, there are plenty of ways to contribute to your community, wherever you are. <br />
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<strong>9) Keep Things in Perspective</strong><br />
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Trying to keep a long-term perspective and look at events in the larger context of your own lfie and the world. Recognize that things can improve. Avoid blowing things out of proportion or jumping to conclusions. Recognize that sometimes the media does blow things out of proportion (for example, claiming that there were several more explosive devices, when there were only the two that went off). Wait for confirmed evidence and avoid making assumptions.<br />
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<strong>10) Limit Exposure to the Media</strong><br />
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On that note, it is also helpful to limit how much time you spend watching, listening to or reading media coverage of a trauma. While staying informed may be important, flooding ourselves with traumatic images and thoughts is, well, traumatic. Take breaks from it.<br />
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<strong>11) Practice Stress-Management and Relaxation Techniques</strong><br />
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Our bodies go into overdrive in stressful or traumatic situations. It's important to restore balance by regulating our stress responses. Relaxation and calming practices such as breathing, mindfulness, progressive muscle relaxation, and yoga all help with this. Addressing the physiological signs of stress early on can prevent longer-term stress-related symptoms, such as PTSD.<br />
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Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com4tag:blogger.com,1999:blog-8734227745996182145.post-35514460046303764692013-04-02T19:20:00.000-04:002013-04-02T19:20:28.244-04:00Autism Awareness: Changes in DSM-VToday is designated as Autism Awareness Day (and April as Autism Awareness Month). The goal is to increase both visibility and understanding of the "Autism Spectrum Disorders," which have also been referred to as "Pervasive Developmental Disorders" (PDD) - disorders involving severe and lasting impairment in several areas of development, most notably social skills and communication, sensory integration, and rigid/repetitive behaviors, interests and activities. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEir-tZLYmedB4UDWUx0x0kgnz_4MjKxl0NHueiUdd6bQbE-MbSYfLDBWIHD9SmtZf4V_5JDnSkPutmL2EddCDsaXvCE0P6qPsf896GgZpmorTeyk6kKxAlZdHr62Z4EHgrQdB5uso80L-vs/s1600/autism-spectrum-disorder.gif" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="247" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEir-tZLYmedB4UDWUx0x0kgnz_4MjKxl0NHueiUdd6bQbE-MbSYfLDBWIHD9SmtZf4V_5JDnSkPutmL2EddCDsaXvCE0P6qPsf896GgZpmorTeyk6kKxAlZdHr62Z4EHgrQdB5uso80L-vs/s320/autism-spectrum-disorder.gif" width="320" /></a>To date, this spectrum has included separate diagnoses: Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Syndrome, and PDD Not Otherwise Specified. However, this is about to change. When the 5th edition of the <em>Diagnostic and Statistical Manual of Mental Disorders</em> (DMS-V) takes effect next month, there will be a significant change in these diagnoses. Rett's Disorder will continue to be a separate disorder, and no longer considered part of the autism spectrum (which makes sense due to its unique symptoms, including deceleration of head growth between 5-48 months of age, and loss of purposeful hand movements, replaced by repetitive, "stereotyped" hand movement [hand washing or wringing motions]). All of the other diagnoses currently classified as PDD will be be compined into a new diagnosis: Autism Spectrum Disorder (ASD). <br />
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The current (DSM-IV) criteria for Autism focus on three categories of symptoms: communication, social skills, and repetitive/stereotyped behaviors, interests, and activities. The new criteria for ASD will include only two categories: social communication, and repetitive/stereotyped behaviors (etc.). The latter category will also reportedly include recognition of issues with sensory integration/stimulation. Language delays will be removed as a criterion, since there can be many reasons for such delays, and delays are not seen universally in those with PDD/ASD. A new diagnosis is also being added for those without repetitive/stereotyped behaviors: Social Communciation Disorder.<br />
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While the DSM-IV criteria have been associated with inconsistent diagnoses from clinician to clinician (i.e., low reliability), preliminary results reportedly show good reliability. A retrospective application of the new criteria to individuals with current PDD diagnoses also shows that most continue to meet the revised criteria for ASD. Most of those who no longer meet criteria for ASD do meet the criteria for Social Communication Disorder.<br />
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These latter findings address the biggest concern within the Autism community: would those who have a current PDD diagnosis no longer meet criteria and therefore become ineligible for services they currently receive. Those with current diagnoses have also been reassured that they will automatically be able to maintain an ASD diagnosis; the revised criteria will be applied primarily to newly diagnosis individuals with ASD. <br />
