It’s a hallmark in criminal procedurals for detectives and prosecutors to determine if a suspect had motive for a crime. I think of motive as trying to guess the “why” someone did something. It’s something that I spend a lot of time wondering about with clients who are in stay or go situations in their relationships.

In relationships, our partners have their motives and we have ours. My experience is that we spend most of our time, energy, curiosity, and anxiety wondering about their motives. It’s far more difficult but ultimately more fruitful to invest in understanding our own motives in our relationships.

Why do I stay? Why do I want to go? What are my needs? Are my expectations too high or too low? What am I afraid of? Do I give too much too easily? These are just some of the questions that we might ask ourselves when we’re facing a stay or go decision in our relationship.

Thought about our partners’ motives are not totally useless. It’s especially worthwhile to examine and clearly see the evidence of our partners’ behavior.

Do they act maliciously or not? Do they act mostly or only out of self interest? Do they treat you the way you want to be treated, mostly? Be honest about your experience with them. It matters.

Invest the most in understanding yourself, however. See your partners clearly. If you need it help is available.

When I was a young therapist in training I was taught to call 911 if a client was in danger. In other words if a client was suicidal I was trained to call the Houston Police Department. To this day I hear therapists with outgoing voicemail message like the one I had in the 2000s.

This is Christopher. You’ve reached my voicemail. Please leave a message and I’ll return your call within 24 hours. If this is an emergency or if you feel suicidal please hang up and call 911.

I had some version of that voicemail message for years without much thought. I’m rethinking it now.

What if calling 911 isn’t helpful for mental health crises? What if calling 911 for mental health crises is dangerous?

What’s a better option for us therapists? What’s a better option for our clients when they’re in crisis?

I’ve lived along side chronic pain suffers for about 20 years. I’ve had it myself. Chronic pain is a matter of time not sensation. The Mayo Clinic describes pain as chronic if it lasts 12 weeks or more. Chronic pain can be steady. It can be intermittent. The pain might ache, it might burn, it might throb, it might be dull, it might be sharp but if it lasts for three months or more it’s chronic.

The US census bureau reports the US population to be about 328.2 million people. The Mayo Clinic says there are about 3 million reported cases of chronic pain in the US each year. Less than one percent of the population sounds pretty good if you’re not one of those cases and you’re not a person who loves one of those people reporting their cases. When chronic pain has affected your life less than one percent of the population seems like a woefully underreported number. By contrast Wikipedia’s entry on “Opioid Epidemic” says in the 1990’s 100 million US citizens were affected by chronic pain. Whatever the current numbers are their big enough to warrant 5120 active research studies on chronic pain as of today. At least better help might be on the way.

Nothing activates my ready, fire, aim response more than the pain of people I care about. I see it, I feel it, sorta, through empathy pain, and I want to fix it. “Feel bad? Take a pill.” I think. Thanks for that thought I say to my American mind. That cognitive knee jerk reaction is a good reminder that my first thoughts are often not my best thoughts. When it comes to living around chronic pain I’ve made more than a few mistakes. 

Most want pain to go away. Whether it’s our pain or our loved one’s pain we just want it gone. When the mind/body connection is working well pain is a signal our bodies send to our brains that something is wrong. Something is wrong and immediate attention is needed. Ideally once the message is received and the right attention is given the signal stops. With chronic pain, however, the signal keeps blaring.

When the pain signals won’t stop the best next step is to go back and find the cause. Get the best most specific diagnosis that you can.

Amateur tip: Don’t passively accept the first diagnosis you get as the best diagnosis. Get second, third, and forth opinions. Get to the right specialists.

I’ve know football players whose chronic pain started with repeated collisions that seem like car crashes. I’ve seen rheumatic diseases up close and personal. Arthritis and joint dysfunction can cause chronic pain. Cancer can do it. Infections can cause chronic pain so can nerve disorders. There are as many causes as there are potential treatments. A good diagnosis provides a path to the right treatments.

Amateur tip: If your chronic pain is localized go to the best specialist in that body part that you can find. If the chronic pain is generalized go to the best rheumatologist you can find.

