Category: Psychotherapy Page 1 of 2

Teletherapy Information

In Psychotherapy

Foley L. Nash, LLC, Counselor: Foley L. Nash, LPC-S, LMFT-BAS

MAIL: 9655 Perkins Rd., Suite C-170, Baton Rouge, LA 70810

Phone: 985-774-3252 Fax: 985-718-0744 Email: foleynash@gmail.com

Website: www.foleynash.com Alternate email: foley1@foleynash.com

Teletherapy Declaration & Informed Consent (3 pages)

(An additional document to the normal declaration of practices used for in-person sessions)

Information for Clients:

Licensed mental health professionals are required by their licensing boards to provide you, the client, with certain basic information. You may have already received and signed the basic Declaration of Practices and Procedures from Mr. Nash. This Teletherapy Policy and Procedure document describes certain important aspects of therapy unique to teletherapy. This information is provided for your review and agreement. Please take time to read it carefully, and discuss any questions you have before signing below.

By signing this form, you are not making a commitment to continue teletherapy as your permanent mode of therapy, but you will continue to have that option should you and I agree that it is in your best interest.

QUALIFICATIONS OF CLINICIAN

I have completed 21+ hours of live telehealth training in addition to my professional qualifications as a clinician. This training covered the law and ethics and clinical skills specifically related to telehealth care. I will continue to receive at least 3 hours of continuing education in telemental health every 2 years. All teletherapy sessions will be conducted through the HIPAA-compliant services of either C3Now (a stand-alone service) or the services of therapyappointment.com, both encrypted to the federal standard.

SCHEDULING AND STRUCTURE OF TELETHERAPY

Counseling sessions will be scheduled in 50-minute increments, unless you and I agree on a different time schedule. The next session will be scheduled at the end of the current session, unless otherwise agreed upon. The structure of sessions will be dependent on the treatment plan and interventions being used.

ETHICAL AND LEGAL RIGHTS RELATED TO TELETHERAPY

Mr. Nash will not be conducting teletherapy in any other state than Louisiana unless he specifically seeks and obtains licensure in the other state. It is important for you as a client to realize that if you should relocate to another state, Mr. Nash’s ability to conduct or continue teletherapy would be dependent on his decision whether to seek licensure in the state to which you are relocated.

RESPONSIBILITIES OF THE CLIENT

Clients should:

be appropriately dressed during sessions.
avoid using alcohol, drugs, or other mind-altering substances prior to session.
be in a safe and private area appropriate for a teletherapy session.
make every attempt to be in a location with stable Internet capability.

Clients should not:

record sessions unless first obtaining Mr. Nash’s permission
have any anyone else in the room unless you first discuss it with Mr. Nash
conduct other activities while in session (such as texting, driving, etc.)

If the client is a minor, the parent or guardian must be present at the location or building of the teletherapy session, unless otherwise agreed upon with the therapist.

POTENTIAL COUNSELING RISKS

When using technology to communicate on any level, there are some important risk factors of which to be aware. It is possible that information might be intercepted, forwarded, stored, sent out, or even changed from its original state. It is also possible that the security of the device used may be compromised. Using methods of electronic communication with counselors outside of our recommendations creates a reasonable possibility that a third party may be able to intercept that communication. It is your responsibility to review the privacy section and agreement forms of any application and technology. Please remember that depending on the device being used, others within your circle (family, friends, employers, and coworkers, as well as those not in your circle (criminals, scam artists, etc.) may have access to your device. Reviewing the privacy sections for your devices is essential. Please contact me with any questions that you may have on privacy matters.

POTENTIAL LIMITATIONS OF TELETHERAPY

Teletherapy is an alternate form of counseling, and it should not be viewed as a substitution for taking medication that has previously been prescribed by a medical doctor. It has possible benefits and limitations. By signing this document, you agree that you understand that:

Teletherapy may not be appropriate if you are having a crisis, acute psychosis, or suicidal/homicidal thoughts.
Misunderstandings may occur due to a lack of visual and/or audio cues.
Disruptions in the service and quality of the technology used may occur.
NOTE (re billing & 3^rd-party payments): I can file insurance claims, & I can also make an invoice available to you to file with your insurance company. While most policies now cover teletherapy, please check ahead of time to be sure your policy covers telemental health counseling.

EMERGENCY SITUATIONS

The following items or important and necessary for your safety. The clinician will need this information to get you help in the case of an emergency. By signing this consent to treatment form you acknowledge that you have read, understand, and agree to the following:

The client will inform Mr. Nash of the physical location where he or she is, and that will be used consistently while participating in sessions, and will inform Mr. Nash if this location changes.
In the first teletherapy session, you will provide the name of a person Mr. Nash is allowed to contact in case he believes you are at risk.
You will be asked to sign a release of information for this contact.
In the first teletherapy session, you will provide information about the make, model, color, and tag number of your automobile.
In each session, you will provide (or confirm) information about the nearest emergency room or emergency services, such as fire station, police station, etc. if there is not an emergency room nearby.
Depending on the assessment of risk, and in the event of an emergency, you or Mr. Nash may be required to verify that the emergency contact person is able and willing to go to the clients location and if that person deems necessary, call 911 and/or transport the client to a hospital.
In addition to this Mr. Nash may assess, and therefore require, that you, the client, create a safe environment at your location during the entire time of treatment.
If an assessment is made for the need of a safe environment, a plan for this safe environment will be developed at the time of need, and made clear by Mr. Nash.
In the case of a need to speak to Mr. Nash between sessions, please call or text, and leave a message. Nash does not provide emergency services on a 24-hour basis. If your emergency is after hours, please contact your nearest emergency room. With some exceptions, typically contact between sessions is limited to arranging for appointments.
If you need the services of other professionals, Mr. Nash is happy to consult and coordinate with them. Clients should not routinely be meeting with more than one counselor, unless the two counselors have agreed to coordinate your care.

