Chris Nufer

[talktochris]

How To Rewrite The Bad Stories You Tell Yourself

Chris Nufer, a Narrative Therapy coach in New York City, discusses how an increasingly popular form of therapy takes special advantage of our natural tendency to organize how we live using stories.

When people have problems, Narrative Therapy simply asks you to tell a story about your problem. Sounds easy. Stories are how we live. They pour out of us almost without thinking. Just listen to someone who has been pulled over by the police or a student who was late for an exam.

The narrative therapist’s job is to listen to a client's story, explore what the client has said and in the process help find the internal or external resources necessary to overcome the obstacles they face.

One way to do this is to help clients externalize their problems. This occurs when the therapist helps the clients describe a problem as though it were a character or event in their lives. Once this story has been told, the therapist and client take the opportunity to question certain plot twists, options and outcomes. In the process, the therapist helps clients work with their story lines to rewrite the causes and the outcomes of their problems.

When I’m with a client, I’m listening to the story but, because of my REBT training, I’m listening for clues about how rigid or resilient they are. I’m asking them to flesh out their thinking about a problem in a way they wouldn’t normally. I’m actively challenging them to imagine possibilities and not to think the stories they are telling themselves are written in stone. 

The final component of the narrative therapy engagement is the story the therapist writes back to the clients.  This is the part I love about this approach. Michael White and David Epston, the fathers of the current person-centered approach to narrative therapy, established the need to document the engagement—much the way a story documents or at least represents events, emotions or personal actions in our lives. For White and Epston, documentation takes the form of a letter.  It is in these letters that the real magic of this therapeutic approach takes place.  

The final letter may be the story of the mistakes they discovered together and also about the progress they made. It may tell the story of decisions the client may be thinking about making or things they feel are missing in their lives. Whatever the plot twists, the letter is a story about them. And, more than that, it is also a story about them finding the tools and the confidence to get their story straight.

  Chris Nufer speaks regularly at Narrative Therapy workshops. He is available as a presenter for groups interested in learning more about “The Stories We Don’t Know We Tell Ourselves"  He is one of the founders of a structured life review practice in Manhattan. Contact: [email protected]

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New York’s SAGE Center – A Unique Oasis For Older LGBT Adults

On a recent visit to the first social space developed specifically for older LGBT adults, Chris Nufer, a therapist in New York City, discovers a living testament to the power of acceptance and community

  I recently had the opportunity to visit The SAGE Center on Seventh Avenue in Manhattan. SAGE is an acronym for Services & Advocacy for GLBT Elders. The Center opened in early 2012 and now serves as a welcoming social hub for older lesbian, gay, bisexual and transgender (LGBT) adults age 60+ in New York City. It is the first center of its kind in the country. In addition to providing meals, social services and educational programming for LGBT elders, it offers two things that are rare in the lives of many of the people it serves—safety and validation.

  My experience working with older LGBT adults has taught me (and research confirms this) that the single biggest threat to their health is isolation.  They often don’t take advantage of available health care and social services because they fear judgment, rejection, or ignorance on the part of medical and mental health practitioners.  As a result, older LGBT adults often find themselves “re-closeted” and avoid openly discussing their sexual orientation or gender identity.

  Old age often hits LGBT seniors hard. In a recent panel discussion at the E/Quality Care Conference, Suzy Ritholz, Director of Social Services for S.A.G.E., pointed out that older LGBT adults suffer from depression at twice the rate of the general population and have significantly higher incidences of disability as they age. She suggested that the long-term effects of living with stressors such as discrimination, identity fragmentation, and the threat of violence may lead to increased risk for diabetes, cancers and other chronic illnesses. There are very few mental health practitioners trained to work with clients suffering from the kind of chronic Post Traumatic Stress Syndrome caused by living in a hostile environment most of their adult lives. Those that are still grapple with understanding the developmental struggles faced by people for whom aging has an even more severe social impact than those in the mainstream.   

  The SAGE Center aims to provide an antidote by offering acceptance, validation, enlightened care providers, and sensitivity to the social, emotional and medical concerns of sexual and gender minorities. When visiting the Center, one can’t help but be impressed by the array of programs and information designed to provide community members with tools to cope with stress and trauma related to family and work issues, alcohol and drug use, and especially HIV. But most of all, SAGE offers older LGBT adults the opportunity to meet with people who have had similar life experiences and views. All you have to do is drop by for dinner and a movie one evening to see the benefits can be enormous.

  Find out more about the SAGE Center here: http://www.sageusa.org/thesagecenter

                                                                                                                                             Chris Nufer  

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Motivational Interviewing: It’s All About Creating Change

Chris Nufer, a therapist in New York City, looks at Motivational Interviewing, how it developed and some applications outside of addiction counseling. 