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Nevertheless, advocacy groups are cautious about the changes, waiting to see results from prospective studies. There is uncertainty about how the criteria will work with very young children and/or adults. There are also some reservations from those who identify with the Asperger's community (or possibly other PDDs) about relinquishing that separate identity. Overall, while the changes seem to be scientifically sound, their actual human impact remains to be seen.Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com2tag:blogger.com,1999:blog-8734227745996182145.post-42160096952001573372013-02-28T17:54:00.000-05:002013-02-28T17:54:05.735-05:00Health Consequences of Eating Disorders<div>
Eating disorders are serious, potentially life-threatening conditions that affect a person’s emotional and physical health. They are not just a “fad” or a “phase.” They are real, complex, and devastating conditions that can have serious consequences for health, productivity, and relationships. </div>
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In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences:</div>
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<li>Abnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower.</li>
<li>Reduction of bone density (osteoporosis), which results in dry, brittle bones.</li>
<li>Muscle loss and weakness.</li>
<li>Severe dehydration, which can result in kidney failure.</li>
<li>Fainting, fatigue, and overall weakness.</li>
<li>Dry hair and skin; hair loss is common.</li>
<li>Growth of a downy layer of hair called lanugo all over the body, including the face, in an effort to keep the body warm.</li>
</ul>
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The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions. Some of the health consequences of bulimia nervosa include:<ul>
<li>Electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death. Electrolyte imbalance is caused by dehydration and loss of potassium, sodium and chloride from the body as a result of purging behaviors.</li>
<li>Potential for gastric rupture during periods of bingeing.</li>
<li>Inflammation and possible rupture of the esophagus from frequent vomiting.</li>
<li>Tooth decay and staining from stomach acids released during frequent vomiting.</li>
<li>Chronic irregular bowel movements and constipation as a result of laxative abuse.</li>
<li>Peptic ulcers and pancreatitis.</li>
</ul>
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Binge eating disorder often results in many of the same health risks associated with clinical obesity. Some of the potential health consequences of binge eating disorder include:<ul>
<li>High blood pressure.</li>
<li>High cholesterol levels.</li>
<li>Heart disease as a result of elevated triglyceride levels.</li>
<li>Type II diabetes mellitus.</li>
<li>Gallbladder disease.</li>
</ul>
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All eating disorders are associated with increased risk of mortality, including death caused by the eating disorder behaviors themselves, substance abuse or suicide, and death from general causes such as cancer, likely because eating disorders impact the immune system. Anorexia has the highest mortality rate of any mental health condition.</div>
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All of these risks are scary, but treatment is available and recovery is possible. If you or someone you know has an eating disorder, reach out to find help. One option is the NEDA helpline at (800) 931-2237.</div>
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Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com4tag:blogger.com,1999:blog-8734227745996182145.post-45071472489200893222013-02-27T20:36:00.000-05:002013-02-27T20:36:16.249-05:00What is "Normal" Eating?<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcL7aaf1VmnXqNmcpHEmZjKZ04_sP5OZ1mgJ-AI0krolp_sC-O_lyjRlZtON3vd_dWyrWqzwX95CdNwBZqhT3TINmKhyphenhyphenE8pxGC8aAcDLolK8cO9MOqCMtdQdiOU66khuzCwJvdXsrTg6Zg/s1600/normal-eating.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcL7aaf1VmnXqNmcpHEmZjKZ04_sP5OZ1mgJ-AI0krolp_sC-O_lyjRlZtON3vd_dWyrWqzwX95CdNwBZqhT3TINmKhyphenhyphenE8pxGC8aAcDLolK8cO9MOqCMtdQdiOU66khuzCwJvdXsrTg6Zg/s200/normal-eating.jpg" width="200" /></a>It's hard to be a part of our culture without adopting some disordered eating beliefs, attitudes, and/or behaviors. Half of the commercials on television promote diet or weight loss products. TV shows such as "The Biggest Loser" portray hard-core dieting. Even the "news media" spends a good chunk of time on diet, and whatever the newest diet fad may be. And all of this attention is driven primarily by dollars.<br />
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Why is this kind of information so profitable? Not because it's good for us, but because, as a culture, we have become chronically dissatisfied with our bodies. We have an unrealistic ideal about what the body should look like, and believe (in part because of what we see on TV) that we could get our bodies to look like that if we just follow a magic diet and exercise plan. The magic solution changes over time, of course, because it's never quite magic enough.<br />
