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  • My First Meeting with a Client

    Melissa Killeen
    Melissa Killeen

    I know every client is nervous, unsure, and very vulnerable when they first meet their recovery coach. A typical client has just been discharged from an inpatient treatment center. It may have been the outpatient coordinator that suggested the client work with a recovery coach. Or maybe it was the therapist that the client employed after discharge. A coach can be there for a client during this incredibly difficult time. Of the clients discharged from rehab, 80% relapse in the first year. Of this number, 30% relapse in the first month. Those are some distressing numbers.

    Not every client can walk into an AA or NA meeting and select a sponsor. Many have to wait a week before they even see their therapist for the first time or move into an Intensive Outpatient Program. Wouldn’t it be nice if someone was there to support this client as they move from the safe environment of an inpatient treatment center back to the very scary environment that they may blame for sending them to treatment in the first place.

    My first meeting with a client is focused on establishing trust. Yes, hoping the client has trust in me as a coach, but also for me to establish the level of trust I have in that client. I ask the client to tell me the story of when they first picked up a drug or drink. I ask them their first childhood memory. We talk about expectations, and deliverables. How they think coaching will help them, and what I expect of them.

    Many of those expectations are the business side of the recovery coaching relationship. For example: Don’t be late for an appointment; if they miss an appointment they pay for it. Other expectations are stated to establish firm boundaries, such as every face-to-face meeting I have with them will include a toxicology screen. The client must email or text me every day and call me when they are scheduled to call since the client has prepaid for this. I also lay out the ramifications if the client slips. I ask them outright what they think will happen if they slip.  Every client thinks I’ll drop them, cold, if they slip. I tell them that a slip is a learning experience and research shows that everyone will slip. But it is the full blown relapse we want to avoid. That’s why I will stick with the client through thick and thin. Asking, what have they learned? How will they change? Next time, what will they do differently?

    After the tox screen I give the new client a Life Orientations Survey, which is a behavioral analysis. This is so I have a sense of what kind of behavior the client will display. I also request a spouse or partner take the survey. I request that the spouse take this behavioral survey so I can coach the client on how to deliver messages to the spouse in a way that the spouse can hear them.

    After finishing up the negotiations on the monthly schedule and fees, I usually exit within an hour or an hour-and-fifteen minutes with a check for prepayment of next month’s coaching engagement.


    If you are interested in purchasing Melissa Killeen’s new book, click below.

    Recovery Coaching
    A Guide to Coaching People in Recovery from Addictions

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  • Guilt = Good, Shame = Bad

    Shame neither encourages nor motivates positive behavior change.

    Published on January 6, 2014 by Robert Weiss, LCSW, CSAT-S in Love and Sex in the Digital Age

     Is Feeling Shameful Healthy?

    Over the past few decades, psychotherapy has looked at the emotional concept of shame. In particular, John Bradshaw, Pia Mellody, Claudia Black, and Pat Carnes have dissected shame, breaking it down into two main categories: healthy shame and toxic shame. In their world, healthy shame describes the feeling of: “I have done something that goes against my core values and beliefs, and I feel badly about that,” while toxic shame describes the feeling of: “I am inherently flawed and defective and therefore unworthy of love and belonging.” Basically, this is the difference between “I did something bad” and “I am bad.” When properly defined and understood, these psychiatric terms are quite useful, but, frankly, the people experiencing these feelings are rarely able to distinguish between the two in the heat of the moment, and many have demonstrated an uncanny knack for turning healthy shame into toxic shame in the blink of an eye.