I had the opportunity to get some insights into the techniques of Motivational Interviewing last week at the meeting of the Metro Chapter of the New York Mental Health Counselors Association of which I am a member. The guest speaker was Obie Nichols, a long-time Motivational Interviewing instructor and an acknowledged expert on the topic. 

Motivational Interviewing is a directive counseling style that is all about creating change. It works on modifying clients’ behavior by helping them explore and resolve their ambivalence. Using empathy, encouraging self-motivation, and diffusing resistance, the counselor helps clients develop their coping skills. The goal is to enable people to realize the discrepancy between behavior that helps them meet their personal goals and behavior that doesn’t.  Mr. Nichols pointed out that motivation for change occurs “when people see the gap between where they are and where they want to be.”

The technique has become the therapy of choice for many addiction counselors and, when combined with education, harm-reduction approaches, social support and (occasionally) Cognitive Behavioral Therapy, it has been proven effective in many cases, especially in the area of relapse prevention.

Motivational Interviewing is based on Abraham Maslow’s Hierarchy of Needs and his concepts of “self-actualization” and “self-transcendence.” Maslow’s theory is that at the most basic level we need food, water, sex, sleep and oxygen.  After taking care of those needs, we turn our attention to finding shelter and safety.  When those needs are satisfied, we look to meet our social needs—things like love, belonging, friendship, and intimacy. After that, we are driven to satisfy our need to think well of ourselves and strive to build self-esteem, achieve things, gain courage and confidence, and obtain the respect of others.

Once you have secured these needs in your life, then you are in position to begin to think about reaching the “apex” which is self-actualization. Self Actualization is the state where your needs for order, creativity, problem solving, are met and you realize your fullest potential. Self-Actualization was the apex of the hierarchy. At least until Maslow added the need for “Self-Transcendence.” In the Self Transcendence area, your spiritual needs are met. These needs are beyond and outside the self and are usually concerned with feeling a part of you will live on after you’re gone. People in this stage are concerned with issues such as success of their offspring and leaving a legacy.

Maslow believed that society’s full focus should not be on creating people who can work and fight, but instead on creating people who are self-actualized.  If people have their needs met at that level, he reasoned, then everything else would take care of itself.

With Maslow’s theory in mind and Motivational Interviewing techniques in hand, the therapeutic possibilities outside addiction counseling are interesting. It helped one member of a couple I worked with recently understand why she was upset with her partner and how to create change when she was certain it was impossible.

For teenagers who feel forced into therapy by their parents, it is an effective tool for building a therapeutic alliance under difficult circumstances. I have also seen MI break therapeutic logjams in cognitive-behavioral treatment for depression and anxiety. I also encourage parents to acquaint themselves with Motivational Interviewing. It can come in handy when your teenager begins acting out or shutting you down.

For those who want more information, Mr. Nichols suggested “Eight Stages In Learning Motivational Interviewing,” an article by Miller and Moyers in the Journal of Teaching in the Addictions. Also Monty Roberts’ instruction manual, “OASAS Training of New Trainers and Supervisors.”

                                                                               - Chris Nufer

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Chris Nufer, a therapist in Office of Dr. Michael DeMarco in New York City, stumbles on a real life example of how sticking blindly to our beliefs can prevent us from getting the satisfaction and happiness we want.

I had a conversation with my son yesterday about his firm conviction that...

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E/Quality Care Conference Promotes Improved Mental Health Services For LGBTQ Community

Chris Nufer, a therapist in New York City, discovers that providing quality mental health care starts with developing cultural competency and learning to ask the right questions.

Last Wednesday, I had the opportunity to attend the E/Quality Care Conference at the Pennsylvania Hotel in Manhattan. The all-day event, which was in its third year, is held to educate mental health providers about policy updates and care strategies for the LGBTQ community. The workshops provided terrific insights into the unique mental health problems that the lesbian, gay, bisexual, and transgender population brings to treatment.

A key part of the discussion for me was how to build a therapeutic alliance with older individuals whose experience with the mental health system has generally bred nothing but mistrust and fear.

It was pointed out that a lot of older members of the community still remember that up until 1973 "homosexuality" was classified as mental illness by the American Psychiatric Association. Others were deeply wounded by the intense homophobia that accompanied the AIDS epidemic in the seventies and eighties. Today, many still face blatant institutional disregard for their chosen or sexual preference or gender identity when they seek medical care or community services.  There are still practitioners that promote the discredited “reparative” therapies. The DSM still pathologizes gender-identity issues. Though it is changing, there are still many culturally insensitive social workers, psychologists and medical doctors who feel entitled to embrace homophobic beliefs on religious grounds. 

