Juliana Kunz, LPC

08/21/2024

Today I heard about a case where an individual physically attacked someone under the influence of delusions that developed after exposure to ketamine and psilocybin. The ketamine was legally prescribed by a doctor, probably for anxiety or depression, but between that and the psilocybin, the patient instead ended up with psychosis.

Psychedelics seem like the next big wave of mental health treatments. They may even seem like a magic bullet or a quick fix. Yes, they can can be very helpful for some people, but unfortunately they carry the risk of inducing PTSD or even permanent psychosis. More unfortunately, it seems that some prescribers, possibly out of pressures to make more money, are not adequately screening for risk factors when prescribing them. I also hear about some of them prescribing unsafe dosing regimens. I'm not against use of psychedelics in mental health treatment, but I'm against improper screening, incorrect dosage, and inadequate informed consent about their use.

As of the current time, psychotherapy is still the safest and most effective treatment for anxiety, depression, OCD, and PTSD. It is also the only effective treatment for personality disorders. If you need help finding good therapy, I have a series of posts on that topic that you can find by searching my page.

Send a message to learn more

03/23/2024

Dating and relational readiness

As a society, we do little to systematically support people's social and emotional development. As such, many adults are fundamentally unready for romantic relationships. They lack the skills and knowledge needed to have a healthy emotionally intimate relationship. Or, they may lack the skills to choose an appropriate partner. However, most of those who aren't ready are unaware of their lack of skills. They may blame the failure of their relationships on their partners or on other factors, but in reality they need therapy or other support in order to get to a place where they could have a healthy relationship.

It's not clear exactly what percent of adults are unready for a relationship, but I estimate it's probably 30% or more. And as adults get older and more of the ones with good relational skills settle into long term relationships, the percentage of single adults who are ready for a relationship decreases. I don't have any good numbers on this, but I imagine it is well under 50% by the time people reach their mid 30's. This makes dating difficult. Not only do you have to pick a partner who meshes with you in terms of interests and goals in life, but you may have to w**d through many candidates who are fundamentally unready.

Of course, none of us are perfect in relationships, but some of us have "good enough" skills and some of us, not so much. If you think your skills may not be good enough, I recommend talking to a therapist about your questions. But how can you decide if a prospective partners has good enough relational skills?

The Gottmans are famous researchers about relationships. From their research, they found 4 factors that predictably cause the failure of relationships. These are:
1. Criticism
2. Contempt
3. Defensiveness
4. Stonewalling

Without going into too much detail about these factors, let's talk about the skills and attitudes needed to avoid them. Here's a list of questions to ask yourself about a prospective partner.

1. Do they bring up their complaints and wishes in a gentle, nondemanding, and non-attacking way?
2. Do they accept differences with respect? Do they communicate hurt feelings without putting the other person down? Do they readily appreciate others?
3. Can they accept feedback without reacting negatively? Are they able to be open to influence?
4. Are they willing to discuss difficult issues, even when it makes them uncomfortable? Can they handle conflict without shutting down?

I will add a couple here that may also be useful:

5. Are they honest as a rule, or do you find yourself having to doubt their truthfulness?
6. Are they capable of expressing their emotions in general, or do they seem detached or withdrawn?

Dating is hard, but it's easier when we understand what we are dealing with. If you go into the dating world realizing that many candidates are not yet qualified for the job of romantic partner, it will make it easier to pass on these and find someone who is.

01/02/2024

The therapy relationship part 3: authority and autonomy

Twice in the last two weeks, I've had clients admit that when I ask them if they want to explore something, they don't hear it as a genuine question. One said she heard it as "this is what we're going to do now." I had to clarify that it's a real question and I don't want to explore anything they don't want to explore. Other clients openly try to get me to tell them what to do, telling me I'm "the expert."

Many of us grew up having subservient relationships with others, especially authority figures, and having to go along with whatever they said. We then expect the same type of relationship in therapy. I consider it part of my job as a therapist to help people have a different kind of relationship, where they have freedom to know and express what they want, and won't have to go along with doing things they don't want to do.

When people start to realize that I care about what they want, and don't want them to just go along with me, many are relieved. Some, on the other hand, are not. For some, going along with other people has become a familiar way of avoiding responsibility for their choices. One client, after months of trying to get me to tell him what to do, admitted that it is easier to do what I say, because if a course of action fails, then he can blame it on me. Other times, doing what others want can be a way of avoiding internal conflict over what we want. Instead of deciding between my own competing desires, I can just go along with someone else's desires. For other people, they have a habit of pretending to go along with what the other person wants, while covertly sabotaging at the same time. This is usually a relational pattern left over from dealing with a controlling parent or other figure. If a parent demands that you take violin lessons, even though you don't want to, you might halfheartedly comply but then always be terrible at the violin. That way you can get back at your parent, without getting punished for open defiance. People can then repeat this pattern in therapy out of habit.

