When the Landscape of Loss Lingers

Within the period of three months, I lost three loved ones. Two of them died three days apart. Although I knew the end was eminent as I processed each situation, my knowledge and anticipation did not soothe me - it only served to bring me closer to the inevitability of my own mortality.

Some say that God will never burden us with more that we can endure - those words seem like idle chatter - it was all too much to bear. I braced myself for the predictability and shock of my pain and sought to manage its effects. There has been no single road that has brought me solace. Each day I meander within trying to find a place of peace or respite from it all.

I'm supposed to know this stuff. As a psychotherapist, I teach people how to grieve. It's different, however, when you are the patient rather than the teacher. You become as everyone else, relying on your instincts, courage, hope and faith to guide you through the darkness. What good is it to recite Elizabeth Kubler Ross’ stages of grief when you are the griever? Talking about loss is not the same as experiencing it.

Each of us, in our own way is frail and vulnerable. As psychotherapist Sheldon B. Kopp used to say, "No one is any weaker or stronger than anyone else." Each of us has a story, some of it wondrous and much of it challenging. Our narrative is about learning, and our losses teach us about the meaning and value of life - to cherish every single moment. Grieving our losses gives us an opportunity to take stock and review our life direction. We hopefully assess what really counts and focus our attention on that which lasts - the content of our character and the quality of our most precious relationships. That is all we have.

Unfortunately, as we age, our losses mount. We grieve the loss of youth, physical prowess, time, missed opportunities and fading friendships. Each must grieve in his own way. I have learned that there is no such thing as closure - some wounds never heal.

I have told others that we don't need to stay stuck in our pain. All of us can find ways to manage our grief so that even if it lingers, it doesn't overwhelm us. Like others, I must remember to:

• Seek the emotional support of friends and family.
• Acknowledge and embrace my pain rather than minimize its significance.
• Refocus attention on activities that bring pleasure.
• Learn this self-nurture. Treat myself the way I would a dear friend.
• Keep the positive memories of loved ones alive.
• Try not to fight my way out of depression. It will lift.
• Live in the present and re-evaluate life priorities.
• Rely on faith to provide me with hope.
• Realize that being vulnerable makes me more human and is a connecting asset.
• Learn to leave the self-pity behind. Accept the fact that I am a grown-up who experiences life as unfair. There are no sufficient reasons why certain things have happened to me.

As a grieving patient, I have a better understanding of what it takes to wind oneself down a path of profound loss - no words are adequate to describe the experience. Contrary to what others think, I do not believe that what I have encountered will make me stronger. I only hope that my experience with lingering loss will make my vision clearer as I look through the eyes of those who have suffered and continue to seek my help.


James P. Krehbiel, Ed.S, LPC, is an author, freelance writer, and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, Troubled Childhood, Triumphant Life. This book is about the impact of “unavailable” parenting on adults and the people they become. His book will be available March 1, 2010 but now can be pre-ordered through Amazon.com. James can be reached at KrehbielCounseling.com.

Eradicating Depression Through Schema-Focused Therapy

Samantha moved to a large sprawling city to join her boyfriend. They carried on a long-distance relationship prior to her decision to move in with him. Unfortunately, the relationship did not last long, and she felt stuck in a city without a plan to move forward in a positive direction – she sank into a deep depression.

This young lady had parents who were extremely passive and detached. Having lived in a rural town, her options for activity were limited. Her parents never encouraged involvement in outside interests. She lacked confidence and was timid around age-mates. Having moved numerous times during childhood, it affected her ability to build trust and closeness. She felt alone in managing her problems.

Samantha came to therapy looking for a way to lift her debilitating depression. She felt sad, grief-stricken, hopeless, unmotivated and unwilling to seek out new friendships. She was troubled by a set of underlying schemas (assumptions) that clouded her worldview and activated depression. These schemas crystallized in response to unmet needs derived during childhood. The schemas were activated anytime that Samantha encountered problems associated with negative beliefs. The schemas that activated depression were:

• "I'm all alone in my problems."

• "I'm not good enough."

• "I don't trust that others will be there for me."

• "Life looks bleak. I feel hopeless."

These core schemas around the theme of depression were activated when my patient encountered the following life situations:

• Trying to establish friendships

• Pursuing intimate relationships

• Facing new problems

• Attempting to change directions in her life

• Trying to get motivated professionally

• Envisioning a positive future

Samantha worked diligently in therapy to alleviate her depression through untwisting her negative thinking. We gently challenged her core schemas by looking for evidence to the contrary. She gained hope in eradicating her depression as we refuted faulty schema-based thinking. She eventually began to respond more rationally and adaptively:

• "I can manage this friendship-making business."

• "I'm not ready for an intimate relationship now, but when I am, I’ll feel confident and will be more selective."

• "I can cope with and manage new problems."

• "I am certain that I can re-create my life."

• "If a chunk things down into smaller pieces, I can set goals and get motivated."

• "The future holds new opportunities."

Samantha "connected the dots" by understanding the relationship between her core depressive schemas and current behaviors. As a result, she was able to modify her current thinking to make it more hopeful and less depressing.


James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, Troubled Childhood, Triumphant Life. This book is about the impact of “unavailable” parenting on adults and the people they become. James can be reached at www.krehbielcounseling.com.

Her Mother and Malia

It is highly unusual for my daughter to ask me for advice. Until recently, I can only remember a few occasions when she sought my wisdom regarding the profundities of life. Maybe denying the need for help from parents is mapped in our genetic code. I never asked for much assistance from my own.

