Why a home visit?

Mental health care looks a lot different these days then it did decades ago (though some things are frustratingly the same but that’s a post for a different day). For people my age and younger, it’s pretty acceptable to see a therapist, online or in real life. In fact, over the past two years, more people than ever have sought out mental healthcare. Not only that, they’re vocal about it. Which is wonderful! Mental wellness should be for everyone; there's no shame in caring for yourself that way.

But for the majority of my clients, who are from an older generation, therapy is still something to be whispered about, not shouted. Many of my clients have never spoken to a therapist before. As a result, they’re a little overwhelmed by sitting down with a stranger to spill their deep, dark secrets.

This is where the home visit really shines.

There is a natural power imbalance between a therapist and a client, no matter how we both may want to pretend we’re on equal ground. The client is in a vulnerable position, about to answer some really personal and difficult questions; the therapist holds a lot of power in that situation. But when I enter your home, I am first and foremost your guest. This evens the playing field immensely. In your private, comfortable space, I am a visitor and you get to make the rules.

For many of my clients, meeting at home helps them open up faster. There are literal objects to point at when they begin to feel stuck, for instance: a wedding photo or a trinket from a long ago vacation. There is the comfort of being in your own safe space as we begin the hard work of feeling better.

So while it may seem strange to some that I don’t have a physical office, others are relieved to hear that they don’t have to go anywhere; I’ll come to you in the place you feel most comfortable. The only expectation is that I’ll show up, we’ll sit down, and you get to talk. How easy is that?

The Fragility of Hope

Sometimes my clients tell me, explicitly or implicitly, that they don't believe they will ever feel better. They are almost entirely without hope. They cannot imagine that their current circumstances will ever change. As their therapist, I want to validate that feeling because it is a real fear. But I also want to help them envision a future without the pain they’re currently experiencing. This doesn’t mean meeting them with platitudes or promises; it means meeting them in their despair and offering them a little light. When they can’t see the possibility of something better, I tell them that I can. Sometimes, I hold the hope for them until they can hold it themselves.

One wonderful perk of seeing a therapist is that the relationship between you is part of the work. You may not believe in your ability to change, but your therapist does. The moment you show up to therapy, you have taken a step towards feeling better, even if better looks or feels really far away.

This is not to say getting there is an easy or pleasant process; it’s often really difficult. But that’s the other great news about therapy! You have to do the work, sure, but not alone: your therapist can help you share the burden. And if you feel stuck in your suffering, your therapist can hold the hope that things will change; that you can change.

If you are struggling or despairing or feeling lost, please know that you are truly not alone. Someone is out there, waiting to hold on to hope for you until it is in your reach again. Just step forward and ask.

"I shouldn't complain; it could always be worse"

There are many phrases I would like to strike from the English language but these two, which are often coupled together, are currently at the top of my list: “I shouldn’t complain; it could always be worse.”

Now listen: I’m not here to deprive you of a helpful coping mechanism. If taking perspective works for you in times of crisis, have at it! But let me challenge you a little by asking you if it really does help.

Sometimes clients say this (or some version of it) because they are tired of having difficult feelings. Their problems begin to feel endless and frustrating; they are stuck. They aren’t looking for perspective so much as minimizing their own experience out of guilt and frustration. Specifically, in a time like this, when the world is full of worst case scenario stories, people are more likely to feel bad about “complaining.” When the news is full of the horrors of war, there is a tendency to minimize our own tough stuff. After all, if you’re safe in your home, with your relative comforts, it’s easy to feel guilty for feeling bad about anything. Of course things could be worse.

But they could also be better. Others’ suffering does not alleviate our own. There is no comparison chart that shows us when we are allowed to complain. Certainly you can count your blessings; in fact, there’s a significant body of research that posits that beginning the day with a gratitude exercise improves your mood. That’s great news! But still, even if you practice gratitude, you are allowed your own moments of sadness; of disappointment; of regret and complaints. You are allowed to experience your feelings without qualifying them with “it could be worse.” You can acknowledge the suffering of the wider world while also making space for your own little corner of grief. I’ll sit there with you until it gets better.

The grief "to don't" list

After a death, people seem to think that there’s a grief checklist, a list of tasks to accomplish that lead to your grief being over. The person dies, you have a funeral, you’re sad for awhile, then you have to “move on,” whatever that means. Sometimes well-meaning family and friends decide that it’s time to help move things along. They start asking, “when are you going to donate all those clothes?” or, “don’t you think it’s time to get rid of the reading glasses?” They want you to rid yourself of the physical reminders of what you have lost as if that will help you “move on.”

