Ask the Therapist

The Downside of Wellness

May 2nd, 2017

I now manage and provide well-being services to the medical staff of Kaiser Permanente of Washington. Here is something I wrote for an internal newsletter:

We all must tend to resilience and wellness. Yoga, running, meditation…knitting. There are limitless options. We need this if our work is stress-free, and we need more when work is taxing. So what could be the problem with an extra tai chi class?

Potentially, the connotation of an emphasis on coping is that your career is stealing your vitality rather than contributing to it. Wellness should stem from your job, not in spite of it. But if you find that your inner dialogue regarding work has become sour, then various forms of distorted thinking, common to all of us, may begin to magnify this negativity beyond proportion. You begin to filter experiences such that negative events are magnified, while positive ones get less notice, and you are at risk for burnout.

Now, to be sure, healthy perspective and practices will only get you so far if basic needs are unmet. Eighty-hour work weeks, toxic personalities or wholly inadequate compensation – no amount of downward dog will let you thrive in untenable conditions. Also, let us accept that even in the best of circumstances, work in this field is inherently stressful, even brutally so in many instances.

But maybe – just maybe, a modified approach will allow you to leave work more often rejuvenated than drained. If we are not too black-and-white, we can experience work as we should experience exercise: fatiguing AND sustaining. Try to envision your tai chi as a complement to your job, not compensation for it.

Consider whether any of these experiments could subtly alter your experience:

1. The [your practice setting] model carries with it unique and intensive pressures. Yet, you and your peers choose to work in that system for a reason. Why? Hopefully, you can articulate an answer in your own words, not the words of leadership. Inevitably, an institution is imperfect in how it carries out its mission, and perhaps this seems especially true where you are. But that shouldn’t erode your personal mission. Pronouncing it to others helps to clarify what it is, and to maximize the gratification you may glean in carrying it out. To put it another way – mix your own Kool-Aid.

2. I knew a self-secure resident who would whisper to herself after every successful achievement, “Perfecto! Shine on.” It seemed to work beautifully for her. But for something more evidence-based, keep a log of meaningful moments at work. Or pleasing accomplishments, or both. Then, write down the emotions you experienced. Keep it brief to ensure that you do it every day for a while. For more, see this 12-minute video. You can sign up for a two weeks of daily Three Good Things prompts by clicking here and scrolling to To enroll 2016/2017 cohorts…

3. Make a point of boasting about others on your team. Don’t just tell your MA what a good job he or she did, tell the whole group with the MA present. When referring a patient to another service or handing off to your nurse, voice the most positive expression you can credibly muster about them. Each time you gripe about someone, also say something positive about someone else. Does your work group celebrate itself enough? Do meetings need more expressions of kudos? Sharing of meaningful moments? An annual out-loud inventory of everything the group does well? How about a system of written complements? You could initiate any of these systems. Even the introverted need the bonds of a tribe. Why not nurture these?

4. Every patient holds a novel in his or her life story. Our co-workers too. You can’t possibly elicit the whole book in one encounter, but you should peek into the pages. If you’re not fascinated on a regular basis, peek more often. The experience of awe and wonderment is available to us every day. Again, jot notes for a few weeks to illuminate this source of reward.

5. Juice up your empathic reflection. Something like, “I hear you’re saying that this pain is searing/preoccupying, and that it harpoons your family interactions/work/peace of mind (what is valued most highly). I imagine this is completely exhausting/frustrating and if I were in your shoes, I’d also be…scared, maybe”. On your best days, you may be able to insert words into a format like this that describe more concisely and accurately what the patient is trying to say, than what the patient himself can articulate. This will help to expedite the encounter, and your patient will feel more deeply understood and respected. Moreover, to see the patients’ expression when they experience a quality of attention they did not expect – this is a momentary but immediate, sparkling experience of being a healer. It’s an elusive but happy convergence – what is good for your patient is what is good for you.

These are a few ways try modest changes in how you participate in your workday, and there is always more. The aim is to experience yourself as empowered in finding a greater balance of reward in a tough but rich occupation.

I welcome comments, especially reports of what has worked and what hasn’t.

Chronic Pain

November 16th, 2010

Question:  How can I live with my constant low back pain when my doctor won’t give me the medications I need? Read the Answer here »

Will you knock it off about the exercise already?

November 16th, 2010

Question: If the exercise habit is so important, why is it so hard to come by?

Answer: First, let’s recognize just how important it is. Exercise is a panacea, the miracle medicine. Almost everything gets better! Low mood, high anxiety, anger, sleep, immunity, energy, concentration and productivity. Self-image, weight, appearance and confidence. Sex, strength, longevity and range of activities…

That’s sixteen things I can list right off the bat. If this stuff was sold in a bottle, we’d pay a skinny arm and a leg for it!

Second, what if you revive your relationship, resolve your depression and cure your phobia…while meanwhile inviting an early and uncomfortable demise? How successful is that?

No health practitioner anywhere will discourage exercise, as long as it’s the right form and intensity for you.

So why aren’t we all doing it?

Mainly because we’re creatures of reinforcement: we do what is rewarding and avoid what is unpleasant. The problem here is that the rewards for exercise are all delayed, while the payoff for passivity happens right here, right now. The consequences for being sedate and inert are grave, but they come later.

We can tell ourselves over and over that the delayed gratification is better, and often this works. It works for those fit and active people you see around you, and it works for anyone who goes through school, raises children and so on. But by and large, immediate reward trumps delayed reward. This is a powerful effect and it is hard to overcome.

Then there is television and the Internet. They employ genius minds designing ways to keep us hooked in and it’s not hard. The allure of the screen, is powerful.