    More recently, author and clinical educator Dr. Brené Brown has sharpened the focus on these very different yet easily confused concepts by re-labeling them in ways that feel not only more accurate but much less murky and open to interpretation/confusion. What has heretofore been described as toxic shame is what Brown merely calls shame. And she calls healthy shame what it actually is, which is guilt. Brown also makes it clear that feeling guilty can absolutely be a healthy thing, as this emotion can and often does lead to positive behavior change: “I feel badly about my behavior, and I’d like to fix the situation and behave differently in the future.” Shame, on the other hand, is incredibly unhealthy, causing lowered self-esteem (feelings of unworthiness) and behaviors that reinforce that self-image: “I am a bad person and there’s nothing I can do about that, so I might as well continue behaving badly.” In short, guilt is potentially a very healthy feeling, and shame is not.

    Guilt: Sharon is shopping for Christmas ornaments. There are two similar ornaments available from the same company — one for $10, and the other, adorned with real crystals, for $60. She surreptitiously swaps them, slipping the more expensive bauble into a $10 ornament’s box. Then she takes it to the counter and pays $10 for it. Later, as she’s hanging it on the tree, she feels terrible. She tells her husband what she’s done, and he suggests she return the ornament to the store and make a $50 donation (the price difference) to a local charity. She takes his advice and feels much, much better. Lesson learned.

    Shame: Sharon is shopping for Christmas ornaments. There are two similar ornaments available from the same company — one for $10, and the other, adorned with real crystals, for $60. She surreptitiously swaps them, slipping the more expensive bauble into a $10 ornament’s box. Then she takes it to the counter and pays $10 for it. Later, as she’s hanging it on the tree, she feels terrible. She realizes that she is an awful human being and she doesn’t deserve the love and/or respect of her husband and children. Each evening thereafter she laces her eggnog with copious amounts of brandy and stares at the ornament, viewing it as proof that she is a bad person.

    In the examples above, we see that the same basic occurrence can lead to either guilt or shame, and that guilt informs a healthy response (talking to a loved one and making amends) while shame drives an unhealthy response (keeping secrets and drinking heavily).

    The Prevalence of Shame in Clinical Practice

    Most people enter therapy because they feel depressed, or they’re riddled with anxiety, or they’re constantly angry, or they’re cheating on their spouse and they can’t seem to stop, or they’re drinking too much and their life is out of control, or whatever. In other words, people typically walk into a therapist’s office because they have a specific problem and they want help with it. Usually a person’s presenting issue is relatively concrete in nature, meaning it fits into a defined and recognizable psychiatric diagnosis (major depression, post-traumatic stress disorder, substance use disorder, etc.) Part of a therapist’s job is addressing a client’s presenting issue in the moment; but that’s only part, and sometimes just a minor part. Usually the real work of therapy is deciphering the underlying emotional triggers that lead to the presenting issue, and for most clients (those without profound mental illness or a serious form of psychosis) a primary underlying emotional trigger is very likely to be shame, shame, and more shame. So even though most people arrive in therapy looking for help with depression, anxiety, and the like, long term healing nearly always requires shame-focused work.

    In my practice, I know that shame is an issue as soon as a client starts talking about the “negative tapes” that play in his/her head, or the “committee” that meets between his/her ears and discusses his/her unworthiness at every turn, or the gremlins that live in his/her skull and shout, “Well, you really screwed that one up!” Essentially, these tapes/committees/gremlins are shame in action — the primary way in which a person’s inherent belief that he or she is defective, flawed, bad, not good enough, and therefore not deserving of love and happiness is reinforced over and over again. Usually these shame messages are introduced very early in childhood via neglectful and/or abusive and/or inconsistent parents, siblings, teachers, and the like (though pointing this out early on in therapy usually does little to help a suffering adult client). The truly sad part of shame is that shame-based people are, at best, likely to have less rich, less rewarding, and less interpersonally meaningful lives than they’d like. And at worst they become mired in depression, anxiety, addiction, violence, isolation, dysfunctional relationships, and various other manifestations of deep emotional pain.