BACKUP PLAN IN CASE OF TECHNOLOGY FAILURE

The phone is the most reliable backup option in case of technological failure. It is highly recommended but you always have a phone at your disposal, and that Mr. Nash knows your phone number. If disconnection from a video conference occurs, end the session, and Mr. Nash will attempt to restart the session. If reconnection does not occur within 5 minutes, call Mr. Nash at the contact number that has been provided. If within 5 minutes Mr. Nash does not hear from you, you agree (unless otherwise requested) that he can call the provided phone number.

CONSENT TO TELETHERAPY TREATMENT

I have read and understood this Declaration of Teletherapy Policies & Procedures, and I have a copy for reference. My signature below indicates my full informed consent to services provided by Mr. Nash via teletherapy treatment.

DATE Client Signature 1 DATE Client Signature 2

DATE Client Signature 3 DATE Client Signature 4

Parental Authorization For Minors:

(Signature of Parent/Guardian) DATE

give my permission for Foley Nash, LPC-S, LMFT-BAS, to conduct counseling with

(Relationship of Minor) Name of Minor (please print)

Options for recording your signature:

You may sign this document while Mr. Nash is watching via video, or
You may scan the signature page, and send it via text to Mr. Nash, or
You may snap a picture and send it via text to Mr. Nash, or
You may mail your signed document, sending it to the address at the top of this document.

Divorce Recovery

In Psychotherapy, Self Help

As a licensed mental health professional, I work with many individuals, couples, and families who are affected by divorce. I have developed this list of survival strategies for people who are experiencing divorce. If you or someone you love is in this situation, I hope these ideas will help you.

1. Take your time as you adjust to your changed life circumstances. Recognize that you are going through a major life transition that cannot be rushed.
2. Set up temporary arrangements to help you get through the changes involved in your divorce process.
3. You will often feel frustrated. Avoid the temptation of acting for the sake of acting just because it gives you a temporary feeling of being in control.
4. When you feel uncomfortable, slow down and identify what you are feeling and why.
5. Don’t force any more changes on yourself than are necessary.
6. Explore both the benefits and costs of your new life.
7. Think about the future. In your journal, explore the question, “What is waiting to happen in my life now?”
8. Remember to ask yourself, “What am I supposed to learn from this?”
9. Protect yourself against the inevitable forgetfulness and absent-mindedness which many divorcing people report. Make a list of important account numbers, telephone numbers, and the like, and keep them in a safe place.
10. Watch out for too many changes in your life as you recover from the divorce and the changes in your life circumstances. Change causes stress, and you have enough right now.

11. Let people help you.
• If it’s impossible to reciprocate, say so.
• People know that your life isn’t like it used to be.
• Don’t let your inability to reciprocate prevent you from accepting what people willingly offer.

12. Let go of your need for perfection. You will not survive emotionally unless you lower your expectations.
13. Develop your ability to be flexible and find creative ways to solve problems.
14. Learn to set priorities. Do the most important things first.
15. Trust your gut feelings. Pay attention to your instincts and act on them.
16. Simplify everything in your life. You cannot afford to keep it complicated.
17. Find an outlet for your anger. If a friend is not available, look for a minister, rabbi, or professional counselor. If money is an issue, look for a therapist who will see you for a low fee.
18. Teach yourself to let go of guilt. You don’t have time for it and it’s not necessary.
19. Focus on issues you have control over. If something is beyond your control, don’t waste your emotions on it.
20. Create a ceremony to acknowledge your divorce.
21. Learn to be assertive. You can’t say yes to every request, whether it is from your family members or people in the community who want your time and resources. If you give it all away, you will have nothing left for yourself.
22. Find ways to take care of your body. Get regular checkups and make time to exercise. You need rest now more than ever. Watch your alcohol intake.
23. Find someone who will listen to you. Sometimes you have to ask, for example, “I need a sounding board right now. Can I have 15 minutes of your time?”
24. Rent a sad movie and let yourself cry (when the kids aren’t around). Crying allows you to release the sadness that you are sure to feel.
25. Do at least one fun thing for yourself every week.
26. In your private journal, make a list of all the things you’re afraid of.
27. In your private journal, make a list of all the things you worry about.

If you have children:

28. Manage your own emotions so you will be able to help your child manage his or her struggle.
• Learn as much as you can about how children respond to divorce and life in a single-parent home.
• Do not expect your child to respond the same way you do.
• Take your child’s developmental stage into consideration when responding to his or her behavior.

29. Make it okay for your children to talk to you about their feelings.
30. Keep appropriate boundaries.
• Don’t give in to the temptation to let your child take care of you.
• Let your children be children.
• Avoid burdening them with your feelings and the facts of the divorce.
• Find another adult to be your sounding board.

31. Even though you may be unable to be present as much as in the past, your children still need adult supervision. Look for ways for other adults to look in on your kids when they are home alone, even when they are teenagers.
32. Just because your child appears to be handling his or her emotions well, don’t assume that he or she is okay. Some kids respond to divorce by becoming overly responsible or by closing down their emotions. They may need to hear, “Tell me how you’re feeling.”
33. While it is important to listen and accept your children’s feelings, it is equally important to set limits on behavior.
34. Keep a private journal where you express your feelings. Be sure to keep it in a private place where your children won’t find it. A journal provides a place to express anger, sadness, loneliness, and fear—all of those feelings you feel every day as a single parent.
35. Remind yourself that recovering from divorce will take time. Your recovery will happen on its own schedule, and it will happen. You will get through this intact.
36. Get together with other single-parent families. Sharing times with people facing similar issues can make you feel normal.

Solution-Focused Therapy

In Psychotherapy

Most types of psychotherapy involve exploring feelings, being validated, finding explanations, exploring wishes and dreams, setting goals, and gaining clarity. Every therapist has unique ways of working with clients, based on his or her personality, training, and views of how people change.