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The result is that many or most people are very misinformed when it comes to what it means to eat "normally." Carbohydrates, for example, have received a bad rap over the last decade. However, carbohydrates are crucial to the body, and particularly to the brain. They are the body's main energy source, and the only type of energy the brain can use. 45-65% of one's diet should be made up of carbohydrates.<br />
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Dietary fats are also much maligned, based on the simplistic notion that fat in the diet becomes fat on the body. That's just not true. It happens to have the same word, but that doesn't make it the same thing! Dietary fats are important for many things. They keep us from getting hungry again too quickly, because they get digested more slowly than carbohydrates. They help us absorb fat-soluble vitamins, and help to protect our internal organs. They are a vital ingredient for healthy hair, skin, and nails. They also help produce the myelon sheathes on our nerve cells, allowing our brain to send messages efficiently.<br />
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So much for low-fat, low-carb diets! If that's not the answer, what is "normal eating?" The best answer to this question that I have ever come across is that offered by Ellyn Satter:<br />
<br /><i>Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it and <a href="http://www.ellynsatter.com/eating-as-much-as-you-need-i-59.html">truly get enough of it</a> -not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good. Normal eating is <a href="http://www.ellynsatter.com/everybody-does-better-with-family-meals-i-69.html">mostly three meals a day</a>, or four or five, or it can be choosing to munch along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.<br /><br />In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.</i><br /><br /><i>For more about eating competence (and for research backing up this advice), see Ellyn Satter's <a href="http://www.ellynsatter.com/physical-products-books-secrets-of-feeding-healthy-family-p-791.html">Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook, Kelcy Press, 2008</a>. Also see <a href="http://www.ellynsatter.com/products.php">www.EllynSatter.com</a> to purchase books and to review other resources.</i><div>
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<i>Copyright © 2012 by Ellyn Satter. Published at <a href="http://www.ellynsatter.com/">www.EllynSatter.com</a>.</i></div>
Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-38322467809010888452013-02-26T10:00:00.000-05:002013-02-26T10:00:01.134-05:00Eating Disorders are Equal Opportunity EmployersOne of my clients went to see a cardiologist to make sure his heart had not been affected by his eating disorder. The tech asked why he was there, and when he told her, she laughed and said that "boys don't get eating disorders." He went home and restricted.<br />
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Many people have the stereotype that eating disorders are something that young, White women get. While it may be true that many individuals who have eating disorders fit this stereotype, there are also many who do not. Boys and men get eating disorders. People of all races and ages get eating disorders. But people who don't fit the stereotype may decide not to seek treatment out of fear that they will be judged, or their suffering will be dismissed, simply because they don't fit with people's assumptions.<br />
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We need to break down these stereotypes so that everyone can get help and support. Eating disorders are equal opportunity employers (and yes, I think "employer" fits because a central feature of eating disorders is that they are demanding task masters).<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-34268250220242791812013-02-25T20:21:00.001-05:002013-02-25T20:21:23.061-05:00Mirrorless MondayWhen you look in the mirror, do you like what you see? Do you notice the good aspects of your appearance, or do you hone in on whatever you don't like about your looks? Many people can pass a mirror or glance at their reflection and think nothing of it. Some people can't.<br />
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Some people get trapped in mirrors. They fall in. They catch sight of some perceived flaw or defect, and stare at it, as it seems to grow and morph in front of them. It may be a blemish or a bad hair day. It may be facial features, or body shape, weight and fat, lumps and bumps we all have. These imperfections become all-consuming.<br />
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For others, mirrors become more animated. Mirrors taunt them, call them names, belittle them. They can hardly stand to glance at themselves, and may avoid their reflection altogether to escape the bullying. Unfortunately, the bully lives in their own heads.<br />
