Mindfulness Meets Internal Family Systems: Richard Schwartz on Helping Clients Move from Acceptance to Transformation

A perennial quandary in psychotherapy, as well as spirituality, is whether the goal is to help people come to accept the inevitable pain of the human condition with more equanimity or to actually transform and heal the pain, shame, or terror, so that it’s no longer a problem. Are we seeking acceptance or transformation, passive observation or engaged action, a stronger connection to the here-and-now or an understanding of the past?

As therapists increasingly incorporate mindfulness into their work, they’re discovering what Buddhists have known for centuries: everyone (even those with severe inner turmoil) can access a state of spacious well-being by beginning to notice their more turbulent thoughts and feelings, rather than becoming swallowed up by them. As people relate to their disturbing inner experiences from this calm, mindful place, not only are they less overwhelmed, but they can become more accepting of the aspects of themselves with which they’ve been struggling. Still the question remains of how best to incorporate mindfulness into psychotherapy.

A perennial quandary in psychotherapy, as well as spirituality, is whether the goal is to help people come to accept the inevitable pain of the human condition with more equanimity or to actually transform and heal the pain, shame, or terror, so that it’s no longer a problem. Are we seeking acceptance or transformation, passive observation or engaged action, a stronger connection to the here-and-now or an understanding of the past?

Many therapeutic attempts to integrate mindfulness have adopted what I’ll call the passive-observer form of mindfulness—a client is helped to notice thoughts and emotions from a place of separation and extend acceptance toward them. The emphasis isn’t on trying to change or replace irrational cognitions, but on noticing them and then acting in ways that the observing self considers more adaptive or functional. As an illustration, let’s consider how more traditional therapeutic approaches contrast with more mindfulness-based methods in helping a client dealing with the mundane challenge of feeling nervous about going to a party. A Cognitive-Behavioral Therapy (CBT) intervention might begin by identifying the self-statements that are generating anxiety—a part of the person that says, in effect, “Don’t go because no one likes you and you’ll be rejected.” The client might then be instructed to dispute these thoughts by saying, “It’s not true that no one likes me” and naming some people who do. A clinician trained in a mindfulness-based approach like Acceptance and Commitment Therapy (ACT) might have the client notice the extreme thoughts about rejection without trying to change them, and then go to the party anyway, despite the continued presence of the irrational beliefs. As this example shows, mindfulness allows you to no longer be fused or blended with the irrational beliefs, releasing your observing self, who has the perspective and courage to act in positive ways. But what if it were possible to transform this inner drama, rather than just keep it at arm’s length by taking mindfulness one step further?

The Second Step

As a therapist, I’ve worked with clients who’ve come to me after having seen therapists who’d helped them to be more mindful of their impulses to cut themselves, binge on food or drugs, or commit suicide. While those impulses remained in their lives, these clients were no longer losing their battles with them, nor were they ashamed or afraid of them any longer. The clients’ functioning had improved remarkably. The goal of the therapeutic approach that I use, Internal Family Systems (IFS), was to build on this important first step of separating from and accepting these impulses, and then take a second step of helping clients transform them.

For example, Molly had been in and out of hospital treatment centers until, through her DBT treatment, she was able to separate from and be accepting of the part of her that had repeatedly directed her to try to kill herself. As a result of that successful treatment, she’d stayed out of the hospital for more than two years, was holding down a job, and was connected to people in her support group. From my clinical viewpoint, she was now ready for the next step in her therapeutic growth. My goal was to help her get to know her suicidality—not just as an impulse to be accepted, but as a “part” of her that was trying to help her in some way.

In an early session, after determining she was ready to take this step, I asked her to focus on that suicidal impulse and how she felt toward it. She said she no longer feared it and had come to feel sorry for it, because she sensed that it was scared. Like many clients, she also began to spontaneously see an inner image, in her case a tattered, homeless woman who rejected her compassion. I invited her to ask this woman what she was afraid would happen if Molly continued to live. The woman replied that Molly would continue to suffer excruciating emotional pain. With some help in that session, Molly was able to embrace the woman, show her appreciation for trying to protect her from extreme suffering, and learn about the hurting part of her that the woman protected her from. In subsequent sessions, Molly, in her mind’s eye, entered the original abuse scene, took the little girl she saw there out of it to a safe place, and released the terror and shame she’d carried throughout her life. Once the old woman could see that the girl was safe, she began to support Molly’s steps into a fuller life and stopped encouraging her to try to escape the prospect of lifelong suffering through suicide. In this way, the “enemy” became an ally.

The Paradox of Acceptance

Years ago, Carl Rogers observed, “The curious paradox is that when I accept myself just as I am, then I can change.” In other words, carefully observing and accepting our emotions and beliefs, rather than fighting or fearing them, is a precursor for using that same mindful state to help them transform. Once people come to compassionately engage with troubling elements of their psyches, they’re often able to release difficult emotions and outmoded beliefs they’ve carried for years. For me, this process of compassionately engaging with the elements of our psyches is a natural second step of mindfulness. If you feel compassion for something, why just observe it? Why not engage with it and try to help it?