However, recently Amy came of age. At 36, she finally decided it was time to lean on dear old Dad. On this rare occasion, during a recent phone call, a bombshell was hurled. Amy retorted, "Dad, what can I do to rein Malia in a bit? My feisty four year old daughter is wearing me out!"

As a psychotherapist, with plenty of parenting expertise, I'm sure that Amy was waiting for my most profound response. However, my spontaneous reaction took both of us off-guard. Impulsively, I replied with, "I don't know Amy - I sure as hell didn't know how to cope with you - maybe it's payback time."

We both had a good laugh as we processed the parallels between Amy and her precocious, pesky daughter. Here are a few of the significant similarities:

• They both are a strong-willed handful.
• They became non-stop talkers before they were developmentally capable of walking.
• They both love to carry the show with intensity - camera, anyone?
• They are both too smart for their own good. Going to school comes disgustingly easy, but is filled with the challenges of unmet academic needs.
• They both are similarly assertive, bordering on aggressive; please look out when they're unhappy!
• They both appear affectionate, but seem to be overly-sensitive to other’s feelings.
• They are extremely independent people. They know what they want and you don't dare hinder their progress!

One area of temperamental variance is worth noting. It is a fascinating distinction and the area where I believe my daughter is being punished for her past. Malia insists on wearing pink clothes and accessories at all times. Malia has a pink handbag, beret’s and beads to match her feminine looking clothes. This fashion statement, required by Malia, is a foreign concept to my daughter. At first, Amy tried to encourage Malia to wear different colors, but to no avail. Malia resisted wearing anything but pink.

Amy wonders where she went wrong. She was the queen of the Gothic look, wearing black as her only color scheme throughout school as a theater buff. However, when Amy came home from the first semester of college, a miracle occurred. I found a pastel colored sweater lying on her bed. “What are you doing with this pretty sweater?” I replied. Amy laughed and said it was a new day in her life.

When I see Malia, I see the wonderful reflections of my daughter. I see the smile, the passion, the precociousness, and the personal need to be understood. They are versions of the same person. Being out-of-state, I don't see Amy or Malia that often, but when I do, I'm so grateful that my granddaughter has not forgotten who I am. She's a slice of my daughter and a good one indeed!


James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. This book is about the impact of “unavailable” parenting on adults and the people they become. James can be reached at www.krehbielcounseling.com.

The Search for Adulthood: Grieving the Past and Embracing the Present

Learning to process and accept our past is a necessary step in one’s search for adulthood. Instead, people often choose neurotic suffering as a way of coping with painful memories. Neurotic suffering consists of coping mechanisms that put a salve over our wounds. Rather than confront one's painful past, adults will convert their grief into physical symptoms, and mask their losses through over-activity, intellectualization, avoidance, self-blame and projected anger.

Neurotic sufferers ignore the stop signs, transcending their grief as if it weren't there. They pretend that everything is running smoothly, ignoring what their bodies, mind and feelings are trying to tell them. They diminish the truth in the pursuit of coping, choosing to ignore their emotional distress.

Holding Ourselves Together

Anxious sufferers hold themselves together like a ball of yarn. They fear that if one strand were pulled from the ball, they would slowly unravel into a mound of scattered threads. However, protecting oneself from the realities of the past eventually creates insurmountable fatigue. One's sympathetic nervous system reacts to the stress of trying to ignore the reality of stored and unprocessed psychic pain.

We must move through our grief and loss in order to get to the other side. There is no substitute. We cannot short-circuit the grief process without paying a price consisting of unnecessary suffering. Grieving our pain allows us to legitimately navigate our loss, finding closure over past perplexing problems.

Mourning and releasing our losses takes time. There is no way to short-circuit the process. There are strategies that we can employ to facilitate moving through the grief process. Here are a few ideas:

• Share one's painful narratives with friends.
• Seek the emotional support of family.
• Journal one’s thoughts and feelings.
• Write a letter (not to be delivered), focusing on the impact of a significant other as you grieve the loss. Explore difficult emotions and thoughts.
• Give up the illusion that people (particularly our parents), will change into the people we have always wanted them to become.
• Face our mortality by grieving the aging process and its affect on us.

Learning to Get Our Power Back

Once we face our grief, our past will no longer have power over us. We are freed from being straddled with false guilt, remorse, regrets, and the inability to connect on an emotional level with others. Grieving is like peeling an onion. There are layers, and it takes patience and persistence to navigate through our turmoil.

If one holds tightly to metaphors of pain, refusing to acknowledge its presence and impact, the lack of resolution creates the conditions to foster self-defeating thinking and behavior in the present. Often, individuals who have thwarted the grief process, continue to play out interpretations and narratives of behavior similar to scripts present during childhood. Individuals may have failed to squarely face their painful past - as interpreted through the eyes of a childhood burdened by emotionally unavailable parents. They may never have come to terms with the pain generated by those who failed to love them unconditionally.

Saying Goodbye to the Magical Illusions

People, who experience the pain of a turbulent childhood, often cling to the illusion that someday their parents will magically morph into the loving parents they longed for. Rather than swallow the "bitter pill" of how our parents dealt with us, we continue to hold out hope that someday, somehow, they will change. By holding out false hope, we minimize the significance of promises un-kept, thus cutting ourselves off from the part of us that needs individuating.

The search for adulthood involves recognizing the power of our painful past, creating and releasing it, and learning to rationally respond with fresh interpretations in the present. The search for adulthood involves finding integrity, authenticity and adventure. By appropriately grieving roadblocks from our painful past, we are able to move forward and become adaptive, functioning adults in the present.