Television creates the illusion of being highly rewarding. We may think we’re relaxing, getting positive stimulation or whatever, but how often do you turn it off and feel better for what you’ve just watched? Can you imagine nearing the end of your life and contentedly thinking on how grateful you are for the programs you saw? Or wishing you’d watched more? Don’t get me wrong – it is plenty of fun. But so is candy.

But while the reward for TV may be insubstantial, it’s quick, vivid and effortless. Again, immediate reinforcement generally beats the pants off delayed gratification – unless we are strategic and conscientiously purposeful.

Another reason it is hard to exercise is that we’re creatures of patterns and familiarity. A body at rest stays at rest, and breaking the inertia takes much more energy than sustaining momentum. If you think about it, why would anyone want to leave a comfort zone?

You do want to exercise, or increase what you going? Contemplating it? Tired of getting it going only to have it drop off? Here are a few extra ways to help yourself:

Watch a program, not the television. Decide in advance what is really worth watching; don’t turn on the tube to see what it has to offer.

Plan before you start. Get everything set up – clothes, schedule, support from others. Anticipate any barriers and scheme around them in advance. Start drinking extra water. You can mark each session in your calendar and program your program your phone to send reminders.

Watch. Watch very intently. Watch for any and all the tiny rewards. Rewards are the key to continuity, but you aren’t conditioned to catch them. You’re conditioned to make note of what a pain in the butt it is, and of all the nice restful things you could be doing instead. You’re also conditioned to look for weight-loss, washboard abs and the “positive addiction”, all of which come much later if at all.

Any improvement in sleep, focus, pride, satisfaction, energy, enjoyment of the activity itself…these things may be very elusive and you must not let them slink away. You’re training yourself to find the payoffs that are available there for you to enjoy. They will grow bigger in time, in part because you’re gaining the strength to generate more, and in part because you’re more alert to them. With time, some elements which feel negative now, like sweating and huffing, solitude and ritual, may actually become positive later.

Accomplished athletes do not have it any easier than you do. They have simply aligned the reinforcers.

Finally exercise every darn day. I did not advise this in the past. I used to advise starting with however many days are realistic, and that approach may be what would work for you. But it doesn’t allow you to develop a hard-and-fast routine. Remember learning to brush your teeth? Did you learn by brushing when it felt right? And how disciplined are you with this dull chore now? Where there is no decision-making, there is no waffling and where there is no waffling you won’t…pancake. So do start small – but only in terms of the duration and the intensity of the exercise, which you’ll expand upon later. The success with frequency starts on day 2.

For more, see Self-Motivating When Stuck.

What if I Fail?

October 3rd, 2009


I decided that my string of failures comes from my lack of self-confidence. I was always fearful and timid and I can see now that this brought me just what I used to dread.

But I’m on a new pathway now. I started my own business, I have a new marriage and a I’m keeping to a solid fitness plan. I know that in the past I would have found some way to sabotage this initiative with doom-and-gloom thinking. This time it’s going to be different! My only enemy is my own fear. I’m visualizing success and refusing to consider a bad outcome. I’m not stupid enough to think failure is impossible, but I do know that we tend to create the reality we expect.



Not quite.

Of course confidence is good, and we need to visualize where we want to go. But to think the positive visualization itself has much power is naive. Instead, I might coach you to study your enemy. That is, imagine and list all the ways in which this initiative could fall dead. Not enough business? Or so successful that you can’t fit in the full workout…or that you have to grab a burger just this time…and one more time the next week…

This is not a lack of self-assurance; it’s a recognition of reality. It’s not pessimistic thinking; it’s strategic foresight. And it’s not a lack of hope; it’s building the confidence to know you won’t come upon bad surprises ill-prepared.

If you made a mistake with your past “gloom-and-doom” thinking it wasn’t in predicting bad events, it was in dwelling on them passively, over-estimating their power, and thinking you couldn’t cope when they came. And a mistake now would be to think that fear has more power than it does. Or that you have the power to control an emotion. These are the surprise enemies, oddly familiar to us all.

So visualize failure. Welcome your fear. Harness it as caution, make your contingency plans and build your preparedness. Then go forward with the confidence that makes you strong. Tempered with the anxiety that makes you human.

My Son Won’t Launch

October 3rd, 2009


Our adult son is getting more and more disabled with his depression. Whether he has bipolar, schizophrenia or something else, we’re not sure, but he is so isolated he’ll hardly talk to anyone. His basement room is in shambles and he smells bad. He used to talk about killing himself but now he doesn’t even talk enough to let us know if he’s suicidal. We worry too about our granddaughter who is brave, but should be a little frightened to visit him on weekends. How can we help when he is so withdrawn? This has been a recurrent or cyclic problem by the way, but more intense each time.

Read the Answer here »

Antidepressant Pros and Cons

March 8th, 2009


How can I decide whether to take an antidepressant medication?


Read the Answer here »

Is Seattle Depressing?

February 20th, 2009


I moved to Seattle to renew my life, yet I’ve been as depressed as ever. Shouldn’t I be less vulnerable in a beautiful place like this?

Read the Answer here »

I Can’t Stop Thinking About my Trauma

February 2nd, 2009


Can you explain to me why it helps with post-traumatic stress to revisit the upsetting event or scene?


Read the Answer here »

I Want a Therapist who Likes Me

January 12th, 2009


I want a therapist who likes me. Therapists I’ve had in the past seem to just seem to want to to want to get me in and get me out. Or, they’d treat me like a child, using pity and patronizing. Another one was young and inexperienced and seemed awed by me which wasn’t helpful, and I imagine others are remote and analytical, too removed.

Read the Answer here »

Is Brief Therapy not Deep?

December 14th, 2008


Why wouldn’t I want some intensive, ongoing therapy, which will instill change on a “deeper” level?

Read the Answer here »

Tom Linde M.S.W.
PO Box 28186
Seattle, WA 981189
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