Once a client, in a mindful state, enters such an inner dialogue, she’ll typically learn from her parts that they’re suffering and/or are trying to protect her. As she does this, she’s shifting from the passive-observer state to an increasingly engaged and relational form of mindfulness that naturally exists within: what I call her “Self.” Having helped clients access this engaged, mindful Self for more than 30 years now, I’ve consistently observed that it’s a state that isn’t just accepting of their parts, but also has an innate wisdom about how to relate to them in an attuned, loving way. I’ve observed over and over clients’ enormous inborn capacity for self-healing, a capacity that most of us aren’t even aware of.

We normally think of the attachment process as happening between caretakers and young children, but the more you explore how the inner world functions, the more you find that it parallels external relationships, and that we have an inner capacity to extend mindful caretaking to aspects of ourselves that are frozen in time and excluded from our normal consciousness. This Self state has the ability to open a pathway to the parts of us that we locked away because they were hurt when we were younger and we didn’t want to feel that pain again. As clients approach these inner parts—what I call “exiles”—they often experience them as inner children who fit one of the three categories of troubled attachment: insecure, avoidant, or disorganized. Typically, once one of these inner exiles reveals itself to the client, their Self automatically knows how to relate to that part in such a way that it’ll begin to trust the Self. These inner children respond to the love they sense from the Self in the same way that abandoned or abused children do as they sense the safety and caring of an attuned caretaker. As parts become securely attached to Self, they let go of their terror, pain, or feelings of worthlessness and become transformed—a healing process that opens up access to a bounty of resources that had been locked away.

The Therapist’s Role

With all this talk of self-healing, I don’t want to downplay the importance of the client’s relationship with the therapist. What does shift is the focus on the therapist from being the primary attachment figure to serving as an accepting container of awareness who opens space for the client’s own Self to emerge. To do this, therapists must embody their own fullest Self, acting as a tuning fork to awaken the client’s Self to its own resonance. To achieve this kind of embodiment, therapists must learn to be mindful of their own parts as they work with clients, recognizing that transference and countertransference are, at some level, a continuing behind-the-scenes dance as therapists and clients inevitably trigger each other. Fortunately, as you become increasingly familiar with the physical experience of embodying this mindful Self, you’ll be better able to notice the shift in your body when a troubled part hijacks you.

Working in this way can be an intense and challenging task, which regularly requires me to step out of my emotional comfort zone and experience “parts” in myself and my clients that I might otherwise wish to avoid. At the same time, on my best days, I feel blessed to be able to accompany clients on inner journeys into both the terror and wonder of what it means to be fully human. At those moments, I can’t imagine a more mindful way to practice the therapist’s craft.

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Dr. Richard Schwartz developed Internal Family Systems in response to clients’ descriptions of experiencing various parts – many extreme – within themselves. He noticed that when these parts felt safe and had their concerns addressed, they were less disruptive and would accede to the wise leadership of what Dr. Schwartz came to call the “Self.” In developing IFS, he recognized that, as in systemic family theory, parts take on characteristic roles that help define the inner world of the clients. The coordinating Self, which embodies qualities of confidence, openness, and compassion, acts as a center around which the various parts constellate. Because IFS locates the source of healing within the client, the therapist is freed to focus on guiding the client’s access to his or her true Self and supporting the client in harnessing its wisdom. This approach makes IFS a non-pathologizing, hopeful framework within which to practice psychotherapy. It provides an alternative understanding of psychic functioning and healing that allows for innovative techniques in relieving clients symptoms and suffering.

This blog is excerpted from “When Meditation Isn’t Enough” by Richard Schwartz and was originally posted at Psychotherapy NetworkerThe full version is available in the September/October 2011 issue, The Mindfulness Movement: Do We Even Need Psychotherapy Anymore?

Improve Insight and Unlock Change Using Metaphors from Daily Life

Metaphors facilitate learning, create a memorable visual, and are usually well received by clients as they communicate a personally relatable point in a non-confrontational manner.

We all struggle with finding the right tools to help change our clients’ behavior.

Throughout my 40 years as a psychotherapist, I’ve found that creating metaphors using everyday objects in life is a powerful strategy for unlocking change.

A penny, a crayon, or even a balloon … there are endless tangible reminders that serve as therapeutic touchstones, reinforcing session lessons.

Here are some examples of how I use everyday items as metaphors:

  • A Penny: Points out that we need to embrace change!  It also reminds us that even insignificant things add up. To further this point, you can ask your clients if they would take a million dollars or a penny that doubles every day for a 31 day month. The answer: $1,000,000 vs. $5,386,709.12.
  • Rubber Band: An elastic band is like stress—we need some “stretch” to thrive. A limp rubber band signifies a lack of engagement and commitment, but too much stretch by not setting limits, for example, will lead to being stretched too thin and even snapping!
  • A Small Bouncing Ball: Reminds us that we can bounce back from anything if we have a positive attitude and learn from adversity. It demonstrates the importance of being flexible in order to bounce back!
  • An Eraser: Tells us it’s okay to make mistakes! We don’t need to be perfect.
  • A Crayon: Reminds us to put color into our worlds by positive thinking, and avoid thinking in “black and white.”

The beauty of these objects is there is no right or wrong meaning; all are subject to various interpretations which are fun for creative brainstorming and engaging for your clients. I suggest my clients carry an item that is soothing for them, right in their purse, wallet or even a back pocket.

I like to take it one step further and create metaphorical toolkits. Some toolkit ideas include anger and stress management, coping skills, positive life, school survival and drug-free toolkit. What I find really handy is that most of these things (and dozens of other potential items) can be found in our household “junk drawer” or purchased inexpensively.

