Ending a relationship. Asking a friend to repay a loan. Critiquing a colleague's work. Asking in-laws to quit interfering. We've all had those moments when we needed to have a difficult conversation that makes our palms sweat with nervous anticipation. It seems like some people really have this skill down, whereas most of us struggle. We might even find a reason to avoid having the conversation at all, telling ourselves it's not really that important, when clearly it is. 

So what do you do? Having a plan helps to build confidence going into a crucial conversation. Try this format:

1. Get clear on what you truly want, then focus on that goal. If we just know we're upset but don't really know what we want, we flounder. It might be an objective to get money back that you loaned to a friend. Or it might be to turn down a request from a coworker without damaging the relationship. 

2. Get right to the point. Lengthy prefaces and explanations about the backstory just make the other person nervous and delays the inevitable. It's best to be clear and get right to the point.

3. Start with yourself. It's tempting to blame others for our position in stressful situations or failed communications. Starting with yourself is much easier to hear and a softer start-up to a difficult conversation.

4. Try a DEAR MAN. Thinking through the following acronym can really help improve clear, concise communication:
     
     Describe the situation. Stick to the facts. No judgements or interpretations. Ex: "My lease is up and I'm scheduled 
     to move in two weeks."
     Express your feelings and opinions. Ex: "I'm panicked because I don't have help and I don't think I can do it 
     myself."
     Assert your wishes. Ask for what you want or say no clearly. Be specific.  Ex: "Would you be willing to help me 
     move a week from Saturday at noon? I imagine it'll take about four hours."
     Reinforce the positive in the situation. Ex: "I would really appreciate it, and also, I'll buy lunch."

     (stay) Mindful and keep your focus on your goal. Don't be distracted to another topic. Ex: "So, can you help me 
     move?"
     Appear confident with tone of voice, body language, and maintaining eye contact. Don't look at the floor or speak 
     softly.
     Negotiate. Be willing to give in order to get. Ex: "What if we barter? I'll help you clean your gutters." 

Resources:
Crucial Conversations: Tools for Talking When Stakes Are High by Kerry Patterson
Dialectical Behavior Therapy, Interpersonal Effectiveness module

Did you know that shame is learned? We are not born knowing how to feel shame, we are taught. Shame is 
a painful feeling of humiliation or distress caused by the consciousness of "wrong" or "foolish" behavior. It is the result of a judgement by ourselves - or by someone we admire - that we are not good enough in some way. We have all experienced shame at different times throughout our lives. For example, when my husband and I entered couples counseling because we were having difficulty in our relationship, I felt shame for not having relationship mastery as a therapist. I judged myself as not good enough.

Like all emotions, shame serves us and it has many functions. Sometimes shame works well for us. First, shame can function as a motivation to achieve. Many people work hard to avoid a shameful situation. Avoidance of failure (which would be shameful) is extremely motivating. Also, shame can communicate to and influence others. Facial expressions and body language are a hard-wired part of emotions. For example, if you are walked in on while using the toilet, you might try to cover up and hide yourself.  This communicates that you do not want a private act to be exposed, and influences the person to leave quickly and close the door. 

On the flip side, shame can also get in our way. Every emotion has an action urge, and shame's action urge is to hide, avoid, and shrink up. It's a sort of pushing ourselves away. If we're busy hiding and avoiding, we're certainly not taking any risks that may be necessary to grow and be our best selves. Also, shame is a result of a discrepancy of who we think we "should" be and who we really are. Our beliefs about who we "should" be may or may not be helpful, in fact, they might be self-defeating beliefs. They may be undermining our self-esteem. For example, a man believes that showing sadness is a sign of weakness, so when he cries at the loss of his dog he then also feels shame on top of the grief. With this in mind, it probably isn't a surprise that shame is highly correlated with depression and anxiety.

So what can we do about shame that isn't serving us?

The antidote is acceptance. Acceptance is the action of consenting to receive or undertake something offered; a willingness to tolerate a difficult or unpleasant situation. Acceptance is saying that We Are Enough.  Acceptance is challenging self-defeating beliefs. Acceptance is knowing that this situation and our reactions make sense, it's what is, at least for this moment in time. Acceptance is acknowledging that "failure" is just a stepping stone toward our goals. Acceptance is understanding that no person is perfect all of the time and having compassion for those parts of us that are not. Acceptance is an attitude of openness, a willing stance. Taking an opposite action to shame's action urge of hiding: being willing to be open and show our true selves without judgement. 

Try this exercise of a willing posture for acceptance:
1) Sit with your arms and legs uncrossed
2) Relax your body
3) Put your arms out, elbows slightly bent, with palms facing up
4) Tilt your chin slightly up and elongate your neck
4) Sit in this position for a minute or two and notice your thoughts and feelings. It is nearly impossible to feel shame.