A solution-focused therapist is likely to do the following:
1. Instead of going over past events and focusing on problems, the therapist helps you envision your future without today’s problems.
2. During the course of therapy (often as few as 3 to 6 sessions), the therapist helps you discover solutions.
3. The therapist encourages you to identify and do more of what is already working.
4. The therapist guides you to identify what doesn’t work and to focus on doing less of it.
5. The emphasis is on the future, not the past.
6. SFBT therapists believe that the client is the best expert about what it takes to change his or her life.
7. The therapist’s role is to help you identify solutions that will remove the barriers to having the life you want.

Solution-Focused Brief Therapy (SFBT) is a process that helps people change by constructing solutions rather than dwelling on problems. This type of therapy tends to be shorter-term than traditional psychotherapy. Steve de Shazer and Insoo Kim Berg of the Brief Family Therapy Center in Milwaukee are the originators of this form of therapy.
The SFBT therapist helps the client identify elements of the desired solution, which are usually already present in the client’s life. The client learns to build on these elements, which form the basis for ongoing change. Rather than searching for the causes of the problem, the focus is on defining the changes and making them a reality. The two key therapeutic issues are: (1) how the client wants his or her life to be different, and (2) what it will take to make it happen.
Creating a detailed picture of what it will be like when life is better creates a feeling of hope, and this makes the solution seem possible. The therapist helps the client focus on the future and how it will be better when things change. It is important to develop a set of specific, detailed goals. These goals drive the therapy process and keep it focused and efficient.
Why SFBT Is Usually Short-Term
SFBT therapists don’t set out to artificially limit the number of sessions. A good brief therapist will not focus on limiting sessions or time, but rather on helping clients set goals and develop strategies to reach those goals. Focusing on the client’s goals and the concrete steps needed to achieve them usually takes less time than traditional therapy, in which the client typically spends many sessions talking about the past and explores reasons and feelings. SFBT therapists aim to provide clients with the most effective treatment in the most efficient way possible so that clients can achieve their goals and get on with their lives. As a result of this focus, the counseling process often requires as few as six sessions.
Types of Problems That SFBT Addresses
Solution-Focused Brief Therapy is an effective way of helping people solve many kinds of problems, including depression, substance abuse, eating disorders, relationship problems, and many other kinds of issues. Since it focuses on the process of change rather than on dissecting the problem, more serious issues do not necessarily require different treatment. The SFBT therapist’s job is to help clients transform troubling issues into specific goals and an action plan for achieving them.

In The Miracle Method, authors Scott D. Miller and Insoo Kim Berg describe how to create solutions with these steps:

1. State your desire for something in your life to be different.
2. Envision that a miracle happens and your life is different.
3. Make sure the miracle is important to you.
4. Keep the miracle small.
5. Define the change with language that is positive, specific, concrete, and behavioral.
6. State how you will start your journey rather than how you will end it.
7. Be clear about who, where, and when, but not why.

Signs That You Should Consider Seeing a Therapist
There are several ways to know when you would be doing yourself a favor by finding a licensed, professional therapist to work with.
1. You’ve tried several things on your own, but you still have the problem.
2. You want to find a solution sooner rather than later.
3. You have thoughts of harming yourself or others.
4. You have symptoms of depression, anxiety, or another disorder that significantly interfere with your daily functioning and the quality of your life. For example, you have lost time from work, your relationships have been harmed, or your health is suffering. These are signs that you need the help of a trained, licensed professional.

Depression – information

In Psychotherapy, Self Help

Depression – part 1

This is the first of a two-part series on depression. In this part, I will explore what depression is and what causes it. In the next part, I will describe how depression is treated and prevented. If you or someone close to you suffers from depression, it is important to educate yourself about it and seek treatment from qualified mental health professionals.

Depression is a serious illness, not a harmless part of life. It is a complex disorder with a variety of causes. It is never caused by just one thing. It may be the result of a mix of factors, including genetic, chemical, physical, and sociological. It is also influenced by behavior patterns learned in the family and by cognitive distortions.
Depression affects millions of people in this country. It is always troubling, and for some people it can be disabling. Depression is more than just sadness or “the blues.” It can have an impact on nearly every aspect of a person’s life. People who suffer from depression may experience despair and worthlessness, and this can have an enormous impact on both personal and professional relationships. In this newsletter, I will describe many of the factors that may cause depression, and I will explore strategies for preventing it.

Depression Is Pervasive

When a person suffers from depression, it can affect every part of his or her life, including one’s physical body, one’s behavior, thought processes, mood, ability to relate to others, and general lifestyle.

Symptoms of Depression

People who are diagnosed with clinical depression have a combination of symptoms from the following list:

• Feelings of hopelessness, even when there is reason to be hopeful
• Fatigue or low energy
• Much less interest or pleasure in most regular activities
• Low self-esteem
• Feeling worthless
• Excessive or inappropriate guilt
• Lessened ability to think or concentrate
• Indecisiveness
• Thinking distorted thoughts; having an unrealistic view of life
• Weight loss or gain without dieting
• Change in appetite
• Change in sleeping patterns
• Recurrent thoughts of death
• Suicidal thoughts
• A specific plan for committing suicide
• A suicide attempt
• Feelings of restlessness or being slowed down

When a person is suffering from depression, these symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. This means that the person’s family and social relationships, as well as work life, are impaired.
When a person is suffering from depression, symptoms such as these are not the result of a chronic psychotic disorder, substance abuse, general medical condition, or bereavement.

Grief, Sadness, and Depression

Depression may include feelings of sadness, but it is not the same as sadness. Depression lasts much longer than sadness. While depression involves a loss of self-esteem, grief, disappointment and sadness do not. People who are depressed function less productively. People who are sad or disappointed continue to function.

Depression and Socioeconomic Factors

Depression does not seem to be related to ethnicity, education, income, or marital status. It strikes slightly more women than men. Some researchers believe that depression strikes more often in women who have a history of emotional and sexual abuse, economic deprivation, or are dependent on others. There seems to be a genetic link; depression is more common among parents, children, and siblings of people who are diagnosed with depression. The average age at the onset of a depressive episode is the mid-20s. People born more recently are being diagnosed at a younger age.