Using familiar items from everyday life that symbolize important life skills offers a great group activity for all ages. For more on the use of metaphors, download this free worksheet, Using Metaphors from Daily Life.

Using metaphors is just one way that you can help your clients change their behavior. You can find over 150 more tips and techniques in my new book: 150 More Group Therapy Activities & TIPS.

DOWNLOAD: Using Metaphors from Daily Life

Judith A. Belmont, MS LPC, has 40 years of experience in the mental health field as therapist, author, trainer and speaker. She is the author of 6 books designed to provide mental health professionals and their clients valuable life skills resources, including 150 More Group Therapy Activities & TIPS.

Wearing Your Heart on Your Face: The Polyvagal Circuit in the Consulting Room

In the interview that follows, Dr. Stephen Porges offers some research-based insights into how therapists can more effectively convey safety to clients and clarifies the evolutionary roots of anxiety, depression, and trauma.

The following was writtin by Ryan Howes, PhD, psychologist and clinical professor at Fuller Graduate School of Psychology in Pasadena, California.

As we all learned in school, we have two options in the face of perceived danger: fight or flight. But that was before neuroscientist Dr. Stephen Porges, author of The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, undertook his research into the relationship between human physiology and social engagement.

Porges’s work—which noted researcher Paul Ekman called “a truly revolutionary perspective on human nature”—dramatically broadens our understanding of the sympathetic and parasympathetic systems and explains how our bodies and brains interact with one another to regulate our physiological states. However, what may be more pertinent to therapists is the extent to which our autonomic nervous systems influence long-term issues with intimacy and trust. In the interview that follows, Porges offers some research-based insights into how therapists can more effectively convey safety to clients and clarifies the evolutionary roots of anxiety, depression, and trauma.

Ryan Howes (RH): Can you explain your Polyvagal Theory in simple terms?

Porges: It’s hard to make it simple, but let’s try by starting with what we’ve all learned about the autonomic nervous system. It’s a pair of antagonistic systems: the sympathetic supports mobilization, and the parasympathetic supports immobilization, usually associated with relaxation, growth, and restoration. In the past, we tended to believe that stress responses were, in general, vested within the sympathetic nervous system’s capacity to support fight-or-flight behaviors. But there’s another defense system, unrelated to the sympathetic nervous system and dependent on the parasympathetic nervous system. The mechanisms and adaptive function of this defense system are impossible to understand from the paired antagonism model. The parasympathetic defense response is mediated through a vagal circuit producing a behavioral shutdown such as fainting or, from a clinical perspective, dissociation. This defense system doesn’t fit within the fight-or-flight model. Nor does it fit within the view that the vagus, the major nerve in the parasympathetic nervous system, mediates calmness and induces resilience and health.

RH: Your work suggests that our autonomic systems are better thought of as hierarchical, rather than competing.

Porges: Right. The vertebrate autonomic nervous system has changed through stages of evolution, and the human autonomic nervous system shares several of these autonomic circuits with more ancient vertebrates. Functionally, our autonomic nervous system is composed of three phylogenetically organized subsystems. We utilize our newest systems first, and when they don’t work, we recruit older ones. In terms of evolution, the newest autonomic circuit is a uniquely mammalian vagal circuit, which inhibits the heart rate by placing a tonic inhibition on the heart’s pacemaker. This circuit also inhibits sympathetic activity. The brainstem areas controlling this neural pathway coordinate the nerves controlling the muscles in the face and head. So people are literally showing their heart on their face. That’s because humans are social beings who have to convey to one another that we’re safe to come close to, to hug, and in some cases, to have sex with. To convey this message of safety, we utilize the newest vagal circuit to down-regulate our sympathetic defenses and present cues of safety when it’s appropriate. While the face is a crucial vehicle for this, the voice also plays an important role in conveying a physiological state of calm. If the voice has a higher-pitched frequency, it’s saying, “Don’t come near me.”

The thing to bear in mind is that the vagal circuit is both expressive and receptive. That’s why you feel calmer when I use a soothing, prosodic voice. When the vagal circuit is working, our middle-ear muscles change our capacity to hear predators or low-frequency sounds. Middle-ear muscles, similar to the muscles of the face, are regulated by the brainstem area that controls the mammalian vagal circuit. Typically, when there’s something in the environment that threatens us, we turn off the vagal circuit, because it inhibits our ability to mobilize: it gets in the way of moving to fight or to flee.

RH: That’s because it’s the vagal system that makes us freeze, right?

Porges: Yes, but there are two vagal systems. The root of the Polyvagal Theory is the recognition that in the absence of the ability to fight or flee, the body’s only effective defense is to immobilize and shut down. This can be observed as fainting or nausea, both features of an ancient vagal circuit that reptiles use for defense. However, unlike the uniquely mammalian vagal pathway, these vagal pathways are unmyelinated, and are only effective as a defense system when the newer circuits, including the sympathetic nervous system, are no longer available for interaction and defense. Our reptilian ancestor was similar to a turtle, and the primary defense for a turtle is to immobilize, inhibit breathing, and lower metabolic demands. Although immobilization may be effective for reptiles, it can be life-threatening for mammals, and for humans it can lead to states of dissociation. The Polyvagal Theory provides a way of seeing how the organization of our nervous system can shape our understanding of clinical disorders and issues, enabling us to see symptoms like dissociation not as bad behaviors, but as adaptive reactions to cues in the environment that trigger our physiological responses to perceived dangers.