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For people with eating disorders, mirrors are triggers. Some try to mask what they see as unattractive (often, what they see as "fat"), engaging in obsessive appearance checking and fixing. Others go out of their way to avoid having to see themselves. Neither strategy helps to correct the misperceptions, or allows people to see their own beauty.<br />
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Therefore, for eating disorder awareness week (and anytime, really), take a stand by participating in "Mirrorless Monday." Cover your mirrors with paper - any kind will do - and write affirmations of inner beauty for yourself, your partner, your kids, or others around you.<br />
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Remember, mirrors do not define us. They don't even give us that accurate a view of ourselves. Let's not let them dominate us!<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-14515273274127736592013-02-24T20:50:00.000-05:002013-02-24T20:50:15.865-05:00Eating Disorders AwarenessToday is the beginning of Eating Disorders Awareness Week, and this year's theme is "Everybody knows Somebody" (with an eating disorder). The purpose of the campaign is to reduce stigma and stereotypes that so often stand in the way of people getting the help they need. As an eating disorders specialist, I'll be participating through a series of blog posts over the course of the week. You are not alone!<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-84349621925775387762013-02-19T11:50:00.001-05:002013-02-19T11:50:40.767-05:00Changing Models of Addictions TreatmentOne of the Harvard-affiliated Boston teaching hospitals has announced that they are closing their inpatient detox unit to channel resources to treatment modalities more consistent with current best practices. Surprised, anyone? I was initially surprised and somewhat skeptical, but I can see both sides of this argument.<br />
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Inpatient detox units have been in existence for many, many years. These units provide medical detoxification for those who are physiologically addicted to a substance, in order to ease the symptoms of withdrawal. Since withdrawal from some substances can be fatal (alcohol and benzodiazapines are two such substances), medically-supervised detox is an important component of treatment.<br />
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Beyond the medical management of withdrawal, inpatient detox units typically follow the basic model of inpatient psychiatric units, with group therapy, psychiatry, and case management services. The content of groups is specific to addiction, and often incorporates 12-step meetings.<br />
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However, during the acute phase of medical detoxification, people often do not feel well enough to get out of bed to attend groups. In the past, when inpatient stays were longer, patients would have time after the worst of the withdrawal was passed to attend and benefit from groups. However, hospital stays have gotten shorter and shorter across the board, and as soon as patients are medically stable, insurance companies push for a step down to a less-intensive level of care.<br />
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Therefore, according to the hospital that is closing its detox unit, offering inpatient group programming is no longer cost effective, because patients are not staying long enough to benefit from it. Instead, the hospital plans to offer a reduced number of inpatient medical beds for medical detox without additional treatment modalities, and expanded ambulatory treatment (Partial Hospitalization: day treatment) as a step down once inpatient medical monitoring is no longer necessary. Of course, this rapid step-down does not account for the fact that people have access to drugs as soon as they are back in the community, and so it seems important to prepare people with some skills to manage triggers and resist opportunities to use, prior to discharging them from inpatient care.<br />
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The hospital plans to channel some of the money saved by closing the inpatient unit into Suboxone treatment for opiate addiction, which, according to a hospital representative, is the current best practice in opiate addiction treatment. Opiate withdrawal is uncomfortable, but not life-threatening. Suboxone is a synthetic opiate available by prescription that is relatively long-acting, is less addictive (people who take it experience less physiological dependence), and has a "ceiling effect" where, after a certain point, increasing the dosage does not increase the effect.<br />
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These qualities make it less susceptible to abuse, and therefore more appealing to providers as an outpatient treatment. It is used both as for detox from opiates (including heroin and various pain medications) and as a long-term maintenance treatment for people who have been chronically addicted to opiates. As a longer-term treatment, it falls into the category of "harm reduction" treatment, because it maintains people on a constant dose of opiates without the risks of IV drug use (Hepatitis and HIV, among other things), and without the psychosocial costs of illicit drug use (various activities to get money for drugs, and to get the drugs themselves, as well as the toll this cycle takes on relationships and ability to function occupationally).<br />