Great news, though: you don’t have to get rid of anything. The people who are telling you this don’t understand that the clothes and the pictures and the glasses aren’t preventing you from getting over your loss. For some of us, keeping those things around is like having an anchor. There’s a reason we have cemeteries and shrines and altars to the dead: we want something physical to go to, to be near, to hold, so we can grieve.

After my mom died, a pair of her slippers stayed by the door for like, four years. I could not bear to move them. She had left them there, thinking she would be back to slip them on when it was cold in the house. She had touched them; that made them sacred. After awhile, the spell was broken and they were put to use by other feet. I can’t tell you why it changed; it just did.

This is all to say, there’s no rush to get rid of the stuff. You are not stuck in your grief if you aren’t ready to clean out the closet or put away the pictures or take off your wedding ring. On the contrary, you are moving through your grief by experiencing it. Some well-meaning (but very wrong) person may soon ask, “when are you going to get rid of all this stuff?” When they do, you can answer, “when it’s time.”

Carrying the weight of grief

Grief brings its own kind of exhaustion. Clients often tell me that they think they’re getting enough sleep—they’re going to bed at a reasonable hour and sleeping through until the morning, minus the usual up-to-pee-at-3-in-the-morning—and yet they still feel tired all the time. Why is that, they want to know? Often it’s the weight of their grief, holding them down even as they try to move through the day.

I’m no somatic therapy expert but it’s widely accepted that our feelings show up in our bodies. It’s no coincidence that we describe being “gutted” or “broken-hearted” when something upsetting happens; we often feel emotional pain in a physical way. We cannot disconnect our minds and our bodies, no matter how we sometimes try.

Just like any other heartbreak, grief can show up physically: as exhaustion for instance, or a general achiness throughout the body. Sometimes you may cry so hard you become short of breath for a minute. We cannot ignore the physical pain and weight that grief exerts on us. So if you feel tired, headachy, occasionally short of breath, certainly check in with your primary doctor first. But after you get the all-clear, spend some time considering: is carrying the weight of your grief hurting you?

This is not to say you’re doing grief wrong. All the ways you grief manifests are normal, if awful. Rather, I hope you take away that if you are suffering, you are not alone. No one can take your pain away from you but others are willing to help you carry it. There is no burden you have to shoulder alone, even (especially) your grief. This is your invitation to reach out—to a friend, a lover, a stranger, a therapist—and let someone else share the weight with you.

Now what? moving on when things change

Most often, I’ve written about grief as it relates to the death of a loved one. But grief isn’t only related to death and dying. In fact, it’s one of the most pervasive and universal experiences we share as human beings. It’s a part of the life cycle: relationships and jobs and the stages of childhood all come to an end. Life is full of changes that feel like losses and those losses have to be grieved.

As I’ve said before, I’m a real hit at cocktail parties when I tell people that I specialize in grief and loss. For most people, my work sounds deeply sad. And it can be! As I’m fond of saying, hard feelings are hard. But looked at another way—I live to reframe things, it’s the only part of CBT that I’m truly confident in—it’s a gift to honor our grief when something ends. We can experience our grief without wallowing; we can honor endings without big rituals. We can choose to acknowledge that endings are hard without staying stuck in the hard part.

So how do we do that? There are tons of sort of pop psychology buzz words people throw around, memes on social media meant to inspire, about “closure” and “closing the chapter” and “rising from the ashes.” Those are all lovely sentiments and I don’t disagree with them. But I think we lose the nuance of the grieving process when we put it into that kind of phraseology. Closure, for instance, isn’t a thing. Our lives are not actually laid out in neat chapters that resolve after X number of pages. We never leave behind the people we were, even if we make dramatic changes or dramatic changes happen to us. Instead, we add layers and learn lessons and yes, move forward. In short, like any kind of grief, the only way out is through.

Caregiver burnout is real. And it sucks.

Caregiving is a gift. The ability to take care of someone you love, at home, with relative comfort and routine, can be a beautiful and rewarding experience. It can also be a living nightmare. Most of the time it’s both, by turns.