Physical Causes

Many physicians believe that depression results from a chemical imbalance in the brain. They often prescribe antidepressant medication, and many people find relief as a result. However, there is no reliable test to identify such a chemical imbalance. It is unknown whether life experiences cause mood changes, which create changes in brain chemistry, or whether it works in reverse.
Depression may be associated with physical events such as other diseases, physical trauma, and hormonal changes. A person who is depressed should always have a physical examination as part of the assessment process to determine the role of physical causes.

Signs That Professional Treatment Is Needed

If you or someone you know is depressed and exhibits any of the following signs, it is extremely important to seek the assistance of a medical or mental health professional.

1. Thinking about death or suicide. This is always dangerous and you should see a professional therapist immediately.
2. When symptoms of depression continue for a long time, you may need professional help. Acute responses to events are normal, but they should not last beyond a reasonable time.
3. Your ability to function is impaired by your depression. Seek help before your life situation deteriorates to a serious level.

4. You have become so isolated that you have no one with whom to check reality. Seek out someone to share your thoughts and feelings with.
5. Depressive symptoms have become severe.

Depression – part 2

This is the second of a two-part series on depression. In this part, I will describe how depression is treated and prevented. If you or someone close to you suffers from depression, it is important to educate yourself about it and seek treatment from qualified mental health professionals.

There are three basic ways to treat depression: psychotherapy, self-help, and medication. Many people respond best to a combination of two or more methods.

1. Psychotherapy: Exploring one’s beliefs and ways of thinking, and learning new ways of thinking and behaving, with the guidance of a professional.
2. Self-help: Exploring one’s beliefs and ways of thinking on one’s own.
3. Medication: Altering one’s brain chemistry by taking antidepressant medication.

A physician may recommend medication when four conditions exist:

1. The patient’s depression is severe.
2. The patient has suffered at least two previous depressive episodes.
3. There is a family history of depression.
4. The patient asks for medication only and refuses psychotherapy.

There are four types of antidepressant medication available today:

• Tricyclic antidepressants (TCAs)
• Monoamine oxidase inhibitors (MAOIs)
• Selective serotonin reuptake inhibitors (SSRIs)
• Structurally unrelated compounds

The TCAs and MAOIs have been used for decades. The SSRIs (such as Prozac) and structurally unrelated compounds are newer and are being prescribed more and more frequently. They have fewer and less pronounced side effects than the TCAs and MAOIs.

Treatment without Medicine

One of the leading methods for treating depression is cognitive therapy. Cognitive therapists help depressed clients feel better by identifying how faulty ways of thinking are making him or her feel bad. The client analyzes his or her thoughts and beliefs, and learns to substitute more healthy ways of thinking and believing.
Many mental health professionals believe that the ideal treatment of clinical depression is medication in conjunction with psychotherapy.

Prevention of Depression

Depression can often be prevented. It is especially important to take preventive action if you are aware that you have predisposing factors such as those mentioned in the last newsletter.

1. Identify your risk factors and be aware of where you are vulnerable. Each of us has unique risk factors, such as things we were taught in our families of origin, values we have learned, and the presence or absence of a family history of depression. Anything that has been learned can be unlearned and replaced with something healthier.
2. Learn to manage stress. You can learn proven techniques for calming and relaxing yourself. Consider taking a stress management class or buying a set of relaxation tapes.
3. Learn problem-solving skills. Many people who develop depression never learned problem-solving skills. They need to develop the ability to see problems from many viewpoints and to look for a variety of solutions.
4. Build your life around things you can control. Learn to recognize what you can control and what you can’t. Avoid spending much effort on situations that won’t pay off for you.
5. Learn self-acceptance. Instead of rejecting the parts of yourself you don’t like, learn to manage them more productively.
6. Become aware of selective perception. Observe how you generate ideas and opinions about people and events. Remember that these are just your views, not necessarily objective facts.
7. Focus on the future, not the past. Depressed people tend to be focused on the past. People who set goals and focus on the future tend to be more positive about life.
8. Develop a sense of purpose. Many depressed people lack a sense of purpose or meaning. This means they have no goals and nothing in the future drawing them forward. To prevent depression, develop your sense of purpose and meaning.
9. Strengthen your emotional boundaries and set limits. Boundaries define your role in a social situation. They determine how you will or won’t behave in a given situation. Having clear, strong boundaries is empowering, while boundary violations make you feel victimized and helpless. Setting limits means having and enforcing rules for the behaviors you expect in a relationship.
10. Build positive and healthy relationships. Think about what you need from others in relationships. Learn to read people and trust your instincts about which people are good for you.
11. Avoid isolation. Talk to others about what’s going on with you. If you keep your thoughts to yourself, you may be unaware that your thoughts are distorted. If you share them with another person, you can become more objective.

Signs That Professional Therapy Is Needed

OCD or Obsessive-Compulsive Traits Checklist

In Psychotherapy, Self Help

OCD CHECKLIST

DIRECTIONS: You may have a problem with obsessive-compulsive disorder (OCD) if you mark several items in the following table. If so, identify your specific worries or rituals in the questionnaire to relabel them as obsessions and compulsions. Underline all concerns that apply in each item.

Obsessions:

Unpleasant thoughts that come into my mind against my will often upset me.
I usually have doubts about the simple, everyday things that I do.
I have little control over my thoughts.
I worry that my bad thoughts will come true.
When I start worrying, I can’t easily stop.
Insignificant events worry me too much.

Compulsions:

I spend more time than most people cleaning, showering, or checking.
Other people have difficulty meeting my standards for order, cleanliness, safety, hard work, or decency.
It’s hard for me to be sure I’ve done something even when I know I’ve done it.
I repeat certain actions over and over.
People think I’m a perfectionist, a “neat freak,” a hypochondriac, superstitious, rigid, or a “pack rat.”