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The hospital I've been discussing plans to offer <a href="http://en.wikipedia.org/wiki/Suboxone#Opioid_dependence">Suboxone</a> as part of a multidisciplinary treatment program, where patients will also receive group therapy and other treatment services to address the underlying addiction. This inclusion addresses my major concern with opiate replacement treatment, that underlying issues may not be addressed. It is unclear whether the hospital plans to continue maintenance Suboxone once patients complete the treatment program.<br />
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What do you think about this shift in addictions treatment? About the harm-reduction model and opiate-replacement? What is really crucial in addictions treatment, and where should it take place? What has been your experience with any of these modalities or forms of treatment?Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com8tag:blogger.com,1999:blog-8734227745996182145.post-44596150903472117552013-02-11T20:09:00.002-05:002013-02-11T20:11:08.867-05:004 Life Lessons from a SnowstormThe Northeast got hit by another major storm over the weekend, particularly New England, where I live. Now, I'm no stranger to snow, having grown up in Buffalo, but it's rare to have multiple feet of snow around here, and we just aren't as prepared for it (plows, salt, etc.).<br />
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The rarity of snow is just fine with me, because I think snow is a huge pain! However, a big snowstorm does offer an opportunity to reflect on a few lessons for therapy, and life.<br />
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1) Be Prepared<br />
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The scouts' motto is good advice for snowstorms. If you're going to get snowed in, and possibly lose power, it's important to be prepared for it! You need food, flashlights, candles, blankets.... It's good advice when it comes to life, too. It's important to be prepared not only with the necessary supplies, but to be prepared mentally and emotionally, too. We tend to handle things more skillfully when we "cope ahead of time," priming ourselves with positive self-talk, rehearsing coping skills, and good self-care. We can also lessen the emotional impact of anticipated stressors through "stress inoculation," by incorporating the skills we want to use in an actual situation into role plays or visualizations of ourselves handling the stressor. Of course, we don't want to spend all our time trying to predict and plan for stressful situations, but when there are big stressors on the horizon, it pays to be prepared!<br />
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2) Take Some Downtime<br />
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If nothing else, snowstorms force us to stay put - we can't do much until the storm passes (especially when the Governor bans driving, the Mayor bans parking, and public transit shuts down). This forced downtime - what some might call "rest" - is actually something most of us would benefit from a little more of! It's good to take time to relax, unwind, destress, and catch up with ourselves. It might be just 10 or 20 minutes of a relaxation or mindfulness exercise, or it could be several hours to a day or more. We have more to give when we take time for self-care.<br />
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3) Work Together<br />
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Cleaning up from a snowstorm is a lot of work. If you have to do it yourself, it can be pretty overwhelming. But, when everyone pitches in, and neighbors help neighbors, it becomes more manageable, AND it creates an opportunity for human connection. Everyone feels more positively about their neighborhood when they feel connected to neighbors. It's a good metaphor for life: much of life can be overwhelming on your own, but becomes more manageable when people support and help each other. Plus, feeling connected to others is part of what makes life worth living.<br />
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4) Practice Radical Acceptance<br />
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There's not much any of us can do about Mother Nature, or the way a storm complicates our lives - especially when it comes to transportation. We can add to our suffering by refusing to accept reality, or we can accept that it is what it is. We don't have to like it, but we can still accept it as a fact. Instead of putting our energy into wishing things were different, we can say: "Ok, if this is how things are, what's my next step? Where can I go from here?"<br />