Resources:
Brene' Brown's Listening to Shame TED Talk
Marsha Linehan's Dialectical Behavior Therapy, Emotion Regulation Module
 

The mind-body connection is both interesting and amazing. Often we can intervene on the mind to change the body, and intervene on the body to change the mind. With these two simple body positions, we're intervening on the body to stimulate a relaxation response in the mind.

The vagus nerve runs along the inside of the spine up to the brain and is one of the longest nerves in the human body. It runs up to the amygdala, which is the part of the brain responsible for processing fear and anxiety. The vagus nerve is also involved in regulating heart rate and blood pressure. Stimulation of the vagus nerve is an effective way to trigger a relaxation response. Here are two ways you can do that yourself:

1. Put your hands on your head like the man in the photo. This body position opens the ribcage allowing for the diaphragm to expand in deep breathing. The diaphragm puts pressure on the vagus nerve stimulating the relaxation response. Hold this position for two minutes.

2. Hook your arms over the back of your chair. Again, this body position opens the ribcage and allows you to breath deeply using your diaphragm. In fact, you can't help but use your diaphragm in this position. The diaphragm stimulates the vagus nerve and triggers the relaxation response. Hold this position for two minutes. 

Resources:
Retrain your stressed-out brain
Information and research on the amygdala's role in anxiety and anger here, here, here, and here

What do you see in this illustration? A young girl? Or an old woman? Or both? Most of us see one easily, and need more information to see the other. (Hint: the young girl's chin is the old woman's nose)

Our brains are wired to problem-solve, to fill in blanks, to put together puzzle pieces, and to make sense of things. Often this process happens so fast and so instinctually that we don't even notice we're doing it, let alone question the accuracy. In fact, this process happens with all of us, many times over, every single day. Our interpretations of events are informed from many sources: our upbringing, a similar event happening in our history, our education or professional background, relationships, culture, where we live, our mood in the moment, something that happened earlier in the day, etc. So when two people have different reactions to the same situation, this is why. Sometimes we label it a miscommunication or a misunderstanding. At minimum it's a blip on the radar and at maximum it's a big emotional response resulting in extreme behavior.


Consider the following scenarios. What are your interpretations? Are they accurate?

1) You're home alone with your infant. You've been up all night with her and you're exhausted and bleary-eyed. All of a sudden you see a strange man move across the backyard, and he's heading toward your house!  

A: It's the meter reader from the utility company.

2) You're driving to work, it's pouring rain, and you get a flat tire. You pull to the side of the road, get out, and get your car jack and spare tire from the trunk. As you're out in the rain getting ready to use the jack, you see your good friend drive by. You try to wave him down and he looks at you for a long moment but continues on. You know he saw you!

A: Your friend's dog is in the backseat, the dog was just hit by a car, and they are on their way to the hospital.

The antidote is a little bit of mindfulness and asking yourself, "What am I missing?" 
We will never know everything about a given situation, there are just too many variables in life. For example, we will never know exactly what it is like to be anyone else on the planet. Even if it is explained in seemingly simple terms, an interpretation still takes place based on the meaning we put onto words. Acknowledge and honor that there is more than one way to see the world.

• Begin by noticing when you have a strong emotional reaction to something, pause, and put your attention on it. 
  
• What interpretation of the event prompted your reaction? In other words, what thoughts were running through your head? 
• Now, look at the facts that you know. Observe and describe what you could see, touch, hear, taste, and smell. 
• What information were you missing? What are other possible interpretations of these facts? 

This exercise is most easily conducted in hindsight. Later, with practice, you will be able build more awareness in the moment and create opportunities to change course. 


Further reading:
The Cognitive Model
"Watching Your Mind" Mindfulness Exercise

Consider the case of the doctor who counsels his patients every day about abstaining from tobacco use for the sake of their health, then takes a smoke break. Or the person who wants open communication and closeness in a relationship, then avoids bringing up difficult topics. These people are both experiencing distress because their choices are not aligned with their personal values. This is called value incongruence. 

We know that when a person acts in opposition to their values and beliefs, their overall wellbeing declines - mental, emotional, physical, spiritual, etc. For example, a person working for an organization whose policies go against some of their personal values results in faster burnout. The more important the value, the bigger the impact on wellbeing.

Value Incongruence Self-test:
Read through this list and write down your top 10 values. Include anything that comes to mind that isn't on this list. Don't put too much pressure on yourself to get it right, just do it quickly and follow your gut.

From your list of 10, now circle your top three values.

Reflect: 
What are you doing (or avoiding) that is aligned with these values? Keep doing it! 

What are you doing (or avoiding) that is NOT aligned with these values? Consider making a change.

Resources:
Acceptance and Commitment Therapy (ACT) for Depression
Some research here and here. 