General Obsessions
I worry (with little reason) that my partner is doing something behind my back.
I worry too much about hurting others’ feelings or making people mad.
I worry too much about household noises, how things feel, or other sensations.
I worry about losing my wallet or unimportant objects, such as a scrap of notebook paper.
I worry that I won’t say things just right or use the “perfect” word.
I worry about always doing “the right thing” or being honest, fair, or on time.
I worry about salvation, having sinful thoughts, blaspheming, or other religious concerns.
I am superstitious that saying or doing certain things can cause bad luck.
I avoid “unlucky” numbers, places, or animals.
I worry that some part of my body is hideously ugly despite reassurance to the contrary.

Aggressive or Sexual Obsessions
I fear losing control with sharp objects, while driving, in high places, and in other ways.
I fear I will harm others or hurt babies, or I get violent images in my mind.
I avoid sharp or breakable objects such as knives, scissors, or glass.
I worry that I will blurt out or write obscenities or insults, even though I never have.
I worry that I might (accidentally) steal something.
I have unwanted sexual thoughts about strangers, family, friends, children, or others.
I get violent sexual images that I would never act out.
I worry about being a homosexual for no actual reason.

Thinking and Counting Rituals
I often have to repeat “good” thoughts or words to “erase” bad ones or to feel safe.
I often find myself praying for nonreligious reasons or have to pray “the right way.”
I feel the need to confess to things I never did.
I try to remember events in detail or make mental lists to prevent bad consequences.
I count floor tiles, books, nails in walls, my teeth, or other things to relieve tension.

1 Checklist was adapted from the questionnaire in Stop Obsessing! by Edna Foa and Reid Wilson (Bantam, 1991).

Checking and Repeating Rituals
I worry that lack of due caution will cause some misfortune, such as a fire or burglary.
I repeatedly check locks, windows, stoves, or other things to prevent misfortunes.
I repeatedly search for news about any accidents caused by others or myself.
When driving, I stop to check that I haven’t (accidentally) hurt someone.
I repeatedly ask or phone others for reassurance that everything is OK, that I haven’t made them mad, that I haven’t forgotten an appointment, or for other concerns.
I repeat activities such as combing my hair or going in and out of doorways.
I make sure I’ve repeated such activities the “right” number of times.
I repeatedly check for mistakes while doing bookwork and worry about it later.
I repeatedly check my body odor or appearance to make sure I’m acceptable.

Ordering and Cleaning Rituals
I must have certain things around me set in a specific order or pattern.
I always want my papers, pens, books, collections, or closets arranged just right.
I spend much time putting things in the right place, and I reposition rugs, pictures, etc.
I notice at once if things are out of place and get upset if others have rearranged them.
I vacuum my house, dust, change sheets, or wash floors more than once a week.
I spend a lot of time cleaning such things as faucets, counters, utensils, or my collections.
I eat foods in a particular order for nonnutritional reasons.
I follow a set order during baths or grooming and start over if that order is interrupted.

Germs, Dirt, Danger, or Contamination Rituals
I worry about getting diseases from my own saliva, urine, feces, or other things.
I worry about getting contaminated or contaminating others by coming in contact with radon, radioactive materials, toxins, dirt, insects, animals, or other substances.
I avoid shaking hands, public restrooms, doorknobs, raw meat, cleansers, dirt, sticky substances, emptying the garbage, changing kitty litter, or other problem situations.
I wash my hands many times a day or for long periods of time.
I often take very long showers or baths and wash to decontaminate rather than to clean.

Hoarding Rituals
I save old newspapers, notes, cans, paper towels, napkins, wrappers, or other items.
I pick up useless objects from the street, garbage cans, garage sales, or other places.
I have difficulty throwing things away for fear I may need them some day.
Over the years my home has become cluttered with collections (that bother others).
I worry excessively about saving money or food, even when I don’t need to.
Health and Illness Rituals
I repeatedly take my pulse, blood pressure, or temperature, or check for injuries.
I worry that I have (or might get) an illness despite reassurance from doctors that I’m okay.

Rate the Impact of Obsessions and Rituals on Your Life
1. How much distress do your obsessions/rituals usually cause you? (0 = none; 10 = intense): _____
2. How often or how much do your thoughts or rituals interfere with social or work functioning?
__Never __ Slightly __Somewhat __Frequently __Severely

