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6 Existential Anxieties That Could Be the Cause of Your Panic Attacks

Panic attacks are among the most common and most distressing symptoms I see as a therapist. Not only do people encounter some of their most primitive existential fears, such as feeling like they are dying or going crazy, panic sufferers also have to deal with the repetitive (and often unpredictable) nature of panic, and the fact that others cannot fully appreciate the intensity of the experience.

Search the web and you’ll find a ton of strategies to deal with panic attacks. In my opinion, very few (none in fact that I have found) adequately address different types of panic attacks. While I do not explicitly address tips for dealing with panic here, I believe we can optimize our coping strategies for anxiety attacks by first identifying what the panic is and what it is signifying. I identify six types of panic that I have observed in clinical practice below. I do not accept that panic attacks “come out of nowhere.” While cues may not be easily identifiable, experience has taught me that there is ALWAYS a reason for experiencing intense feelings.

Looking at broader categories of basic, primitive fears can be extremely informative when it comes to understanding and coping with panic. Below is a list of some of the most common classes of panic I see. This list may not be exhaustive, nor are these classifications mutually exclusive; However, if you suffer from panic attacks, one or more of these should resonate at an intuitive level.

Key point: it’s my belief that symptoms, like panic, are generated by personalities. If personalities are the mechanics of a person’s mind and ways of relating to the social world, then symptoms are inefficiencies or mis-attunements between the personality and its social environment. An ill-fit between personality and society can stem from a society that provides a very narrow range of healthy adaptations. It similarly can come from a dysfunctional family environment that demands adaptations ill-suited for the broader social context. Psychotherapy is much better at dealing with the latter than the former.

1. Losing Control – The Obsessive-Compulsive Personality:

Practicing in New York City, compulsive desire to be in control is ubiquitous. A former supervisor and I used to joke that we should propose “NYPD,” or “New York Personality Disorder” as an addition to the Diagnostic and Statistical Manual to account for the high frequency of anxiou and obsessive goal-directedness for which the city is known. “Obsessing” can take many forms, ranging from “Type A” driven-ness, to perfectionism as well as chronic constipation. It’s characterized by hyper-focus at the expense of feeling, and/or thinking and doing as a means of attaining mastery over emotions. Following rules instead of one’s instincts is a hallmark. In the obsessional who values control above feeling, routine almost universally supplants spontaneity.

The obsessional can experience panic in a number of different contexts. Commonly, any situation that involves giving in, letting go, being overwhelmed, experiencing a flood of emotions, exhausting all familiar means of exercising one’s will. Falling or showing up for a test unprepared are common dreams of the obsessional. Whenever maintaining the fantasy of perfection or mastery cannot be maintained in an emotionally charged situation, panic attacks can appear.

2. Abandonment – The “Borderline” Personality:

As social creatures, we all fear exclusion, ostracization and abandonment. However, the centrality of this fear and the degree to which it expresses itself varies. Abandonment is especially problematic for people with poorly defined senses of self, identities, as well as significant problems regulating emotions. Other people, especially romantic partners and children are used as extensions of the self to compensate for the aforementioned deficits. The problem with using other people to fill our internal voids is that we don’t have the capacity to control others (although we can maintain this illusion in infancy and in regressed relationships). Panic, resulting from fear of abandonment, is evoked when the illusion of omnipotent control over others breaks down. For example, your partner doesn’t respond to a text during a night out with friends, or when a spouse leaves the house in the middle of an argument.

Fear of abandonment is the defining characteristic of Borderline Personality Disorder, but can also be seen in a disguised form in Narcissistic Personality Disorder (rejection of reality through grandiosity alongside rigid insistence on the right to control others). Primitive fantasies and dreams are frequently are characterized by impotent rage and despair, often taking the form of damaged creatures, destruction, violence, and decay.

3. Devoured – The Narcissistic/Schizoid Personality:

Panic about being devoured is often the reciprocal of abandonment anxiety. An empty, identity-less person will long to consume the entity that possesses what the devourer lacks. Being devoured is not an experience of being suddenly attacked; rather it is an experience of being stalked, in a deliberate, unyielding fashion. Panic resulting from this core existential dread feels like a psychological boa constrictor. The devourer’s hunger may first feel like a warm embrace. But as time goes on, the squeeze intensifies and breathing becomes more difficult. Past a certain point, moving, speaking, and acting are impossible.

What the constrictor imagery illustrates about the annihilation anxiety behind being devoured is that danger is not immediately apparent. What first feels like a gratifying (and voluntary) pursuit of feeding the starving caregiver/companion gradually becomes an unrelenting demand. The more you give, the more the other takes, the less you know your own desires, and the less able you are to speak about the danger in which you find yourself.

This interpersonal pattern of feeling suffocated, drowned, paralyzed, catatonic, and/or depleted can begin to establish itself as early as 4 months of age. Infants naturally need to avert their gaze away from their mother, both to establish themselves as separate and to find relief from the intensity of face to face contact (in the natural world, prolonged eye contact precedes the two F’s–fighting and fucking, and is thus highly stimulating). A mother (or other caregiver) who feels rejected by the infants turning away, or perhaps insatiably chases the feeling of being fully attuned with the child, feeds herself instead of the infant. The child learns implicitly that the caregiver comes first, and that there is no escape from the needs of the powerful caregiver–the adult upon whom the child’s survival depends entirely. A template for relationships forms that is akin to Seligman’s learned helplessness paradigm; i.e., an inescapable situation from which escaping is not possible. In the animal kingdom, this resembles the anesthetized surrender before being devoured by a predator.

Drowning and futile attempts to escape characterize dreams and fantasy when this existential fear is most pronounced. Narcissistic personalities and Schizoid (detached, more interested in internal fantasies than the world around them) are adaptations to early environments where the fear of being devoured was most salient. Both of these personality structures are based on maintaining separateness at all cost to intimacy and connection to large portions of unsavory social reality.

4. Mutilated – The Dependent/Avoidant Personality:

Mutilation is the risk of action. We can only be maimed when we undertake a difficult challenge with a valuable reward. Being in the world, acting in the world, and assuming a position of agency inevitably leads to negotiating conflict and reconciling your desires with fellow actors when each agent’s respective ambitions are in direct conflict–i.e., being an actor in the world means risking serious injury. For the male spirit (I use spirit since increasingly we see biological women identify more as male), fear of mutilation was termed by Freud as “castration anxiety.” For feminine agents, mutilation tends to focus on general threats to bodily integrity, especially non-consensual penetration.

When mutilation is your existential fear, avoidant and dependent character traits often emerge. In classical terms, when the threat of castration looms too large, a regression back to childlike insulation and dependency is a natural–though highly costly–solution. Panic is likely to occur when you are forced to confront an avoided conflict and/or situation, or have no choice but to complete a difficult task alone. Internal conflict is characterized by competing feelings of anger and need to depend on others. Whenever this internal tension increases, the likelihood of a panic attack increases.

5. Disappearing – The Histrionic Personality:

Early neglect or misattunements with caregivers can lead to repression the detachment of thoughts from feelings), or more primitively, dissociation. In less technical terms, not being seen puts young children in a state of extreme anxiety. Without internal or external means of soothing themselves, decoupling consciousness from pain is often the default defense. Consequences of this are that the child does not feel “together” or “anchored” in a sense of what s/he is feeling. States of panic can arise in adulthood when circumstances conjure states of being neglected, unseen, dismissed, etc.

Increasingly rare, the personality type most likely to feel as if they do not exist or are completely unseen is the histrionic personality, or dramatic/flamboyant character type. Anger and rage about being ignored are supplanted by attention-grabbing theatrics, highly seductive behavior, and/or concrete, physical ailments that are more difficult to dismiss than emotional pain. Changes in culture have made this type of personality both rare and slightly changed, but at its core, the histrionic closely resembles Freud’s first patients.

6. Death – Post-Traumatic Stress Disorder (non-specific to personality):

Perhaps the most straightforward existential fear, death, especially when a significant traumatic event has occurred, can lead to intense panic attacks. During both brief and prolonged exposure to violence, death, destruction, and other forms of danger, a common way we deal with terror is to detach our consciousness from experiencing the traumatic event. Because the event cannot be tolerated, the experience is put into a kind of psychological lockbox. The problem is, these events require that we adjust our behavior to avoid them in the future, so these experiences cannot simply be annihilated from our minds. Any cue from a dissociated traumatic event, whether central or contextual to the trauma, can intrude into our awareness at unexpected times. In my experience working with 9/11 first-responders, any number of cues were capable of bringing the responders back to the scene of the attack. Tall buildings, certain smells, bridges, planes, sirens, crowds, etc. could all bring about a flooding of consciousness with vivid experiences from the locked-away experience. Panic attacks can certainly follow from intrusive imagery of a life-threatening event.

While this type of panic can arise in response to disguised, apocalyptic fantasy, the hallmark of this type of panic attack is often the “flashback” quality, where you “relive” traumatic events in what feels like a high-fidelity simulation. The earlier (developmentally) and more confusing the trauma (children don’t always recognize that they are being victimized), the more likely panic will follow from more abstract cues that are difficult to connect to direct past experience.

Conclusion:

I have presented in this post a framework for classifying types of panic attacks as a means of helping people better understand the contextual features that precipitate sometimes “uncued” attacks of anxiety. This framework is built upon core psychological anxieties; that is, anxieties about the annihilation of our psychological, conscious, selves. Of these annihilation anxieties, I have included the following: losing control, being abandoned, being devoured, being mutilated, disappearing, and dying. I have also made an effort to connect distinct experiences with panic with specific types of maladaptive personality organizations. These categories of panic are based on my clinical experience, theory, and some empirical data. They are not meant to be mutually exclusive, and many people will experience panic multiple types of panic and/or panic attacks that include features of several of these classifications. I will address coping strategies that are most likely to help when one of these types of anxiety is most salient.

Let’s have a dialogue to better clarify and spread the word about existential anxiety, panic, and types of personality structure! Comment below, sign up for my mailing list, and/or follow me at @mindsplain on Twitter.