Delivering quality community mental health care under these circumstances is difficult. The presenters pointed out that the LGBT population has higher rates of disability and experience two times the average rate of depression. Research has now shown that coming out is good for your health if you have a good support system in place. The reasons for this are many. There is the emotional cost of hiding, the psychic stress of feeling isolated and rejected, the trauma of systemic discrimination, or the very real threat of violence and exposure on a daily basis.

The attendees learned that there are three important steps in improving the quality of mental health care for this population. First, mental health providers need to increase their cultural competency around LGBTQ issues including the presence of trauma or abuse in daily life.  Second, they need to be able to ask better questions during the intake and assessment process. This includes having a clearer understanding of how to approach unique relationship and identification issues sensitively. And finally, we need to understand that sexual orientation and gender identity play a key role in a person’s biopsychosocial make-up and best practices dictate that both should be validated. Sexuality is as important as religion, race or ethnicity for other minorities and can’t be disregarded. The consensus at the conference was mental health providers who avoid discussing these issues with their clients are doing them a grave disservice.

To make a difference the level of mental health care to the LGBTQ population, we need to address community-specific issues such as identity fragmentation; provide clients with the tools to cope with intolerance, stress, family or work issues or the trauma of multiple oppressions; and provide support to deal with HIV, substance abuse and other physical health issues.

The Rainbow Heights Club and the other sponsors should be commended for offering this event free-of-charge. Thanks go out as well to the speakers and panelists such as Suzy Ridholz of S.A.G.E and Barbara Warren of Beth Israel Medical Center for donating their time and expertise. If the mission of this conference was to offer non-LGBT providers of mental health services the tools and skills necessary to work effectively with LGBT mental health consumers, then from my perspective it was a huge success.

Here is a link to the conference website and many of the resources provided to attendees: http://www.equalitycare.org                              

                                                                                           -Chris Nufer

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Chris Nufer, a Mental Health Counselor in New York City, provides a brief summary of his approach to therapy with individuals, partners and families.

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What Are Experts Saying About Healthy Sex And Aging?

A therapist working with older adults in New York, searches for answers to questions about issues of sexual rights versus sexual safety and finds the answers are still hard to come by.

by Chris Nufer

I had the opportunity to attend a program sponsored by the American Society on Aging on the topic of Healthy Sexuality and Aging. The seminar presented by the LGBT Aging Issues Network was led by Hilary Meyer, the director of the National Resource Center on LGBT Aging, Karol Markosky from the Council of Senior Centers and Services of New York City (CSCS), Robin Dessel, a well known advocate for elder rights, and Mark Brennan-Ing, a Senior Research Scientist at the AIDS Community Research Initiative of America (ACRIA)

The agenda included addressing truths and myths about sexuality and aging, sharing the recent research findings on the sexual health of older LGBT adults, discussing the spread of sexually transmitted diseases in the older adult population and debating the current thinking on the critical issue of consent to sexual activity for people with various stages of dementia.

The panel presented issues related to aging from three different perspectives: from within a continuing care environment, from the point of view of a community-based organization and through the eyes of a cutting edge researcher on LGBT older adult sexuality.

The discussion began with a conversation about the current attitudes around sexuality in our society today, specifically Ageism and how it breeds an atmosphere of misinformation.  Too many people prefer to believe that older adults are asexual.  “No one wants to imagine their mothers and fathers having sex,” was one comment.  This led to a discussion of what “sex” is.  For many in the general population, it is defined solely as the act of vaginal intercourse performed in the name of procreation.  However, a more progressive definition that takes into account a broader spectrum of possibilities, defines “sex” as encompassing any number of intimate behaviors. Studies show that 88 percent of older LGBT partners (65+) were sexually active in the last year. This statistic highlights the fact that the need for intimacy doesn’t fade with age.  One panelist summed up the discussion by saying that “There is no end to sexuality. Granted your sex life in your twenties is going to be different than when you are seventy. But just because you’re older doesn’t mean you aren’t interested in touching and other forms of intimacy.”