Whether my clients are relieved to not be told what to do, or actually angry or disappointed about it, it's important for me to hold a stance that I have no right to tell anyone what to do. Why? Having an internal sense of choice and agency is a cornerstone of emotional health. Without it, we will feel stuck, and like there is nothing we can do about our problems. Therapy should be a place where people can learn to make decisions for themselves, even if it feels unfamiliar and scary at first. Holding this stance also teaches people to seek out relationships in the future where their autonomy is respected, rather than continuing to settle for relationships in which others want to control them.

12/27/2023

Covert control tactics #1: "Not understanding"

Acting like you "don't understand" can be a surprisingly effective manipulation tactic.

Let's say someone does something that is mean or that crosses your boundaries, like touching you in a way you don't like or insulting your taste in movies. When you tell them to stop, they claim to "not understand" why you're bothered by it. No matter how much you try to explain, they still "don't get it." Instead of getting an apology, you end up endlessly defending yourself or starting to doubt yourself, to the point that you give up trying to get them to stop whatever it was.

Or let's say someone asks you to do something you don't want to do. For example, your controlling ex asks you to hang out "as friends." When you say you don't want to, they say they don't understand why. No matter how much you explain, they still "don't understand." You end up doing what they asked you to do out of pure exhaustion, and possibly out of starting to doubt yourself about your reasoning.

People aren't necessarily using this manipulation tactic consciously on purpose. Not understanding and respecting that other people are separate beings who may not agree with one's thoughts and desires is an important part of having an abusive personality. And even people who aren't usually controlling may use this tactic occasionally. However, it does frequently work as a tactic precisely because it is covert. If someone openly said "I think your thoughts and feelings are crazy" or "I don't care what you feel because I will do what I want to do anyway," it would be obvious what they were up to. But saying "I don't understand why you don't like what I'm doing" tends to get the other person focused on trying to justify their reasoning, or even doubting themselves, rather than realizing that they shouldn't have to.

Fortunately, self defense against this tactic is usually fairly simple. You can say "I don't need you to understand, I just need you to stop" or, "I don't want to explain it, I just don't want to." If this doesn't work, try walking away if possible.

Can you think of another covert manipulation strategy I should write about? If so, leave it in the comments!

12/16/2023

The therapy relationship part 2: Conflict with your therapist

I was talking to a friend last week, and she was recounting that she'd had issues with her past therapists policies and ways of working, but she'd never expressed this to either one of them before leaving. She felt that since the therapist wasn't her friend, she had no right to bring such things up.

This is where the therapy relationship is a strange animal. On one hand, it's a professional relationship. Your therapist is not your friend, and if they become your friend, the relationship is no longer serving its intended purpose. On the other hand, the therapy relationship is not just another relationship with a professional, like your hairstylist or interior decorator. It is, by necessity, an emotionally intimate relationship, and as in all intimate relationships, the ability to discuss how you affect each other is a necessity. If you're not able to constructively talk about your feelings about your therapist and what your therapist does, it compromises your ability to work well together, and it may even repeat problematic interactions from previous relationships.

Many of us grew up with "my way or the highway" relationships with parents and authority figures, and we may even have endured this in romantic relationships. We had to swallow our feelings for fear of a negative reaction or disruption to the relationship. We never really learned how to handle conflict constructively. And yet, handling conflict constructively is essential to healthy relationships. Therapy should be a place where we can practice this skill and experience new possibilities. If you tell a therapist that her way of working isn't fitting for you, she may be able to work with you in a different way that fits better. A therapist might not change his cancellation policy after hearing how you feel about it, but if he understands and respects your feelings, this may lead to growth in you and in the relationship.

There is another reason to talk about feelings in the therapy relationship, besides improving the relationship and learning how to handle conflict in relationships. This has to do with transference, or the tendency to view current relationships through the emotional lens of the past. Understanding what emotions come up with your therapist can help you better understand the patterns you carry with you into other relationships. I'll write more about this in another post.

12/10/2023

The therapy relationship part I: What are we paid for?

I think every therapist has been told many times by clients that our care for them isn't real or doesn't count because we are paid to care. Most of us disagree strongly with this idea. But what DO we get paid for?

I first want to reference this article from a wonderful blogger who greatly influenced me early in my career, as she said a lot of things better than I could: https://www.whatashrinkthinks.com/blog/what-you-pay-for

But I will now give my own take on this issue.