Further Scholarly Reading on Annihilation Anxieties:

Hurvich, M. S. (1989). Traumatic moment, basic dangers and annihilation anxiety. Psychoanalytic Psychology, 6(3), 309.

The “No” Quadrant: When To Say “No” and Maintain Healthy Boundaries

Published by Michael Kinsey, Ph.D.

To be healthy in our emotional life we need good boundaries. What does it mean to have good boundaries? In a basic sense, good boundaries means being able to define yourself and your values as distinct and separate from those of others. Defining ourselves is important because we must first be separate to fully experience and benefit closeness to others. In all relationships we need to be able to protect our interests, take care of others without excessive sacrificing of our needs, and maintain the freedom to say no. These abilities correlate highly with self-confidence, self-esteem, and healthy intimate connections with others. Good boundaries are incompatible with two of the most common afflictions of modern society, anxiety and depression. Saying no is a critical aspect of boundary-setting, as denying others’ requests is essential to freedom. Without freedom, relationships begin to feel like servitude.

Dialectical Behavior Therapy, or DBT, is an approach to treating a condition notorious for both poor boundaries and extreme states of distress. Marsha Linehan, the creator and matriarch of DBT, provides a number of useful tools to help not only the clinical population she initially targeted, but all people determine when their boundaries were being violated and what corrective action to take. One such tool is a useful list of questions to help determine whether we should say no to a request and how forcefully we should say no.

These questions were designed for you to consider when weighing whether or not to agree to something being asked of us that makes us uneasy. The questions to ask ourselves are as follows:

Capability: Do I have what the person wants?
Priorities: Is my self-respect on the line?
Self-Respect: Will saying no make me feel bad about myself?
Rights: Is it my duty to give this person what they want? Would it violate their rights to withhold what they are asking for?
Authority: Does the person asking me have authority over me (boss, teacher, etc.) within the domain of the request?
Relationship: Is the request appropriate to my relationship with this person?
Long-term vs. Short-term Goals: Is giving in in the short term best for the relationship in the long-term? Is it best for me outside of this relationship in the long run?
Give and Take: Do I owe this person? Does this person do a lot for me?
Homework: Is the request clear? Do I know what I am agreeing to?
Timing: Is this a bad time for me to say no?

Inspired and informed by Linehan’s Interpersonal Effectiveness skills, I developed my own tool to help people sort and manage requests. The tool is a quadrant that allows us to sort requests according to relationship type–especially relevant to question #6 above. My hope is that consistent practice with the tool will eventually become an automated, internal process of evaluating all types of requests, favors, inquiries, propositions, and the like.The Trusting Relationship: High Commitment, Low Intrusiveness

This is the type of relationship we all aspire to have. In this quadrant we can place all family, romance, and friendships wherein participants are dedicated to one another without demanding excessive control over the other.

Need a ride to the airport? These are the people you call. Have a problem you don’t know how to solve at work? You see if one of these trusted confidants is free–free being the operative word.

Trust is the hallmark of these relationships. Not only do you trust these people to support you in a manner that prioritizes your best interests, but you also trust them to decline if they are unavailable. No one wants to be resented, so before we ask for help it is important to feel like the person to whom we reach out will be honest about what they can provide. One sage mentor of mine frequently says the following: If you can’t be angry with someone, then you don’t trust them. I believe the same thing can be said about saying no. In fact, I could argue that saying No is a capacity rooted in an ability to express anger without conflict.

Put another way, the prospective helper must also trust that the request is not a demand or obligation. If the recipient of a request cannot say no without retaliation, then intimacy and connection will suffer. Calls will be dodged. Excuses will be made. Gossip and backstabbing will emerge.

Very few consider how essential the word no is to mature relationships. Developmentally it arises when the child is no longer fused with with mother. From this perspective, being able to say no means accepting that we cannot return to this fused state and we must gift the autonomy we wish to receive from others.

The Enmeshed Relationship: High Commitment, High Intrusiveness

In my clinical experience, one of the most common misunderstandings is that mental illness comes from harsh, abusive childhoods. While this true, it is not the full story. Many enter therapy for the first time confused and ashamed that they need help (and may have unnecessarily delayed the realization that treatment is indicated) because their parents were some of “the most loving.”

Children need love, attention, and nurturance. They need it especially when in distress. However, too often love and affection are “given” when the parent is in distress. Very young children, as early as 4 months, can experience the needs of the primary caregiver, implicitly learning that the parent demands synchrony with the child to meet the caregiver’s emotional needs. This is a form of harshness and neglect, but is not typically recognized as such. These early experiences can lay the foundation of a lifetime of poor boundaries, resentment, and guilt–no matter how many times they say “yes.”

When in relationships, people with this relational pattern, will often provide sensitive and attentive care, but will do so with feelings of obligation instead of genuine empathy. Oscillating patterns of avoidance and dependence predominate over boundaries, empathy, and trust.

As a therapist, what is most cruel about this pattern is that the people suffering believe that they are flawed because of the conviction that the seemingly abundant love, care, and affection was for them–despite having a nagging feeling that something was missing. They doubt their instincts, feel frequent guilt, and have difficulty enjoying pleasant activities because they are compulsively tuned into the thoughts, feelings, and desires of others.

For this growing population of people, saying “no” is both the most difficult and most important.

Expert tip on how to say “No” in an Enmeshed Relationship:
Use “The Broken Record” Technique:
Say the word “No” with a succinct, unapologetic explanation for declining.
The enmeshed party who is asking will likely insist on further discussion and negotiation. Simply reply to every subsequent request with “No.”
The enmeshed party who is asking will likely demand further explanations. Of course, explanations are requested to challenge, not to gain understanding. Respond to any “why/why not?” question with “I already stated my reason(s)”
Repeat as many times as necessary to end the discussion.

The Neighborly Relationship: Low Commitment, Low Intrusiveness

The neighborly relationship is one we often take for granted. The low commitment and intimacy makes the possibility of saying no easier. Most of us want to live in a world where a stranger can be trusted to watch your belongings while you go to the bathroom, your neighbor can spare a cup of sugar if they have extra, and we can ask a passerby for directions when we are lost. In most cases, we don’t feel like we are burdening others with simple requests, nor do we wring our hands when we have no sugar to spare. These acts of “altruism” are now explained as down payments on future favors. That is, we help others because it is in our best interest in the long run. In a healthy social world, a good-faith effort to help out is all that is required. If you can’t help, then you do not lose goodwill in this type of boundaried relationship. This is perhaps why we work so hard to create excuses when we simply don’t want to offer help.

The Parasitic Relationship: Low Commitment, High Intrusiveness

Residents of New York City or other major metropolises, will recognize this dynamic immediately. The classic example from my day to day life, is the gaunt, disheveled man who moves from subway car to subway car, peddling a tragic tale of being unjustly fired, serious illness, hard luck, and other unfavorable circumstances. While I don’t dismiss all of these stories as fraudulent, my cynicism spikes when the pleading, obsequious tone shifts to an indignant, guilt-inducing scold upon the realization that donations are not forthcoming.

Here’s an important point. These characters are extremely successful in evoking guilt. As social creatures, the healthy among us are disturbed to see such pathos and suffering–regardless of whether the story is genuine. Some are content to make a small or even substantial contribution to remove this guilt (behaviorists call this negative reinforcement). Those who do not donate rationalize their restraint by stating with conviction that the beggar is probably trying to support a disgusting drug habit. In my view, both of these responses miss the point.

The point I believe is this: your boundaries are being violated. Obligation and human empathy are being conflated in a way that breeds resentment and erodes social goodwill that healthy societies require–especially as these societies grow in size and complexity. When you feel the urge to help a lost soul, I encourage you to ask yourself whether you are acting out of empathy or out of parasitic exploitation (i.e., coercion through guilt). While the latter may feel like “the right thing to do,” I would argue that confusing being manipulated with empathy contributes to an erosion in social goodwill rather than helping to create a more just and equitable society.

Expert tip for saying no in a parasitic relationship:
Make eye contact, force a polite smile, and say a firm “no.” Fight the temptation to say, “I’m sorry.”
Any protest, objection, further pleading, etc. should be ignored. Remember that you do not owe a stranger with whom you have no prior or ongoing relationship anything more than a singular, polite response.
Alternative response:
A mentor of mine has a wonderful judo-like stock response to these intrusive inquiries from strangers with a phrase akin to the “Free beer tomorrow” sign commonly posted in bars. She responds with a simple “Not today.” This works, and the more you think about it, the more brilliant it becomes.

Summing Up:

I close with a priceless rant from Dave Ramsey on saying “No.” Without realizing it, Dave demonstrates a key technique in confronting people who push boundaries: “The Broken Record” technique (See above).

Dave’s rant here is funny, inspirational, and spot on. However, people who struggle saying no often need much more than a single inspirational rant to change their relationship to limit-setting. I invite questions, comments, and messages on setting boundaries to keep the discussion going!

Linehan, M. (2014). DBT Skills Training Handouts and Worksheets. Guilford Publications.

Parenting Advice: Practical Wisdom on How to Approach a Temper Tantrum

Published by Michael Kinsey, Ph.D.

Many years ago at a training for how to de-escalate emotionally disturbed teenagers, my instructor illustrated the concepts of negative and positive reinforcement with the following example:

You take your child to the grocery store. After gathering all your items, your three-year-old inquires “Mom, can I have this candy bar?”

“No Honey, I already got you those cookies you wanted, remember?”

“But I want this!”

The exchange continues until your child is crying and screaming. Just before you complete your errand and move on to the next item on an impossibly long list of chores, this embarrassing scene arises. You can feel the eyes of other customers bearing down on you, judging you and your impotent parenting.

With things to do and resentful glares upon you, you grab the candy bar with an indignant huff from your child’s hand and present it to the cashier.

“And this too,” you utter in defeat.

Your child’s wailing ceases and you are back on schedule–all for a paltry sum of a buck fifty.

