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Clinician Need and COVID Fatigue

After nearly 24 months of life turned upside down by the worldwide COVID-19 pandemic, how are you doing? I’m certain you regularly ask others a similar question, but when was the last time someone asked you, or you even asked yourself? As clinicians, we pivoted from in-person to telehealth multiple times as the numbers grew or diminished. We altered policies and practices, learned new modalities, and experienced uncertainties personally and professionally. As social workers, we have been challenged with personal health and financial concerns, feelings of loss, guilt, and have at times felt ill equipped by our training to navigate the unprecedented changes which have been required. Social workers struggled to meet the needs of clients through virtual settings and to address complicated social justice issues which have been exacerbated by the pandemic. The many challenges associated with the pandemic require us as social workers to recognize the personal and professional toll this has taken. 

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Happy New Year!

Happy New Year! As we reflect on 2021 and look forward to this brand new year, here are a few things to consider;

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Mining Conflicts

In previous posts, I have explained why it is countertherapeutic to shut down the repetitive conflicts that bring couples to therapy.  Within those conflicts are the unmetabolized feelings that their right brains have been waiting to experience and voice.  The therapist’s job is to mine their conflicts for every possible ounce of meaningful emotions that the couple has been trying to bring to consciousness.

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Self-Reflection

What makes social workers successful? What do we strive for? How do we find contentment in our profession? After almost 10 years as an active duty social worker in the Air Force, my search for the answers to these questions is still a work in progress. What remains meaningful to me are the core things that brought me to the profession--my passion for helping, my desire to advocate for social justice issues and for those in need to receive appropriate support and services.  Some days I am more successful than other days and I must admit making time to observe my thoughts does not always come naturally.  

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Therapeutic Response to Needed Conflicts

Conflicts in couple relationships hand us the potential for profound, deep, permanent change “on a silver platter”.  Knowing how to respond to this opportunity is the key to effective couples treatment.  Too often couple conflicts make therapists anxious, and they prematurely shut down the most fertile ground for empathy and understanding.  In a previous blog post, I addressed the concept of regulation.  This should be an end-goal for the work; not the first reaction from the therapist.

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Needing Conflicts

The concept of needing conflicts is central to understanding how Neurodynamic Couples Therapy heals.  Some other forms of couples treatment characterize conflict as simply an important avenue for communication and negotiation between partners.  A popular notion of marital health says that couples have to fight in order to work out their differences–i.e., partners who fight together stay together.  Our idea of needing conflicts is quite different from these.

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A Daughter's Dilemma

Mami always told me, “when I’m no longer able to take care of myself, put me in a nursing home…my dignity is very important to me”.  These words and personal preferences were shared, by my now 87 year-old Mother, close to twenty years ago. At the time, Mami was physically healthy, and her mind was clear and strong. Other than never driving or speaking English, she was self-sufficient and a great role model to all her six children. At the young age of  thirty-seven, she managed to raise her four daughters and two boys on her own, after my father passed away. She was as beautiful as she was focused and her sole purpose in life was to be  a loving  parent and ensure that all our needs and necessities were met.  

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Transformation

Some form of transformation is the stated or at least implied promise of most types of psychotherapy, including Neurodynamic Couples Therapy.  The term literally means “changing form”, although Google goes further and says that transformation is some type of extreme, radical change.

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Reading the Room

Every good comedian knows that in order to be successful at their job they must be adept at reading the room.  This means watching the body language of the patrons in the audience, looking for signs of inattention or boredom, and being able to feel whether there is a connection with their audience.  An entertainer who does not have this skill can quickly lose the audience.

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Mutual Empathy

The previous blog post ended with the question “What comes after wondering?”  The answer is mutual empathy.  Wondering and exploring about the meanings of intimate partners’ triggers and the feelings they expose must lead to empathy in order for metabolizing to occur.  I have had occasions when a consultee will say about a couple, “They seem to understand each other, but they’re not getting better.”  They are not feeling their partner’s pain; the work is remaining intellectual.  Without the final step of empathy, the feelings will recycle back into the right brain to be relived another day in another drama.