Becoming your own individual

In Psychotherapy, Self Help

FamilyDIFFERENTIATING FROM
YOUR FAMILY OF ORIGIN
You may handle family pressure by trying to conform or by divorcing yourself emotionally. However, there is an alternative. You can learn how to express your differences or differentiate without getting caught in conflicts or abandoning your significant others. Once you’ve left home, the best place to reclaim the freedom to be yourself is with the family that raised you because:1
• When you are away from home, you will have time to evaluate your interactions with family members, regain a sense of yourself, and plan future strategies.
• Attachments to spouses, bosses, and associates often mimic early entanglements and will automatically change as you develop a new style of being with your parents.
• Your ability to be your own person is determined by how well you have resolved issues with your parents and the degree to which your parents are differentiated.
METHODS FOR DIFFERENTIATING WITHIN YOUR FAMILY
1. Separate, person-to-person relationships: Develop an individual relationship with each parent instead of dealing with them as a unit.
• Correspond with each parent separately instead of writing Dear-Mom-and-Dad letters.
• Have individual telephone conversations instead of talking with both parents on extension lines.
• Balance the time you spend with each parent alone during family visits. Talk about subjects of interest that do not involve others. Stories of past family history, ancestry, philosophies of life, and beliefs are all good topics: “What was it like for you when we were little and Daddy was gone a lot?” “What was your most embarrassing or proudest moment?” “What upset you when you were a child?”
2. The I position: When conflicts emerge in the family, your goal is to state your position and underscore the fact that there are differences in the family. There are few opportunities to take the I position during periods of calm. Deaths, serious illnesses, family gatherings, weddings, divorces, and disclosure of secrets often spawn issues that are fertile opportunities to differentiate. Openly define where you stand on an issue, what you want, and what you intend to do without defending yourself, attacking, or withdrawing:
• “I won’t be getting a prenuptial agreement, even though that may be unwise.”
• “I don’t agree with your position on premarital sex, and I’ll be glad to keep the details of my weekend plans private if you find them too disturbing.”
• “When you give me unsolicited advice, I feel too resentful to consider it.”
3. Neutralizing attacks: After stating your position, it helps to anticipate a series of reactions from your family. This backlash is so important that if it does not happen, you may not have made a successful attempt at differentiation! Initially, family members may be surprised, hurt, or angry and label your ideas crazy, irresponsible, or immoral. Then they will do their best to convince you to change your mind. When this does not work, they may threaten to disown you, but these accusations will probably reach a peak and then subside. Finally, the family will come to respect and appreciate your convictions. “Surviving” expressions of individuality will help all family members differentiate. The hardest part of this task is to maintain contact while under fire.
1 Murray Bowen’s ideas on differentiation are summarized in Family Therapy in Clinical Practice (Jason Aronson, 1978).
Making a casual, empathic response will empower you and can defuse nonstop tirades. For example, if you are told that you are ungrateful, you can:
• Agree (in theory): “I could be more grateful.”
• Act as if you’ve been complimented: “Is that a bad thing?” or simply say, “Thank you.”
• Exaggerate the attack: “I’m very selfish as well.”
• Use reverse psychology: “Maybe you should try harder to reform me.”
• Label feelings: “You sound very disappointed in me.”
• Validate feelings: “It makes sense that you’d think I’m ungrateful because I do not call as much as you’d like.”
• Sympathize: “My ways sound difficult for you.”
When you truly give up seeking approval, other’s judgments will not hurt you. However, if you cannot remain calm, state that you will revisit the discussion later. It is important to resume contact as soon as you are able to show that asserting independence is not the same thing as rejection.
4. The neutral stance: Even when you are not involved in a conflict between two family members, you can use their disagreement as an opportunity to differentiate by simply understanding the difference in each person’s position. This takes you out of a judging position, demonstrates tolerance for varying viewpoints, and minimizes the chance for alliances to form. The following situations suggest ways to stay neutral without retreating:
• Practice the neutral stance in circumstances that are not emotionally charged: Start with conflicts between young children or siblings before the challenge of staying neutral with your parents or when you have strong biases toward one person.
• If you find yourself reacting negatively to one party, spend time alone with that person until you can understand his or her position.
• Handle gossip by breaking confidences: Ask the “gossipee,” “Why do you allow such stories to be told about you?” This will anger the gossiper, force the family to deal more directly with each other, and give you an opportunity to make a casual comment to any attacks: “With a little bit of practice, I’m sure you could develop as big a mouth as mine.”
• Avoid alliances by exposing them when you sense someone is trying to get you to take sides: “Mom and I have been plotting how to get everyone over this impasse.”
Rehearsing possible interactions and writing a script for taking the I position or the neutral stance can help. However, discussing your plans with a family member establishes an alliance and hinders efforts to differentiate.

Relationship Worksheet – 28 useful questions

In Psychotherapy, Self Help

RELATIONSHIP WORKSHEET
1. What qualities first drew me to my partner?
2. What troubling qualities does my partner have that are similar to my early caretakers?
3. What qualities does my partner have that I think I lack?
4. What needs am I (unsuccessfully) trying to meet through my relationship:
Understanding
Appreciation
Approval
Freedom
Other:
5. Which of the above needs did my early caretakers have difficulty meeting?
6. What opposite roles do my partner and I currently take (teacher/student, rigid/impulsive…)?
7. What action would I need to take to change conflicting roles in my relationship?
8. What facts about gender differences help me better understand my partner?
9. What changes would I need to make to better balance Yin/Yang qualities in myself?
10. What defend-withdraw-attack reactions do I use when communicating with my partner?
11. Which understand-express-defuse responses am I willing to start using regularly?
12. What am I currently doing to “fix” or tolerate relationship problems that is no longer working:
Nagging
Begging
Pleasing
Criticizing
Ignoring
Disagreeing
Other:
13. What could I do that would be the opposite or different from the above?
14. What things do (did) I do when my relationship is (was) going well that I no longer do?
15. What would my partner say I need to change for my relationship to improve?
16. What could I do to change how, where, and when a problem happens or who handles it?
17. What action could I take when attempts to solve a problem through talking are not working?
18. For which problems do I need strategies?
Selfishness
Distancing
Jealousy and control
Lack of Romance
Sexual problems and differences
Handling my partner’s upsets
Helping my partner handle my upsets
Preventing or making the best out of separations
19. What strategies am I willing to start using today?
a.
b.
c.
20. What strategies would my partner most like me to use?
a.
b.
c.
21. Does my relationship need more/less distance to add passion and romance?
22. If we have too much togetherness, what can I do to meet my own needs?
23. If there is too much distance, what fun, exciting, meaningful activities would I be willing to ask or arrange for my partner and I to do?
24. What caring behaviors would I be willing to ask for from my partner:
Hugs
Messages
Flowers
Cards
Other:
25. What things am I willing to do that would pleasantly surprise my partner?
26. What negative beliefs do I get about myself when my partner’s behavior disturbs me? What early life experiences first gave me those beliefs?
27. What positive beliefs would I like to adopt about myself instead?
28. What disorders do my partner or I have that could make progress difficult without help?

