Telehealth in the Era of Covid-19

As of mid March, many therapists moved their counseling practices online, using telehealth as a means of providing sessions for their clients. I am no exception. Due to how quickly California shut down on March 13th, I abruptly moved all of my clients online and have not been back to my office, except to get mail.

To be honest, I love providing telehealth. Don’t get me wrong, I do miss seeing clients in person; and I miss seeing clients in my cozy office with my mid-century modern chairs and shelves of books. But during the pandemic, I am loving that I am able to connect with my clients over the internet. I love that I can see them and we don’t have to worry about having just washed our hands and wearing a mask. I love that I can see my clients and neither of us had to schedule a commute to get to the session. Teletherapy also allows for one to do counseling in one’s home, or if absolutely necessary, in the car, at the park, at work, on a walk.

Telehealth definitely proves to be more convenient and a quick google search reveals that the research has proved it to be just as effective as in person sessions. Telehealth is becoming mainstream as we continue to engage in social distancing. However, many folks may still have some hesitation about starting counseling without ever meeting a therapist face to face. I understand this, how can you trust someone you’ve never met in person? However this is what I’ve noticed about telehealth: yes, at first, it’s weird, it feels a little disconnected, but after a little while, the electronic device is just an initial barrier and once the story begins being told, the electronic device melts away and the exchange is about the emotions, the pain, the triumph, the difficulties, and success. The session is just what it needs to be during this challenging time.

Tips for a great telehealth session:

1.       Find a comfortable and private place to take your call.

2.       Be sure to inform your provider of your location, especially if you are not at your home. Have the address or cross streets to tell your therapist.

3.       Be sure that you are not back lit and that your face can be seen on the screen

4.       If you get distracted by seeing your picture on the screen, hide it or cover it up so that you can focus on looking at the person to whom you are speaking.

5.       Relax the back of your neck and shoulders, sit tall, and protect your back.

Be you.

So Much. Right Now.

Every day, it seems, there is something big in the news that’s happening. Every day, if we’re exposed to any news, our nervous system is hijacked and we experience fear, anger, sadness, grief, overwhelm, worry, anxiety, pain. Every. Day. This is just if you’re paying attention to the news. So what must it be like, for anyone who already experienced these emotions on a daily basis prior to 2020?

How can we stay well, be our best, when we are so clobbered by everything else going on in the world?

I don’t have answers, as a therapist, I have suggestions. I have suggestions for mindfulness, breathing, trauma therapy, acceptance techniques, techniques for managing thoughts, techniques for managing emotions, techniques for communication. I have lots of things to try to help manage the emotions coming up in all this chaos. And many of these suggestions work.

Here, I don’t want to give you more suggestions. I just want to say I see you. I hear you. Everything you’re feeling about all that’s happening is real, valid, and understandable against the backdrop of your life prior to 2020.

This year may be like a trauma. It will change you. It may completely transform you. It may be something you need to talk about, make art about, write about, and live through until goodness starts to bubble up from inside of you, showing you your inherent resilience, wisdom, and power. Don’t give up now. Move those emotions through your mind and body. This experience, as tough as it is, may lead you to something truly lovely.

Rebooting your values in the New Year.

Happy New Year!

During this time of year, many of us are thinking about what the year ahead will bring and how we want to live better, do better, and be better. It seems like New Year’s Resolutions have gotten a bad reputation, so many of us don’t engage in healthy goal setting during this time of year, when it really is a wonderful time to reflect and set some positive intentions. As an Acceptance and Commitment Therapy therapist, I prefer to consider the New Year from the lens of reflecting on one’s values and thinking about how one might live more fully in alignment with those values.

Some suggestions for using values to set intentions for 2020:

1.       Identify a few words that you would like to live by this year that represent your values. Write these words down and place them in a prominent place. Perhaps even create art or make a collage with these words.

2.       If you are a goal oriented person, consider reframing your goals from a values based perspective and see if this motivates you differently. For example, if your goal might be “to lose weight,” think about what values are at that root of this goal. This goal might be a result of wanting to feel stronger and lighter, be able to spend time with loved ones, a desire to feel confident and attractive. Beneath this are the values of health, family, and positive self-esteem. Therefore, reframe “to lose weight” to “I want to pursue good health, time with my family, and use positive words toward myself.” This will then inform additional values oriented goals.

3.       Set intentions, such as “I will be kind to myself,” “I will learn more about myself this year,” or “may I be peaceful.”

Let me know what you do to give your values a reboot at the beginning of the year!

**As you know, doing an exercise on the internet is never a substitute for counseling. Please engage in the exercise safely. If you feel unsafe, please reach out for help, the suicide hotline is: 800-273-8255

Acceptance and Commitment Therapy: Let’s Explore Values

Acceptance and Commitment Therapy is one of the theories that I use the most in my work as an individual and group therapist. Values come up in almost every session and are a wonderful way to ground us in what’s important and how we want to move forward in difficult situations. Also, values is one of the six pillars of Acceptance and Commitment Therapy.

