Tuesday, October 28, 2014

Patient care

I have had the privilege recently of going with my dad to his dr appointment. Sadly he was diagnosed with esophageal cancer and has been trying to manage the healthcare system. Now, as you all know I am a psychotherapist who has worked in healthcare for over 30 years. My expectations for the medical profession remain high. I expect patients to be treated with respect, compassion, and dignity. Yet I'm again frustrated by the lack of genuine empathy and common courtesies we want from our doctors and their staff. Scenario: dad walks into the room. Nurse does not look up but stares at his computer and quickly reads off questions, and types furiously filling in the blanks. Then he asks,"when were you diagnosed, what else do you have, depressed?" My dad softly responds with a look of despair in his eyes. I start to tear up. The nurse never breaks his stare with the computer. The dr walks in, introduces himself, asks some questions and listens. Then gives some quick advice and a referral to yet another specialist...delaying treatment. Then, he asks have you lost weight? Depressed? We answer in unison, "yes". The dr says ok here are some instructions, nice meeting you and kindly walks out. The same scenario plays over and over again with patients of all ages, races, and backgrounds. Wait, he was just diagnosed with cancer and no one might perhaps ask how are you coping??? Would you like to talk with someone? Would you like information on support groups? Resources? Medications to ease the depression or anxiety? In all my years of being a therapist, mom, daughter and patient myself.. No one asks. Physicians don't seem to know or care. Is it too time consuming? Is it not billable? I'm very disappointed with the quality of care, when our providers are too cold to ask the obvious. 

Monday, October 6, 2014

Relationships- Make it or Break it?

     Of all the research that has been done on couples, by far the most thorough has been that of John Gottman, a Seattle-based researcher. 

Gottman is probably most famous for his research over the 1980s and 90s where he observed, videotaped and studied more than 3,000 couples in a specially equipped studio called the “love lab”.

Distinguishing The “Masters” From The Unsuccessful Couples: How They Fight

One of the most interesting findings is that the amount that couples fight is not what counts; some successful relationships are characterized by lots of fighting, while some unsuccessful relationships appear to be calm and peaceful, at least on the surface.

Even in the most successful couples (the “masters”), people will respond when provoked — if one person gets angry, the other is likely to get angry back. And, over the years, they will tend to repeat the same arguments about the same issues. In fact, 69% of couples’ issues turn out to be perpetual problems that never get solved, and this is true even for the “master” couples!

What distinguishes the “master” couples from the unsuccessful couples is not how much they fight but how they fight. For example, how do they handle those conflicts that cannot be resolved — those conflicts that involve basic differences in values or personality? Does the disagreement feel more like a dialogue, or is it more of a gridlock?

While the “master” couples often find ways of discussing difficult topics without inflicting too much damage, the unsuccessful couples are likely to exhibit many or all of the following behaviors:

Harsh startup. If the discussion begins in a harsh way (and it is usually the woman who will bring up the discussion) — with criticism, sarcasm or contempt, the discussion is very likely to end on a negative note.

The Four Horsemen of the Apocalypse. Four behaviors are strongly correlated with divorce, particularly if they have become permanent features of a relationship: 
1) criticism (a more global put down of a person’s character, as opposed to a specific complaint); 
2) contempt, which ultimately conveys disgust; 
3) defensiveness, as opposed to listening to what the other person is saying; and 
4) stonewalling, meaning that one person tunes out or otherwise disengages from the discussion (likely to be the husband 85% of the time).

Flooding. Men are more likely than women to feel physiological “flooding” in response to what feels like overwhelming or sudden negativity on the part of their spouse and, if the flooding happens frequently, it is a good predictor of divorce. This flooded feeling is often behind the “stonewalling” mentioned above. And the men are not just being difficult; there is a physical explanation for why men tend to become more overwhelmed by marital conflict than their wives. Men are more reactive to stress — and their physical signs, such as heart rate, blood pressure, and levels of adrenaline respond more strongly and recover more slowly than is the case for women.