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We can also remember that the snow melts - "this, too, shall pass" - Spring will come (soon, if you believe the Groundhog), and the storm will be just a memory, and a story to tell when the next big storm rolls around!Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-59501777949903651952013-02-04T20:08:00.002-05:002013-02-04T20:08:28.161-05:00Mindfulness and the SuperbowlDuring last night's Super Bowl broadcast, one of the commentators made a reference to mindfulness and acceptance! Did you catch it?<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcZ2o3eGmIF0ENlmuzVYxP64-evjuBPs8RhVK1_WnsygkUoYht6fBYsYpFaTrVN3deEnpdKJe_4cvgmJMiKkPT9RWz764TwD6uwCwBUxatNSS6Bi4BJmkCGTK47SbQF3wz5yvxjnfZRtW2/s1600/super-bowl.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcZ2o3eGmIF0ENlmuzVYxP64-evjuBPs8RhVK1_WnsygkUoYht6fBYsYpFaTrVN3deEnpdKJe_4cvgmJMiKkPT9RWz764TwD6uwCwBUxatNSS6Bi4BJmkCGTK47SbQF3wz5yvxjnfZRtW2/s200/super-bowl.jpg" width="197" /></a>Ok, ok, he didn't use quite those words, but he was talking about those concepts. It was during the 34 minute game delay caused by a power-outage that shut down the lights in half of the stadium. The delay occurred early in the second half, when the Ravens had a sizable lead and quite a bit of momentum. As it became clear that the delay would be lengthy, questions were raised about how the teams and players would manage it: Would they be able to stay warmed up? Would the Ravens lose their momentum? Would the 49ers be able to capitalize on the delay to change their game plan? Which team would it benefit/hurt more?<br />
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A commentator was asked what he thought the coaches would be saying to their players. His response was that both teams needed to stay focused on the present moment. The Ravens needed to avoid jumping ahead to imagine themselves winning, and the 49ers needed to not get caught up in what they wished they could change about the plays that had already occurred. They needed to do what was needed in the current moment.<br />
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Mindfulness, of course, is at its heart an awareness of the present moment. While mindfulness meditation involves quiet observation of our internal experiences (thoughts, feelings, sensations), mindfulness can be applied to more active pursuits. One mindfulness exercise is to "do one thing" in the moment: if you're washing dishes, be fully present in the experience of washing dishes. If you're playing football, be fully present in the current play. Not the last play. Not the next play. Just this one - be here now.<br />
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Another element of mindfulness is nonjudgment: observing whatever is present in the moment without judging it. This is where acceptance comes in. This was also another aspect of the commentator's advice to the teams in the midst of the game delay. If they got frustrated or angry or impatient as a result of the delay, that could throw them off their game. Their heads wouldn't be in it anymore, and their emotions could get in the way of executing important plays. Instead, they needed to accept it without judgment: "it is what it is."<br />
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How well any of the players last night achieved a state of mindfulness and/or acceptance is something only they could say. The Ravens did in fact lose their momentum, and the 49ers almost eked out a win in the end...almost. The 49ers, like the rest of us, can only adopt that non-present-moment refrain: "Next year!"Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-45719077913752937292013-01-28T11:14:00.001-05:002013-01-28T11:14:49.223-05:00Duty to WarnConfidentiality is one of the pillars of therapy. If there were no expectation of confidentiality, people would be unlikely to be as honest about what's going on with them, as a result of shame/guilt, fear of judgment, or fear that someone else would find out what they said. Therefore, the law has taken steps to protect clients' right to confidentiality, with only a few notable exceptions. For example, therapists are "mandated reporters," meaning that they are required by law to notify the relevant authorities of any suspected cases of abuse or neglect of a child, elderly or disabled person. <br />
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Another exception to confidentiality that is more controversial and varies significantly from state to state is the so-called "duty to warn." Laws related to the duty to warn are based on legal precedent set in the case of <em>Tarasoff v. The Regents of the University of California</em>. The court decided (albeit by a narrow margin) that a therapist may be held liable and subject to civil suit if s/he has reason to believe that a client poses an imminent threat to another person and does not take steps to warn that person. In fact, the client in question did not tell his therapist at the University of California the name of the person he planned to kill (Tarasoff), but the court felt that the therapist would have been able to deduce that person's identity from what the client did say. <br />
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This decision understandably sent shock-waves through the mental health community: therapists could be held liable if a client posed a threat to someone, even if that someone was not clearly identified! Professional associations and legislative bodies were faced with the challenge of determining how best to respond to this landmark case. Because of the controversial nature of the decision, States have varied significantly in the resulting laws. Many States, including California (where the Tarasoff case took place), and Massachusetts (where I live) passed laws <em>requiring</em> mental health professionals to notify the police and intended victim of a threat (in other words, they established a "<em>duty to warn</em>"). Other states passed laws giving mental health professionals <em>permission </em>to warn, meaning that they could divulge information about a threat without fear of repercussions for violating confidentiality. Some States (such as Texas) only allow the therapist to warn the police (not the intended victim), and some leave it up to the clinical judgment of the therapist.<br />