Validation is the single greatest relationship tool for relationships of all types. If I could master only one skill, it would be validation. In short, validation is recognizing and honoring another person's experience. If you've ever seen the movie Avatar, the Na'vi greeting, "I see you," essentially meaning "I understand who you are," sums it up nicely. 

Validation deescalates a conflict faster than anything else because it is the opposite of arguing against someone. Feeling seen, heard, and understood helps people connect in a deeper way. Be patient with yourself when trying to use validating statements. This is a skill that takes practice, like any skill. But the payoff for the practice is worthwhile.

How to validate:

1) Check your righting reflex. Validation isn't about helping someone see the error in their thinking - in fact, that's invalidating - it's about meeting someone right where they are now. When you validate someone's experience, it does not mean you agree or that you believe their thoughts, feelings, or actions are justified. It simply means you are present and acknowledge their truth, as it is, here and now. 

2) Seek understanding. What emotions are they experiencing? What sensations do they hear, see, touch, etc.? What beliefs or interpretations of the event(s) led to these emotions? Does this situation remind them of another experience in their history? You may already know the answer to some of these but ask questions if you need.

3) Summarize the what and the why. Show that you understand their experience by reflecting it back out loud. Here is a simple formula to follow:

It makes sense to me that you feel _____________________________ 
because ______________________________________________________. 

Example:
It makes sense to me that you feel frustrated and hurt
because it seemed like your needs weren't important to me when I forgot to put away the dishes.

Further reading
Marsha Linehan's Six Levels of Validation

The Seven Principles for Making Marriage Work, by Dr. John Gottman and Nan Silver, is a relationship self-improvement book for not only married couples but any type of romantic partnership. The book is based on decades of research by Dr. Gottman with thousands of married couples in his "Seattle Love Lab."  The Gottman Method style of couples therapy is based on this research and is one of the few evidence-based couples therapies in existence. This book is relatable, humorous, action-oriented, and - most importantly - it works. I have recommended this book as an adjunct to therapy for almost every couple I have seen.

A few of my favorite things about this book:

1. The principles progress from the ground up. You do get to the hard stuff but you don't start there. First, you work on strengthening the foundation of your relationship, the friendship, fostering warm feelings toward each other. It's as though you're strengthening your coping skills for when you start to address the difficult issues, so you are better equipped to deal with them. Later in the book you are invited to address those unresolved hot conflicts that have plagued your relationship for years, and actually get somewhere.

2. There are questionnaires and exercises in every chapter. After reading about the concepts, you have a chance to self-assess areas of your relationship with questionnaires. Who doesn't love self tests? Then, there are quick and fun activities to help you put those concepts to practice in your own relationship. You are not just reading, you're doing, and that feels like progress toward change and healing.

3. The Emotional Bank Account concept. The authors use the metaphor of a bank account to talk about balancing positive and negative interactions in a relationship. A traditional bank account can avoid being overdrawn as long as withdrawals do not exceed deposits. If you take $1 out, you have to put $1 in to retain your balance. This ratio does not hold true for the Emotional Bank Account. Through their research, they have found that for every one negative interaction (withdrawal), a couple needs to have at least five positive interactions (deposits) in order to stay in balance. It's easy to see what's wrong, but very important to see and express what's right.

4. There are solvable problems, and then there are perpetual problems. It is human nature to want to fix problems. Yet, not all problems are able to be fixed. The good news is that doesn't mean you're doomed for a lifetime of the same fight over and over. You learn to tell the difference between the solvable problems and the perpetual problems, and then learn the tools to deal with both kinds. Basically, how to solve the solvable problems and understand and avoid aggregating the perpetual problems, much like a bum knee. 

For more information about the Gottman Method, visit The Gottman Institute website.

Even if you don't suffer from Seasonal Affective Disorder, a type of depression during the fall and winter, this is the time of year when the weather in many parts of the country has been dreary for months and can really get you down. Here are five simple, evidence-based acts to combat the blues or even just the blahs:

1. Turn on the light. Light therapy is a proven treatment for seasonal affective disorder and can be used for other types of depression, too. The light mimics natural light and is thought to affect chemicals in the brain to improve mood. It's a special type of light available to anyone, but follow the directions because it's meant to be on for short periods of time.
   
2. Go for a walk. Research has shown over and over that exercise is actually just as effective as antidepressants in treating depression. It doesn't matter what, or for how long, just move your body somehow. Put an appointment in your calendar to go for a walk around the block and honor it just as you would any other appointment. 
3. Fake laugh. Seriously! Even just making our bodies go through the motions of laughing sends signals to our brain that boost mood. And I don't mean "ha ha." I mean "HAHAHAHAHAHAHAHAHAHA!!" So close your door and throw yourself into a giggle fit.
4. Pick your playlist. I think we can all relate to the power of song. Whether you prefer to listen to a sad song when you're feeling down ("Taylor Swift, you really get me") or a more uplifting song, it's really about what works for you. And if you can make the music yourself, even better.
5. Take a break from screen time. The average American has 8 1/2 hour of screen time a day. A day! That includes computers, television, smartphones, GPS navigation, and even in-cinema movies. And - get this - it's not kids who get the most screen time. Adults ages 45-55 average 9 1/2 hours daily! The link between screen time and depression is well-established. Try turning it all off, just for an evening.