Failed repair attempts. The success of “repair attempts” (those efforts that a person makes in the midst of a fight to de-escalate tensions) is one of the primary factors in predicting marital outcomes. While repair attempts are commonly observed in most marriages, they often get ignored in problematic relationships. The combination of the four horsemen and failed repair attempts is an ominous sign; alternatively, couples that routinely argue using the four horsemen but have successful repair attempts are likely to have stable, happy marriages!

Avoiding The Worst Communication Traps

Now that we know what predicts failed relationships, couples can take advantage of this and learn how to avoid the most serious traps. Therapists can teach couples to replace harsh startups with softened startups and to practice effective repair attempts. Most important, couples can be taught to recognize and eliminate the four horsemen and replace each with their antidotes.  

Let’s say that one partner criticizes the other: “I can’t believe what a selfish person you are that you can never manage to give me any of your time!”  That person is encouraged to replace the criticism with its antidote, which is a specific complaint. Instead they might say, “It really frustrates me that you are working again this Saturday and that we have to cancel our plans again.” The argument is more likely to end well if the other person doesn’t feel that his or her character is being attacked.

Contempt is the most damaging of all the four horsemen and should be challenged in couples therapy. It can be overt (direct put downs, or hostile cynicism or sarcasm), or it can be more subtle (a look of disgust accompanied by rolling the eyes, sneering, etc.). Contempt is always delivered with a kind of meanness — there is an intention to hurt or demean. When contempt becomes prevalent, the relationship is in trouble; it is necessary to really step back and make a conscious effort to begin to create a culture of fondness and admiration for each other — the antidote to contempt.

Defensiveness is a natural reaction. It is human to want to defend our position when we are blamed or attacked, since we usually think that the blame is unjustified. The problem is that defensiveness is counterproductive — it leaves the other person feeling that their complaint has not been heard or validated, and the discussion becomes increasingly polarized. The antidote to defensiveness is willingness to take some responsibility, but, if that feels like too much, just listening and letting your partner know that you want to understand their position can go a long way toward eliminating gridlock and creating dialogue.

When negativity has been present in a marriage for some time, it is not uncommon for one person, usually the husband, to start stonewalling. They may look down, hide behind the newspaper, refuse to talk, leave the room, etc. Generally stonewalling is a response to feeling flooded; that is why the antidote to stonewalling is self-soothing. Flooding can best be addressed by creating time outs of at least 20 minutes and learning soothing techniques to calm down. Ideally both partners can cooperate together to understand what triggers the flooding in the first place and how they can operate better as a team.


Given the high divorce rate that we have today, it is a shame that more couples are not aware of these valuable research findings and the solutions they offer. For couples who have trouble implementing these strategies on their own, couples therapy offers a safe way to confront the most destructive behaviors and receive coaching on more constructive approaches. 

Friday, October 3, 2014

Is this Good Enough?

     "Is this Good Enough?" is a great question to ask yourself, when you are stuck. By stuck I mean confused about a relationship, a career, your appearance, or even your car. The list can go on and on. For example, if we are uneasy about something in our relationship, but our spouse is not, then we should pose the question, "Is this good enough for you ?"  Their reply will most likely be YES, while yours most definitely will be no. Asking this question will lend itself to deeper communication and understanding. Why is it good enough for 'him' and not for you?

     Is this job good enough? If yes, then you are more likely to stay and tolerate your job responsibilities and all that it entails. Change occurs when we can no longer tolerate things that aren't good enough. Our weight for example, might be acceptable, but if we gain weight, making us feel uncomfortable, then our body image might not be good enough for us. We might change the color paint in our home, when it is no longer good enough. Please consider this question and make it a topic of conversation with others, when you are at a crossroad. It might shed some light on whether its time for a change.
~Nancy Shertok, Psychotherapist