In this episode, both you and your child have just been taught something by the other. You have learned through negative reinforcement. By purchasing the candy bar, you have learned that the way to make the pain stop is by appeasing your child. According to behavioral principles, you are now much more likely to engage in similar acts of capitulation with your child in the future.

Your child on the other hand, has just received positive reinforcement. For the histrionic display, your child has obtained the coveted reward. Do you think tantruming will become a more or less frequent behavior in the future? This question is of course rhetorical.

“The tension and struggle between your child’s will and this reality is what eventually leads to the development of more advanced, sophisticated adaptations to the world.”

Inevitably, disappointed children will learn how well you tolerate this nuclear option of child protest. Leading up to the tantrum of course, there are various stages of escalating rebellion and discontent. The leverage children have here of course is your anxiety, time demands, unhappiness, and concerns about what others think about your approach to parenting. Never lose sight of what these tantrums are–bully tactics. While your children are not mustache-twirling villains, they are an immature mammalian species with primitive affects and reptilian survival instincts. The helplessness and vulnerability you see in your child is certainly present during tantrums, but isn’t that the case with all bullies? Children are simply wrapped in a much cuter package than the schoolyard punk. Give the bully your lunch money once and you’re officially a mark.

Let me phrase this in the most concise manner I can: Children learn to regulate their emotions by both how and how well you regulate yours. If your coping strategies and capacities to tolerate negative emotions break down in moments of stress, so will theirs.

A critical point to remember when you are confronting your diminutive bully is that the more effective you are, the higher your child raises the stakes. Many parents make the mistake of assuming that a child who continues to escalate their tantrum is evidence of a failed method of dealing with their child’s discontent. Quite the opposite. The tantrum increases in intensity because it is not working. Stay the course and you’ll have saved yourself and your child many future moments of suffering.

Now, I have stressed here the importance of being tough and firm. Let me be clear about what I am not saying: mocking, insulting, dismissing, teasing, or any other form of humiliating provocation is extremely harmful. Parents must be firm, but also warm and kind. In my view, this is the most difficult part of the job of parenting. Consider saying to your child something in the tone of: “I know you’re mad. Sometimes I have to say no even though you get mad.”

How you say this is equally important as what you say. You are not appeasing or apologizing. You are stating a fact about reality–a fact about which neither of you need to be happy. Your tone and demeanor should convey that you do not relish your child’s suffering, but you are resolute and speak authoritatively about what social reality dictates. You are saying through your actions that tantrums do not lead to rewards. The tension and struggle between your child’s will and this reality is what eventually leads to the development of more advanced, sophisticated adaptations to the world. Out of this comes humor, and redirecting of destructive impulses into creative pursuits. It is through this struggle that your child becomes a resourceful adult.

The emotional pain tolerance required in these moments is exactly why effective and well-adjusted adults have successful children.* Buy the candy bar and it will cost you and your child a lot more than a buck fifty.

* I will cover effective discipline in a future post, but many of the strategies I recommend can be found in 1-2-3 Magic, by Thomas Phelan.

Putting The Pieces Back Together: 5 Tips On Mending A Broken Heart

Published by Michael Kinsey, Ph.D.

Breaking up with a romantic partner is pure agony. While it’s worse to be dumped, ending a longterm relationship is no picnic either. In both cases, our brains and bodies experience the same kinds of effects that folks who are depressed and recovering from addiction feel. The harsh reality is dealing with loss in any area of life takes time and there is no quick and easy way out. Fortunately, we don’t have to grieve forever, and if we approach the breakup with the right mindset, we emerge from the darkness of loss a more well-rounded person. Five things that can minimize damage and promote healing are the following: 1. Practice acceptance; 2. Do damage control; 3. Take inventory; 4. Plant a seed; and 5. Befriend the future.

Practice Acceptance:

The shortest way out of the pain of breakup is to find a way to reconcile, right? In most cases, chasing the urge to get back together with your ex simply delays the inevitable. For every bushel of breakups, only a small handful are true mistakes. If you initiate the breakup, approach the separation with the assumption that your instincts are right. Do we sometimes follow a misguided feeling? Sure. But doubting yourself rarely leads to gratifying outcomes. To function optimally in life, we have to believe in our own inner wisdom. If you truly don’t have any inner wisdom, then your breakup has just given you an opportunity to develop some.

If you are the one dumped, acceptance means accepting a steaming pile of crappy realities. To name a few these difficult truths: life is unfair, we can’t control others, nothing in life is certain, abandonment is one of life’s deepest pains, and that pain can be both indifferent and unreasonable.

Depressed yet?

Not to worry, reality acceptance is tough in the beginning but gets easier with momentum. Visual imagery can be extremely useful.

Imagine yourself at a fork in the road. While the place that each path leads is out of sight, you know from this blog that the path on the left, though it’s sunny and lush, takes you in a loop back to where you are standing. The one on the right is dark and thorny, but will leads to a mysterious new place. Acceptance means both longing to take the pretty path, while knowing the darkness and thorny path is the direction you need to go. Repeat this visualization as well as the image of you making the courageous choice to take the mysterious path whenever you are tempted by the instant gratification to be found on the left path.

Like Odysseus, resisting the call of the sirens, acceptance of our own seduce-ability may mean lashing ourselves to the mast of our ship. Use this image and put in the necessary constraints to choose the right path again and again. Accepting reality is not a step taken one time, but rather is a lengthy series of repeated choices to act with the awareness of what cannot be avoided.

Mindfulness is another tool that assists in helping us accept our lot in life. Mindfulness is fundamentally an exercise in accepting what is, observing it, and watching it drift away. Whatever arises, whether good or bad, ultimately dissipates. The following books and videos I have found to be useful in facilitating the process of accepting our fate.

Do damage control:

My first heartbreak happened when I was in 4th grade by a girl we’ll call Laura. Sometimes I still feel the sting of that first abandonment. Being so young and naive at the time, I made all kinds of outlandish efforts to get any attention I could from my lost love. When I saw nothing worked, I persisted in making intrusive efforts to win her back. She became so annoyed by my relentless pursuit, she made her own grand gesture. Laura planned and executed a plot to publicly humiliate me in order to get me off of her back. She and a group of friends hid behind a playground backstop while one of her co-conspirators goaded me into professing my undying love for her. Laura and her accomplices listened in while I poured my jilted heart out. The gaggle of girls jumped out with the glee of sated revenge. Don’t be 4th grade me.

Sometimes the best thing we can do is nothing. We all know that success is the best revenge. The only problem with this axiom is that success takes time and is its own reward; by the time it has been achieved, the feeling of accomplishment often eclipses a longing for revenge. Successful tolerating of distress means taking precautions against drunk-dialing or any other act of desperation conceived with the aim of reaching your ex. Recall the image of Odysseus lashed to the mast of his ship as he and his crew passed the island of the sirens. Even the greatest heroes know to fetter themselves when they are most vulnerable to temptation. People were not designed to tolerate these kinds of separation, and yet we are so often called upon to endure them. Oftentimes wisdom is knowing the limits of your will.

Doing nothing when motivated to act out of spite or hopeless longing may seem unfulfilling. But not doing something can be a form of proactivity. Be relentlessly vigilant about making choices to spite your ex. Do you really like the person your friend set you up with, or are you just hoping your ex finds out? Would you be tempted to post this content on instagram if you did not think your ex would see it? Do you need that 5th, 6th, or 7th drink or do thoughts of your ex make you want to move closer to psychic oblivion?

Doing damage control means protecting your dignity. When we feel as though we’ve been dropped by someone, dignity may seem like the least of our concerns. It’s actually extremely important. Keeping our dignity and maintaining self-respect are active choices that allow for self-love to seep into the empty spaces left by lost love.

Take inventory:

I’m a big believer that the language we use to describe things carries deep meaning about the human psyche. I thus put a lot of stock in the phrases “break up,” “take a break,” “broken heart,” “heartbroken,” etc. When we are with a partner long enough, we build a life with them. When the relationship ends, that life falls apart.

Surveying the damage can be overwhelming. However, the broken pieces of the old life contain both valuable raw materials as well as hoarded trash. These pieces must be sifted through one by one. Did you really like the newest Woody Allen film, or did you simply get off on your ex’s enjoyment of it? Perhaps you can finally throw away that ugly sweater your ex’s family bought you last Christmas. Conversely, that tiny Turkish restaurant your ex introduced you to is cheap, delicious, and needs to be MY go-to Turkish restaurant. Consciously deciding what will remain yours and what goes in the bin is an important and empowering process. If we insist on throwing everything out, and banishing all reminders, the energy we spend destroying all traces of our ex is still an emotional connection.

Loving someone changes us forever, and that’s almost always a net positive. Just because some amount of hurt, angry, or sad feelings linger from a failed relationship does not mean we cannot have been changed or affected by our ex’s. Everyone is a mix of desirable and undesirable tastes, habits, and qualities. A breakup is a fantastic time to keep as much of the desirable as you can while leaving as much of the the undesirable aspects as can be discarded in the past.

“Go with the grain of your impulses towards growth, wherever they take you, adopting an attitude of playfulness and creativity.”

Plant a seed:

The things that fall apart in a breakup are the compost for new growth. Developing new areas of our lives require time, energy, commitment, and nurturance that may not have been available to us when we were doing so much of this for our partner. This needn’t be a project on the scale of the great American novel. I love symbols and metaphors. Finding a meaningful pursuit rife with symbolism is a good place to start. If you want to grow but are not sure in what area, learn some basic gardening (literally plant a seed!). If you feel ugly, take an art class that helps you find beauty in the world. If you feel your relationship ended because of a rigid personality, take up yoga or stretching. Shortly after my divorce, I developed a keen interest in woodworking. My unconscious mind was actively working on building a new life. Go with the grain of your impulses towards growth, wherever they take you, adopting an attitude of playfulness and creativity. Symbolism may not be obvious or even relevant, but can provide direction in the absence of inspiration.