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According to <a href="http://www.jaapl.org/content/30/3/417.full.pdf">Herbert (2002)</a>, "At present, one knows what to do in only half of the jurisdictions in the United States — those that impose a duty to warn. Any 'permission' jurisdiction could, without warning, turn out to be a 'duty' jurisdiction, and in the one-quarter of the states that maintain a legal vacuum on the issue, one can only guess what to do" (p. 423).<br />
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Interestingly, New York's newly-passed gun-control law takes the duty to warn in a different direction: it mandates that therapists notify a state official if they believe a client poses a threat to self or others. The client would then be blocked from (legally) purchasing guns, and police would be able to confiscate any guns in the client's possession.<br />
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So, what are your thoughts on how therapists should respond to threats against someone's life? Should there be a "duty" to warn, simply "permission" to warn, or neither? Who should be warned: the police, the intended victim, or some other state official? What should the response be?<br />
<span style="font-family: AGaramond-Regular;"><br /></span>Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com3tag:blogger.com,1999:blog-8734227745996182145.post-30064681603798313652013-01-26T20:37:00.002-05:002013-01-26T20:37:27.583-05:00New CPT Codes for Mental Health ServicesFor those who do their own billing: make sure you've updated your CPT codes to reflect the changes that became effective 1/1/13.<br />
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CPT stands for "Current Procedural Terminology." The American Medical Association establishes a code (a number) for each service or procedure a medical provider may perform, including mental health services. From time to time, things are added and removed from the list, and procedures are reorganized based on current practice.<br />
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The codes for psychotherapy services have been changed starting this year. The biggest change is that, instead of separate codes for each duration of standard and "interactive" psychotherapy, "interactive complexity" has been added as a separate code to be billed <i>in addition</i> to the standard psychotherapy code when applicable. Therapy is considered "interactive" when it is conducted with non-verbal clients.<br />
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Here are the update CPT codes applicable to psychotherapy:<br />
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90791 Psychiatric Diagnostic Evaluation (by non-prescribing professionals)<br />
90837 Psychotherapy, 60 minutes (client or family member)<br />
90834 Psychotherapy, 45 minutes (client or family member)<br />
90832 Psychotherapy, 30 minutes (client or family member)<br />
90839 Psychotherapy for Crisis, first 60 minutes<br />
90840 Psychotherapy for Crisis, each additional 30 minutes<br />
90846 Family Psychotherapy (without client)<br />
90847 Family Psychotherapy (with client)<br />
90853 Group Therapy<br />
90785 Interactive Complexity<br />
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<br />Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0tag:blogger.com,1999:blog-8734227745996182145.post-71973242517748847302013-01-17T21:32:00.003-05:002013-01-17T21:33:36.988-05:00The 3 C's of Stress HardinessThe concept of “stress hardiness” was developed by Dr. Suzanne Kobasa, based on research that looked at many groups of people who have very stressful occupations. Those who seem to cope with their job stress - in other words, those who have a "hardiness" to it - seem to share three specific characteristics or personality traits. (Conveniently enough, all three begin with the letter C).<br />
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1) COMMITMENT:<br />
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People who are high in commitment feel like they are part of a larger purpose, They are therefore able to find meaning in their work, are fully involved in what they are doing and they give it their best effort. In this context, problems are more likely to be experienced as minor setbacks in the larger scheme of things, rather than major roadblocks to the work at hand.<br />
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2) CONTROL:<br />
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People who feel that they are in control believe that they can influence events and surroundings, that they can make things happen. They have a strong sense of self-efficacy and an internal locus of control versus feelings of powerlessness or feeling like a victim of circumstances. At the same time, they recognize what is beyond their control...and don't waste effort and angst trying to control those things. Instead, they stay focused on their purpose and intent, but are flexible when it comes to strategy, and will alter goals when necessary.<br />