Think about it this way. When you want to calm a person down, you smile and talk to them in a soothing way. The nervous system detects these cues and down-regulates or inhibits the sympathetic nervous system. But when the sympathetic nervous system is activated as a defense system, it turns off all those social-engagement behaviors. Clinicians are aware of that. But what they often don’t understand is the role of the vagal system in shutting down as a defensive strategy in response to a life threat. When someone is immobilized, held down, or abused, the vagal system is triggered, and they may disassociate or pass out—or perhaps drop dead or defecate. It’s an adaptive response.

I often talk about immobilization with fear and contrast it to immobilization without fear. The mouse in the jaws of a cat is immobilized with fear. The mouse isn’t voluntarily playing dead; it’s fainted. But someone in the embrace of a lover, parent, child, or friend is immobilized without fear.

RH: We might call that stillness, or peace.

Porges: Right, you’re still, but you’re being present. For reptiles and more primitive vertebrates, the primary defense system was to disappear—to immobilize, stop breathing, and look like you’re dead. For mammals, immobilization is a risky business. We have to be selective about whom we can feel still, calm, and comfortable with. Many clients have difficulty feeling comfortable in the arms of another. They can’t immobilize without fear. If you go through their clinical histories, you’ll find that many were severely abused and had experiences of being forcedly held down. These experiences of forced immobilization trigger fear responses and shutting down. Those who survive these experiences don’t want to be immobilized and find it difficult to be held and calmed, even by people who are trying to be helpful. This response is often expressed as anxiety and a need to keep moving, which is a functional defense to a fear of immobilization. Often individuals with a history of immobilization with fear will adaptively become anxious and go into panic states to avoid this immobilization state. This is a problem many therapists see in their practices.

RH: What are the practical implications of Polyvagal Theory for clinical work?

Porges: It heightens our appreciation of the role of creating safety in therapy. For example, our bodies, physiologically, are extraordinarily sensitive to low-frequency sounds. We, like other mammals, interpret these low-frequency sounds as predatory. If your clinical office is bombarded with sounds from ventilation systems, elevators, or traffic sounds, your client’s physiology is going to be in this more hypervigilant defense mode. Likewise, if you sit some people in the middle of the room away from a wall, they may become hypervigilant and concerned with what’s going on behind them. If we’re not safe, we’re going to assume that neutral faces are angry faces. We’re going to assume the worst because that’s what our nervous system tells us to do. As vertebrates evolved into mammals, they had to interact with other mammals for survival. They needed to detect the social cues and identify when it was safe to be with another mammal. Thus, vocalizations in social contexts are less about syntax and language and more about the intonation conveying emotional state. Again, this is critical in therapy because the intonation of voice conveys more information about the physiology of the client than the syntax.

RH: In other words, how you’re saying something means more than what you’re saying.

Porges: Absolutely. When you were an undergraduate, what were the lectures that put you to sleep? Was it the college professor who was off in space, who basically read from notes and had no prosodic features and no engagement? Social communication has little to do with syntax and a lot to do with intonation, gestures, and a cluster of behaviors we would call biological movement. The face is moving along with the voice and hand gestures. The behavioral features trigger areas of our brain outside the realm of consciousness and change our physiology, enabling us to feel closer and safer with another. Good therapy and good social relations, good parenting, good teaching, it’s all about the same thing—how do you turn off defensiveness? When you turn defense systems off, you have accessibility to different cortical areas for more profound understanding, learning, and skill development.

Ryan Howes, PhD, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs for “In Therapy” at Psychology Today. Contact: rhowes@mindspring.com; website: www.ryanhowes.net.


The Adverse Childhood Experiences Study and Why it Matters

In life, getting dealt a hand of ACEs is surely not the thrill that it is in a card game. But thanks to the ACE study, communities are developing creative ways to intervene and prevent intergenerational transmission of the issues caused by high ACE scores.

In most card games aces are valued and prized. In life, getting dealt a hand of ACEs is surely not the thrill that it is in a card game.

The Adverse Childhood Experiences (ACE) Study highlights the long-term negative impact of traumatic events in childhood. The results are staggering. Childhood trauma has potentially devastating consequences in many realms: physical, behavioral, emotional, social, and financial.

Download: Finding Your ACE Score Questionnaire

Physical fallout includes increased smoking, addictions, chronic diseases, obesity, STD’s, and fetal death. With a score of 6 or more life expectancy is shortened by 20 years.

The behavioral impact includes a much higher suicide risk, and increased likelihood of being a perpetrator or victim of violence, risky sexual behavior, and more marriages.

Emotionally, higher ACE scores correlate with a dramatically elevated risk of depression, anxiety, PTSD, conduct disorder, and learning problems.

The social consequences are stunning. With a score of 4 or more we see lower academic achievement, poor social skills, more delinquent and criminal behavior, and even food insecurity in the family.

In looking at the financial ramifications of high ACE scores we see expenses related to criminal justice, healthcare, and behavioral health costs, and family financial stress.

In fact, the lifetime cost of nonfatal child abuse and neglect in 2008 was over $210,000 per victim, and the total lifetime economic burden in the U.S. was a whopping $124 billion.

Not all the news is bad.

There has been a recent surge of interest in the ACE Study and communities are developing creative ways to intervene and prevent intergenerational transmission of the issues caused by high ACE scores.