Befriend the future:

If you find yourself completely immersed in despair during a breakup, with no hopes or dreams for the future, then you should probably not be surprised your relationship ended. This is a sign you placed too much importance (and strain) on your romantic life. It becomes essential to find something to strive for and look forward to. Could this be the time to take that month-long roadtrip across the country? Perhaps now is the time to apply for a job in a new country, state, or city. Maybe a savings/investment goal is more achievable now that your spendthrift ex is out of the picture. Plan for the time when you are ready to get to know an attractive, available, and previously forbidden potential love interest. Picturing new possibilities, the more vivid the better, means embracing the newfound freedom purchased by comfort and security. The same principles of play and creativity from tip four apply here as well.

Summing Up:

Breakups place us face to face with realities we would prefer not to confront. These realities, especially pain, can only be avoided at great future cost. But like any wound, we can treat it and ourselves in a manner that allows our inner resources to do the necessary work of healing. I propose 5 practices to treat a broken heart after a difficult end to a meaningful relationship. The five tips are to practice acceptance, limit damage, take stock of the pieces of your life, begin a project of growth, and make friends with the future. Godspeed on your journey.

What the Heck Is a …? A Guide to the Most Common Mental Health Professions

Published by Michael Kinsey, Ph.D.

Once you have had some experience working with different professionals within the field of mental health, differences between each discipline’s values, style, approach, and skillset can be easy to detect. However, if you are reaching out to a mental health professional for help for the first time, it can be overwhelming to differentiate between the different types of professionals, who may be best equipped to help you, and what practitioner will offer the treatment you have in mind.

I’ve provided an editorialized guide to the most common professions within the field to mental health, along with some resources that provide a little less opinion.

Psychiatrist

Degrees: Medical Doctor (M.D.), Doctor of Osteopathy (D.O.)

Years of Training: 7+

Description: Psychiatrists are usually placed at the top of the mental health hierarchy because they are the only clinicians in the world of mental health that are medical doctors (although, they are not necessarily the only mental health practitioners that can prescribe medication). All psychiatrists are trained first as doctors (usually 3 years) before applying to obtain specialized training in a psychiatric residency program (usually 4 years).

Psychiatrists are considered qualified to provide the full range of mental health services, although typically psychiatrists do not provide all forms of treatment. Psychiatrists tend to receive most of their training in the most “medical” areas of treatment, such as diagnosis and assessment, biochemistry, neuroanatomy, prescribing medications, and administering electroconvulsive therapy. Contrary to popular belief, most psychiatrists do not receive much training in psychotherapy or psychological testing.

While some psychiatrists will focus on developing skills as therapists, especially those who obtain additional training in psychoanalysis, psychiatry has increasingly become synonymous with psychopharmacology (i.e., prescribing psychotropic medications). A psychiatrist who primarily functions as a psychopharmacologist can be easily ID’d based on how often they schedule appointments with patients, and how long these appointments last. Psychopharmacology, once a regimen is established, typically does not require more than 1-2 meetings per month lasting 30 minutes each. Psychotherapy, however, is optimally provided every week for 45-50 minutes.

Comments: As a psychologist, I have great respect for the intelligence and drive possessed by most psychiatrists. Getting through medical training is not easy, and it can often be helpful for patients to have someone familiar with basic medical principles when screening out medical and substance-induced symptoms. Medication can also be an incredibly powerful tool in providing immediate relief (although individual differences in responses to medications can lead to people giving up too soon on medication due to negative side effects or extended periods before medications take effect).

On the downside, in my experience, psychiatry is a discipline prone to a number of unhelpful biases. Some psychiatrists are prone to seeing people as brains rather than minds. As prescribers of medications, it is tempting to get into the habit of focusing too much on neurotransmitters and ignoring other relevant aspects of the person. To use one example, many psychiatrists, especially at community clinics, are likely to place a greater emphasis on what the correct medication is without giving proper weight to whether or not the patient will actually take it.

Another example of unhelpful biases comes with (the lack of) diagnosing personality disorders. Personality disorders are both highly stigmatizing and notoriously difficult to treat with medications. I don’t even want to count how many patients with clear cases of borderline personality disorder I have diagnosed and/or treated who had previously been given a diagnosis of bipolar I or bipolar II disorder. Psychiatrically, these conditions are all treated very similarly. However, the wrong diagnosis can hinder progress in psychotherapy, which nearly all people with personality disorders need–whether or not they are also receiving medication from a psychiatrist. I don’t believe this to be done in animus, but I do find this to be a common-enough oversight to warrant mention here.

In my experience, when patients develop strong negative feelings with their psychiatrist, these feelings most often stem from feeling ignored, dismissed, and/or “poisoned” by their psychiatrist. This is not necessarily an indictment of the quality of work done by a psychiatrist, but over-emphasizing medications without proper weighting to psychological issues may naturally result in misunderstandings, misattunement, and adversarial dynamics developing between doctor and patient.

Another bit of insider experience I’ll toss out there has to do with the nature of medical training. I have come across a great number of passionate, hardworking psychiatrists who care deeply about their patients and providing the best possible care to individuals who are both difficult to deal with and profoundly suffering. These docs tend to be the ones who endured countless hours of grueling, unrelated medical training in order to reach a position where they can help people with mental illness lead healthier and more productive lives.

On the other hand, medicine attracts many people who are drawn to the prestige of medicine but do not have a particular talent or passion for any one specialty. Medical lore suggests that psychiatry has historically been a discipline wherein students who lack a certain drive and focus accumulate. Many unfairly criticize psychiatry for not being sufficiently rigorous for this reason. I think it’s very easy to understand why relatively aimless med students would choose psychiatry over something like surgery. I believe that the best psychiatrists are among the smartest people in medicine. However, if you find yourself with a psychiatrist who does not seem to be living their best life, I may have just provided you the reason why.

Additional Resource: American Psychiatric Association

Clinical Psychologist / Counseling Psychologist / Neuropsychologist

Degrees: Ph.D., Psy.D.

Years of Training: 5-6+

Description: The term psychologist refers to any individual who has completed doctoral-level academic work and research in a sub-discipline of psychology. Clinical (for simplicity, I omit neuropsychologists here) and counseling/school psychologists differ from other psychologists (e.g., social, developmental, cognitive, industrial, etc.) in that training includes pre and postdoctoral experience working directly with patients. Predoctoral training includes multiple offsite yearlong placements (~20 hours per week), along with one yearlong full-time placement. Most states require one to two years of supervised postdoctoral work in order to become licensed as well. Clinical and counseling/school psychology training varies by program with regards to how much psychotherapy, psychological testing, and academic research are emphasized. Psychologists tend to be the only mental health practitioners with competence in testing, and also tend to receive the most training and supervision in psychotherapy before licensure.

Comments: As a psychologist, my opinion here is extremely biased. For any services besides medication management/psychopharmacology (or possibly psychoanalysis) and medical rule-outs, I believe psychologists, on average, to be the best equipped to handle most issues for which people seek treatment. Many would disagree, I’m sure. I make this argument primarily based on the amount and focus of training. Exceptions exist, which is why I take care to say “on average” and “most.”

The problem with psychologists is that 1. There are not enough of them to meet the growing demand for mental health services; and 2. the cost of training prohibits many psychologists from seeing patients who cannot afford high fees or have excellent insurance. It should be obvious that the places where psychologists are most needed do not often have the resources to adequately attract/hire them. The same is true for psychiatrists, although psychiatrists who focus on managing medication can sometimes see as many as four individuals in the time a psychologist needs to see one. Thus, psychiatrists’ expertise can be better leveraged, though not without burdening them with heavy caseloads.

Additional Resource: American Psychological Association

Licensed Psychoanalyst

Degrees: M.D., D.O., Ph.D., Psy.D., M.S.W., M.A., M.S., etc.

Years of Training: Years of professional training + 3-4 years

Description: Psychoanalysts are trained to approach psychotherapy and psychoanalytic treatment through the lens of the unconscious motivations, drives, and conflicts. Think of the Freudian tradition. When psychoanalysis was first created, only medical doctors could become psychoanalysts. Training in psychoanalysis is now open to all licensed clinicians, both masters-level and doctoral; in more rare cases people from outside the mental health training to pursue the ability to practice as a licensed analyst. New York is one state that provides this option.

Becoming a fully fledged psychoanalyst is a rigorous process that includes approximately four years of coursework, one’s own personal analysis (i.e., as a patient, entailing 3-4 analytic sessions per week, in addition to completing several (the number varies, but typically four) “control cases.” In control cases, candidates receive supervision from an experienced psychoanalyst who closely monitors progress in each one of the candidates’ active cases.

Comments: Again, I disclose a personal bias here. My own therapies have all been with psychoanalysts, including one formal 4-times-per-week analysis. Critics call psychoanalysis outdated and anti-scientific, however, I have found psychoanalysis to be the only model of psychotherapy that has the sophistication, nuance, and depth to provide patients who have been failed by other therapies a satisfying and intuitive understanding of how their problems came to pass and why they persist. This is more than just my personal opinion. Psychodynamic treatments, a broader category of psychoanalytically-informed psychotherapies, are in fact well-supported by clinical trials and most importantly, have been shown to provide continuing returns long after treatment has been discontinued.

Most psychoanalysts are psychologists and psychiatrists, who have undertaken costly and rigorous training above and beyond medical and doctoral-level training. They are, in my view, among the most erudite and scholarly individuals out there.

The biggest detractors of psychoanalysis are academics and insurance companies, each with too many self-interested reasons to criticize this mode of treatment to list here. As one of my mentors, David Shapiro, Ph.D., often says, “It doesn’t seem to require much skill or training to understand how someone’s behavior is irrational.” Put another way, it requires a more sophisticated theoretical model to understand why someone’s irrational behavior makes sense. Psychoanalysts work with a theoretical model that does exactly this.

Additional Resource: American Psychoanalytic Association

Clinical Social Worker (LCSW)

Degrees: M.S.W.

Years of Training: 2-3+

Description: Clinical Social Workers are masters-level counselors/therapists who have undergone a period of additional supervised training to meet state licensure requirements. They are trained in both general and specific psychotherapeutic techniques in addition to the core aspects of social work, such as case management and providing advocacy (or locating advocacy programs).