Disorders affecting relationships

In Psychotherapy, Self Help

DISORDERS THAT AFFECT RELATIONSHIPS
Not all relationship problems result from unhealthy patterns of interaction. Sometimes, one person has a disorder that has a direct impact on his or her partner. The better a spouse is able to recognize such disorders, the less chance there is of intensifying them. Mark any of the problems described below that may be affecting your relationship.
DISORDERS
Chemical dependency is one of the most common problems affecting relationships. It often goes unrecognized because the substance abuser is still able to work and is competent in many ways. Spouses who have been accused of being too tense or unreasonable often think they are overreacting. The truth is that whenever someone else’s use of drugs or alcohol is a problem for you, it is time to get help! Self-help groups such as AL-ANON and NAR-ANON address many of the problems non-using spouses face. Telephone listings for these organizations are found in most community phone books.
Sexual compulsions are another kind of addiction that have a tremendous impact on relationships. Normal differences in sex drive and interest can usually be worked out through empathy and good communication; but, when one person has a sexual compulsion, he or she can make demands or show interests outside the home that have a devastating impact on the relationship. Learn to recognize the signs of sexual addiction:
• A person feels compelled to have sex repeatedly within a short time period.
• Sexual activity becomes the only or main way a person has to relax or feel loved.
• Sexual interests cause a person to feel empty or remorseful afterward.
• Pursuit of sex interferes with family life, friendships, work, or school.
• Partners are pushed to engage in unwanted sexual activity.
• Contact with one’s spouse is replaced by such sexual activities as masturbation, pornography, chat rooms, massage parlors, telephone sex, or affairs.
Realizing that your partner’s sexual preoccupations have little to do with how much he or she loves you can free you from feeling unloved or inadequate. Take a firm but sympathetic approach by standing up for what is right for you sexually and setting limits on what you will not tolerate.
Sexual dysfunctions such as premature ejaculation, impotence, sexual aversion, underactive interest, underarousal, and inhibited orgasm can also cause relationship problems. Usually, these conditions are more easily recognized than sexual compulsions and there is less confusion about who needs help. If your partner has such a problem, it is important to realize that it is not a reflection of your attractiveness and that you cannot solve it by badgering him or her to be more sexual. If you are unable to resolve sexual differences on your own, persistently request that you and your partner seek help.
Obsessions and compulsions that are nonsexual also affect relationships. When a person is overconcerned with safety, tidiness, germs, and order, the whole household can be affected. Feeling as though you can never meet your partner’s standards may be an indicator that an obsession is operating. Seek help to distinguish between obsessions and standards that fall within the normal range. Let your partner know that compulsions can be treated with medication and therapy. Even if your partner won’t get help, recognizing obsessions for what they are will relieve you of the pressure of trying to satisfy them.
Depression and moodiness may go undetected in their milder forms. Your partner may be tired, withdrawn, unmotivated, and have little sexual desire. You may feel rejected or frustrated with this lack of initiative. At other times, your partner may show increased interest in sex, spending money, traveling, business ventures, new projects, religion, or talking, and cause you real concerns about his or her poor judgment. It is important to know that mood disorders are biochemical in nature and are very treatable. Assure your partner that feelings of hopelessness or (unrealistic) fears of losing “high energy” are part of the disorder and encourage him or her to seek help. Recognizing mood disorders for what they are will help you have more realistic expectations and develop your own sources of support for periods when your partner has little to offer.
Attention deficit (ADD) and hyperactive disorders (ADHD) are often missed in adults. One partner’s forgetfulness, disorganization, distractibility, impulsiveness, moodiness, restlessness, and temper may cause the other to become increasingly critical. The person with ADD withdraws, criticism mounts, and the added stress increases symptoms. Often, spontaneous ADD people and organized perfectionists are drawn to each other because they seek what they lack in themselves. This can greatly compound problems.
Personality disorders can significantly impair relationships and employment. People with this problem have a self-image that is dependent on the actions of others. They scrutinize their partner to find out if they are loveable, good enough, or safe. Their ability to look inside themselves for the cause of distress is limited, and they avoid painful emotions with anger, blame, distancing, fantasy, or addictions. In a no-win fashion, they vacillate between feeling abandoned or suffocated, thinking they’re superior or worthless, and fearing intimacy or isolation. Two personality disorders are especially toxic to relationships:
1. Erratic personalities seem to have stormy relationships with everyone. They may be unpredictable, engage in self-destructive behavior, act impulsively, avoid being alone, change moods wildly in just a few hours, and think in extremes (good/bad, black/white). At the same time, their passion and intensity can (initially) make them enticing. If your spouse has such a problem, it helps to avoid the extremes of withdrawing from or trying to control him or her. Over time, he or she may become more moderate. Long-term therapy and medication can help these people achieve more stability.
2. Defiant personalities have so little empathy for others and knowledge of right and wrong that fulfilling relationships (and therapy) are impossible. They may relate to others only to get sex, money, or power and be irresponsible, unlawful, violent, aggressive, impulsive, dishonest, reckless, or unfaithful. The more pronounced these traits are, the less hope there is of change. Because they know how to charm and con people, it may be difficult to face how destructive a relationship with them can be. The spouses of such people need to face their own addiction to control or “save” their partner.

Beliefs that help relationships

In Psychotherapy, Self Help

BELIEFS THAT HELP RELATIONSHIPS
Often, problems that surface in relationships are indications of underlying self-destructive beliefs. If you have difficulty making changes that could help your marriage, it may be because of such ideas. These thoughts are not actually caused by your partner, but were instilled in you from early life experiences. To discover thoughts you have that cause relationship glitches, ask yourself:1
• When my partner’s behavior disturbs me, what does that mean about me?
• How do my partner’s upsetting actions make me feel about myself?
• When did I first have this disturbing thought(s) about myself?
Directions: Mark any of the thoughts in the table below that come to you during relationship problems. Then, mark any of the beliefs you would like to have when your partner upsets you.
Change Thoughts That Hurt into . . . Beliefs That Help Relationships
1. I have trouble asking my partner for help or expressing myself because I think:
I have to fix everything and keep others happy, or I’m a failure.
I’m not important.
I cannot get my needs met.
I can’t show emotions or express feelings.
2. I have trouble handling my partner when he or she is upset because I think:
I’m trapped, helpless, or powerless.
I have to get my way or I lose.
I’m responsible for others’ distress.
3. I have trouble when my partner wants distance or a separation because I think:
I’m alone or empty. No one is there for me.
I can’t survive if I’m “abandoned.”
There is only one right person for me.
4. I have trouble with jealousy and control because I think:
I’m stupid or foolish if I’m deceived.
I can’t trust anyone.
Other: I can ask for help or express myself when I believe:
I can understand others without having to fix them or keep them happy.
I am important.
I can get my needs met.
I can show emotions, express my feelings, etc.
I can handle my partner’s distress when I think:
I have options and choices; I can do something.
I can do things to reach a satisfying solution.
I decide when I contribute to others’ distress.
I can handle my partner’s desire for distance or a separation when I believe:
I can find many sources of support.
I can enjoy myself without my partner.
I can love more than one person in a lifetime.
I do not have difficulty with jealousy when I believe:
Deception is caused by my partner’s dishonesty.
I can take appropriate action when I’m deceived.
I can find people to trust.
When your relationship is going well, the above desired beliefs may seem completely true. It will be harder to maintain them during conflicts of interest or when your needs are not being met. Affirming new thought patterns regularly will help you adopt positive beliefs that can overcome your resistance to change and put you and your partner on the fast track to relationship success.