    Unfortunately, as mentioned above, feeling shame neither encourages nor motivates positive behavior change. In fact, Dr. Brown’s extensive research into the issue has revealed an inverse relationship between shame and the belief that one is capable of changing for the better. Her research also found that shame-based people often behave in ways that reinforce their shame. In other words, shameful feelings lead not to connection and reaching out for support, but to ill-advised behaviors that bolster feelings of shame. This creates a downward spiral of bad behavior, shame, more bad behavior, more shame, etc. So when people behave in ways that go against their values, feel badly about it, and work to behave differently in the future, shame is not the motivation. Guilt is. So, once again, guilt is potentially a very useful and socially informed emotion, while shame is not.

    Managing Shame

    Sometimes, by the time a person walks into a therapist’s office and asks for help, shame is the driving force in his or her life, manifesting negatively through depression, anxiety, addiction, and numerous other unhealthy feelings and behaviors. For these individuals, regardless of the presenting issue, long-term healing by necessity involves addressing and overcoming shame. In 12-step recovery groups this work occurs in steps 4 through 9, while in therapy settings it usually happens through a specific shame reduction methodology. At Elements Behavioral Health treatment facilities, where I am Senior Vice President of Clinical Development, we are currently implementing Dr. Brown’s recently developed Daring Way™ shame resilience curriculum, using it in conjunction with 12-step work and other practices when appropriate.

    Whatever approach is taken, developing shame resilience is a process of reaching out to supportive others by sharing one’s story and experiencing empathy. Shame thrives in the dark, and it withers in sunlight. Talking about shame with supportive and empathetic others kills it, while keeping it a secret helps it grow. In fact, one of Dr. Brown’s most important research conclusions is that not discussing a shaming event can be more damaging than the actual event. So keeping secrets about shame can actually be more damaging than the shame itself. But when people share about their most difficult experiences — the experiences that leave them feeling defective and unworthy — with caring, supportive, empathetic others, even long after the fact, they feel better. Their stress levels decrease and their mental and physical health improves. It’s just that simple.

    Easier Said than Done

    Unfortunately, opening up about shameful topics and experiences is not an easy thing to do, as shame is something most people try very hard to avoid feeling, owning, acknowledging, or addressing. Simply put, the natural reaction to shame is to hide it. Because of this, shame-based people sometimes isolate and keep secrets, or they worry more about looking good than feeling good, or they become people pleasers, or they busy themselves with the problems of those around them to such a degree that they never have time to look at themselves. Other times shame-based people can become aggressive, either verbally or physically (using shame to fight shame), or they simply “numb out” and avoid all feelings via addictive substances and/or behaviors. Most shame-based people actually rely on a combination of these and other unhealthy coping tactics depending on the situation. Unfortunately, the defense mechanisms that shield people from shame also tend to shield them from meaningful interpersonal connection.

    Needless to say, talking about shame can be incredibly scary. For many people, especially those who do not have a supportive atmosphere at home, it is important that “shame sharing” occurs in innately empathetic settings like therapy sessions (individual and/or group) and 12-step support meetings. The good news is that talking about shame helps to shift this highly toxic emotion into something that can be viewed more neutrally. Over time, shame-based people are able to progress from “I am bad” to “I did something bad” or “Something bad happened to me” or some other less damaging self-belief. When the shift is to a guilt message, such as “I did something bad,” this can serve as powerful motivation for positive behavior change. Eventually, instead of existing in a downwardly pointing shame spiral, shame-based people can spiral upward toward happiness, improved self-esteem, and healthy intimacy.

    If you are interested in reading more on this topic, I strongly suggest Dr. Brown’s books Daring Greatly and The Gifts of Imperfection.

    Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and The Sexual Recovery Institute in Los Angeles. Mr. Weiss has also provided clinical multi-addiction training and behavioral health program development for the US military and numerous other treatment centers throughout the United States, Europe, and Asia. An author and subject expert on the relationship between digital technology and human sexuality, he has served as a media specialist for CNN, The Oprah Winfrey Network, the New York Times, the Los Angeles Times, the Times of London, and the Today Show, among many others.