Comments:

The up-front cost of training to become a social worker is far less than becoming a psychologist or psychiatrist. However, just because social workers put in less time, money, and brainpower into their training initially, it does not mean that they will not pursue further training to catch up with the training done by clinicians with more advanced degrees. In fact, many clinical social workers choose to train in social work because they know they can begin clinical work sooner while they earn an income that helps them to obtain more expertise. Some of the most resourceful and grounded clinicians that I have encountered have been social workers, as they have been more responsible financially while they approach training with no less drive than any other mental health practitioner.

On the other hand, a sizeable percentage of clinical social workers chose social work as the fastest road to doing clinical work without considering the costs involved in taking a shortcut. If you are trying to choose the best therapist, you may be best served by a clinical social worker; the problems is you’ll likely have to do additional work to screen out the less able, and less committed group.

Don’t assume either that the better clinicians will be the ones charging higher fees. Yes, some clinicians may charge the higher fees because it’s the only way to manage the demand for their highly-effective services. But also bear in mind that another reason for charging a higher fee is a lack of self-awareness. Plenty of people in all walks of life will overvalue themselves because they avoid fully engaging with their own limitations. You’ll find plenty of these among psychotherapists, with higher concentrations, I suspect, among those who trained as social workers. You’ll also find plenty of highly skilled and educated therapists as well. I risk writing this publicly since I make the assumption that the social workers reading this blog are less likely to be in the shortcutting camp.

The main point I’m trying to make is that you place an additional burden on yourself to sort out the best from the mediocre by opting to focus your search clinical social workers. Choosing a psychologist or psychiatrist does not eliminate the need to filter, but I do believe it reduces screening efforts considerably.

A final point I’ll make about the training of social workers is that training tends to emphasize social systems and structures. This is either an advantage or disadvantage depending on your perspective. It’s an advantage because social workers tend to be especially savvy at helping people connect to resources in the community and are much more sensitive to factors outside a client’s control. In some cases, I have found this to be a tremendous help to individuals or families who face too many existential threats (e.g., poverty, undocumented status, chronic illness, etc.) to fully benefit from a purely psychological treatment.

Conversely, one of the primary reasons for ignoring such factors in psychotherapy, is that providing people with “help” has all kinds of hidden costs. Every time anyone, whether a mental health professional or otherwise, provides assistance, the implicit communication is that what is being provided cannot be obtained by the individual being helped. Each decision to provide practical help requires that the “helper” carefully weigh the pros and cons of the decision. Clinical social workers who have trained in psychoanalysis tend to be much more cognizant of this. In some instances, practical assistance is absolutely indicated. In other cases, “help” may actually be over-indulging clients’ dependency needs, thus undermining progress.

An honest look at what you are seeking help with can be helpful in determining whether a more “helping” framework is indicated. If you tend to take on too much responsibility and overburden yourself with the needs of others, then a more resource-oriented treatment can be helpful (or at least not harmful). On the contrary, if you have not properly “launched” (sadly, an ever-growing epidemic), then a less-involved form of treatment would be better in my view.

I hope that it goes without saying that I am painting with a broad brush and there are indulgent psychologists and appropriately withholding social workers. The reality is that initially we need filters to narrow down our options when there are so many variables to factor into a decision like choosing a therapist.

Additional Resource: National Association of Social Workers

Marriage and Family Therapist (MFT)

Degrees: M.A., M.S.

Years of training: 2-3+

Description: Marriage and family therapists are also masters-level counselors/therapists who have undergone a period of additional supervised training to meet state licensure requirements. They are trained in basic psychotherapeutic techniques as well as some more specific intervention strategies. The main difference between MFT’s and clinical social workers is the focus of training. Academic work in social work is far more systems-based, whereas marriage and family therapy tends to appeal more to individuals who are interested in an expedited way to become a therapist (i.e., non-doctoral) and spend more time learning about psychotherapy and counseling as opposed to social/systems-level ways of providing assistance.

Comments: My 2 cents on marriage and family therapists are essentially the same as my opinion on clinical social workers when it comes to choosing a therapist. The barriers to entering the field as a masters-level clinician compared with a doctoral clinical/counseling psychologist are drastically fewer. Does this mean doctoral-level clinicians are always better? Of course not. What it does mean is that there are way more masters-level clinicians to choose from, and I believe, a broader range on the continuum of excellent to poor. Recommendations, testimonials, or extensive face-to-face consultations (if these are offered free of charge) are all ways of finding the standouts.

I fully acknowledge my bias as someone who has put in the additional years, cost of training, and opportunity cost associated with becoming a psychologist–not to mention the additional rigors of being selected to a doctoral program. So take my opinion with a grain of salt if this offends.

I’ll say again that I have had the opportunity to work with talented, competent, dedicated, and hardworking therapists from social work and marriage and family backgrounds. A great therapist, is a great therapist. A great anything is hard to find and should be valued and compensated commensurately.

Alcoholism and Substance Abuse Counselor

Degree: A.A., B.S., M.A., M.S.

Years of training: 2 – 3

Description: Obtaining a certification as an alcoholism and substance abuse counselor varies in its requirements from state to state. This qualification may be an additional certificate to a masters-level or doctoral-level professional license, or it could be a sole qualification, requiring as little as an associates degree and on-the-job training. If a private practitioner has this certification, s/he is certain to have at least completed masters-level training. In a clinic or other outpatient treatment facility, alcohol and substance abuse counselors can work with substance misusers without having completed a masters or even a bachelor’s degree. Even in a multidisciplinary setting, without a masters degree, counselors can only provide a small range of counseling services (e.g., goal-setting, skills training, motivational interviewing) and must be supervised by a licensed professional.

Comments: Substance misuse, abuse, and dependence is a challenging area in which to specialize for a number of reasons. First, substance use is often accompanied by physical dependence. Second, substance use is typically only one of several mental health issues with which a client needs to contend when obtaining treatment, and third, many long-time substance users have consumed all of their social resources by the time they reach care, and thus are socially isolated, lacking material resources, and often homeless. Those who choose to specialize in this area, in my experience, are often among the most committed to helping others and have some form of personal stake in the treatment, no matter what level of training. Many substance abuse counselors got into the work after battling their own substance use issues (or have watched friends, family, and/or romantic partners struggle with addiction). Experience with addiction has the potential to give a counselor more credibility than any degree. Many clinicians, especially psychiatrists (because of potential risks associated with substance-medication interactions), are reluctant to work with substance users. However, what I have observed is that those who do the work are highly motivated and committed individuals. If substance use is a part of the picture, finding someone with this specialty or focus area can be an important predictor of how engaged the client will be.

Additional Resource:

If the above information still leaves unanswered questions (sadly, what I have summarized here is not an exhaustive list), the National Alliance on Mental Illness (NAMI) provides an excellent guide to understanding who does what in the field of mental health. To be taken NAMI’s site from here, click here.

6 Tips to Crush Passive Aggressive Behavior

Published by Michael Kinsey, Ph.D.

Passive Aggression

Passive aggression is difficult to define, but tends to be unmistakable when we encounter it. It can take many forms: a backhanded compliment, an act of martyrdom, a plaintive remark that’s “not about you” (but almost certainly is). Even more frustrating are more ambiguous and disavowed actions that seem to be about something bigger than the issue at hand. Showing emotional distance, “forgetting” to do something important, not responding to a text message, or simply expressing small grievances when a bigger complaint is the elephant in the room.

So what makes the passive aggressive behavior we receive so frustrating? I believe the attack in passive aggression to be a combination of abandoning and “gaslighting” (i.e., making someone doubt the validity of their own thoughts, feelings, and/or perceptions). We’ve all had the experience of impotently asking an passive-aggressive offender the naive question “What’s wrong?” The inevitable reply? “Nothing.” The perpetrator of passive aggression delights in our anxious feeling that something is off, our powerlessness in resolving the main issue, and the needy persistence with which we pursue clemency. As long as the offender can maintain plausible deniability about feeling angry, we can feel powerless about restoring an important relationship to its desirable state. We feel alone and abandoned by the other and begin to doubt our sanity.

Before getting into some practical tips about how to deal with someone who is acting passive aggressively, we need to ask ourselves a few questions.

a. How important is this relationship?

How we will proceed depends largely on who the offender is and what we are willing to tolerate. It’s reasonable to put in a bigger effort to deal with our mother showing passive aggressive behavior than an eye-rolling server at a restaurant. Is it a date? First date or tenth? If it’s a first date, it might be best to keep swiping. If it is a coworker, how much interaction do you have and how vital is the relationship to your success at work?

b. What is my goal in navigating this interaction?

A natural extension of question one, what do you need to have happen? If the passive aggressor is a waiter, you probably just need to finish your meal without him spitting in your food. With a romantic partner, your goal could be to address not only the current occurrence, but also to establish a set of expectations around what type of behavior you will and will not tolerate. With a parent or close family member, you may have to balance acceptance of who the person is with a plan for how to survive this (and the inevitable next) instance of passive aggressive behavior.

c. What values of my own do I need to preserve?

No matter who we are dealing with, we need to create a plan that allows us to live with ourselves and navigate the conflict with as much self-respect intact as possible.

With this framework in mind, let’s look at some guidelines for dealing with passive aggressive behavior.

1. Trust your gut

We are extremely sophisticated social creatures. We are wired to detect all kinds of cues from our environment, as well as from members of our community. We are also a highly interdependent species. And while we rely on others for many things, we have our own senses, perceptions, and emotions for a reason. We must listen to others, but maintaining our own autonomy and trusting our own impulses is essential in maintaining a sense of agency, developing an identity, and being able to have healthy relationships with others. Passive aggression makes us anxious because of the discordance between what we perceive and what another tells us. When we trust others’–especially hostile others–perceptions over our own, we begin to lose some of our individuality and sense of self. Mental health means balancing needs for independence and dependence. Dismissing our own feelings often pushes us to far into the direction of dependency.

In short, when you feel someone is acting passive aggressive, you’re probably right. This does not mean we don’t check in with the other person, but when the inconsistency between what you’re told and what you feel continues, it’s usually better to go with your gut.

