It’s All In Your Head

This is one in a series of short discussions of the myriad ways our society in general, and the mental health field in particular, fail to understand the veteran culture. That there is a such a thing as a “Veteran Culture” as something unique is itself a hotly contested when not summarily dismissed concept.

One of the most satisfying things I get to experience as a therapist is hearing, “this is not what I expected in therapy. If I had known…” In that vein, I want to break the fourth wall and explain what actually happens, or at least is supposed to happen in therapy. This is the way I operate but what I do, my orientation of cognitive-based modalities, is the most common therapeutic orientation of therapists. Because it works.

When meeting a new client, I have a spiel. My concentration is trauma, and much of my caseload is veterans and first responders, populations not known for having a positive opinion of therapy. I’ve learned this opening is necessary to level the playing field, so to speak. Many therapists, even those with a cognitive orientation, usually begin with, “What brought you in?”

If I went to someone and they started with that inane question I’d probably walk out. My spiel lets those who, with justification, have a strong reluctance to engage in therapy get the lay of the land. Often, the only reason they are sitting in my office is the wheels have, or are about to, come off. So, my little speech is an introduction to how I view therapy, mental health and, well, life.

Right off the bat, I explain I have little to no information about them beyond “seeking help with stress” or whatever they said when they called for an appointment. This is only fair as they really don’t know anything about me either, and that can be daunting. I explain what my license, education and orientation are: I’m a Licensed Professional Counselor, my degree is Clinical Psychology, and I work from a very science and evidence based, cognitive orientation. I don’t use words like “mindfulness”, though we will do what that term is supposed to accomplish.

Then, we’re going over the limits of confidentiality, meaning harm to yourself or others, or abuse, neglect or harm to a vulnerable person, i.e., a child, the elderly or the disabled. Other than that, confidentiality is sacrosanct. Of course, I have a supervisor and someone owns and therefore oversees, to some extent, the group practice but the conversations I have with them are about professional development for me, gathering resources, etc.

I happily report I have never been forced to break confidentiality. If I ever do, it won’t mean I’m automatically calling 911 or that men with one-size-fits-all white jackets are coming to take you away. Then there’s a bit of business, like the no-show fee that is pretty steep, but with the caveat that I can waive it under special circumstances. I make it clear it is not about the money, it is about despite being part of a decent-sized practice, most of us have full caseloads. That means if you’re not going to use this hour, someone else who wants our services can’t either.

Then, my personal statements come. Such as, I am very direct and will challenge you. It is akin to physical therapy in that it is hard work. If it is not hard work, there is no point to it. It is neither bragging nor a false, smarmy fishing for compliments to say I am very good at what I do. I openly admit I can be off base, so feel free to call me on it and I’ll humbly take your criticism.

I thoroughly enjoy the reactions I get to one of my favorite lines, “If you are looking for someone to hold your hand, to make you feel all warm and fuzzy, get a lap dog.” Then, they tell me why they are sitting in my office.

Every person has a right to know what they are paying for, and to whom they are divulging the things that go bump in their mind’s night. In the last few minutes, we wrap up with what they can expect to happen and how.

I get right down to it by addressing the elephant in the room, the thing most are thinking and fearing but don’t say, “It’s all in my head”. Um, duh? Our brains are in our heads. Except for those special souls whose brains reside where the good Lord split them. Or other areas in that general region. But I digress. And no, I have not said that to a client. Not explicitly.

Mental health is all in your head, which is attached to your body. It’s biology. More accurately stated, it is neurology. Different people experience mental health discomfort primarily in one part of the body, the so-called somatic symptoms. Paying attention to where in your body you feel it first is an important conversation. Think of it like an engine warning light. Ignore it long enough and the vehicle stops functioning.

Having a bad day and your chest tightens? It gets hard to breathe? Your neck muscles tense? You grind your teeth? Or your stomach feels like it’s in knots, and sometimes those knots suddenly loosen and you’re doing the butt squeeze trot to the nearest, hopefully private, toilet? People are astounded to learn that the gut – the enteric nervous system – contains five times more neurons than the brain.

That said, it is actually all in your brain. That’s where thoughts come from. Think of a thought as a noun, a thing. It is not the sum total of you but it is a significant part of how you experience life. Thoughts influence emotions, which impact our behavior, which affect how we feel in our bodies, which create thoughts, etc., etc., etc. Each of these four parts influence the others, so adjusting any one means a change in the others.

By the time someone is sitting on my couch, and yes, I have a couch (actually a sofa) but also a nice, comfy Barca as well as a desk chair – sit wherever –, there is something going on in you that is not comfortable. So, if you want to start with thoughts or emotions, or you’re here because the ER doctor told you to come after the EKG said it’s not, thankfully, a heart attack, it’s your choice.

Where ever someone starts, the most common complaint is anxiety, usually expressed as thoughts that won’t stop, in dreams or while awake. So, we talk about how it is logical and expected to get anxious about being anxious and about how long-term anxiety exhausts us. That exhaustion combined with the anxiety is depressing to live with which makes us depressed about how we don’t have the energy to do the things we used to and anxious about the things we need to do … and now we’re spiraling.

In the most general terms, I explain that our actions and reactions, particularly the less than healthy ones, served a function at some point. That function was survival.

We say humans are creatures of habit. It may be better envisioned as our brain being a creature of habit serving the primary goal of all organisms, survival. When faced with a discomfort, a challenge, a danger or threat, the brain takes special note of whatever we did in response. The next time there is a discomfort, challenge, danger or threat, the brain says, “I know! I know! This is what to do!” And the brain is right, at least from a strict survival perspective. The proof is we are alive to face this new discomfort, challenge, danger or threat.

Each thought both forms and follows a neural pathway. Each time that neural pathway is used, it is reinforced. Before we know it we have entrenched patterns, most of which are well outside our awareness. But that doesn’t mean outside of our control. Because we can talk about, challenge, and rewrite the script that are the thoughts that influence emotions, which impact our behavior, which affect how we feel in our bodies, which strengthen or weaken those neural pathways. Talk therapy is the process of how we can alter those thoughts, even when those thoughts are the result of memories we’d rather not have.

Neural connections that are weakened and eventually no longer used are flushed away by the cerebrospinal fluid. That is literally it’s function. Sometimes, however, the system stops working. We have so much wadded up, it backs up and overflows the rim. Piles of anxiety. Liquescent depression. The lingering scent of nightmares that cling as intrusive thoughts.

Therapy is neural Draino. Sometimes a plunger or auger is needed as well. So, that’s me. That’s my job. I’m a brain plumber. Everyone needs a plumber once in a while. You hate having to call the plumber, but if you don’t, you will be clogged with crap.

If you are struggling, reach out to a buddy or call 988 and press 1 if you want to identify as a veteran. If you are not struggling, reach out and be the buddy to someone else.

Category: Mental Health