James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. This book is about the impact of “unavailable” parenting on adults and the people they become. James can be reached at www.krehbielcounseling.com.

The Hazzard of Dichotomous Thinking within the Therapeutic Community

In cognitive therapy, cognitive distortions represent the lenses out of which we view the world and filter our version of reality. In light of recent developments among some therapists, dichotomous (either/or) thinking has emerged as a professional hazard. I recently attended a national mental health conference. I was intrigued as presenters and colleagues alike made comments that presented a distorted perspective regarding some significant behavioral health issues.

As M. Scott Peck eloquently articulated in his work, The Different Drum, it is important that as thinkers we look at problems multi-dimensionally. We must not get trapped by any one side of an argument, but stay open to multiple sides of an issue; by doing so, we show integrity. Staying open to the truth wherever we find it allows us to be more grounded, rational and informed.

Within the last several years, many clinicians within the counseling profession have started to under-cut the role of prescription psychotropic medications as a facet of treatment. Some of the arguments from these naysayers of medication management are:

• There is no evidence that serotonin or norepinephrine levels affect mood.
• A quality therapist’s treatment is sufficient to free us from the dependency to psychotropic medications.
• Primary care physicians and psychiatrists have a propensity to push medication, thus justifying the need for their professions.
• Touting the use of antidepressants and other mood-stabilizers is primarily a marketing ploy.

Lately, high profile cognitive-behavioral therapists have been down-playing the efficacy of antidepressants and other mood-elevating medications by stating that CBT is sufficient to "cure" any problem without a crutch, thus “ditch the Zoloft.” Although many research studies support the synergistic effect of cognitive therapy and antidepressants, CBT therapists are dismissing such findings as misguided.

Existential therapists are also following suit. Since they believe that all suffering is legitimate, using medications to stabilize mood remains unnecessary. In fact, existentialists believe that taking antidepressant medication thwarts the grieving process, thus delaying the natural progression of growth. According to their viewpoint, we must not pathologize the human experience.

I believe that a more pragmatic, balanced and useful position is to acknowledge the legitimacy of psychotropic medications in curbing anxiety, depression and other disorders of mood. We should accept these medications because for many sufferers they work. Antidepressants serve as an aid, an emotional "floor" while patients undergo therapeutic treatment to derive more long-lasting benefits in coping with emotional distress. Furthermore, it is essential that those suffering from bipolar disorder take mood-stabilizing medication to treat their symptoms. There is no other viable option for treatment.

Why is it that many therapists now embrace a philosophy which discounts the use of psychotropic medications? It is true that people generally do what’s in their best interest, and many therapists hold a position which dismisses the legitimate use of medication for several reasons:
• It enhances their belief that their therapeutic orientation is unique and sets them apart from the competition.
• It increases their ability to generate income. Therapists postulate that marketing an approach that will fix you without the use of medication (prescribed by a PCP or psychiatrist), is more enticing and potentially lucrative.
• Therapists, who disown the use of psychotropic medications prescribed by physicians, are driven by their feelings of exclusivity about their approach, coupled with the desire to market themselves. The practicalities of what is in the best interest of the patient are ignored. Marketing takes precedence over pragmatism and utility.

Another danger involving dichotomous thinking relates to mind-body therapies. Holistic thinking has taken root in the mental health profession. Many therapists integrate alternative therapies that claim to remedy behavioral and emotional conditions. Some of the treatments are evidence-based, but many cannot be supported empirically. Case in point is reflexology and therapeutic touch, which claim to explore and heal energy systems. The therapeutic community needs to do a better job of ferreting out modalities that have functionality versus those which are of questionable utility. Once again, in the process of propagating the mind-body connection, we may error on the side of discounting physical medicine, including psychotropic medications.

As a therapist, one must carefully weigh all sides of an issue before making value judgments. Therapists must be honest and informed when making statements about psychotropic medications and the mind-body connection. At a recent mental health conference that I attended, a participant claimed that she was dismayed by the over-use of stimulants for students experiencing ADD. However, it is clear that ADD has been under-diagnosed, not over-diagnosed, and those who receive treatment with stimulant medication in concert with therapy do significantly better than those prior to treatment or without treatment.

It is imperative that therapists represent their profession appropriately. This means that we take a carefully crafted approach to treatment based upon sound research and a sense of balanced thinking and integrity. Being blinded by any one perspective only polarizes the profession. Theory and practice must come together in a way that provides our patients with the best chance of making improvement. Part of the answer is to offer our clients a multipronged approach with the best quality evidence-based theory, medication management (if needed), and alternative adjunctive treatment modalities that have a history of demonstrated effectiveness.

The Identity of Imperfection

When Alex was a kid, he recalls his father chastising him for not washing the car properly. Alex volunteered his services as a five-year-old child, but his dad showed little appreciation. On the contrary, when he "missed a spot," his father would berate him by calling him stupid. He was a sensitive child who wanted to please his father, but ended up feeling devalued.

Over time, Alex associated his less than perfect performance with his personal identity. If what he did was less than acceptable, then by all means he must be defective. His father never encouraged or coached him on a better way to wash the car, so he was left to feel inadequate about any task he attempted.