First of all, care is something that naturally happens when an openhearted person hears about another person's inner life. It doesn't take work for me to care about my clients, it would actually take work NOT to care. So I don't think I get paid for caring.

Here are some things I do think I get paid for:

1. Education.
Not only am I still paying off loans from graduate school, but I continue to spend time and money improving my skills and increasing my knowledge. My clients in part are paying for all this time and money spent learning and improving my craft.

2. Following ethical and clinical standards.
There's a whole list of things I must do and cannot do according to legal and ethical standards and best practices of my profession. You are paying me in part to keep up with and follow those standards. For example, you can't expect your hairdresser to help you find a different one if you can't afford them anymore or they're not the right fit for you, but if you ask your therapist to help you find a different one, they are legally required to do so. Similarly, your hairdresser will probably give you a mullet if asked, even if they think it will look terrible, but if clients ask me to do things that would be against ethical standards or against what I believe to be the client's best interest, I have to refuse, even if this results in losing a client or even getting a bad review.

3. Undivided, one-sided attention.
If you talk to a friend for half an hour about your life, you can expect to have to listen for about an equal amount of time to what is going on with them. And they might check their phone during the conversation. I get paid to give you my total attention for a full hour without inserting any of my own needs.

4. Tolerating difficult behavior.
Clients can engage in some pretty frustrating behaviors, either because these are their normal habits or because the nature of therapy brings these out in them. I don't judge this, because I myself did a lot of difficult things to my first therapist, but that doesn't make it a walk in the park. When I say frustrating behaviors, I'm talking about things like the suicidal client who cancelled a session at the last minute with no explanation, leading me to frantically try to get in touch with her, then when I finally did she told me she'd cancelled because she was feeling good that day and didn't want to bring her mood down by talking about her problems. If people did this kind of stuff to me in a social setting, I would just avoid them. But when my clients do those things, I normally have to tolerate them until I can find a way to help them change the behaviors.

5. Time spent out of session.
Clients don't just pay me for the hour I'm with them. The fee also includes all the out of session time I spend on them. This can include writing notes, communicating with the client's other providers, and research or consultation with other providers about how to help the client better. When seeing kids and teenagers, it can include time spent communicating with parents. In some more complex cases, this out of session time can take more time per week than the actual sessions.

6. Business expenses
Renting an office can be a large business expenses for most therapists (around $800 to $1,500/month in my area), but even telehealth therapists have other operating costs, such as the cost of a website, HIPAA-compliant software, licensing fees, continuing education, etc. The percentage of fees that go back into business costs can be up to 50% for therapists.

7. Dealing with our own crap
Therapists can't really get away with not dealing with our own emotional issues. We can't phone it in at work. Most of us need our own therapist to help us with the emotional complexity of our work and to make sure we don't inflict our own issues on our clients. This can be quite expensive, as not all therapists are good at working with other therapists (we tend to be able to bu****it better than the average person).

So that is my list so far. If you have other ideas for what you think therapists get paid for, please post them below!

Every few years, I encounter a certain kind of wounded, fearful client who - in order to wiggle out of any vulnerability - attempts to hang onto their sense of power and privilege by insisting that the therapeutic fee makes establishes the payer as a "loser" who has to buy friendship from

11/30/2023

The unprecedented burden of modern parenting

Psychodynamic therapists talk a lot about the emotional and psychological influence of parents on their children, as though it's a universal assumption. We also talk to a lot of stressed out parents, and it mostly goes without saying that parenting is exhausting and anxiety provoking. But what if both the outsize stress on parents, and the disproportionate influence of parents on children, are anomalies in the course of human history?

Humans lived in hunter-gatherer groups for most of our history, and recent research on modern hunter-gatherer cultures shows that young children have up to 14 caregivers, mostly consisting of siblings and extended family. Furthermore, caregivers other than the mother responded more than half the time when a young child cried.

It's hard to overstate the implications of this. In clinical practice, we often find that a supportive grandparent, aunt, older sibling, etc., was able to buffer a child from the worst of abuse or neglect, such that they are much less traumatized as an adult than we would expect given the abuse or neglect they recount from their parents. We also hear from parents how much help it is to have other family members be able to take care of their children when needed, if only for a few hours a week. Imagine then, the benefits for both children and parents to have more than ten alternative caregivers available and nearby at all times! Not only would children be buffered from the negative effects of neglectful, abusive, mentally ill, or misattuned parents by having other caregivers, but parents would probably be much less likely to be abusive, neglectful, or just generally overwhelmed if they had that much support.