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3) CHALLENGE:<br />
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Those who are susceptible to stress tend to perceive difficulties as threats, stress-hardy people perceive such difficulties as challenges. Instead of becoming defensive, they become curious, and begin to look for angles and ideas they may have missed. These people welcome new situations as opportunities to learn, to grow, and to develop on a personal level. As a result, they are able to turn difficulties to their advantage.<br />
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There is a fourth "C" that could be added to the list: CONNECTION. Social support plays a vital role in shielding people from the detrimental effects of stress. Those who are stress-hardy are able to turn to others for support when times are tough.<br />
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How do you see stress-hardiness? Do you agree with the C's? Is there anything you'd add to the list?Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com5tag:blogger.com,1999:blog-8734227745996182145.post-69293316492875021782012-12-31T23:53:00.001-05:002012-12-31T23:53:59.645-05:00Over the "Cliff" - the Power of LanguageThe latest word out of Washington is that the Congress will not agree on any kind of legislation by tonight's deadline that would avert the spending cuts and tax increases set to take effect tomorrow. There are any number of things I could write about this situation - perhaps about the importance of compromise, the implications for social services, or the class inequality which will mean the poor shoulder a heavier burden. All of these issues are important. However, from a psychological perspective, what has stood out to me throughout conversations on this topic is how the language we use to talk about it influences its emotional impact.<br />
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Notice in my first sentence that I referenced "spending cuts and tax increases," rather than the more common phrases that are being used to describe the situation. In contrast, media and politicians speak of the "financial crisis" as "the fiscal cliff." Words like "crisis" and "cliff" imply threat and danger. These words are chosen to incite anxiety among the public, and therefore to further stir up an already tense political climate.<br />
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Post-modern schools of practice such as Narrative Therapy, and Acceptance and Commitment Therapy are based on the premise that our perceptions of "reality" are based on language rather than fact. They build on Social Constructionism's stance that all "truths" are constructed through social processes. What all this means is that we use language to construct reality, and the reality we end up with is more a function of the language we choose than "facts."<br />
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In therapy, we work with clients to alter their perceptions of reality by changing the way they think about things. We may call it reframing, or cognitive restructuring, or reauthoring, or interpretation, but the desired result is that people will find more flexible and less negative ways of making meaning out of their experiences.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOiXGgIE39U6EJI9KMAlHvCwdcoYtn3Iw-opjKn3QMwa1QLyD78tz30M4ivm0Ms3Mr2QflMjviV8Ud3mSSXlJO3RNT6enV3s29UChDk9577r5mp1RIapuOp0EsTtjLYKp7cFKsn5TkEIE9/s1600/cliff_edge_warning.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOiXGgIE39U6EJI9KMAlHvCwdcoYtn3Iw-opjKn3QMwa1QLyD78tz30M4ivm0Ms3Mr2QflMjviV8Ud3mSSXlJO3RNT6enV3s29UChDk9577r5mp1RIapuOp0EsTtjLYKp7cFKsn5TkEIE9/s320/cliff_edge_warning.jpg" width="252" /></a>The same process might apply to the so-called fiscal cliff. Because talk of "going over the cliff" calls up a vivid image of...well, falling off a cliff...the natural response is to want to dig in our heels and cling to something for safety. That reaction does not inspire balanced and flexible ways of thinking about our economy!<br />
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Unfortunately, "tax increases" and "spending cuts" have also become layered with socially-constructed meaning. These seemingly-neutral descriptions have become rallying cries for partisan politics - the words elicit a negative, defensive response from conservatives and liberals, respectively. Unfortunately, this effect of language has paralyzed our entire political system, preventing any of our politicians from taking a balanced, flexible approach - an important ingredient in any meaningful compromise.<br />
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I don't have an answer or solution here. It is more of an observation, and an encouragement to be aware of the impact of language - the language you choose, and the language you hear - and consider whether that language is the only, or most helpful, way of thinking and speaking.Natalie L. Hillhttp://www.blogger.com/profile/00819024936453125795noreply@blogger.com0