To find out how you can help build stronger, healthier communities, please join us for a webinar that will arm you with tools to help individuals and families with high ACE scores. We’ll talk about prevention, intervention, and how you can use this information in your work with people in community.

-Martha Teater, MA, LMFT, LCAS, LPC

This blog was contributed by PESI speaker Martha Teater, MA, LMFT, LCAS, LPC.  Martha has been in private practice in NC since 1990. She is a speaker in the US and internationally on compassion fatigue, evidence-based treatment of trauma, DSM-5, and behavioral treatment of chronic pain. You can learn more about Martha at www.MarthaTeater.com and www.teaterhs.com

Join Martha Teater on July 7 from 1-2:30 EST for the live webinar—ACEs: What You Need to Know TODAY About the Adverse Childhood Experiences (ACE) Study—to learn how you can help your community intervene and prevent issues caused by high ACE scores.


A Trip to Cuba: A view of the island from the eyes of Christina Taylor, PhD

As a psychology resident on staff at the mental health center in Key West, Florida in the early 90s, my interest in Cuba was piqued by work with Cuban-American exiles who brought their vibrant Cuban culture to our most southern American city. This past March my dream of visiting Cuba came true on a tour focused on birding, people, and cultural exchange.

From the desk of PESI author Christina J. Taylor, Ph.D. pictured above with the President of the Cuban Society of Psychology, Dr. Alexis Lorenzo Ruiz.

For many of us of a certain age who lived through the Bay of Pigs invasion, the Cuban missile crisis, and the trade and travel embargo, the island of Cuba, only 90 miles away from US shores, has for too long been an intriguingly unavailable neighbor. As a psychology resident on staff at the mental health center in Key West, Florida in the early 90s, my interest in Cuba was piqued by work with Cuban-American exiles who brought their vibrant Cuban culture to our most southern American city. This past March – three weeks before Obama in fact – my dream of visiting Cuba came true on a tour focused on birding, people, and cultural exchange.

It was a completely fascinating and sometimes very difficult trip; conditions in the hotels in the countryside falling well below standards that would be considered budget lodging in the US. Sadly, the island is in a state of decay, buildings standing vacant and in disrepair. A formerly grand home, that is now a resort near a magnificent nature preserve, was reminiscent of Miss Havisham’s run down mansion in Dickens’ novel Great Expectations. The shower in our bathroom with the exposed light bulb, provided barely a trickle of cold water, necessitating creative maneuvering to get at least nominally washed and rinsed.

The Cuban people, on the other hand, possess an indomitable spirit in the face of truly difficult economic conditions. They engage in what our young Cuban guide called the struggle to make ends meet. While the average Cuban salary is about $24 a month, he explained that it really takes 10 times that amount to meet basic needs. Hence the need to find additional sources of income – alluding to making do by struggling to find jobs that pay under the table. If possible, many people seek out employment in the tourist industry – one cab driver explained that although he possessed a college degree in mechanical engineering, he could make more money in two hours driving a taxi than in one month working as an engineer. The irony is that there is free education, including up to the level of a Ph.D., for those who are qualified, but the downside is that there are many obstacles to earning an adequate income.

The deprivation that the Cubans are experiencing now is still not as bad as in the 1990’s following the collapse of the Soviet Union and the withdrawal of its economic support. Our guide told us that the average Cuban lost 30% of their body weight during that time because of severe food shortages. Fidel Castro labeled this period “the special period” because of the hardships faced by the Cuban nation. Food is certainly more plentiful now, but again, the restaurant quality in the countryside is generally not up to American standards. Stray cats and dogs are seen everywhere – sometimes to the point of their ribs showing through – leading some of us on the tour to regularly drop food onto the floor for them and to surreptitiously wrap up part of our meals for feeding other stray animals.

The long history of economic difficulties and hardships definitely accounts for why the Cuban people are so enthusiastic about the renewal of relations with the US. Everywhere we went, Cubans who initially thought we were Canadian, broke out into big, big smiles when they learned we were Americans. It is clear that they believe the normalization of relations with the US will have a positive effect on their lives.

To this point, people in the travel industry wore a pin with adjoining Cuban and American flags, and many taxi drivers displayed both flags on the dashboard of their vintage American cars. The cars are, of course, a hoot for all of us, especially for us baby boomers who rode around in them with our parents in the 50’s and 60’s. It was incredible to ride in a 1938 Oldsmobile that appeared to be right out of a Hollywood gangster movie, sans the tommy guns, of course! I also spoke to the owner of a 1958 yellow Rambler exactly like my father’s who told me that he had installed a Russian engine to keep it going. That is a testament to the ingenuity and perseverance of a people who have surmounted great obstacles. To this point, the drivers are excellent, adept, and by far more polite than those in the US! And for those who want to travel more frugally, cheaper taxi fares can be had by riding in the less glamorous non-vintage cars! And forget about seat belts and emission controls!

Despite the decay, pollution, deprivation (internet service is extremely scarce – available in some hotel lobbies for $4.50 an hour) and all the physical and social rehabilitation that needs to be done, Cuba is surreally enchanting. It is both weird and tranquil to look out over Havana harbor and see no boats except for one Russian cruise ship parked at a dock. And by the way, not one seagull! Outside of Havana, horse drawn carts are common and oxen are used to plough the fields.