One takeaway here is that many of our understandings of parenting, and psychology in general, suffer from unquestioned assumptions based on our current culture. Another takeaway is that if we really prioritized mental health, our systems for supporting parents and young children would look very different. It will take a lot to overhaul those ideas and systems on a broad scale, but one immediate implication is that we could all be easier on parents, by realizing that what we generally expect from them (to care for young children in isolation without multiple other caregivers constantly available) was never expected for the majority of human history.

11/30/2023

Everyone is lovable, but not everyone is good at loving

When people come from backgrounds of abuse or neglect, whether physical or emotional, it is quite common for them to carry a deep, unquestioned belief that they are unlovable or undeserving or love. This belief was probably formed very young, and is maintained by disqualifying or ignoring any contradicting evidence. These are the clients who tend to tell me that I only care about them (or pretend to) because they're paying me. It would be too threatening to their belief system to realize that I actually do care.

What this type of person fails to realize is that being lovable is not hard, but being consistently loving is difficult. Love, in reality, depends upon embracing someone as they are and acting in a way to help the other person feel valued and cared for. This can break down in many ways. Some parents are unloving to their children because they keep hoping the child would be different: easier, less loud, better at school, more like themselves (or less like themselves!), etc. They can't let go of their fantasies to embrace the child they have. Other parents are unloving because they use the child as someone to blame for their own unhappiness or problems. Other parents have trouble showing love because they had few examples of how to listen or show affection. Still other parents have trouble loving because they are too preoccupied or weighed down with their own difficulties, like addiction or mental illness.

The main point to understand is that any child that was unloved in some way by one parent or set of parents, could loved quite easily by someone else. I saw this all the time when I worked with children. Parents would complain on and on to me about their children, and tell me how I should fix them. But when I actually met with the child, I found them quite enjoyable and easy to connect with. Or perhaps the child had some difficult behavior due to their history, but this only increased my compassion for them. The child wasn't hard to love in general, but the parent had a hard time loving them due to their own issues.

If you have an issue of feeling unlovable, you are probably agreeing with me that most people and most children are lovable in general, but thinking that you are the exception. Sure, other people are lovable even if their parents couldn't love them, but YOU are too [fill in the blank] to be lovable. You might stand back for a second and consider just how improbable this is. Why would you be so unique as to be unlovable when everyone is lovable? Is it more likely that you are unlovable, or that the people who raised you had limitations in their ability to love you?

The real reason people hold onto beliefs of unlovability is more emotional than logical. Trying to change your belief about your basic lovability can rock your whole worldview and unleash a tsunami of different emotions. If feels safer and less painful to hold onto the same belief you've always had. Other people manage to change their belief on a logical level, but still FEEL unlovable on an emotional level. I recommend finding a good therapist if you want to embark on changing your beliefs or feelings of unlovability.

11/16/2023

Accepting non-acceptance

Most of the time, accepting things as they are is one of the best ways to lower our level of distress. But what can we do at times when we just can't get to acceptance? When we can't accept something and then get frustrated or self-critical over not being accepting, it makes the situation worse.

As weird as it sounds, we can start by accepting our non-acceptance. Think of it as a way of sneaking some acceptance in through the back door. It can sound like this:

"It's okay that I'm not okay with my weight right now."

"I wish I could accept my family as they are so they wouldn't drive me crazy on holidays anymore. I accept that I have a hard time with that."

Do you have any other strategies that help you with practicing acceptance?

10/15/2023

Why therapy improves the effectiveness of antidepressants

Somewhere around 15% of Americans take antidepressant medication. But the number who go to therapy or counseling is much smaller. However, research indicates that medication plus therapy is more effective than medication alone for depression and other mental health disorders. How come?

Many people believe that antidepressants simply correct a "chemical imbalance" in the brain. However, the truth is more complicated than that. Many antidepressants have been shown to actually cause the brain to create new neurons and new connections between neurons. This has the effect of increasing neuroplasticity, the ability of the brain to change and adapt. One reason that therapy may increase the effectiveness of antidepressants is by leveraging this increased neuroplasticity to change one's beliefs and habits and learn new behaviors.

Research shows about 40% of people taking medication for depression become depressed again while still taking medication, while over 50% relapse when they stop taking medication. One reason this can happen is that people didn't take advantage of the time while the antidepressant was working to address issues and build new habits. Then when the medication becomes less effective as their body adjusts, or when they stop taking it, they are back where they started. Taking an antidepressant without going to therapy or doing anything else to create change is a little like eating more protein in order to help you gain muscle, but never actually working out.