  The discussion concluded with conversations about two topics that are on the minds of anyone working in the area of aging and sexuality: educating older adults about safe sex practices and addressing the issue of sexual rights versus sexual safety when it comes to older adults with various stages of dementia.  Regarding the former, it was generally agreed that introducing making better information about the dangers of STIs more available to the older adult population should be a priority for therapists, educators, caretakers and administrators.  Concerning the issue of protecting older adults’ rights in general and concerns about mutual consent in particular, definitive conclusions were a little more difficult to come by. The participants were reminded that until recently exhibiting sexual desire in advancing years was seen as a symptom of dementia. Everyone concurred that individual rights should not be affected by age.  However, as older adults transition into more and more clinical environments, what is clinical and what is personal becomes blurred. The consensus was that it should be the goal of clinicians to develop more effective assessment tools to determine when and if certain individual levels of mental capacity are diminished.  At the same time, it is critical to make caregivers more aware of how Ageist attitudes often proliferate in the guise of patient safety and unfairly intrude on older adults’ rights to privacy and intimacy. 

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How Resilient Are We?

A therapist in New York working with older adults looks at how people react to loss and realizes that in the end most of us do a pretty good job of coping.

By Chris Nufer

While providing crisis counseling to people who suffered significant losses in the aftermath of Hurricane Sandy, I began to wonder what the natural response is to losing someone (or something) we hold dear, especially among the older adults I work with.

  First off, it’s well known that all of us face a mounting number of losses as we get older-- Parents and friends pass away, careers end, bodies wear down, and our minds aren’t as sharp as they once were.  How we respond to those losses varies depending on a number of factors.  A socially (and clinically) accepted response to a significant loss is profound sadness.  But how long that sadness lasts and how it affects the way we function on a daily basis reveals a lot.  First a few quick definitions: Bereavement is the state of having suffered a loss. Grief refers to how a person deals with loss. Mourning has to do with society’s rituals surrounding the loss, such as funerals and burial rites.

  The Handbook of Assessment in Clinical Gerontology edited by Peter A. Lichtenberg, cites a longitudinal study by Zisook, Paulus, Shuchter and Judd of how prevalent depressive disorders are after the loss of a loved one.  The results showed that 20 percent of the participants met the criteria for major depressive disorder two months after the loss.  After 13 months, that figure fell to 12 percent. After 25 months, it dropped even further to only 6 percent.  At the same time, during all three periods, the study showed that nearly half the participants displayed no symptoms of depression, major or otherwise. These people coped.  They may have been very sad, but they processed the loss and moved on. 

  How did they do it?  My guess is that they had positive social supports that gave them a time to grieve and at the same time signaled them when it was proper to stop grieving.  Furthermore, since having depressive symptoms or other problems prior to a traumatic loss is a prime indicator of whether or not a person will become depressed when a loss occurs, it’s safe to assume the resilient ones were not prone to rumination, negative self-talk, or delusions that God was somehow punishing them. Studies have shown that in most cases half of us will bounce back from a significant loss after about two months, about a third of us will have trouble adjusting but eventually let the loss go, and the remaining 20 percent will continue to suffer for a while.  In the end, the number of people who have the most difficulty getting better is approximately equal to the number of people in the general population who are already at risk for mood disorders.

  Bereavement is a normal reaction to loss.  Depression is not. Statistics show that in most cases paying attention to others, maintaining a healthy lifestyle, staying mentally active and keeping a positive outlook will provide the resiliency we need when we lose someone or something we hold dear.

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Mindfulness Training: A Proven Brain Changer

As I was researching material for an upcoming workshop on pleasure, I came across an article by Dr. Frank Sommers who is the author of “Lose Weight, Stop Stress and Make Better Love” (Amazon.com / Caversham Booksellers). The article appears in The Sexual and Relationship Therapy Journal’s special edition on Mindfulness (ed. By L. Brotto and M. Barker).  In the abstract for the piece, Dr. Sommers says, “Increasing evidence is accumulating on the real benefits of mindfulness training. It is also emerging as a core, effective component of modern sex therapy practice.” He notes that neuro-endocrine and neuro-imagery studies he’s observed provide evidence that a treatment called Visually Enhanced Psycho-Sexual Therapy is effective in treating sexual dysfunctions in a number of cases. He discusses applying two basic mindfulness principles, which he terms, “Present Centered” and “Process Absorbed,” as a way of “training the autonomic nervous system, and the integrative and sensory components of the central nervous system.”  He sums up by saying that the “graduates” of his 10–15 session practice program “learn to become mindful not only in their loving and love-making behavior, but also generalize this way of being in the world in their daily lives.”  

Dr. Sommers' findings echo what many therapists I talk to are discovering: that using mindfulness techniques in tandem with evidence-based therapies such as CBT and REBT in treating sexual dysfunction not only changes behavior but actually alters brain structure and chemistry in a way that makes those changes more lasting. When you become more mindful about the sources of your pleasure, it encourages the brain to set up a positive feedback mechanism that motivates us to recreate that pleasure we’re feeling now in the future. As a result of becoming more mindful of where our pleasures come from, we can almost assure a consistent increase in the amount of pleasure we will experience.  This pleasure, according to Dr. Sommers, will encourage our nervous systems to become more tuned to pleasant experiences and (one hopes) make us more resilient and resistant to negative thoughts and mood disorders.