1 See EMDR: The Breakthrough Therapy by Francine Shapiro (Basic Books, 1997) and A Guide to Rational Living by Ellis (Wilshire Books, 1997) for further long-established ideas on how thoughts affect emotions.

Understanding Family Drama

In Psychotherapy, Self Help

UNDERSTANDING YOUR FAMILY DRAMA
Do you ever feel as if you’re trapped in the web of your own personal family soap opera, unable to make a move without inviting disapproval or “wounding” someone? Have you ever thought you escaped your past, only to find yourself caught in dramas with spouses, children, friends, or coworkers? Expressing your individuality or differentiating while remaining close to your family can break this distressing cycle, but this is not easy. Recognizing how expressions of individuality become stalled can help you avoid problems:1
• Early in life, you have an outer, false self that keeps you attached and in harmony with those on whom you depend. This false self is capable of acting, pretending, and doing whatever is necessary for the sake of survival.
• Beneath the outer layer is a solid self that strives to be unique and self-governing. When your caretakers are threatened by differences, you may feel unsafe shedding your outer, false self. Your priority becomes maintaining the bonds of survival by fusing or acting as though you are one with others.
• At some point, the desire for independence pushes from within. An emotional cutoff can happen in an impulsive burst. At this stage, you may become rebellious, withdrawn, a relationship nomad, “ruggedly independent,” or you may move a great distance from home.
• Surprisingly, attempts to fuse with the first appealing person often follow an emotional cutoff. Initially, the new relationship masquerades as freedom. Eventually, the desire for independence surfaces, causing another emotional cutoff. The more intense the cutoff, the more likely it is that a cycle of fusing and cutting off will repeat itself in other relationships.
DIFFERENTIATION IN MARRIAGE
Courtship is usually the most open period in a relationship, when people express many of their thoughts, feelings, and fantasies. However, after marriage, each spouse becomes sensitive to subjects that upset the other and avoidance of differences begins. When the urge to merge conflicts with the reality of differences, problems develop. Clinging, pleading, helplessness, aloofness, rigidity, arguing, and possessiveness, all indicate anxiety about differences. There are three ways that friction in the struggle for oneness is handled:
1. Dominance/yielding: One spouse becomes dominant and appears rigid, and the other adapts and becomes pliant. Neither person is in touch with his or her true needs. One is constantly giving up self-awareness and the other is overextended. In times of stress, the yielding spouse loses the ability to function and becomes physically sick, depressed, or acts out impulsively. If the dysfunctional spouse dies or takes a healthy stance, the rigid spouse can collapse into the dysfunctional position. In a healthy marriage, the dominant and yielding roles are not fixed. Spouses can alternate roles with ease, and both are comfortable assuming the leadership of the family.
2. Marital conflict: The outer, false selves of both spouses are rigid and resistant to differences. The couple alternates between periods of intense closeness and periods of distance and conflict. During the latter, divorce can occur. Sometimes, conflict evolves from dominant/yielding patterns. The compliant spouse refuses to continue in the role and becomes rigid. The couple may be able to bypass a divorce crisis if one spouse begins to express individuality without being influenced by the other’s distress about changes in long-standing patterns.

1 Murray Bowen’s ideas on differentiation are summarized in Family Therapy in Clinical Practice (Jason Aronson, 1978).
3. Triangulation and projection: Spouses avoid differences and conflict by forming alliances with children or by focusing on “disturbances” in a vulnerable third party. The conflict between the parents is then displaced or projected onto the emotional state of the child, as the following examples show:
• A mother who does not feel sufficient levels of closeness with her husband tries to meet her emotional needs with her child. The child exhibits the mother’s rejection anxiety by being fearful of school.
• If a father is missing intimacy, he may overfocus on his daughter. The mother supports this bond, as it enables her to avoid anxieties that closeness triggers. At puberty, “Daddy’s girl” takes drastic action to break away through an unwanted pregnancy.
Sometimes, all three patterns of domination, conflict, and triangulation can operate to form a very complex system. When tension is great, other people get involved to form interlocking triangles. Social service agencies can even become entangled with a family during crises.
DIFFERENTIATION IN “RECREATED” FAMILIES
Those who cut off from parents and later from spouses often seek intense relationships at work and in social settings. These environments can provide a “safe” means for satisfying emotional needs without the demands of intimacy. Gossiping, alliances, and coalitions in these groups imitate the triangles that occur in families. Expressing opinions by saying “I agree with . . . that . . .” or siding with one of two conflicting parties suggests that triangulation is taking place. You can differentiate in such organizations by having some differing views while remaining involved with the group.
BECOMING YOUR OWN PERSON
Despite an obstacle course of emotional cutoff, conflict, and projection, there are young people who find a way to develop their own views and make independent decisions. In adolescence, some denial of attachment to parents and fusion with peers is necessary, and the more differences a family tolerates, the smoother the journey out of the nest will be. In adulthood, the differentiated individual can have close, intimate relationships while pursuing outside interests. Regardless of the group or relationship you are in, you can avoid alliances and triangles so that you can be tethered to loved ones without being tied.