What are values?

So what are values? In Acceptance Commitment Therapy, we talk about how values are not goals. They are consistent ways of doing things. The common metaphor for values is that they are a direction, whereas goals are the stops you make on the way while heading in that direction. Imagine you are heading west from Boston, going west is your value, your goals are stopping in New York City, Cleveland, Chicago, Denver, Phoenix, and San Diego.

Values are not things, but ways of being and doing. For example, values are “being loving,” “being reliable,” “having integrity,” and ”showing respect.” We find values associated with different areas of our lives. To start identifying our values, we begin by looking at the major areas of our lives. These primary categories may be: relationships, health/personal growth, education/work, spirituality/leisure. If I zoom into these categories, I will probably find sub-categories. For example, under relationships, I don’t just have one relationship, I also have family relationships, intimate relationships, and friendships. Under health and personal growth, I might have the sub-categories of how I think of my body, my relationship with food, how I interact with healthcare, and how I want to interact with the environment and nature. For education and work, I might consider the work or school environment, my work or school ethic, and my work or school relationships. Under spirituality and leisure, I may also find hobbies, play, and creativity. Once I’ve identified these sub-categories that are most important to me, then to really find my values, I have to look at how I want to be in those different areas.

How do I use my values to change?

Now that I’m aware of all the different areas where I might have values, it’s time to isolate my specific values for each area. Let’s look at relationships. In my family relationships, I want to be loving, consistent, and patient. Those are my values. In whatever I do with family members, I can strive to be loving, consistent, and patient. With regard to health and personal growth, one value about my body may be self-respect, and feel strong, energetic, and healthy. With regard to the environment, I want to be conscientious of my waste and engage in the world in a respectful way.

Setting Values Based Goals

Now that I’ve identified some of my values, I can start setting goals for values based action. If my primary value for my family relationships is “being loving,” and I realize I don’t tell my family members that I love them on a regular basis. Then I can set a goal to act more loving. If I want to work on being patient with my toddler or parent, I can practice taking a breath before I engage with them.

If I want to work on treating my body with more respect, I can start noticing when I am not nice to myself both by what I say about myself and what I put into or do with my body. I might set a goal to respect my body by exercising it once per week for 30 minutes. Then, I am not only exercising, but I am fulfilling my value of self-respect.

When setting goals, it’s important to break them down to the smallest bites. Most of us don’t achieve lofty goals that are unattainable. They often have to be attainable with minimal effort in our current system.

The Values Worksheet

Use the Values Worksheet (below) to begin to explore your values and begin to learn about ways you might better express these values in your daily life. (Click on the link below for the worksheet.)

The Values Worksheet and Action Plan

**As you know, doing an exercise provided on the internet is never a substitute for counseling. Please engage in the exercise safely. If you feel unsafe, please reach out for help, the suicide hotline is: 800-273-8255

Hurt vs. Harm in Personal Growth

Severe and chronic pain can be unbearable, dehumanizing, and can seem to steal one’s life force. The tenacity of individuals with chronic pain who strive for some quality of life, continue to go to work, and care for their loved ones, is truly admirable.

What’s the difference between hurt and harm?

One concept that has stuck with me is the that of “harm” versus “hurt.” When working through physical goals, individuals with chronic pain are sometimes encouraged to continue with suggested exercises despite “hurt” because the exercises are meant to strengthen their bodies and over time decrease the “hurt” or pain. And it is made clear that this different from “harm.” Harm is that which causes further or additional injury.

Moving through emotional hurt

Hurt versus harm is helpful in other areas as well. As a yoga teacher, I might invite participants to notice discomfort and be with the discomfort as long as it is not creating injury. As a therapist, I invite clients to move into, sit in, or move through emotions or thoughts that “hurt” or are uncomfortable with the intention of this being healing.

Wherever you feel “hurt” or pain in your life, I invite you to notice this discomfort with mindfulness. Would sitting in this discomfort increase your strength or resilience, or is it truly your body telegraphing impending injury? And if your body is telegraphing impending injury, is this from previous experience, or is this true information. As always, it is recommended to explore “hurt” whether physical or emotional, with a trained professional so that you can safely explore “hurt” without experiencing “harm.”

Boundaries: Obligation and Commitment, and Internal and External Emotional Boundaries

You know what boundaries are, right? Sure, we all do. But as soon as I start defining my boundaries, things get messy.

Stealing and Boundaries

One of the best ways I found to think about commitment boundaries was introduced to me during a yoga teacher training. We were discussing the eight limbs of yoga, the first limb of yoga includes the Yamas, which are ethical standards and ways one conducts herself. One of the five yamas is Asteya, “non-stealing.” At this point, you may be wondering why I’m bringing up stealing with regard to boundaries. But here’s the thing, stealing isn’t just ripping off a local shopping center. We steal when we don’t practice good boundaries. In the example in the yoga class, it was given that running over time in class could steal from the following class, could cause someone to feel anxious about their car being parked at a meter, or could cause concern for someone who has to pick up their child right after class. Running over a scheduled class time, is not demonstrating good boundaries, and stealing.