Music is everywhere and marvelous. Even in the small restaurants and hotels in the countryside, the local bands and singers serenaded us with the beat and sounds of salsa. The live music that reverberates all throughout the country is an anthem to the passion and soulfulness of a people who have endured.

As an American, I am hopeful that the renewal of relations between the countries will be positive for both peoples. The Americans I encountered in Cuba all expressed gratitude that we had the opportunity to visit the island before the anticipated onslaught of American tourists. Most expressed reservations about the negative effects that mass American tourism may have on this island nation stuck in time. Hopefully, the transition unfolding before us will work out in the end for both Cuba and the US. It is inevitable that something will be lost and gained.

At the end of my tour I had the opportunity to meet with the President of the Cuban Society of Psychology, Dr. Alexis Lorenzo Ruiz. I was able to contact him prior to my trip about my wish to meet and to share with him my recently published book on OCD. With that, he cordially invited me to meet him in his home (his day off from campus at the University of Havana).

We spent an hour and a half together talking about our respective careers and work as psychologists, finding out that we shared many commonalities. He has a background in social and clinical psychology, which I do as well. We both teach courses in Psychopathology and he is currently authoring a book on Psychopathology. Dr. Ruiz is a trauma specialist and knowledgeable about current evidence based treatments, including cognitive behavior therapy (CBT), Exposure and Response Prevention, and Acceptance and Commitment therapy (ACT). He spoke about the epidemiology of OCD, the importance of using ERP for treating OCD, and cited a case of a young man whose treatment was complicated by a co-morbid condition. He was truly delighted to receive my book as well as the one I donated to the University.

Dr. Ruiz was trained as a psychologist in the Soviet Union and speaks several languages. Following the Chernobyl disaster, he spent significant time in the Ukraine treating people suffering trauma from the disaster. His English has suffered as a result of his multi-linguistic experiences, and he is now interested in finding a post-doctoral position in the USA to perfect his English language skills. His lovely daughter, who is studying to become a physician, served as our translator. He is a brilliant, knowledgeable, and warm man who welcomed me into his home despite his busy schedule – working to finish his book by June! At his home, I met his two daughters, Aleli and Azucena, their grandmothers, and their new puppy, Lassie! His wife, Alma, is a physician and was away at work.

We parted with the understanding that we will hopefully meet again — with invitations to come to one another’s homes — Mi casa es su casa!

Christina J. Taylor, Ph.D., specializes in Cognitive Behavioral Therapy for Anxiety Disorders, including Obsessive Compulsive Disorder, Panic Disorder, Agoraphobia, Social Phobia, Generalized Anxiety Disorder, and specific phobias. Dr. Taylor lectures widely on anxiety disorders and provides training workshops for mental health professionals. She is an Associate Professor of Psychology at Sacred Heart University in Fairfield, Connecticut.


What Does it Mean to be a Culturally Competent Counselor?

As clinicians, we are often called upon to support and treat people during their incarceration, release, and parole. We also support their family members during this time. Understanding how social injustice, like racism, poverty and mental illness, contributes to incarceration is essential to effective clinical care.

In the United States, the legacy of slavery is a cultural wound that remains unresolved and unhealed, and it has resulted in, among other symptoms, the mass incarceration of African American men and women.

More people are imprisoned in the United States than in any other country in the world; and people of color constitute a disproportionate part (60%) of the incarcerated.

The Sentencing Project has further broken down the chances of being imprisoned by race, and the numbers are eye opening:

  • African-American men have a 1:3 chance of being imprisoned
  • Spanish-speaking men have a 1:6 chance of being imprisoned
  • European descendants have a 1:17 chance of being imprisoned

It might also surprise you to know that American Indians are jailed at a 38% higher than the national rate according to the U.S. Commission on Civil Rights.

These disproportionate incarcerations are linked to differential treatment by the criminal justice system, lack of access to adequate counsel, and racial profiling.

As clinicians, we are often called upon to support and treat people during their incarceration, release, and parole. We also support their family members during this time. Understanding how social injustice, like racism, poverty and mental illness, contributes to incarceration is essential to effective clinical care. This awareness allows us to speak  up when we see the mental health system perpetuate myths that oppress people; for example, treating substance abuse or incarceration due to drug use as an “illness” rather than  symptoms of a far greater problem such as trauma, intergenerational trauma and social injustice.

There are many factors that can contribute to our failure to engage social injustice such as: lack of awareness, “white fragility” and denial, compassion fatigue and a sense of helplessness. We become inured to the ongoing effects of racism and oppression in peoples lives. This also occurs if we do not allow ourselves to experience the daily direct effects.

But as clinicians, we are confronted with the effects of oppression in the lives of our clients every day.  Personal and social oppression affect physical and mental well-being.

What do we need to know about that to improve our work with clients? How do we deepen our understanding of our own internalized oppression?

There are so many levels at which this is important, and yet one that directly affects our clients is the concept of allostatic load. Allostatic load is defined as the “wear and tear” effect of chronic stress from daily life on the body and mind. Racism, bigotry and poverty all contribute to allostatic load, and this load accumulates during a lifetime leading to mental and chronic physical illness; especially illness that is autonomically mediated like cardiovascular disease and diabetes. It is believed that to be due to the effects of racism in the U.S., African-Americans have higher early mortality compared to non-Hispanic whites.