If you'd like to explore how evidence-based therapy can be a "Brain Changer" that will improve your relationships, please call me at 917-525-2205, extension 8 to schedule an introductory session.

You can also request an appointment online at www.mytherapist.info/chris

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Using Sex Therapy To Solve Relationship Problems

By Chris Nufer

A therapist in New York City realizes that when working on relationship problems with older adults, using sex therapy techniques as part of the encounter can often make a big difference.

Whether it’s a mixed or same-sex relationship, when working with unhappy partners that have been together a long time, the biggest obstacle in the path to solving problems is one or both partners’ reluctance to discuss their sexual behavior.

The first thing I try to establish is that we are all adults and we acknowledge that, like it or not, sex is something that lights up every genogram like a Christmas tree. But take away the parents, siblings and children for a minute and put your hand on the live wire that connects two life partners. You will understand that sex or lack of it is the main switch in the circuitry of any long-term relationship. It has the power to rewire the personalities of the participants in shockingly unexpected ways over time. 

When older adults and their families come into a therapy situation, sexual concerns are not often the presenting problem.

It’s true that sometimes Mom or Dad will behave in what the children may consider inappropriate ways and this becomes a problem that will precipitate a search for treatment. The shame and guilt bred by a sex-negative culture often makes it impossible to go to a therapist for that problem alone.

Instead, the issues that bring older couples to therapy are most often couched in realm of personality conflicts. There are accusations, complaints and misundertandings aplenty. This complicates the therapy process and often forces the participants to wrestle with clearing up distortions that have grown into entrenched givens.

Dr. Marilyn Mason provides an excellent solution in her chapter in the Handbook of Family Therapy, Volume 2, titled “Family Therapy As The Emerging Context For Sex Therapy.” In it, she suggests that therapy is most helpful when individuals can be guided to weave their sexuality into the fabric of the complaints they have about each other or their family. This allows the therapist to broaden the scope of the conversation adding sex education, new information, and sexual attitude reassessment techniques in addition to the Rational Emotive Behavioral Techniques developed by Dr. Albert Ellis.

For older adults, when seeking therapy for straight or LBGTQ relational problems, it’s important to determine whether your therapist’s attitude toward sexuality is biased or not.  Is the therapist open and non-judgmental?  How does he or she define sex?

But most importantly, is your therapist in tune with the vision you have for yourself as a sexual person? And are you ready to confront the energy that gets loose in the room when you have permission to articulate that vision?

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In Defense Of Pleasure

A sex therapist in New York wonders, What would happen if therapies were designed to increase our pleasure instead of simply focusing on reducing our pain?

Traditionally the therapist’s first obligation is to reduce clients’ distress by helping them feel safe and understood. If therapy is successful, the client becomes more flexible and learns from the therapist how to manage painful emotions on their own. Often in the case of depression or anxiety, this means learning how to develop or reconnect with sources of strength or pleasure in their lives.  A successful intervention requires much more than the “pain relief” provided by antidepressants or other pharmaceuticals.  Instead, I wonder if healing can be achieved by the proactive introduction of pleasure into the individual’s life.  Can pleasure be relearned and applied to the affairs of daily living? From a physiological perspective, could a consistent triggering of dopamine reverse the physical damage caused by long-term stress or trauma?

What would happen if a treatment program could be a constellation of interventions that might include increased human touch (massage), along with assisted social engagement (dance/games/laughter), mindfulness training (yoga/meditation), and other confidence-building activities?  Could this “pleasure focused” approach produce better outcomes than talk therapy and pharmacological interventions alone?  Of course, there will always be those situations that require medication, but wouldn’t it be better if we provide pharmaceuticals only when a caring environment and efforts of a healing community have failed.  Is it possible that having masseuses, therapists, sex surrogates, nutritionists and personal trainers working as something of a “personal crisis team” can help older adults improve their sense of well-being more effectively than drugs can?

The reason I mention all this is that, too often, as people get older, their opportunities for pleasure diminish. Older adults deserve to feel good and that includes having physical intimacy with others or themselves. The fact that people who are uncomfortable with pleasure–whether adult children, institutional caregivers or administrators--restrict older adults’ opportunity for privacy, intimacy and pleasurable activity is a situation that is both blatantly ageist and thoroughly contemptible.

Perhaps we could treat pain and distress more effectively by finding ways to increase the amount of pleasure a person is experiencing rather than simply simply trying to relieve their pain.