Alex evolved into a self-critical, angry youngster. In Little League, he excelled as a player. He was known for his outstanding skills and performance. Nevertheless, he berated himself, other players and the umpires during his occasional unsuccessful at-bats during games. He recalls running feverishly towards first base, being called out, and throwing his helmet, stomping his feet and raging at the officials. Although he was conflicted and confused about his poor sportsmanship, he wasn't capable of stopping his inappropriate behavior. His parents never got involved, intervened and discussed the "why" of his self- defeating thinking and behavior nor tried to correct it.

In adulthood, Alex was able to trace his painful memories of personal performance-related criticism and anger through the filter of his son’s experience. His son, Damon, was a very talented basketball player. Alex was perplexed because he never recalled Damon losing his "court presence" during a game. His son was grounded, focused and in control. These qualities actually helped enhance the level of his game. Alex was thrilled that the legacy of persistent perfectionism never created a problem for his child.

As he sat in the stands and watched one of his son’s tournament games, Alex recalls reflecting on what parenting skills he had implemented with Damon that were different from the way in which he was raised:

• Like Alex, his son was very sensitive. Alex made sure that he never harshly scolded him.
• His form of discipline was facilitated through coaching, instruction and encouragement.
• He always let Damon know that he was proud of him.
• He believed that mistake-making was a necessary part of child-development.
• He challenged his son to excel without motivating through intimidation.
• He remained involved with Damon and attended his activities at school and in the community.
• Alex's limits were firm, but reasonable with logical consequences for positive and negative behaviors.
• He always differentiated Damon's behavior from his personal worth.

Alex gave his son what he found difficult to provide for himself - support, soothing, comfort and affirmation. Ironically, he learned through role-modeling his son’s behavior how to begin parenting himself. The process of learning to self-nurture involved facing his past, grieving and releasing its emotional impact while creating fresh interpretations of his thinking and behavior.

He cut into the "pedestal of perfectionism" and learned to allow himself the freedom to perform less than admirably at times. He practiced selective mistake-making as a way of giving up some control and allowing for a measure of vulnerability. Alex worked on being less self-critical and judgmental of others, and eventually learned to hold the identity of imperfection. He learned to push less, and relax more as his performance, like his son’s, actually improved.



James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. This book is about the impact of “unavailable” parenting on adults and the people they become. James can be reached at www.krehbielcounseling.com.

Make Way for a Different Kind of Thinking

I distinctly recall when Nathan began seeing me for counseling. He was a skinny, sensitive kid with a big heart. At age 13, he struggled in the midst of a tumultuous custody battle that left emotional scars. My job was to prop him up - to give him hope that things would change for the better - and they did.

Nathan came back to see me three years after he had "graduated" from therapy. He brought his new guitar and treated me to few melodies in the privacy of my own office. He was serenading me - it was a gift for being there for him. However, Nathan's visit took on a more important purpose. He came to tell me, in so many words, how he had become a different kind of thinker - the type of young person who inevitably would change the very foundations upon how we view matter and energy and life itself. At age 16, Nathan had graduated from a college preparatory high school and made his way to a prestigious university to study nanotechnology.

As I intently listened, Nathan explained that nanotechnology will allow us to snap together the fundamental building blocks of nature more easily, more cost effectively, and in a way that is permitted through the laws of physics. Nanotechnology has the ability to transform our thinking about science, physical health and disease, emotional well-being, computer programming, and travel to outer space. Not only was Nathan "studying" this complex, molecular thinking, but he was actually conducting research with the world's greatest scientists in this technological field.

Like an H. G. Wells of his time, Nathan passionately projected what the world would look like in the next 15 years due to his work. His words seemed prophetic and powerful, and I sense that I was sitting before one of a new age of young people - the dreamers, the problem-solvers, the visionaries who would create a new way of thinking about thinking. These are not “egg-heads,” but balanced, well-rounded kids who have the capacity to not only reflect on problems but to communicate about how the world will dramatically change due to their influence.

Nathan represents an influx of thinkers among thinkers, who will quietly work behind the scenes to make things happen. These are not our future leaders or managers, but those who empty themselves of all internal clutter or preconceived notions about how the world works. By staying open to the truth, wherever they may find it, new, exciting discoveries will be made that will impact all aspects of the human condition.

Like Nathan, our future thinkers can recognize the qualities and significance of emptiness. They can handle the perplexing nature of uncertainty and ambiguity. They understand that there are multiple dimensions to any problem with conflicting and paradoxical meanings. They are willing to surrender conventional notions about how the world works in order to make room for the new. By cutting a path through the clutter and letting go of a traditional means of thinking, these talented young people will open themselves up to what Robert Schuller referred to as, "possibility thinking."
In the midst of all the incivility and strife that we are faced with, Nathan will make a difference. He has not forgotten what it was like to stand face to face at a young age with problems that were bigger than he was capable of solving. He will use that experience to empower and propel him in a direction to bring peace as he thinks about and humbly solves problems that raise hope and healing for all humanity.



James P. Krehbiel, Ed.S., LPC is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. James is the featured Shrink Rap columnist for TheImproper.com, an upscale arts, entertainment and lifestyle web magazine. He has contracted with New Horizon Press to publish his latest work entitled, The Search for Adulthood: Saying Goodbye to the Magical Illusions of Childhood. James can be reached at www.krehbielcounseling.com.

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From Alcoholic Enmeshment to Rational Recovery

Todd came to see me at the encouragement of his mother. He "talked the right talk" about leaving his drugs and alcohol behind, although he had a long track record of failed attempts. Todd had been in and out of residential treatment programs without success. This young man looked to me and rational recovery as his last chance to live a lifestyle free of the ravages of addiction.