Caregiver burnout doesn’t just appear one day, though it can feel like that: one day you’re fine and the next day you’re not. In truth, it’s not that dramatic; instead, it creeps in over time, slowly and steadily, until one day you find yourself overwhelmed, exhausted, frayed. It can be easy to miss or ignore the signs of burnout at first because caregiving is a full-time job. Additionally, you might also have a regular job and a family and friends and you know, a life. Or you did, before you became a caregiver. Slowly those other parts of you become buried underneath the weight of being someone’s sole care provider. It’s no surprise then that one day burnout hits you like a ton of bricks, in the form of exhaustion, irritability, anxiety, guilt, a miasma of shitty feelings.

You aren’t alone and it’s not unfixable. There are, in fact, both big and small steps to take when you discover that you’re burnt out. Before we explore those though, I would be remiss if I didn’t note that there are big systemic problems here that can make accessing those solutions tricky. For instance, one solution is to hire private help. However, for many people, hiring someone to help out is simply not a choice. There are programs through the county and state that will subsidize the cost but they’re means-tested, which means you have to come in under a certain income and asset level to access those programs. The result is, a lot of people fall into the middle ground of not rich enough for private care and not poor enough for state assistance.

That being said, there are still options. Maybe you can’t afford 24 hour care but you can swing a few hours here and there so you can take a break (an old client once called this Granny sitting, a phrase I find delightful). Maybe you can call on some nearly grown grandkids or other family members to take the occasional overnight or midday shift so you can rest. Maybe you’re resistant to that idea, and for good reason. But I would encourage you not to dismiss the idea of asking for others to step up out of hand. Sometimes someone becomes so stuck in their role as a caregiver, they don’t hear the other people in their lives who are offering to help. Or they decide not to ask for fear of hearing no. But if you don’t ask, you definitely do not receive.

Beyond that, there are other, smaller remedies. Who were you before this? What brought you joy? This is important because you cannot pour from an empty cup. In order to be someone’s caregiver, you have to be in good working order yourself. Meaning it isn’t selfish to take a shower or eat a hot meal or exercise. It’s actually a necessity that you do things for yourself so that you don’t become a shell of a person who resents what started as a gift: caring for someone you love.

There’s more to say here, namely about what happens when you’re caring for someone you don’t love or even like that much. But that’s another story for another day. Today, if you’re a caregiver, I want you to consider what things you do to keep yourself healthy and sane. If you can’t think of anything, it may be time to take a real break and take stock, and yes, consider therapy. Caregiving should be a gift, not a prison sentence.

"I'm lonely but I also want to be alone"

A common theme for my recently bereaved clients is an overwhelming ambivalence about being around others. They’re lonely but at the same time, they’re avoiding phone calls and visits from their well-meaning friends and family. They can’t bridge these two feelings of abject loneliness and also real resistance to being around other people; they’re stuck in ambivalence.

Ambivalence is uncomfortable. We’ve all been in that space and you just can’t stay there for long; it feels too bad. I have to borrow from the late, brilliant Stephen Sondheim here for an accurate description: “Sometimes I stand in the middle of the floor, not going left, not going right… am I losing my mind?” Ambivalence is like being paralyzed. How do you move out of it when you just feel stuck?

The answer, as usual, comes with more questions. Sometimes this conversation about being alone but being lonely but not being up for socializing but feeling isolated … leads to this: “which feels worse?” It can depend on the day! Sometimes answering the phone feels like climbing a mountain. Other days, the thought of spending another hour alone in a quiet house is the more daunting choice. Investigating our ambivalence is the ticket out of it. There is always a stronger pull in one direction or another if we allow ourselves to really sit with our feelings.

As with all parts of grieving, your mileage may vary. There will be days when being alone feels horrifying. On those days, use your energy reserve to reach out to someone. Likewise, there will be days when the mere thought of being with others feels exhausting. On those days, you have my permission to relish in your loneliness. Whichever choice you make, loneliness or connection, remember that it is just how you feel right now; it’s not permanent. You only have to get through the next day, the next hour, the next minute. The ambivalence of grief will ebb and flow, like all the other grief feelings. Give yourself the gift of waiting it out. Relief is coming; it may be beyond you right this second but any minute it will be within your grasp. Hang tight.

"The second year is harder" and other difficult truths about grief

I’ve written before about grief not having an end date. It’s a nebulous, unpredictable process. That’s because each of us experiences grief in different ways and on different timelines. That being said, we can expect certain periods to be universally hard during the bereavement process: the first birthday of your lost loved one, for instance, or the first holiday season. After a death (or a divorce or another kind of ending), there is a whole year of firsts to wade through. That first year can feel full of landmines—but also full of the comforts of reminiscing and tradition-keeping. There can be some sweetness in our loss, some celebrating of the birthday or the holiday, a heavy reliance on really marking the tough days. And there is a kind of relief in getting through that first long year.