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The “Wondering” Spouse

The ability to wonder is an amazing capacity of the human mind.  Wondering springs from genuine interest in knowing what happened, what was its meaning, who was involved, what did they feel and why.  One school of psychological thought says that in order to be able to wonder we must be able to mentalize.  This basically means that we must be able to think about ourselves, our experiences and our feelings.  Essentially, we must be able to feel and think at the same time in order to wonder.

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What to Say That Fits the Frame

As I have written about before, the goal of Neurodynamic Couples Therapy is the metabolizing of emotions that leads to integration.  We believe that this process is a naturally healing function of partner relationships.  So, whatever the therapist says during treatment should be in service of fostering the metabolizing process.

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Maintaining the Therapeutic Frame

All types of therapies have a therapeutic frame that defines the boundary around what the therapy is and what it is not; what it does and what it does not do.  Neurodynamic Couples Therapy is a right-brain therapy; many other forms of couples treatment are left-brain therapies.  It is outside the frame of Neurodynamic Couples Therapy to utilize cognitive or behavioral interventions to change the behaviors of the couple, but that is often what our clients are looking for when they first come to treatment.

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The Roles of the Couples Therapist

The roles that couples therapists perform with their clients depend on the approach to therapy that they prefer.  They can be advisors, experts, coaches, educators, facilitators, provokers, observers, diagnosers and many other roles throughout the course of the treatment.  Here I want to clarify which roles the neurodynamic couples therapist does and does not perform.

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Regulating vs. Metabolizing

The goal of affect regulation came to the forefront of therapeutic wisdom in the mid-1990’s, primarily through the work of the neuroscientist, Allan Schore.  In his writing, he advocated that any effective psychotherapy had to address the dysregulated emotions that are stored in the right hemisphere of the brain.  Other researchers and experts (i.e., Daniel Siegel, Diana Fosha, Pat Ogden, Peter Fonagy, Marion Solomon and Stan Tatkin) translated this dictum into techniques such as mindfulness and mentalization, in which the therapist enters the patient’s experience to calm that unruly right brain with left-brain understanding.

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Training & Competency in the Treatment of Eating Disorders

Becoming an expert in the treatment of eating disorders takes time. Scroll through any Psychology Today professional listing, and chances are you find a number of clinicians who seem to “specialize” in almost every disorder listed in the DSM-5. While I believe that everyone should be trained initially as a generalist, with exposure to as many therapeutic modalities and clinical populations as possible, it is also important as social workers to make sure that you are practicing within your scope of expertise and knowledge. As a Faculty and Supervisor, I often remind my students, that experience does not always equal expertise. Someone can attend a training on a treatment modality or specific diagnosis, and while that imparts some knowledge and experience, it does not make one an expert. Most complex mental health issues are best treated by a clinician who has specific knowledge, expertise, and practice treating them, and eating disorders in particular are a cluster of syndromes that necessitate specific and advanced training in order to be providing standard of care. Consider this, if you needed an operation, would you choose the surgeon who has operated on cases like yours a handful of times, or the surgeon who has spent the better part of their career understanding, treating, and operating on conditions like yours and is up to date on the most recent protocols? 

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Mutual Emotional Triggers

The emotional triggers that spark conflicts between intimate partners are well-known:  he says he’s going out with friends from work, his husband feels rejected, his partner gets angry; she asks for more time to talk, her husband gets angry and defensive, she feels guilty; she tells her wife she’s disappointed in her, her wife bursts into tears, her partner tells her she’s overreacting.  One partner’s action triggers an emotion in the other partner, which automatically evokes a predictable and patterned emotional response from the original actor.  I have repeatedly written about this cornerstone concept of Neurodynamic Couples Therapy–mutual emotional triggers are a natural, inevitable, and useful aspect of couple relationships.

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