I pushed Todd to explain to me, in every conceivable manner, how "this time" things would be different from all of his other failed attempts at sobriety. In a straightforward, yet probing way, I took him apart in the process of working to hold him accountable for his wasted life. Fortunately, he didn't run away from therapy.

Todd came to see me every week as we combined my cognitive-behavioral treatment with a local outpatient rational recovery program. Since the efficacy of inpatient substance abuse treatment programs is marginal, I felt that this would be a more effective treatment approach. This two-pronged strategy appeared to be the perfect mix. Naltrexone, a medication employed to stop the urges and cravings of alcohol was used with my patient. The goal of treatment was to focus on his lifestyle of excessive drinking and to rationally, reconfigure patterns of behavior that were consistent with a lifestyle of sobriety.

Todd began drinking when he was eight years old. His father would take him on camping trips and would provide him with hard liquor during their journey. Todd recalled his father handing him small, open alcohol bottles for consumption which had been purchased from the airlines. Todd reminisced about how he would eventually end up vomiting during stops along the way to the camping sites. According to Todd, his father was too "wasted" to be of any assistance to him.

This father and son drinking dynamic went on throughout Todd's adolescence. Todd began being admitted to residential treatment programs by the time he was thirteen years old. Each time Todd was placed in a rehab program for drugs and alcohol, Todd's father would make a special effort to visit him during recovery. Ironically, he would wish his son well and then would depart. On one occasion, Todd remembered his father drinking and smoking pot with him in their car just prior to his being admitted.

I found it fascinating that Todd never thought about the peculiar, symbiotic, outrageous abusive nature of his father/son relationship until we began exploring it. Even then, Todd deflected the experience through anxious laughter. As I "turned up the heat" on the emotional impact of what he experienced, Todd's vision of his past became clearer. He began to understand the betrayal, shame and humiliation foisted upon him by his father’s alcoholic enmeshment. It was painful for Todd to learn to hold his father responsible for the hurt, disappointment and destructive behavior he created.

As we moved through therapy, Todd was afraid of his anger and where it would lead him. We addressed that fear along with ways of coping with his enfeebled, alcoholic father in the present. Todd set more appropriate boundaries related to any contact with his father, and on several occasions broached the subject of his father's past behavior to no effect.

Todd learned to accept the fact that his father would never change, and that he would need to grieve and release a history filled with horrible memories. Todd's rational recovery, based upon cognitive-behavioral therapy, is working. He has a positive support system, medication for his urges and cravings, and takes full responsibility for his recovery. Every day is a choice about whether to allow his father to continue to have power over his life or to choose to forgo a pattern of drinking that started many years ago during his father/son camping trips.


{Note: This narrative is a composite. It has been deliberately altered in order to protect an individual’s right to confidentiality and privacy.}

Cognitive Therapy and Sleeplessness

It appears that "as the world turns" many are having a difficult time falling asleep and/or staying asleep. Our fast-paced lifestyle can leave one feeling fatigued, apathetic and restless as a result of a cycle of sleep deprivation. Some turn to sleep medications as a way of rectifying the problem of insomnia. Others look for naturopathic remedies to provide respite from a sleepless night.

Certain chronic insomniac conditions that result from pain-related problems may warrant the use of sedating medications. Other cases, however, may respond to various non-medicinal treatments, including the use of cognitive-behavioral therapy.

Cognitive-behavioral therapy is at the forefront of treatment for various disorders, including depression, anxiety, pain management issues and insomnia. Insomnia may be caused by life stressors, physical illness, emotional discomfort, environmental factors, self-medicating or disruption in one's sleep pattern due to work-shift changes or jet lag.

CBT seeks to work with insomniacs through their thought processes, ways of viewing the world and underlying beliefs about sleep. Many adults become anxious about their lack of sleep. They may ruminate about the horrible things that they believe will happen to them if they fail to promptly fall asleep. I often tell patients, "Where is the evidence that not sleeping tonight will cause you undue harm? What's the worst thing that will happen?" Frequently, it is the anxiousness about not sleeping that sets up a self-defeating dynamic of frustration and restlessness.

CBT uses paradoxical intervention strategies for dealing with sleeplessness. I recommend that patients who experience insomnia stay awake as long as possible prior to going to bed. Individuals should be sufficiently fatigued and drowsy before lying down. The bed should always be used for sleep purposes and never used for reading, relaxing or ruminating. If the patient's sleep is interrupted, the sufferer should get out of bed and read, watch television, until sufficiently tired enough to resume sleep.

Often, people do not realize that the human body will automatically self-regulate. If one only gets three hours of sleep on a given night, the body will automatically compensate, eventually providing appropriate rest. It is the fear of not sleeping that sets up a negative dynamic for the insomniac. Individuals may set up a self-defeating cycle by remaining in bed as they ruminate about sleeplessness. Ironically, this process only compounds the problem by leading to further restlessness.

Learning to relax the body and mind is important to getting quality sleep. Learning mindfulness meditation helps the insomniac to calm the sympathetic nervous system, setting the stage for restful sleep.

What people do with their time prior to going to sleep is important. Playing stimulating music, working at the computer and using alcohol will negatively affect one's ability to sleep. Learning to let go of work-related stressors is imperative. Individuals who are "pusher-drivers" are more likely to carry their workday into the night.