Pro tip: If you’re having chronic genital pain get a consultation from San Diego Sexual Medicine.

Treatment for chronic pain has come under great and appropriate scrutiny given the over prescribing of opioid medications in the United States for the last 25 years.

Amateur tip:: For a heartbreaking illustration of this disaster check out The Pharmacist on Netflix.

What can we do about chronic pain besides taking a pill? There has been some evidence that shows chronic pain suffers have lower levels of endorphins in their spinal fluid than non-suffers. Acupuncture and electroacupuncture increase endorphins in that same fluid.

I’ve bought more than one TENS unit in my life. These help some episodes of nerve pain and low-endorphin levels.

There are medications that are not opioids that can help. For more information call your friendly neighborhood rheumatologist. Humira is a drug that treats chronic pain among other things and in 2018 alone the drug brought in $13.7B (that’s billion) of revenue for AbbVie.

The supplemental treatment that’s caught my eye is a specific protocol of psychotherapy – CBT-CP – or cognitive behavioral therapy for chronic pain. Cognitive behavioral therapy is a type of psychotherapy that focuses on changing our actions and our thinking so that we can influence our feelings. It’s been around since the 1960s and is one of the approaches to psychotherapy that has a lot of evidence to prove that it works. CBT works well for a lot of people with depression. CBT works well for a lot of people with anxiety so it doesn’t surprise me that CBT has been applied to people carrying the burden of chronic pain.

The protocol that I found is a manualized treatment which means in part that there’s a book telling therapists how to do it. Manualized treatments are also in theory easily replecated so that their outcomes can be more easily quantified, studied, and published. I have my reservations about this whole trend in psychotherapy. That said I’m glad to have the manual because I’m going to use this in my practice next month. The more I figure out the more I’ll share.

Love y’all,

– c

Pro Tip: If you can’t find a provider to help your client then be that provider that can help your client.

I can’t decide if this is more about relationships or sexual experiences so take your pick.

Relationship satisfaction is an underrated measure of what makes for a “good relationship” and tenure is overrated. I’ve known a few married couples who get lots of praise for hitting milestone anniversaries: 30, 40, 50 years and I inevitably wonder how happy those decades have been?

Eli Finkel wrote of our era of marriage in his book The All or Nothing Marriage. Marriages that have longevity in this era must have high relationship satisfaction too. Otherwise we leave. Have all the reactions to that which you need. The trend remains.

Today we will not stay forever in situations that aren’t contributing to our growth as human beings. I see it all the time in people coming to my practice with stay or go decisions.

If you’re facing a stay or go decision there’s your work.

Full disclosure, I’m in recovery from depression and anxiety disorders.

It’s been a number of good years in recovery. There are days when that recovery feels like an expansive landscape stretching far out in front of me. Then there are other days when my recovery feels like a precipice that I’m clinging on to for dear life. 

On my precipice days I have a few go to coping behaviors because what I do and the choices I make are what I have the most control over. My coping actions help me get on solid emotional ground again. Making “to do lists” and checking items off those lists are some of my favorite coping acts. 

Given my particular crutch of productivity both real and imagined I was puzzled by a mindfulness group exercise I did last October with @dr.saranasserzadeh . She told us that we were doing enough simply by breathing. By breathing I was contributing to the ecosystem that makes our atmosphere livable and that simple act, that we all do automatically, was enough. 

Breathing is enough? 

We talk about trust in our relationships all the time and for good reason. Trust is a fundamental component of rock star relationships. When it’s there we have a sense of security and safety at home that lets us venture out into the world with confidence. When trust is shattered it makes us question everything. “If I can’t be okay here, how can I be okay anywhere?”

We should be talking about trusting ourselves just as much. Trust in yourself can provide security when others fail you. Because they will fail you, sometimes. More on that later.

We come into the world dependent on others. If our parent types were mostly good; there more often than not; and we could mostly count on them we get a good relational base inside of us. We go from parent types to middle school friends. They solidify our relational insides and then we wander into the young adult world hopefully more or less ready to connect with others as we continue to discover who we really are. That’s the job of a lifetime.