2. Confront

Most problems, whether interpersonal or otherwise, are best addressed early and directly. Avoiding problems, especially the emotional dishonesty of passive aggression, very often feels like the safest and easiest path. Avoiding a problem only serves to increase our perception of threat. It never gets easier and usually gets worse. If it’s a passive aggressive toll collector, then don’t bother, you get a pass. But if your adversary is important to you, confronting the problem head on is the most healthy option. As a wise mentor of mine once said, “If you can’t be mad at someone, then you don’t really trust them.” A logical consequence of this truism is that leaning in and confronting passive aggressive behavior is an excellent way to enhance trust.

3. Picture the other person as a young child (and you’re the adult!)

Mercifully, passive aggressive behavior has one redeeming quality: it is often easy to imagine a young child showing similar behavior as your passive aggressive foe. When we can view the other as a more vulnerable (and cute) type of human, we are in a better position to find empathy and to feel less threatened by the conflict that the passive party is avoiding. If you are not sure how you would confront a young child, due to lack of experience and parents who were similarly unskilled, imagine someone you know who is skilled with kids. Remember, that you can be (and often must be!) very firm with children. Children receive the message of care and concern when adults are angry through tone and language. Research has shown that setting limits is an essential when parenting, and I would add, to all relationships. The caveat here is that limit setting is most effective when delivered with empathy.

4. Assert your needs and expectations about the process of resolving conflict

Just because someone regresses to passive aggressive strategies instead of openly discussing a grievance does not mean that the grievance has no merit. Assure the offender that you would like to understand what you have done to elicit such a reaction and that the relationship is important. Explain that while you care about the passive perpetrator’s feelings, you find {passive aggressive behavior X} to be extremely annoying. Emphasize that as an adult person, you expect that this person will communicate with you in a more direct, constructive manner.

5. Accept that being effective does not mean eliciting a “positive” response from the passive aggressor

Addressing passive aggressive behavior with a fellow adult means that you are confronting a pattern of behavior that has lasted the better part of a lifetime. At some point, withdrawing, being cold, denying that there is a problem, etc. were tactics that obtained some desirable outcome. To create a change in behavior in another person, you will need to expect that passive aggression could get even worse. Like the tantruming toddler who increases their volume and distress when mom denies him a new toy, the passive aggressive individual could very well get both more passive and more aggressive before he learns that you don’t back down. There is even a fancy label for “it will get worse before it gets better,” called “extinction burst” by the behaviorists. The key is to be resolute in your stance, knowing that neither one of you will be better off by rewarding childish behavior with hovering attention.

6. Remember that it is not the other’s responsibility to resolve your abandonment fears

Being abandoned is a primal existential fear to which nobody is immune. However, if you have had a history of receiving abandoning and invalidating care, you will feel this more acutely than others. Dealing with passive aggression effectively requires an ability to tolerate another’s emotional withdrawal and thus your own abandonment fears. If you cannot tolerate these negative emotions, not only will you be easily manipulated by passive aggressive behavior, but you will also reinforce passive aggressive behavior, ensuring you receive it with increasing frequency.

The best response to passive aggression I have ever encountered:

Tania, a friend of mine, confided in me her frustration about how her coworkers were treating her at her new job. She felt angry and hurt that her office mates seemed to go out of their way to make her feel unwelcome. Tania described conversations, where these coworkers would complain about Tania in her presence, but would not name her.

One said to the other: “Can you believe that some people here think they don’t have to do their work the way everybody else does?”

Excuse me!? “Tania responded.

Unphased and without any acknowledgment to Tania, the same coworker continued “And now they think we’re talking about her. It’s all about her.”

Instead of speaking up, Tania moved closer to her passive aggressive coworker, whose back was to Tania. Tania positioned herself just behind the bully, fixing her eyes on the back of the offender’s head. Tania held his position until her colleague turned around. Upon seeing Tania’s stern and steadfast gaze, the coworker gasped and nearly jumped out of the chair.

I shared my delight with how well I felt she had handled herself. Tania beamed, explaining that her coworkers had become extremely friendly towards her since the described incident.

Some may find Tania’s response heavy-handed, but I’ll tell you what I like about it. Knowing what I did about Tania, I understood that her posturing, though intimidating, did not come with any threat of violence. The brilliance of her response comes from the gaze itself. It is often difficult to confront passive behavior because the perpetrator can explain away hostile behaviors. Tania’s stare, without words, seemed to say “I see what you are doing. We both know what you are doing, and I do not like it.”

It’s true that “using your words” is almost always the best approach to conflict and confrontation. However, I think Tania’s response is the exception that proves the rule. She did not shy away. She did not offer her coworker the opportunity to deny her aggression. Her response was both confident and symbolically meaningful.

I encourage everyone to follow Tania’s lead and be bold in your confronting of passive aggressive behavior. Explain that you know what you see and will not be convinced otherwise. Expose concealed aggression to the light of day. And most importantly, enjoy the benefits of having a direct and open dialogue, rather than coldness of silence and disowned aggression.

For more insights into dealing with difficult people, behavior, and situations, follow Dr. Kinsey on Twitter (@mindsplain), and/or sign up below to receive Dr. Kinsey’s newsletter. Dialogue, questions, and comments are welcome!

What a Long Strange Trip It’s Been: Return of Psychedelics to Mental Health

Published by Michael Kinsey, Ph.D.

What do psychedelics have to do with psychology?

The world of psychology has enjoyed an explosion of innovation as of late. The industry has been filled to the brim with creative minds and experimental researchers over the last few years, and some truly groundbreaking research has taken place.

One area of research that psychology has been particularly involved in lately is the area of psychedelic drug use. As society’s opinions and acceptance of substance use changes throughout time, medical and psychology experts tend to follow suit- and this particular topic has been no exception.

In this blog, we’ll examine the use of psychedelics in the world of psychology, the impact on mental health and the arguments for and against using them in a professional context.

What are psychedelics?

First things first, what exactly does the term ‘psychedelic’ refer to? The most commonly known examples of psychedelic drugs are LSD, mescaline, Ayahuasca, psilocybin and DMT. These substances are taken by a user in order to achieve a psychedelic experience, which can involve auditory/visual changes, perception alterations and altered states of being.

The psychedelic culture

There’s always been a heavy culture surrounding psychedelics, and the most notable one would be the hippie culture in the 1960s and 1970s. LSD (or ‘acid’) was heavily associated with young adults who lived an alternative lifestyle and relished the mind-bending properties that psychedelic substances could bring.

Another notable culture that’s involved with psychedelics is the culture surrounding the drug Ayahuasca. Originally, this psychoactive brew was used by Amazonian tribes for spiritual enlightenment in traditional ceremonies, and it is now used by people all over the globe for precisely the same purpose.

Nowadays, psychedelics are used by many people from all walks of life. They are used by some for spiritual enlightenment, some to treat mental illness and some for a simply eye opening and mind altering experience.

The history of psychedelics in psychology

As much as some people may like to pass psychedelics off as something that only rebellious young people with dyed green hair are interested in, there is a rich history of the substances being used for positive reasons in the psychiatric industry.

The most noteworthy person to bring up in this discussion is Humphrey Osmond, who was responsible for some of the first recorded psychedelic experiments in psychiatric history. In 1951, he took up the post of deputy director of psychiatry at the Weyburn Mental Hospital in Saskatchewan in Canada, and started on his experiments within the next year.

Osmond is certainly a big name in this discussion, alongside his colleague John Smythies. He made waves with his 1953 alcoholism study as it had incredible results. Out of his two alcoholic participants who received a microdose of LSD. One patient stopped drinking immediately, and the other stopped drinking 6 months after.

Someone else that’s worth noting here is Ronald Sandison, who started his experiments with psychedelic drugs around the same time as Osmond, but in the UK. His experiments with LSD reported the same style of results as Osmond, and Sandison eventually opened an LSD-therapy specific facility.

Over the years, many other researchers have done intriguing experiments with psychedelics in psychology- such as Gasser et al in 2014, who experimented with LSD and anxiety, and Moreno et al in 2006, who looked at OCD and psilocybin.

The level of research done each year always depends on how willing the current society is to work with substances, as some researchers have faced a lot more stigma and hatred due to the illegal classification of psychedelic substances in multiple countries. As society’s opinion on substance use changes, you can be sure that science’s opinion will change too.

Positive aspects of psychedelic experimentation

So, why do researchers insist on working with psychedelics in psychology? One of the main reasons is simply that psychedelics appear to work well on helping people overcome mental illnesses and addictions, as the previously stated examples showcase. The Osmond 1953 study alone strongly suggests that the participants giving up alcohol was linked directly to the microdose of LSD that they took.

Additionally, if these substances are used in a very controlled and organised environment, they can be easy to monitor and track in an experiment. This can lead to less external variables interfering with the results of a study, which further suggests positive results.

Negative aspects of psychedelic experimentation

Of course, there are negative aspects to drug trials and experiments in psychology- notably, ethical issues. Many people disagree with substances being used in psychiatric studies, arguing that it could have negative ramifications for the participants in the near future (both mentally and physically).

Additionally, some might argue that it glamorizes and promotes drug use in popular media. A lot of modern studies in this area are promoted quite heavily in the media, and some may suggest that this is a negative thing to promote.

Furthermore, the effects of the drug on a person can only be assumed under a correlation not causation. It is difficult, especially with earlier studies, to exactly link the external results of an experiment to the internal effects of a drug. Developments in brain scanning technology have made this easier over the years, though.

To sum up

Overall, the debate over the use of psychedelic substances in the modern world of psychology is certainly a fascinating one. The opinion on this matter will vary from culture to culture, from person to person and from era to era as general opinions and taboos change, and as science progresses further. It’s fascinating to observe, and this area of psychology is definitely one to watch as the years go on.

If you want to read more about psychology and the innovation in this industry, make sure to browse through the rest of the site. We’re constantly updating it with new, intriguing content to help keep you at the forefront of the world of mental health. If you’d like to find out more about what we could help you with, feel free to get in touch with a member of our team at michael.kinsey.phd@gmail.com today.