Patients, who experience insomnia, generally suffer from the following self-defeating thoughts and assumptions:

• "If I don't sleep, something awful will happen to me."
• "I must sleep or else I won't be able to function anymore."
• "I'm afraid to go to sleep because something might happen to me."
• "If I don't fall asleep promptly, there must be a problem."
• "I have so much work to do that I don't have time to sleep."
• "I must stay in bed until I fall asleep."
• "Worrying about things helps me to control my life."
• "I must complete everything on my list, especially work tasks."
• "Being alone at night is a scary thing."

Assisting patients to reframe negative thinking is essential to treatment for insomnia. Anticipatory anxiety in the form of negative self-statements must be replaced with more adaptive ways of thinking about sleep. By employing strategies that emphasize the “reverse-effort” of not trying to fall asleep, patients learn to relax their bodies through passive volition and secure needed rest.

Cognitive Therapy's Application to Tinnitus

Lisa was referred to me by a physician who specializes in treating ear disorders. The neurologist was familiar with the efficacy of cognitive-behavioral therapy and its application in treating pain-related syndromes. This patient was referred to me as a part of a multidisciplinary approach to managing tinnitus.

Tinnitus is a ringing, swishing or other type of noise that seems to originate in the ear or head. Nearly 36 million people suffer from this disorder. Many factors, such as certain medications, ear wax, fluid, infection or disease of the middle ear bones or eardrum can cause tinnitus. As with any pain syndrome or disturbance, emotional factors can exacerbate the disorder.

Lisa complained of a loud, swishing sound emanating from both ears. The disturbance was significant enough that it began affecting her ability to function in a meaningful manner. At home, while preparing dinner, she found herself shifting her head in an unusual position toward her right shoulder in a ritualistic attempt to minimize the annoying vestibular volume.

Her bodily compensation reminded me of a clutched position that battle-scarred soldiers assume in combat that represents a way of warding off impending doom. In reality, such posture actually symbolizes the heightened hypervigilance experienced by those who have been exposed to physical and emotional trauma.

It has been my experience that a pain syndrome often serves as a mysterious metaphor for the way we relate to the world. M. Scott Peck, author of the Road Less Traveled, used to talk about the nemesis of his neck pain. Although he sought surgery to rectify his condition, he viewed his problem as a more complex pattern. The origin of his neck stiffness transcended bones and tissue. Peck often said “he was afraid to stick his neck out." His malady was a metaphor for holding things in and avoiding conflict at all costs. Learning to assert himself paid dividends, and further minimized the significance of this problem.

As Lisa and I explored her problem, I began to see a thread that linked her nonsensical noise into a self-defeating cycle. "The volume was chronically turned up in Lisa’s life and it made her head spin." She often affirmed this impression through the narrative of her life’s experiences.

Lisa had always done what others required of her. Her earliest recollections of this behavior occurred when walking home from school on a rainy day with several friends. As a mean-spirited lark, her friends asked her to stick her feet into a large puddle of water soaking her shoes and socks. She obliged her friends so as not to disappoint them. She felt humiliated as her school-mates looked on and mocked her. From that moment forward, the power of pleasing others emerged as a benchmark for how she would conduct her life.

Alfred Adler used to say that our earliest childhood recollections embody a constellation of beliefs, thoughts and feelings that have the power to profoundly impact one’s future behavior. Lisa’s experience in a mud puddle would fuel her later behavior within adulthood.

Lisa worked as a full-time tutor. Her students loved her. One day, she taught ten students in a row, driving to and from each student's house. She then went home, did her chores and prepared her evening meal for her husband. It was typical for her to push to accomplish tasks for others without ever setting appropriate boundaries for herself. She never requested or required anything from others – finally she gave in to exhaustion.

As Lisa began to disclose more freely in therapy, her story of unyielding sacrifice for others at her own expense became more evident. All the money she earned went to subsidize her granddaughter, who refused to work. Lisa disclosed that her granddaughter had a $200 a month smoking habit. Although she was conflicted about supporting her granddaughter’s addiction, she paid her the money to cover the cost. Lisa’s showed regret rather than appropriate resentment for enabling her granddaughter’s behavior.

In order to decrease the background noise in Lisa’s life, we worked on the following issues:

• Balancing the need to please with a sense of personal protection

• Learning assertiveness skills

• Requesting and allowing others to care-take for her

• Letting go of the need for frenzied activity

• Listening to her body and honoring it by slowing down

• Learning to get un-trapped from the fear of abandonment

• Learning to never do for others what they can do for themselves

• Relaxing the sympathetic nervous system through exercise and meditation.

In order to address the above issues and decrease the volume of her tinnitus, I work with Lisa on her thoughts, distorted cognitions and underlying assumptions about life. I taught her to rationally respond to self-defeating thoughts and behaviors. Some of the types of thoughts we reframed were:

• "Where is it written that people can't get along without me?"

• "If I say no, and people don't like it, it's their problem."

• "It's okay to have abandonment feelings, just don't act on them by trying too hard.”

• "I need to focus in the moment, rather than stressing about things I can't control. If certain things don't get completed, it's not the end of the world."

• " I need to treat myself as if I were a dear friend.”

• "If I give in to others, I'll only resent it later.

• What's the hurry, anyway?"

As a result of the modifications in her thought-processes, Lisa began to make progress with her tinnitus and she learned that self-defeating thoughts were a metaphor for self-defeating assumptions which aggravated her ears. These were factors that complicated her condition by creating unnecessary stress.

[Note: This case is a composite drawn from my practice as a psychotherapist. It has been altered to protect the individual's right to confidentiality and privacy.]