In today’s culture of social injustice, we are no longer just clinicians: we are social justice advocates. We take on this role every time we are asked to treat someone who is incarcerated, addicted, or has multiple physical illness co-occurring with PTSD. And it doesn’t stop there.

Our work goes beyond the daily routine of our office–our mandate is to advocate and act. To be successful clinicians, our work in multicultural competency must incorporate anti oppression. To do this, we incorporate understanding about the structural racism at work in our practices, our agencies, jails and the society at large.

Further learning about “Race” in America

Read: Multicultural Counseling Workbook: Exercises, Worksheets & Games to Build Rapport with Diverse Clients by Leslie Korn

Watch: Advance Your Cultural Competency in the Clinical Setting: DSM-5® Guidelines, Ethical Standards and Multicultural Awareness, a CE seminar with Leslie Korn.

Listen: When Ancestry Search Led To Escaped Slave: ‘All I Could Do Was Weep’, an interview with author Regina Mason.

View: The Dhamma Brothers story of the introduction of Vipassana meditation into a maximum-security prison in Alabama.

leslie korn 2015

Leslie Korn, Ph.D., MPH, LMHC, has over 35 years of experience in cross cultural counseling, research, and traditional healing practices. For over 10 years, Dr. Korn was the president of a multicultural consulting firm to design and implement multilingual and multi-ethnic mental health and wellness programs to reduce chemical dependency in urban Boston and rural Massachusetts. She lived and worked in the jungle of Mexico for over 20 years where she directed a public health clinic working alongside traditional healers. She has contributed to the design of cultural revitalization programs for mental health in tribal communities in the Pacific Northwest and Canada and has provided over 40,000 hours of private practice and agency-based clinical treatment to diverse individuals, families and communities.

Dr. Korn has a dual doctorate in Behavioral Medicine and Traditional (indigenous) Medicine and a Masters of Public Health from Harvard School of Public Health. Dr. Korn also earned a Masters in cross-cultural health psychology from Lesley University. She was a clinical fellow in psychology and religion at Harvard Medical School. An approved clinical supervisor, licensed mental health counselor, Fulbright scholar and NIH-funded scientist, Dr. Korn is the author of Nutrition Essentials for Mental Health: A Complete Guide to the Food-Mood Connection (Norton, 2016),  Rhythms of Recovery: Trauma, Nature and the Body (Routledge, 2012) and Preventing and Treating Diabetes Naturally, The Native Way (Daykeeper Press, 2010). Dr. Korn is core faculty and fieldwork supervisor in mental health counseling at Capella University and maintains bilingual clinical consulting practice in Puerto Vallarta, Mexico.


4 Strategies to Jumpstart Progress When Therapy Stalls

What do you do when a client stops making progress in therapy and it seems like your sessions are going nowhere? There are many reasons why this can happen including fear of change, unresolved trauma or a lack of clarity between client and therapist on the goals for therapy. Here are 4 strategies that not only dissolve standstills, but can also trigger big breakthroughs for your clients.

Counselor Courtney Armstrong explains what can cause therapy to stall and offers 4 simple strategies for getting a client moving again when they have got stuck.

What do you do when a client stops making progress in therapy and it seems like your sessions are going nowhere? There are many reasons why this can happen including fear of change, unresolved trauma or a lack of clarity between client and therapist on the goals for therapy. In this article I will share 4 strategies that not only dissolve standstills, but can also trigger big breakthroughs for your clients.

Please note: all client names have been changed to maintain confidentiality.

Strategy #1: Respectfully Address the Impasse and Normalize Fears of Change

Although clients seek therapy to make changes in their lives, the act of making those changes can seem scary or daunting. For example, my client Susie initiated therapy because she kept getting into relationships with men who had addictions. When she contacted me she was in an extremely codependent relationship and said she wanted to gain the courage to get out of it and build her self-esteem.

Susie actively participated in our first few sessions and showed a great deal of insight. Around our 4th session, she felt her self-esteem had greatly improved. Yet, she still couldn’t bring herself to break off the dysfunctional relationship with her boyfriend, who had recently stolen money from her and wrecked her car while driving drunk.

In the next several sessions Susie seemed to just want to complain about the emotional and financial burden this relationship placed on her. She dodged my best efforts to explore her deeper fears with replies like:

“Oh, I am planning on ending this relationship and setting boundaries like we talked about. I just can’t do it right now because he is dealing with the DUI and all. I’ll wait and do it after we get all of that resolved.”

Then, she’d go back to complaining about her frustrations with him.

When I found myself feeling bored and exasperated in our sessions, I knew I had to be more direct. I said:

“Susie, I feel like our last few sessions have degraded into focusing on all the ways you are unhappy in this relationship. But, that’s not going to lead you out of this dilemma. We’ve got to look at the fear and guilt that’s holding you in this pattern if you want to get any relief from it. Can we focus on that for a minute?”

Susie nodded and replied:

“I know. I guess I’m scared that either he’ll die if I don’t help him or that I won’t find anyone else to love me if I leave this relationship.”

This led to a much richer session in which Susie revealed an attachment trauma with her father who was a recovering alcoholic. Prior to this, she’d never disclosed that her father had a drinking problem. At the end of the session, she thanked me for redirecting her and asked that I continue to keep her accountable if she lost focus in the session.