Resources: 
American Music Therapy Association
Exercise for Depression (Cochrane review)
Laughter and Depression (review) & Laughter Yoga website
Light Therapy for SAD
Screen-Free Week: May 5-11, 2014
Seasonal Affective Disorder
Verilux HappyLight natural spectrum light (there are many options but this is a brand I know)

It is well-established that volunteering combats depression and boosts happiness, including this recent systematic review and meta-analysis of 26 studies on the matter. Giving to others gets us out of our heads and away from our own inner struggle. Putting our attention on helping others makes us feel less alone or even less bad-off than we realized. And, let's face it, it just feels good to contribute to a larger cause. 

So, in honor of Volunteer Week, here are 10 small ways to pay it forward today. Try one and notice how it makes you feel.

1. Pick up a piece of litter. 

2. Tip your barista/server/hairdresser a little extra.

3. Open the door for a stranger.

4. Write a letter and send it through snail mail.

5. Give a flower to each of your officemates.

6. Give a bottled water and a snack to a homeless person.

7. Let someone use your frequent shopper card who forgot theirs.

8. Go through your house and fill a bag to donate.

9. Leave encouraging post-it notes in random places.

10. Buy a coupon for a car wash and leave it on someone's window.

A question I'm often asked is, "What are the differences between all the different mental health professions?" There are therapists, psychotherapists, counselors, psychologists, clinical social workers, psychiatrists, LMFTs, LPCs, LCSWs, PhDs, PsyDs, MDs.... it's incredibly confusing! Allow me to break down the most common mental health professions for the state of Oregon.

Some of these titles are general and can refer to practitioners of all backgrounds. They include therapist, psychotherapist, and counselor. You may have also heard the term QMHP, which stands for Qualified Mental Health Professional, and encompasses several degrees and competencies. See the full list of requirements to be a QMHP in 
OAR 309-039-0510,

Licensed Clinical Social Worker (LCSW)
Known for: Using a person-in-environment perspective, which means addressing both internal (thoughts, emotions) and external (environment - social, political, familial, economic, etc.) influences that affect a client's condition. Social workers often also have an interest in social justice and helping more vulnerable populations.
Education: Master of Social Work, which includes two years interning under supervision.
Clinical training: 3500 work hours, 2000 direct client hours, 100 hours meeting with clinical supervisor, then pass two exams
Ongoing requirements: 40 hours of continuing education courses reported every two years
Licensing board: Board of Licensed Social Workers

Licensed Marriage and Family Counselor (LMFT)
Known for: Specializing in working with couples and families using a systemic approach.
Education: Graduate degree with specific amounts of coursework related to marriage and family counseling as well as an internship. Several master of art, master of science, and master of education degrees meet the education criteria.
Clinical training: 2000 direct client hours, 2-3 hours/month meeting with clinical supervisor, then pass two exams.
Ongoing requirements: 20 hours of continuing education courses every year.
Licensing board: Board of Licensed Professional Counselors and Therapists

Licensed Professional Counselor (LPC)
Known for: Using recognized counseling techniques with individuals, couples, groups, organizations, career counseling, and school counseling.
Education: Graduate degree with coursework related to counseling and career development. Several master of art, master of science, and master of education degrees meet the education criteria.
Clinical training: 2000 direct client hours, 2-3 hours/month meeting with clinical supervisor, then pass two exams.
Ongoing requirements: 20 hours of continuing education courses every year.
Licensing board: Board of Licensed Professional Counselors and Therapists

Licensed Psychologist
Known for: Psychological testing and diagnosing complicated cases.
Education: Doctoral degree in psychology (PhD or PsyD).
Clinical training: 1500 hours of residency providing psychological services, 2 hours meeting with a clinical supervisor for every 40 hours of psychological services, 2 hours of learning activities (case conferences, seminars, etc.) for every 40 hours of psychological services, then pass two exams.
Ongoing requirements: 50 hours of continuing education courses every two years.
Licensing board: Board of Psychologist Examiners

Psychiatrist 
Known for: Prescribing mental health medication, especially for complicated cases. 
Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
Clinical training: Minimum three years post-graduate residency in psychiatry, then pass a minimum of three exams (several exam combinations are accepted). 
Ongoing requirements: 60 hours of continuing medical education courses every two years.
Licensing board: Oregon Medical Board