The Magic Embedded in Life's Stories

Recently, my wife took an introduction to genealogy course at our local library. She was interested in gathering more information about her family history. She found the class very useful in filling in some missing pieces about the story of her parents.

One way of generating genealogical information is to download census data, in this case dating back to the 1930’s. My wife was very excited about her discoveries and the process had piqued my interest. I wondered what I might find out about the life of my 93 year old mother.

I pulled up the fifteenth census of the United States, completed on April 17, 1930. My mother was raised in Richwood, West Virginia. She lived with her grandparents during her pre-adolescent years. She and her grandparents lived on Boggs Street with her grandfather working on a dairy farm.

Although I was aware that my mother lived in West Virginia and resided with her grandparents, some of the census information was new to me. When I mentioned that I discovered that Mother’s grandfather was a dairyman, she perked up and began telling me stories about how she helped out on the farm by feeding the animals and milking the cows. When I mentioned to my mother that she lived on Boggs Street, she drew a blank. However, hours later, she called me back with renewed excitement to share her story. The street was named after the Boggs family who were their only neighbors on top of a hill in rural Richwood.

Life is a tapestry of memories, some which unfortunately go unspoken. Stories define the nature of our life, and link us to our history and our future. Memories are made of the stuff that illuminate our legacy.

Family stories help people become three-dimensional. They make our loved ones more than what we see on the surface. They change our perception of significant others. Memories clarify the experiences of our families, making our loved ones appear fuller, richer, with more emotional depth.

Family memories provide everyone with recollections that are treasures that can be recaptured. They can be entertaining, informational and fill in missing pieces about the nature of our history. Sharing stories can be therapeutic for the story-teller, helping them get closure regarding prior life events.

The story-teller passes down to other family members’ information and experiences that provide links to those who came before us. As we intently listen, we are able to integrate information which broadens our heritage and identity. We feel more complete as we gain new knowledge about traditions, experiences, and values from those who shaped our family heritage.

Family members who share their stories enrich relationship connections. Story-telling is an emotional experience and creates an opportunity for healthy bonding to take place. We only truly know an individual based upon the degree of emotional expressiveness disclosed. Story-telling provides ample opportunity to make this process happen.

When our parents or other family members share their recollections, it provides us with clues to the social-cultural history that serves as a foundation for our family heritage. We also get a glimpse of what our loved ones were like during different periods of their life. We are able to get a sense of how our family experienced life when members were younger or lived in a different era.

The expression of memories provides us with the wisdom of our parents. Stories are a catalyst for pulling our family history together so that it makes sense to us. We become more personally integrated, authentic and complete, while we are enjoying the fun of listening to interesting experiences from the past.

The Mystery of Fibromyalgia and How Cognitive-Behavioral Therapy Can Help

Fibromyalgia syndrome (FMS) is the medical terminology used to represent a complex clinical disorder of symptoms characterized by soft tissue pain, stiffness, and altered deep pain threshold with psychological fallout. It can mimic or accompany symptoms of joint injury, but it is not an arthritic or neurological condition. The disorder affects between 3 to 6 million people – or as many as one in 50 Americans. About 80 and 90 percent of those diagnosed with fibromyalgia are women.

There is usually an emotional overlay of depression and anxiety that affects the sufferer. There are numerous reasons why this is true. Many within the medical community have discounted fibromyalgia as a bona fide disease. Patients have been told that they are over-dramatizing their pain and that the stiffness or soreness has been psychologically induced. Others have been told that the condition was fabricated for attention or perceived by health providers as feigned helplessness. These assertions from medical experts make patients with FMS feel ignored, mistrusted, alone and without support. Patients often turn to self-blame, which fuels the pain cycle.

The pain and symptoms of fibromyalgia are real and have a definite physical basis.
There is no known cause for fibromyalgia. Some researchers have speculated that physical trauma or viral influences have triggered FMS syndrome in many patients. There are no known abnormalities in the muscle tissue of fibromyalgia patients that would account for the disease.

Current research has focused on regions of the FMS patient’s brain and the susceptibility of certain brain locations to pain sensitivity. The brain receives a pain signal from the muscles and stays in a state of alert. For unknown reasons, the brain fails to let go of the pain signal and sets up a chronic pattern or pain syndrome. The brain stays in a constant feedback loop, consisting of a system of amplified pain signals.

Recent brain scan research studies have shed new light on this disorder. Results published in the May 2008 edition of the Journal of American College of Rheumatology shows that neuroscientists have been able to conduct scanning technology to areas of the brain affected by fibromyalgia. Mild pressure on trigger points of the patient has produced measurable brain response in processing the sensation of pain. The elevated response of pain in FMS patient’s brain scans was significantly different from those in the control group of the study. This is one of several studies that validate the reality of fibromyalgia as a disorder affecting the brain's response to muscular and neuropathic pain. Hopefully, future studies will lead to new treatment options.

Currently, treatment options consist of the use of a multidisciplinary approach. Medication management, physical therapy, meditation, exercise, alternative therapies, and cognitive-behavioral therapy are useful. CBT is a valuable therapeutic treatment option for those suffering from pain syndromes. One of the byproducts of pain can be the escalation of anxiety and depression. Likewise, anxiety and depression can intensify the impact of pain and make it more debilitating.