Strategy #2: Explore For Earlier Traumatic Experiences

Just as Susie revealed, internal conflicts about change are often rooted in a prior emotional trauma the client has experienced. The problem is that many clients won’t connect these prior experiences to their current problem. Susie discovered this connection when I asked her if her feelings of guilt and fear around setting limits with her boyfriend reminded her of any other relationships in her life. It took a few minutes, but her eyes widened as she recalled an incident from her childhood when her father came home inebriated and her mother asked him to leave. Susie said her father went into a tirade and told her mother:

“Fine I’ll leave. But no one will ever love you and Susie like I do.”

He got into a car accident that night and suffered a head injury that left him in a coma for several days.

Although he survived, Susie thought her father was going to die and continued to fear for his life any time he started drinking. He eventually stopped drinking and they have a pretty good relationship now, which is why she’d never consciously connected her relationship with her father to her current relationship problems.

Susie realized she’d inadvertently acquired the belief at a young age that that she and her mother should put up with her father’s drinking so “he wouldn’t die” and because “nobody would ever love them like he did.” Once we were able to reprocess this memory and these associated beliefs, she felt much less compelled to accommodate her boyfriend’s drinking and made headway in stopping her codependent patterns.

Strategy #3: Consider the Downside of Being Free of the Problem

Sometimes being free of a problem creates a host of other new problems. For example, when I asked one of my clients who struggled with recurrent depression and chronic fatigue what the downside would be to feeling content and having more energy, she realized that her family would make more demands of her if she wasn’t chronically tired and depressed. She said the only time she ever felt like it was okay to rest and take a break was when she was sick.

Similarly, another client who suffered horrific physical abuse as a child discovered that his pattern of depression and underachievement was his way of holding his father accountable. He commented:

“Damn. I hate to say it, but if I’m successful and happy, then my father will continue to think he did a great job as a parent. Being a screw-up is my passive-aggressive way of punishing him for how he treated us. I know that sounds crazy, but I think that’s why I always stop short of achieving success in anything I do. Whenever I achieved anything as a kid, like making the All-Star baseball team, he took credit for it. I don’t want to give him that satisfaction.”

Another example in this category could be a person in an unhappy marriage with children. As miserable as they may be in the relationship, the thought of leaving the relationship, moving house, managing all the financial stressors, and upsetting the children seems worse than staying with the “devil they know.”

In all of these cases, it takes much more time and preparation to determine a feasible long-term goal. Therapy sessions may be better suited to assisting the client in achieving small goals that make their living situation more tolerable until they are in a position to make a bigger life change.

Strategy #4: Clarify That You and Your Client Are In Agreement on Desired Goals

Therapists are generally well-intentioned and seek to help clients move toward what is in their best interest. But, if the client doesn’t agree with the therapist’s intentions for the sessions, therapy is likely to go nowhere. This discordance between the client’s agenda and the therapist’s is not always obvious or clearly stated. The client’s nonverbal cues will let you know if you’ve hit on an appealing goal that triggers his or her motivation.

For instance, I worked with Saundra who said she wanted me to assist her in better managing stress at work. She had lost her temper a couple of times on the job and had been given a written warning. I noticed that when we were exploring ways she could center herself and adjust how she was approaching work tasks, her motivation seemed superficial at best. I commented:

“Saundra, I can tell these goals aren’t really lighting you up, so I think there must be something else I’m missing. What is more important to you than your job? What would being less stressed at work enable you to do?”

Saundra began to cry and said:

“My kids! I want to be able to come home and enjoy being with my children. I hate coming home in a bad mood every night and I resent my company for making us work more and more hours.”

Aha! This was the real source of Saundra’s angry outbursts at work. She felt like her job was taking away time with her children. When we centered our therapy on creating more space and time for her kids while balancing demands at work, she progressed quickly.

Closing Thoughts

In sum, when therapy stalls, it is usually because there is an internal conflict about making a change or about realizing the goal itself. The first step is to acknowledge to the client that you are aware things aren’t moving forward for them and ask them what they think might be causing the problem. If you sense they feel apprehensive about making a change, reassure them this is normal and invite them to give voice to their fears.

Second, explore for any earlier experiences that may be contributing to the current pattern they want to change. Even when a person knows a certain belief, behavior, or relationship pattern is irrational; his subconscious, emotional brain will sustain patterns that seemed to work in the past until he has a new emotional experience that changes the pattern.

Third, invite the client to consider what the downside of achieving their goals might be. Again, clients may not be consciously aware of possible drawbacks until you give them a safe place to look at them.

Last, make sure that you and your client have the same goals and agendas for therapy. Clients often look to the therapist to set the goals for a session and may not feel comfortable voicing their hesitation about moving forward. Furthermore, they may not even understand why they lack the motivation to follow through and blame themselves for falling short of their goals. You can avoid this by reading the client’s body language, which will instantly let you know when you’ve hit on a goal that really motivates them. When you’re in the zone of a viable, appealing goal, the client will be more animated, her facial expressions will broaden, and she’ll be more enthusiastic in her participation. If you’re not seeing these signs, then ask your client:

“What else do I need to understand? What am I missing? What would be the best thing that could come out of these sessions?”

They’ll tell you. All you have to do is ask and give them a safe place to tell their truth.

Courtney Armstrong, LPC, MHSP, is a licensed professional counselor in Chattanooga, Tenn., and the author of “The Therapeutic ‘Aha!’: 10 Strategies for Getting Your Clients Unstuck.” She also offers training and free resources for therapists at her website: www.courtneyarmstrong.net.