Find A Therapist: 28 Questions to Ask When Vetting a Therapist

Published by Michael Kinsey, Ph.D.

The psychotherapy consulting room can feel like a foreign place where a different social rules seem to apply. Most clients with whom I meet for the first time are nervous about being in someone else’s space and beginning the daunting process of therapy; this discomfort often impedes their willingness to ask their most pressing questions.

I created a list of questions that are very much appropriate to ask (and that most people do not ask). Not every question will be relevant to everyone, and I couch this post with the warning that an indiscriminate litany of questions will not elicit the most generous and flexible approach from a prospective therapist. Ask all that seem relevant and important.

If you have sufficiently narrowed down the relevant questions, asked with a sincere curiosity, and avoided a challenging and/or interrogative tone, then any abrupt, non-collaborative responses you get back from the clinician are a poor reflection on the therapist.

Finding the right psychotherapist is important, so I encourage you to ask all the questions you need to feel comfortable with your decision.

FEE, POLICIES, & USEFUL INFORMATION

1. Will I be charged for the consultation session?

2. What is your fee and do you ever make exceptions?

3. Do you offer a sliding scale?

4. Do you/Would you file out of network claims for your clients?

5. Do you offer any discount for clients who pay in cash?

6. Do you adjust your fee when you meet with clients multiple times per week?

7. What is your cancellation policy? How much notice do you require? Do you ever charge for missed sessions?

8. Which days are you in the office? Are there recurring periods where you know you’ll be away? Out of the office?

9. Do you have a policy about phone calls between sessions?

THEORY, TECHNIQUE, & APPROACH

10. What is your theoretical orientation?

11. What is your theory of how therapeutic change occurs?

12. What do you think would be the biggest benefit I would get from psychotherapy?

13. Do you consider yourself to be a more active or reticent therapist? How come?

14. What do you see is my main issue and how do think we should address it?

15. Do you recommend medication/psychiatric consultation for your clients who experience similar problems?

16. Are there other ways of treating my problem and what do you think the advantage is of going the route you are suggesting?

17. Do you feel my issues are something that could be addressed in short-term treatment or is a long-term treatment the best option?

18. Which issues do you think could be addressed in the short-term and which issues require longer-term treatment before I see changes?

19. What books, articles, and/or resources do you suggest for people who have similar issues to me? Who are just beginning psychotherapy?

20. Will you be giving me a specific diagnosis? Why or why not?

21. Is there a difference between the diagnosis for which you would bill my insurance and the one for which you would treat me?

22. Do you think my issue is more situation-dependent (acute) or personality-based (Chronic)?

23. Do you consult with anyone regularly on your cases and might you be speaking with another person about my case?

REFERRALS & OUTSIDE RESOURCES

24. Do you have any recommendations among your colleagues/supervisees who would work on a sliding scale? Take my insurance?

25. Do you know of any community clinics with a good reputation?

26. Do you have any psychiatrists that you trust/collaborate with?

27. Can you recommend any resources that you know to be helpful in finding the right therapist? Clinic? Treatment facility?

28. Do you have any recommendations/Know of any resources that can help me to focus more on my mental health and less on my immediate life stressors (e.g., support finding employment, addiction treatment, domestic violence resources, childcare/parenting resources, government programs/benefits, etc.)?

Trigger Warning: Four Reasons to Remove the Word “Triggered” from Your Lexicon

Published by Michael Kinsey, Ph.D.

The word “triggered,” which I used to hear only in mental health circles, has now fully permeated everyday language. What was once a term created to refer to the behavioral response (e.g., dissociation, panic, flashbacks) to cues resembling a specific, circumscribed, traumatic event, has evolved into having at least three additional common uses.

First, the evocation of a painful emotion:

“I was really triggered when she interrupted me and started talking about herself.”

Second, a derivative of the first with a more narrow application, the elicitation of offense or political outrage:

“The way the terms “poor people” and “racial minorities” were used interchangeably was highly triggering.”

Third, its reappropriation for satirical use:

“Stay triggered snowflakes” is Tomi Lahren’s, the provocative conservative political pundit, catchphrase.

I confess to feeling annoyed with all of these uses, including the original use of the word. When the opportunity presents, I steer clients away from using this term, for reasons (beyond my own annoyance) I will explain. In no particular order, I list my reasons for cringing at the word “triggered” below.

The relinquishing of agency
The disavowal of aggression
Erosion of our abilities to express ourselves
Curtailing of free expression

1. The relinquishing of agency

To say “I was triggered” means accepting the role of passive, inert recipient. Of course the world affects us, and it is correct to assume that the things others say and do have an impact on us. However, to say “I was triggered,” in my view, carries the assumption that the world should not have acted upon us in such a manner. This rings of a regressive, and omnipotent complaint. To say, “I felt triggered” is an improvement, insofar as an acting, feeling entity (i.e., the feeler) mediates the outside world’s influence. Still, even in this improved form, which I take to mean feeling helpless, can be self-validating, but may not best capture the actual feeling incited by the “triggering” event. Which leads me to point 2.

2. The disavowal of aggression

The seldom-explored referent of the figurative expression being “triggered” is that of a gun being fired. When someone has been triggered, the outside world is the finger and the passive recipient is the gun. I can only assume that this metaphor caught on because it captures the reactive force of anger that underlies “being triggered.” If we react with an attitude of helplessness in response to feeling triggered, we are not acknowledging the feeling of being angered. If you can recall being in a fit of rage, you may indeed be helpless in reality, but the feeling of anger itself is inimical with helplessness. My view is that anger has become a taboo emotion in our current cultural context, and the proclamation that “I am triggered” is a sneaky way of saying “you are to blame for the anger I feel.” No matter how provocative the offender, feeling triggered diverts attention away from the more empowering reality of our emotional energy. After all, what function does anger serve if not to empower us?

3. Erosion of our abilities to express ourselves

Responsible parents teach their children to “use your words” when they feel angry in order to help regulate their emotions and to open up a means of resolving conflict without violence. Not only does the assertion that we are triggered not serve the function of affect regulation as no emotion is being labeled and expressed, but also “being triggered” is much less collaborative and related than “I felt angry” or “I felt sad when…” By expressing real feelings, two or more parties have the opportunity to clarify their intent and negotiate solutions. When one party is triggered, intent is irrelevant and so are other solutions other than censorship. This type of dynamic is precisely what is meant by sadomasochistic dynamics, where both parties are simultaneously the aggressors and victims, each remaining stuck assuming one or both roles of aggressor and/or victim. In other words, this results in a divisive rather than cooperative form of relatedness.

4. Curtailing of free expression

When intent does not matter and silencing oneself are the only ways to solve a moment of conflict, the potential for resolution has been supplanted by resentment. Psychotherapy’s earliest “golden rule” was to free associate, or say whatever comes to mind as it arises. The assumption underlying free association is that unconscious conflicts are brought to light and a resolution can be achieved. As humans, we all have dark and sinister forces residing inside of us, along with their opposites. The emergence of these emotions can lead to dialogue, intimacy, and freedom, whereas being triggered by one another’s inner darkness leads to primitive defenses, such as dissociation, denial, and projection. In other words, we drift further away from one another and blame other people for darkness that exists within us. As a therapist, it is essential that I not be triggered by clients’ darkest thoughts and feelings. I assume that the expression of shameful feelings leads to understanding, intimacy, and inner cohesion. My experience is that such a stance works to relieve inner conflict and tension while helping people deal with undesirable thoughts and feelings in more mature ways.

Summary:

Instead of communicating to yourself and others that you cannot tolerate their speech or actions by being “triggered”, work towards expressing more accurately what you feel, allowing yourself and the offending party to express one another’s point of view, and find ways of fostering resilience when no obvious compromise can be reached. Although aspects of pure traumatic re-experiencing symptoms that are “triggered” by external cues can be captured by the analogy of “being triggered,” the implication is that the outside world must be changed rather than inner resilience developed; in other words, avoidance must prevail over habituation and desensitization. At the very least, next time you are tempted to use the word triggered, be curious about what you are feeling and hope to achieve by endorsing this experience. To put it more succinctly, I believe we would all be healthier if we adopted a resilience-focused stance towards trauma and offensive speech rather than the stance described by Jonathan Haidt as a culture of “moral dependence.”

5 Pro Tips On How to Find the Right Therapist

Published by Michael Kinsey, Ph.D.

With all of the hardships of modern living, many people have restored balance in their lives by finding a competent psychotherapist. But psychotherapists are just like any other kind of professional: with a thorough search you can find the superb, the mediocre, and the subpar. Experiencing an encounter with one of the latter two, the result can be not only wasted time, money, and effort, but also innoculation against an effective means to improving your life. In this post, I suggest some strategies that could help you save hours of time, thousands of dollars, and unnecessary headaches in your search for the help you need.

1. Establish a geographic perimeter.

The first step in finding the right therapist is winnowing down the options. Therapy first and foremost relies on regular meetings and repeated investment of effort. Relaxing your criterion for geographic proximity could mean setting yourself up for failure. A great therapist who is hard to get to will make both consistency and persistency more of a challenge than it will already be with someone local.

Think of therapy as a place to do work. While psychotherapy can indeed be gratifying, it can also be trying. Start with the assumption that all of the following are true: psychotherapy will be difficult, rewarding, and could very well scale up in frequency as you make new discoveries about yourself. Ask yourself, how far am I willing to travel twice per week before or after work?

I saw a brilliant psychiatry attending working on becoming an analyst 4 times per week for 2 years at a rate of $10 per session.

2. Narrow the search by taking an honest look at your insurance.

Much of what was said about geography can also apply to insurance. When the going gets tough, balancing your budget can make dropping a productive treatment seem like a wise decision. Be realistic with what you can afford and determine whether insurance is a way to make competent psychotherapist’s fee a sustainable expense.