Trusting ourselves means seeing us as fundamentally good. It means believing our own experiences especially when they’re hard. To trust ourselves we need a mostly well-functioning emotional system. That means we know what our feelings are what they’re trying to tell us. Then that we act accordingly. 

Trusting ourselves means that we are competent and capable problem solvers and that we believe in ourselves to get a job done in whatever way works. 

After a year or so of writing #therapynotes, people mention this one to me more than any other. 

Some people are allergic to responsibility. 

So this is a sequel of sorts. I know all about people who are allergic to responsibility because I was one. I spent most of my 20s living in victimhood. Every bad thing that happened in my life was someone else’s fault or so I thought. No wonder I felt so terrible. 

The lesson of my first therapy was MY choices led to the misery I was feeling in MY life. Personal responsibility and learning to take it session by session were my allergy shots. 

Those early shots were painful and invaluable. When we stay perpetual victims in our own lives we choose to be powerless to change. However, when we are responsible it means that we can make new choices. We have the power to effect the outcomes in our lives. We can feel better. We can be better. 

If you’re miserable being a perpetual victim it does not have to stay this way. There’s your work. 

John Gottman often says, “You pick your partner and you pick your problems.” Esther Perel says, “When you pick your partner you pick your story.” Sometimes I like to ponder these two things…what a therapy nerd.

John’s point is in part that we are going to have problems with any partner we choose. I think this is a good antidote to the toxic myth of “the one.” 

Esther is elegantly providing us with a powerful tool in her version. How could Esther be anything other than elegant? She’s framing romance and our romantic lives as “choose your own adventure” stories. To me that’s exactly what our love lives are. We choose a partner, we choose a story. That story is going to have parts we hate, parts we love, and some parts that drag a little bit but further the plot. 

Relationship problems are the parts we hate in the stories we love. Chronic fights are prime opportunities to reframe. If you and your partner(s) keep having the same fight over and over then reframe the issue as a problem for you two (or three or four) to solve instead of a fight to have. If y’all need help with that there’s your work.

I have mixed feelings about this #therapynote. My feelings about expectations depend on the context.

Context matters. Context matters in all things most especially in sex (thinking of you @enagoski). More on that another time.

When I wrote this particular note about the title fight of expectations v good times I was thinking about my holiday season just last year. I had one great experience after the other last year I think it was because I had no expectations. I didn’t expect the moon of the holidays and I didn’t dread them. I went in expecting nothing good, nothing bad, and then every positive experience truly was a gift. Luckily there were many gifts last year in the forms of experiences had and memories made with family and friends. So in this context my expectations did not get in the way of my good time.

On the other hand, in relationships we have rights to expectations from our partners. We are right to expect respect and admiration. We have the right to expect our partners to know us. We are right to expect that our suggestions and bids for connection be taken with open hearts. We expect support for our goals and accept the expectation of supporting theirs. In relationships expectations aren’t the nemesis of good times they are the protector of our selves.

Context matters. If you need help defining which context you’re in, there’s your work.

Are you motivated most by avoidance or desire? 

Avoidant leaning folks like me tend to be able to see the worst case scenario easily in any situation. When we avoidants go too far we venture into paranoia. “Nothing is going to work.” “Everyone’s out to get me.” “Everything I do is wrong.” There’s no quicker way to be wrong than to think a version of “All ____ are ____.” When avoidants venture into paranoid town our chances at relief plummet and our chances at happiness dwindle to zero.

The desirous among us know what they want and they go for it. At least that’s my understanding. Gone too far the desirous don’t get paranoid they get obsessive. In the extreme there’s seemingly nothing else in the world save for the object of the obsessive’s desire. “To hell with the consequences, I’m getting, doing, thinking about, pursing ‘the thing’.”

Like with any dialectic both avoiding pain and pursuing pleasure are important motivations. The trick is to have both desire for what you want and protection for yourself. BOTH/AND.