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  • Don’t Ask, Don’t Tell – The Hidden Life of Family Secrets

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    Dr. Ron Cohen

    This guest blog was written by Dr. Ronald Cohen, a psychiatrist from Great Neck, New York, specializing in Family Systems.

    Family secrets impact individuals, and family functioning. Dr. Ronald Cohen discusses four types of family secrets: essential, sweet, toxic and dangerous.

    “All human beings have three lives:
    public, private and secret.”
    —Gabriel Garcia Marquez

    In life, we must respect all three.

    What is life like growing up in a family where one of the most firmly adhered to rules is “Don’t Ask, Don’t Tell?” What do you do with significant information when you are inhibited from sharing it, the road block being either in yourself, in your family relationships, or in larger societal constraints? How is a secret different from healthy privacy, a safe and secure “Room of One’s Own?” When is a secret not a secret?

    Evan Imber-Black, PhD has spent a professional lifetime investigating types of secrets and their impact on individuals and family functioning. She separates secrets into four, not necessarily distinct, categories: essential, sweet, toxic and dangerous.

    Essential secrets create necessary limits and boundaries around a family and its sub-systems, delineating couples, children, parents and friends. They enhance closeness and connection, are protective of self, others, and relationships. By their very nature, essential secrets must be honored. Sharing without permission and/or consent creates devastating attachment injuries and violations of trust. Essential secrets are woven into the “second family” culture of adolescents and young adults. Honestly now, how much did we want our parents to know about our experimentation and indulgence in sex, drugs and rock’n’roll?

    Sweet secrets are time-limited, created for someone else’s good, and usually have positive outcomes for the entire family. Sweet secrets are created for the fun of a surprise such as gifts, parties, unexpected visits and other celebrations.

    Toxic secrets are often long-standing and damaging to relationships and personal well-being. They become harmful and destructive when they involve keeping information from others that they have a right to know. Over time, toxic secrets corrode relationships, destroy trust and create otherwise unexplained symptoms and increased anxiety. Abundant non-productive energy is expended on maintaining who’s in the know and who is outside the cone of silence. Toxic secrets include current extramarital affairs, irresponsible gambling, concealed illness, and undisclosed plans for divorce as well as an individual or family history of abortions, adoptions, DWIs, psychiatric hospitalizations, and incarcerations.

    Dangerous secrets put individuals in physical jeopardy and/or debilitating emotional turmoil. They include plans for suicide and violence, life crippling drug and alcohol dependence, rape and incest, abuse and child neglect. Dangerous secrets require immediate disclosure and intervention to ensure safety and protect the innocent.

    Secrets occur in context and live not just inside one individual but exist within the entire family system. For this reason the category and function of a secret depends on its context.

    Embedded within, and extending over these categories is the concept of self-secrets, which are shared with no one (paradoxically the concept of a shared secret is not an oxymoron), and engender excessive guilt, shame, and embarrassment as one does not get realistic feedback on the consequences of the behavior and/or its disclosure. Self-secrets include concealed eating disorders (which can also be toxic or dangerous) and the shame of involuntary corporate downsizing.

    The safe disclosure of toxic secrets and repair of damaged relationships require careful planning and deliberate behavior. Because of their long standing nature, there is usually no immediate requirement to reveal a toxic secret and there is time to consider how to open the secret in a safe way. Coaching from a well trained Bowen Family Systems Therapist can help one balance caution and candor when evaluating the potential positives and negatives of revealing the secret. It can also help determine where, when, how, and to whom the secret should be disclosed.

    This guest blog was written by Dr Ronald Cohen, a psychiatrist from Great Neck, Long Island, New York, specializing in Family Systems. To contact Dr Cohen, please visit his web site: http://www.familyfocusedsolutions.com/ or at his email: RBCohenMD@FamilyFocusedSolutions.com or by phone: 516.466.7530.

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