Health insurance providers vary in their helpfulness in longterm psychotherapy treatments. As a student, my insurance (AETNA student health plan) paid for 90% of my therapist’s fee for twice-weekly therapy, costing me $12/week for two 50-minute sessions with an experienced, skilled, and deeply invested psychoanalyst. Other insurances develop such a bad reputation with psychotherapists that no competent provider would ever accept them. If you value the premium insurance plans to pay the extra expense, or are lucky enough to have the luxury plan through work, staying in-network is usually the way to go. In fact, if you have a plan like I had, my humble opinion is you have no reason NOT to be in therapy.

Conversely, if you have opted for a budget health plan and don’t have tons to spend on a weekly full-fee treatment, good options are limited but not completely unavailable. Training clinics and teaching hospitals can be decent options. As a resident of New York City, I am perpetually shocked by the fact that so few take advantage of the plethora of psychoanalytic training institutes. NYPSI, IPTAR, William Alanson White Institute, NYU, and Columbia are all well-reputed institutions that train licensed professionals who are seeking to specialize in psychoanalysis. Becoming a training case for an aspiring analyst is a big commitment (often 4x/week), but can both be an incredible value and a life-changing experience. I saw a brilliant psychiatry attending working on becoming an analyst 4 times per week for 2 years at a rate of $10 per session. Admittedly this was an extraordinarily rare opportunity, but good value can most certainly be found by working with analytic training candidates. Other major cities besides New York also have training institutes, although not nearly with the same abundance as the Big Apple.

If finances are tight and mental health problems are overtly interfering with your capacity to increase your earning potential, many therapists will offer a generous sliding scale and/or pro bono work. This may take some scouring of psychology today as well as extra phone calls and consultation sessions, but many psychotherapists allot a certain number of slots in their private practice for individuals with strained finances. Remember: mental health professionals enjoy helping and are most definitely not in the field for the money!

3. Determine what kind of help you need right now.

A high percentage of people I’ve worked with have entered into treatment thinking they needed a quick tune-up, only to develop a deep appreciation for how deep and complex their symptoms truly are. I suppose these are the type of people most likely to seek me out. Others however have little interest in learning more about themselves but need desperately to resolve a maddening fear of public speaking, anxiety over bedbugs, or panic attacks while flying, to use a few frequent examples. While these individuals would undoubtedly benefit from a longer course of treatment, at the time they arrive in a therapist’s office, they demand it be a pitstop rather than a full restoration (my secret hope with these individuals is that their experience in therapy piques their curiosity sufficiently to revisit therapy when they are not in such a hurry).

If it’s your first time in therapy, it can be difficult to predict which one of these sketches best portrays you. And at the risk of being redundant, I could easily describe many other common types of therapy-seekers. Presenting yourself with the following forced choices could help figure out which type best describes you:

“This feeling came out of nowhere”	vs.	“It’s finally time I deal with this”
“If I could just fix this one issue, I’d be fine”	vs.	“I notice a problem in a few different kinds of situations”
“I don’t care where this came from, just make it stop!”	vs.	“I would really like to understand how it got to this point”
“There’s nothing wrong with my relationships”	vs.	“My relationships are often disappointing”
“I know exactly who I am and where I’m going, don’t interrupt me”	vs.	“I feel a little stuck,” “I feel unfulfilled,” “I feel I’m capable of more than what I’m doing now.”
“Whatever you do, don’t ask me about the past”	vs.	“I’m sure my early experiences affected me.”
“These statements capture me pretty well”	vs.	“How can this silly exercise tell me anything meaningful about myself!?”

If you agree with more of the statements on the left, a short-term, time-limited treatment, such as Cognitive Behavior Therapy/Cognitive therapy, Behavior therapy (such as exposure and response prevention, flooding), or Acceptance and Commitment Therapy, could be good places to start.

On the contrary, if the statements on the right resonated with you more, then a longterm, insight/depth therapy, or psychodynamic therapy/psychoanalytic treatment would be more appropriate and rewarding (other psychologists are sure to have other opinions, but this is mine).

Plenty of resources exist on the web to explain the types of treatment I referenced, but any provider you speak to on the phone should be able to tell you if they favor behavior therapies or insight-oriented approaches. If you receive the response of “I take a more integrative approach,” press for which kind of interventions they use more.

While this is the most complicated step of this article, it may be the most important in sorting out a good fit from a mismatch.

4. Figure out if gender matters.

It’s very common to seek out a particular gender as a therapist based on comfort level and past experience with men and women. In my own therapy, I have only worked with men, as having a male therapist has helped me to find the optimal amount of discomfort.

Many therapy-seekers will ask specifically for a female therapist due to incidents with abusive men in the past, or vice versa. Comfort is important, but it is wise to remember that confronting fears and anxieties is a major component of change. If you are just dipping your toe in the water with psychotherapy and have strong negative reactions to women, then starting with a man might be wise. However, if you have a great deal of experience in therapy and have only worked with men, perhaps leaning into some discomfort could be the catalyst you need.

Having no preference whatsoever can also be helpful as flexibility on this dimension allows you to pick from the best fit in other areas and/or the most highly recommended.

5. Don’t be intimidated by a high fee in the beginning.

While it may seem like I’m contradicting earlier advice, there is in fact a way to reconcile the disparate remarks. If you can afford one session with a high-priced therapist, you may save a ton of money down the road if you are truly able to use it as a consultation session. Pricey, highly-regarded professionals typically have large networks and can be helpful in finding a reputable option in your budget–that is if you can’t convince the consulting therapist to meet for reduced fee. Many clinicians are not flexible with fee, but plenty others will accommodate the right fit. A face-to-face meeting is a great way to plead your case.

Summing Up

The world of psychotherapy is a unique culture that often feels strange and uncomfortable when you have no experience with it. These tips along with a face-to-face meeting (and asking lots of questions!) will help demystify the psychotherapy world, and hopefully even get you excited about the journey on which you are about to embark.

Latest Posts

1. Losing Control – The Obsessive-Compulsive Personality:

2. Abandonment – The “Borderline” Personality:

3. Devoured – The Narcissistic/Schizoid Personality:

4. Mutilated – The Dependent/Avoidant Personality:

5. Disappearing – The Histrionic Personality:

6. Death – Post-Traumatic Stress Disorder (non-specific to personality):

Conclusion:

The Enmeshed Relationship: High Commitment, High Intrusiveness

Expert tip on how to say “No” in an Enmeshed Relationship:

The Neighborly Relationship: Low Commitment, Low Intrusiveness

The Parasitic Relationship: Low Commitment, High Intrusiveness

Expert tip for saying no in a parasitic relationship:

Alternative response:

Summing Up:

Practice Acceptance:

Do damage control:

Take inventory:

Plant a seed:

Befriend the future:

Summing Up:

Psychiatrist

Clinical Psychologist / Counseling Psychologist / Neuropsychologist

Licensed Psychoanalyst

Clinical Social Worker (LCSW)

Marriage and Family Therapist (MFT)

Alcoholism and Substance Abuse Counselor

Passive Aggression

a. How important is this relationship?

b. What is my goal in navigating this interaction?

c. What values of my own do I need to preserve?

1. Trust your gut

2. Confront

3. Picture the other person as a young child (and you’re the adult!)

4. Assert your needs and expectations about the process of resolving conflict

5. Accept that being effective does not mean eliciting a “positive” response from the passive aggressor

6. Remember that it is not the other’s responsibility to resolve your abandonment fears

The best response to passive aggression I have ever encountered:

What do psychedelics have to do with psychology?

What are psychedelics?

The psychedelic culture

The history of psychedelics in psychology

Positive aspects of psychedelic experimentation

Negative aspects of psychedelic experimentation

To sum up

Recommended Reading

If you have sufficiently narrowed down the relevant questions, asked with a sincere curiosity, and avoided a challenging and/or interrogative tone, then any abrupt, non-collaborative responses you get back from the clinician are a poor reflection on the therapist.

Finding the right psychotherapist is important, so I encourage you to ask all the questions you need to feel comfortable with your decision.

FEE, POLICIES, & USEFUL INFORMATION

1. Will I be charged for the consultation session?

2. What is your fee and do you ever make exceptions?

3. Do you offer a sliding scale?

4. Do you/Would you file out of network claims for your clients?

5. Do you offer any discount for clients who pay in cash?

6. Do you adjust your fee when you meet with clients multiple times per week?

7. What is your cancellation policy? How much notice do you require? Do you ever charge for missed sessions?

8. Which days are you in the office? Are there recurring periods where you know you’ll be away? Out of the office?

9. Do you have a policy about phone calls between sessions?

THEORY, TECHNIQUE, & APPROACH

10. What is your theoretical orientation?

11. What is your theory of how therapeutic change occurs?

12. What do you think would be the biggest benefit I would get from psychotherapy?

13. Do you consider yourself to be a more active or reticent therapist? How come?

14. What do you see is my main issue and how do think we should address it?

15. Do you recommend medication/psychiatric consultation for your clients who experience similar problems?

16. Are there other ways of treating my problem and what do you think the advantage is of going the route you are suggesting?

17. Do you feel my issues are something that could be addressed in short-term treatment or is a long-term treatment the best option?

18. Which issues do you think could be addressed in the short-term and which issues require longer-term treatment before I see changes?

19. What books, articles, and/or resources do you suggest for people who have similar issues to me? Who are just beginning psychotherapy?

20. Will you be giving me a specific diagnosis? Why or why not?

21. Is there a difference between the diagnosis for which you would bill my insurance and the one for which you would treat me?

22. Do you think my issue is more situation-dependent (acute) or personality-based (Chronic)?

23. Do you consult with anyone regularly on your cases and might you be speaking with another person about my case?

REFERRALS & OUTSIDE RESOURCES

24. Do you have any recommendations among your colleagues/supervisees who would work on a sliding scale? Take my insurance?

25. Do you know of any community clinics with a good reputation?

26. Do you have any psychiatrists that you trust/collaborate with?

27. Can you recommend any resources that you know to be helpful in finding the right therapist? Clinic? Treatment facility?

The relinquishing of agency

The disavowal of aggression