Cognitive-behavioral therapy’s goal is to teach the FMS patient to embrace pain rather than fight it. Cognitive distortions, such as magnification and “catastrophizing” need to be addressed so that patients learn to de-escalate fueling the pain process. How one thinks about his pain affects its impact. One can learn to rationally respond to pain by saying:
"Although this problem is difficult, I can learn to manage it."
"What's the use of getting all upset about my pain, it won't help anyway."
"If I relax and walk into my pain, maybe all this will feel less troublesome."
"I'm not alone in this. I have the support of my family and friends."
"I'm not helpless, I have many strategies I can try to minimize the effect of my pain. Just keep moving!"

Cognitive-behavioral therapy can assist the fibromyalgia patient to identify stressful triggers that exacerbate pain. This may involve examining family struggles, exploring inner-conflict, and working with core, self-defeating assumptions that affect thinking and behavior. Teaching the patient mindfulness meditation as a way of relaxing the sympathetic nervous system is beneficial.

Through the use of CBT, a therapist can provide the fibromyalgia patient with structured homework assignments that will help pain sufferers to experiment with new behaviors such as increased involvement and activities. Motivating the client to set realistic goals for everyday functioning can be helpful. Encouraging a multidisciplinary approach involving exercise, physical therapy, rehabilitation and pain management are essential.

Fibromyalgia patients fear that their disorder will cause them to lose the ability to function at work and at home. Teaching patients to focus on what they can do rather than their limitations is important. There is a tendency for fibromyalgia patients to distort reality by focusing on negative perceptions to the exclusion of the positive. Helping the patient and family to accept physical limitations is a necessary component to successful treatment.

Fibromyalgia patients can easily get enmeshed in a cycle of pain and associated emotional symptoms. It is the goal of cognitive-behavioral therapy to assist the patient in coming to terms with his disorder and making plans to manage it. This is accomplished through acceptance and teaching the patient positive ways of thinking about his condition and multiple ways of treating it.





James P. Krehbiel, Ed.S., LPC, CCBT is an author, freelance writer and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. His book, Stepping Out of the Bubble is available at www.booklocker.com.

Are You Anxious About Your Anxiousness?

Excessive anxiety is troublesome. For many, it can be an immobilizing experience. Anxiousness can be associated with social avoidance and withdrawal, can be a factor in relationship difficulties, can create painful symptoms, and trigger a need to rehash issues related to our past and future. Anxiety triggers the "fight or flight" response, ramping up our sympathetic nervous system.
The most successful treatment approach to dealing with anxiety is through the application of Cognitive therapy since anxiety is a reaction to our thinking, beliefs and underlying assumptions about life. It is usually not our primary anxiousness that creates our distress. It is our secondary thoughts and feelings - the "anxiety about our anxiety" that intensifies our symptoms.
Almost everyone experiences anxiety, but not everyone catastrophizes about it. Let's say you are taking a midterm exam in college. There are several ways you might respond when you open the test booklet and note that there are numerous questions that you are not prepared to answer. First, you might respond by saying, "wow, none of these answers look familiar. I don't remember studying for us- I'm going to flunk this test. If I fail it, there goes my grade for the semester. Wait until my parents find out, they will kill me!" Or and alternative, rational response might be, "Gee, I don't understand these first three questions - that's okay, I'll just take some deep breaths, relax and work on the questions that I am familiar with. Then I'll go back and tackle the ones I couldn't answer before."
An individual’s manner of self-talk determines the level of anxiety. When we "awfulize" about anxiety, it tends to intensify it. When we respond rationally to our anxiety, that diminishes its effect. Rationally responding to anxious thoughts is critical to minimizing its effect.
Many people tend to believe that their panic or general anxiety "appear out of the blue." They may feel confused and perplexed by the sudden emergence of their feelings. Cognitive therapists view anxious feelings as a byproduct of faulty thinking. There is no mystery to it. Teaching others to respond rationally to self-defeating talk is the primary goal of therapy.
Individuals who experience panic attacks are usually troubled by symptoms such as racing heart, sweating, fear of dying, hyperventilating and a need to escape social situations. Helping individuals to manage panic attacks takes understanding and patience. Assisting people to realize that their panic is time-limited is important. Since panic tends to take on a life of its own, it is important to address the secondary symptoms or the "panic over the panic." When people panic, they tend to magnify their symptoms through self-defeating thinking, perpetuating the attack. Teaching people to relax into their panic is necessary.
The following are some guidelines for those who experience anxiety and panic:
1. Anxiety is time-limited. It is comforting to know that it always diminishes in its impact over time.
2. Don't fight with your anxiety. It only makes things worse. Lean into your anxiety, embrace it, and it will subside.
3. Schedule a "worry time." Go into a quiet room, relax and try to expose yourself to your anxieties. Try to bring on your symptoms and you will find that it is difficult to do.
4. If you have a tendency to panic, create an exit strategy. Plan a way to remove yourself from anxious situations to bring relief.
5. Refocus your attention away from your anxiety. For example, when people experience panic attacks that involve a racing heart, I might encourage them to do jumping jacks to demonstrate that there is nothing physically causing their symptoms. This strategy actually lightens the situation and their symptoms.
6. If you are anxious, chunk things down into smaller parts. People tend to feel overwhelmed when they look at the entire picture. Rather than clean the entire house, pick a few specific tasks such as shredding a few unnecessary documents.
7. Stay in the present. Don't rehash your history or anticipate your future. Worrying about your future or history serves no useful purpose. You can't control it anyway.

Cognitive therapy emphasizes replacing self-defeating thinking with more rational ways are responding to stressors. Identifying goals of therapy, approaching them in a practical manner, and providing homework assignments are significant ingredients to addressing anxiety.