Then the second year hits.

You would think the second year would be easier. And in some ways it is; time does heal, after all. But in other ways, the second year is a reminder of the finality of your loss. People prepare for that first year to be difficult but they aren’t necessarily prepared for the second year to hit so hard.

This sounds like bad news. But remember, your grieving process is not something to get over. Grief is a reminder of how deeply we loved someone; that love doesn’t just disappear. This holiday season, whether it’s your first or second or tenth with someone missing, don’t hide from your grief. Take some time to honor your losses—in big ways or small, whatever feels natural to you. And remember, you don’t have to do it alone.

Happiest holidays to you, even if they are a little tougher this year.

What if I want to know about my therapist?

Once, during a job interview, the interviewer asked to describe my boundaries with clients. A pretty vague question, right? Like, it depends! But seeing as how I was in an interview for a job I wanted (and eventually got, thank you very much), I played along and responded: I answer the questions my clients ask me (within reason).

Because here is the thing: when you are sitting across from me in that first session, I want to know some pretty deep stuff right off the bat. For instance, do you drink alcohol? Use drugs? Are you religious? Have you ever tried to hurt yourself or someone else? Not exactly cocktail party conversation. So if a client has a question for me (like how old am I or how many kids do I have, etc.), I’m more than willing to answer.

Some things about me are already clear: I wear a wedding ring, for instance. I’m fairly young. I’m a woman. I’m white. For some therapists, this is about as much information as clients are allowed to know. There are different schools of thought and none of them are wrong; in some ways, it’s a personal preference. There are good reasons for a therapist to not spend a lot of time talking about herself. For one thing, that’s not why you’re paying me; we’re here to talk about you, my friend. For another, some clients use this tactic to deflect and avoid the stuff they need to talk about. But I think, especially in the rapport building phase of therapy, it’s normal for a client to wonder, who is this person I’m telling all my secrets to?

So ask away! If I don’t want to answer, I won’t. Part of this process is developing a relationship and setting boundaries within it. I’m happy to tell you that I have two kids and a little dog and a husband. I’m happy to tell you that I’m in therapy myself, and that it helps me be a better therapist for you. I’m happy too, to talk about why you want to know about me instead of telling me about you. Like I said last time, almost nothing is off limits. This is a road we walk together. So tell me, what do you want to know?

You can say (almost) anything to your therapist

This week, in my series about what to expect from therapy, I want to dive into what may be off limits to talk about with your therapist. The short answer is, pretty much nothing!

There are exceptions to this of course: if your therapist thinks you’re going to hurt yourself or someone else, or that you already have harmed someone, they’re obligated to do something with that information. But otherwise, you get to say whatever you want. You don’t have to be on your best behavior when you’re talking to your therapist. Therapy is a relationship but it’s not a friendship or a conversation at a cocktail party; you don’t have to come armed with your best stories or convince anyone of how delightful you are. In fact, once some trust is established, you can be on your worst behavior if you so choose. In therapy, you get to explore the darkest and meanest parts of yourself. It’s safe there.

Still, it feels risky to open up to someone, even a professional. On the one hand, you’re seeking out therapy because you need to talk to someone and presumably, you’re ready to do just that: talk. On the other hand, there may be a fear that you’ll say something so dark, your therapist just won’t like you anymore. Generally, we want people to like us; we’re only human. So it can be difficult to drop the social niceties we’re practiced at performing. For instance, hearing “how are you?” from your therapist is different than hearing the same question from a co-worker. And yet, for many of us, the automatic answer is the one that comes out: “Fine, thanks, how are you?”

This isn’t to say you can’t be nice to your therapist. Believe me, we’re happy to be asked how we are, even if we won’t tell you the actual answer. I’m only saying that in that therapy session, you are released from surface-level social stuff. You can talk about whatever you want.

Which brings me to another caveat: you can also NOT talk about whatever you want. You don’t have to recount every dark thought that has ever entered your mind. You don’t have to review every embarrassing moment or delve into something that feels too tricky to explore. In that session, you get to decide where to begin and where to stop. When your therapist asks how you’re doing, you can tell the truth. And if the conversation starts to go somewhere you aren’t ready to go, you can say no. You don’t have to worry; you can say (almost) anything to your therapist.