This is why I always recommend that people taking antidepressants (whether for depression, anxiety, or both) also go to therapy. This gives you the best possible chance for long-term recovery. If you can't afford therapy, you may want to look at my previous post about how to find affordable therapy. Alternately, you could look at my post about non-therapy activities that are therapeutic. The important thing to realize is that antidepressants can make it easier to change your brain and your life, but you still have to actually change them!

10/14/2023

Self defense against verbal abuse, part VIII: ways abusers avoid accountability

This is a list of tactics (whether consciously intentional or not) that people use to avoid accountability to others or to their own conscience for their abusive behavior. Keep in mind that all of us probably do a few of these occasionally, and some of us are trying to unlearn them as bad habits that come up from time to time. The question is whether they are being used to reinforce an abusive power dynamic in a relationship.

1. Blaming the victim.
"Look what you made me do!"
"I wouldn't have done that if you hadn't..."

2. Projection.
The abuser accuses the victim or others of doing what they are actually doing.
"You're so self-centered."
"You're controlling."
"You don't care about my feelings."

3. Denial.
The abuser denies what they did or the intent behind it.
"I didn't mean that."
"I never said that."

4. Helplessness
The abuser claims they are not in control of their behavior.
"I couldn't help myself."
"It's because I have an addiction."
"It's because my trauma got triggered."

5. Counteraccusation/distraction
The abuser interrupts a conversation about what they did to bring up something someone else did in the past.
"Okay, but remember when you called me immature?!" (this happened three years ago)

6. Compartmentalization/denial through deeds
The abuser simply acts like the abuse never happened.
Example: Offering you coffee in the morning with no mention of having kept you up until 2:00 AM berating you.

7. Minimizing
The abuser acts like what they did was smaller than it was.
"Okay so my tone of voice wasn't very nice." (They were screaming)

8. Appeal to majority opinion
"Everyone I talked to thinks you're the one taking advantage of me and I shouldn't be so patient with you."

9. Splitting/demonization
The abuser acts like their victim is all bad, so the abuse is justified, even though they may act adoring towards them at other times.
"You are toxic."
"They're not humans, they are animals."

10. Stonewalling
The abuser flat out refuses to discuss their behavior.

11. Gaslighting
The abuser attempts to discredit their target by making them seem insane.
"I can't believe you think that about me."
"What is wrong with you??"
"You don't have a good memory."

12. Lousy apologies
"I'm sorry you felt that way."
Sometimes followed by:
"What?! I already apologized!"

13. Sulking
When you bring up someone's bad behavior, they act so hurt, "guilty" or miserable for the next few hours or days that it doesn't feel worth it to ever try again.

14. Self berating/making you reassure them
Rather than apologizing in a way that cares about their feelings, they say harsh things about themselves until you drop the issue or reassure them that their self judgments aren't true.
"You're right! I guess I'm just a terrible person!"
"I can never do anything correctly according to you."
"I know, I'm an as***le."

What have I forgotten? Feel free to comment on other strategies you've seen.

10/13/2023

Self defense against emotional abuse part VII: Other types of power differentials

Last time I talked about some typical sources of power differentials (money, social status, physical size, conditioning). Today I am going to look at a few more specific ones.

1. Lack of freedom to leave the situation.

This is a prime example of a power differential that keeps people in abusive situations. One person can do whatever they want because the other person feels they can't leave. There are multiple ways this can happen:
a) Threats of violence if the person leaves.
b) Financial control making it impossible financially to leave.
c) Threats to take children away.
d) Isolation or threats of isolation from friends, family, or social supports. (This is a major control strategy among cults.)
e) Ideology. For example, women are taught that divorce is evil or will make them go to hell.
f) Surveillance of the person so they have no time to make preparations to leave.

2. Difference in willingness to engage in violent behavior or hurt others

If one person is willing to threaten someone with a gun or beat the other person up (to get the upper hand and not just in self defense), while the other person's conscience forbids this, it creates a power differential.

I'm not suggesting that targets of abuse should return violence (except when absolutely necessary for self defense), but that they should feel free to avail themselves of other sources of power (police, legal representation, outside support, etc.) to the maximum extent in order to counter the power imbalance they are in.

3. Difference in manipulative skill

One person may be much better at skills of aggressive interpersonal manipulation. If one person is a master manipulator, and the other is too naïve to realize they are being manipulated, this creates a power imbalance.

Fortunately, we don't have to become good at dishing out abuse and manipulation in order to get good at recognizing and countering it.

Feel free to comment below if you can think of other situations that can cause power differentials in relationships or situations.