Social Boundaries

Yikes! So this is one form of boundaries, these are boundaries around time, but also the boundaries we have with regard to social obligation and commitments. We create boundaries when we make appointments or are held accountable to an appointment. We can do this with ourselves, with loved ones, or within our community. When we don’t show up when we say we will, and when we don’t set expectations for others to do the same, we are not maintaining healthy boundaries, and in a way, we’re stealing from others or allowing others to steal from us.

External Emotional Boundaries

There are also emotional boundaries. These are a bit stickier. There are internal and external emotional boundaries. External emotional boundaries are hard to communicate because emotional boundaries get crossed, often at unexpected times. We may have to restate our emotional boundaries multiple before they are heard, especially in longer term relationships. These boundaries are about how we want to be treated (“I want to be able to have hard conversations, but I struggle to listen when you are raising your voice with me”), and what we are emotionally willing to take in or take on (“I love you, but I don’t want all of our conversations to be you venting about work,” or “I care about you, but this is really hard for me to hear right now because of what I’ve been going through”).

Internal Emotional Boundaries

There are also internal emotional boundaries. These are about what we choose to take in, such as in the case of a long term relationship wherein perhaps you’ve tried to set external boundaries, but things haven’t changed, and the small aggrievances are not intentionally hurtful. In these situations, we set internal emotional boundaries with regard to how we will respond and allow ourselves feel (“That person is important to me and they are always going to have to tell me about the great new thing they are doing and I am going to decide to remember I love them, it’s not personal, and no matter what they are doing, I am safe and secure with who I am”).

Setting Healthy Boundaries

So you may have realized that you have to work on your external emotional boundaries, perhaps you’ve allowed yourself to be a doormat in the past, you’ve been passive, let your needs be ignored in deference to others, and now you realize, “I need to make a change.” This is not saying “ef you, get it yourself.” Setting boundaries, takes thoughtfulness and precision. It’s recognizing what your needs and wants are, as well as the spectrum of compromise you are willing to take. Keep in mind, as you do this, needs are different from wants although they may feel similar. It’s also having a plan for how you will push for your needs or a compromise. Again, this is not, “if I don’t get with I want, I’m going to keep yelling until I get it.” Sometimes, it is repetition of what we need in a calm and controlled manner with respect to other person’s capabilities. Other times it compromise. Giving a little to get a little.

Three Strategies for Managing Racing Thoughts

Cognitive Behavioral Therapy

The thoughts come rapid fire, you can’t catch them, so how could you possibly catch them, change or reframe them, and notice your emotional shift upon changing your thought process? This is what Cognitive Behavioral Therapy invites you to do. Although this requires practice, time, and a strong willpower to change your thoughts and rewire your brain, it can be very effective. Start with small steps. Recognize a pattern. Is your brain jumping to conclusions, like you know what’s going to happen in the future or you know what someone is thinking? Or are you catastrophizing, thinking the worst is going to happen? What about making a mountain out of a molehill? Are you blowing things out of proportion? Do you say things in your mind like, “should” (people should know better), “never” (that never happens, she never does that), “always” (that always happens, he always does that)? Notice these patterns, and see if you can put an optimistic twist on your thought, or reframe it with objective facts. Practice these optimistic or reframing twists like a script. This script is for the play of your life and how you want the protagonist to complete her hero’s journey.

Acceptance Commitment Therapy

There are other ways too. You can recognize that your thoughts come rapid fire because you grew up in a culture of fear and this led to constantly being on edge and anxious, scanning the room, and getting ready to run or fight. Your thoughts flood you to keep you informed. So you could gain some perspective on this. You might decide to zoom out, recognize this pattern, and step into your observing self. This is a term from Acceptance Commitment Therapy. By stepping into this zoomed out, observing self, position, you then can choose how to respond to those rapid fire thoughts. You might say, “there goes my brain again, okay, what was I doing and what do I want to do despite these thoughts?” Acceptance Commitment Therapy invites you to choose an action despite your brain based in what you value, what’s important to you.

Mindfulness

Perhaps you just want to slow the thoughts down, after all, if you could slow them down, then you could think clearly and make a choice based on logic. This requires grounding and mindfulness. Mindfulness is a primary tenet of most therapy ideologies, and for good reason. Being able to be present in the moment slows you down, but it requires you to be grounded and in your body. It also, takes some work. Over time it is incredibly rewarding. Here is a mindfulness hack to get you started: square breathing (inhale for 4, hold for 4, exhale for 4, rest for 4; repeat for a total of 4 times, then breath comfortably).