When your body betrays you

Last week, I wrote about grief. I was mostly referring to the grief we experience when someone we love dies. But there are losses throughout our life cycle that don’t necessarily have to do with death.

For the majority of my career, I’ve worked with people experiencing life-changing and often chronic illness. The prognosis doesn’t have to be terminal for the symptoms of being ill—of having a body that doesn’t do what it used to do—to be devastating and isolating. Your friends and family can’t understand what you are experiencing. It’s difficult to explain pain or fatigue or some other unquantifiable symptom to someone whose body is not sick. In a misguided attempt to help, these family members and friends may tell you that your situation isn’t as bad as it could be; that you just have to push yourself harder; that you need a second, third, fourth opinion.

Their hearts are in the right place. They’re hoping that the power of positive thinking will do the trick and cure you. But not everyone is helped by the relentless positive thinking memes that social media throws at us: believe you’ll get better and you will! Trust your body! Mind over matter! Et ceterra, et ceterra, until you start to doubt your own feelings. Among these feelings, of course, is the grief of what you have lost.

Because although you are still here, your body has betrayed you. Illness takes from us. Maybe you aren’t able to exercise anymore, or even get on the floor with your kids or grandkids. Maybe you can’t drive anymore. Or your brain fog is making it hard to concentrate at work or school or in social situations. Those are big losses to bear by yourself.

Therapy is not going to cure your illness. Further, your therapist will not be able to tell you how long you’ll be sick or if any of what you’ve lost will be returned to you. Your therapist can’t tell you that everything is going to be ok. What therapy can do is meet you where you are. You can grieve. Then you can start to rethink and rebuild your life. Then grieve some more and then rebuild some more… You can be hopeless and hopeful both at once. And you do not have to walk this path alone.

Stuck in grief

Grief never ends.

I don’t mean that grieving is a hopeless, forever state of being, though it can certainly feel that way. I only mean that there is no magic solution to fix it. There is no timeline to follow; there is no guidebook. You can experience your grief in any way that feels natural to you. The only caveat is, you cannot fast forward or go under or over or around it. You have to experience the hard feelings of grief and loss.

Hard feelings are… hard! And so many people enter therapy hoping for answers, to solve the issue they are presenting: I have a feeling, it is hard to have it, please can we make it go away? But grief doesn’t go away. It continues even when we think we have “solved” it. The task is to learn how to live with it instead of trying to outrun it.

And you can live with it, even when it feels suffocating. Over time, grief softens. It feels less like a dark hole you can’t climb out of and more like a shadow: always with you but less obtrusively. You can be released from the idea that you have to solve your grief, or outgrow it, or close the door on it. You don’t have to do that to be helped.

Then what can help? Most importantly is to acknowledge our losses: ritualize and memorialize and speak the names of the people we have lost aloud. And then, in our acknowledgement, we can also reach out to others. We can ask for help—from our friends, our family, our religious faith. We can go to therapy and allow someone else to carry the burden of grief for just a little while. We do not have to experience any of our feelings alone, even if they feel isolating. Grief is a universal experience. It never ends and it can’t be solved. But it can be shared. And sometimes, just sharing our burdens can go a great way towards relief.

Where do we start?

How does therapy… start?

Some people come to therapy fully ready to spill: they’re like a pot of water ready to boil over. Those first two or three sessions are just full of words and feelings and sometimes tears. That’s been my personal therapy experience and it’s one I really understand: talk until you can’t talk anymore and then we can figure out where to go next.

But not everyone is like me (thank God). Some people enter therapy reluctantly or cautiously; they are not in fact ready to spill their guts to a stranger. It’s not that they don’t know why they came, it’s more that they don’t know how or where to begin. Or they start and then get stuck. Or—and this one is the toughest for me as a clinician—they want an immediate answer.

There’s good news and there’s bad news, here. The bad news is, I do not possess a magic wand. I can’t make sisters or lovers or children behave better; I can’t bring back a loved one from the dead; I can’t give you a secret code that will make your anxiety disappear into thin air. But—and here’s the good news I promised!—there are going to be answers. We can find them together, by sifting through the past and the present. We can find a way to set boundaries with the misbehaving family members; memorialize the dead loved one; understand and quell the anxious thoughts that plague you. In short, we can start wherever you are that particular day, that particular moment, and see where we end up. We just have to start.