A Roadmap Through Adulthood

Wouldn't it be great if we had a map of adult development so that we would know what to expect?

We well do--to a degree.

For example, Daniel Levinson has worked out a map based on his studies of adults.

And before him, others did too, including Carl Jung and Erik Erickson.

Every counselor who has worked in the field long enough has some kind of a basic map in their head of what lies ahead for adults--not one learned from books but from real life experienice.

In the show today [KTOK radio show] I'm going to talk about "tasks" and "stages" of adulthood.  What is the difference? 

Stages are windows of demand and windows of opportunity.  They are time limited.

    Procreation is a good example, it is definitely a time limited opportunity.

    Getting training for a career is almost as time limited--although we have all seen stories of people

    going back to college at an advanced age.

A stage can be approximate (such as mid life reorientation) or it can be absolute (such as menopause and the end of female childbearing).

Stages can flow smoothly from one to the next, or they can be turbulent, with depression, anxiety, divorce, change of career, etc.

We do not yet have a perfect map of adult stages, and as soon as we do, it is likely to be obsolete because our culture is changing so fast.  Nevertheless, there have been adult "roadmaps" going back to Confucius (see the last chapter of Levinson's book The Seasons of a Man's Life.)

A good "map" helps us to navigate through life, just as a ship needs a navigational map to steer through dangerous waters.  We might say that we don't really need a map.  However, ships have run aground due to poor maps.  And adults have run aground in life.

Here is a basic roadmap of adulthood:

Early adulthood 20's--the goal here is to leave the family of origin.  Nature has given us tremendous optimism and energy during this stage.  We can in fact be unduly optimistic.  We pull away from family, either amicably or perhaps with anger.  And often we come home once, twice, or three times before being able to sustain ourselves financially.  We want to be self governing, living by our own rules, even if they are pretty much the same as our parents.

For many persons, sexual drive plays a large role in this pulling away as persons often struggle with parental restrictions of different sorts.  (It has been said that every generation thinks that it invented sex.)

In the 20's, persons are proving, for themselves and for others, that they can be self sustaining.  They are gathering basic skills, e.g. how to pay taxes, how to maintain a car, how to pay bills on time.

For some, the 20's are a period of child bearing and child rearing, whereas for others, it is a period of exploring dating partners and learning about what they like and don't like, and what characteristics to beware of.

By our late 20's we realize that the job we are in may not be a suitable career.  It may make us money, but not enough.  Or it may not bring meaning and satisfaction.  The late 20's can also bring with it the fear of not getting married or not having children.  As the end of the 20's approaches there can thus be a crisis as we try to get into the right career pathl

The late 20's can bring a rapprochement with parents.  They are now approached as equal adults.  A whole new level of communication is often possible, adult to adult.

For reasons that are not clear, the decades seem to play an important role in crisis, turning 30, turning 40, and so on.  Even the mid decades of 25, 35, and 45 play such a role.  It is as if we are prompted to look ahead at each decade.  

(Age 25 does not play a very large role.  The physical organism is at its height.  Death is so far in the future that it is generally only an idea to be acknowledged for brief periods of time.  But 35 and 45 may play important roles as turning points)

Transition to the 30's.  In this transition, the person realizes that the time for experimentation is coming to a close.  It is time to build something substantial in career or family.  In Levinson's terms, it is time to climb the ladder in one's career.  He also refers to this as the "settling down phase."

The 30's are a period of great energy and accomplishment for many people.  By this point most people have made an occupational decision.  They are hopefully climbing the rungs of a career and occupation.  They are honing their skills to take an important place in their organization.  At home, they are settling down to establish something secure for themselves and their families.

The 40's and the midlife reassessment.  Much has been said about midlife transition and midlife crisis.  Looming over life is our ultimate mortality as well as the mortality of our parents, as well as our frriends and our siblings.  It becomes clear at a very real level that life comes to an end.  

For some persons who have been driving themselves hard in their career but without much pleasure in life, this strategy quits working in the 40's.  They may lose their drive to work hard if it is not balanced with pleasure and recreation or other meaningful pursuits.

If we have been wanting our parents to change and give us the love and affection they denied us, we may finally give up on that every happening in the 40's.  

A major change occurs in the 40's and 50's as children leave home.  While they may return home occasionally, it is usually only temporary.  This may be experienced as liberating and freeing, or it may be felt as a tremendous loss.  For many, it is both.  Energy and time can be and must be redistributed.  New goals and activities can be developed and need to be developed.  For some, there is a loss of meaning ("If I'm not a parent, who am I?")

We are now focusing on our legacy.  We want to leave something behind of substance.  Pleasure may take a back seat to leaving something of permanence behind.

There is a transition at 65 when we begin to retire and to take Social Security.  We have to adapt to a new self image as a "retiree".  Friends start to move away or die.  Our social circle begins to dwindle for various reasons.  Mortality looms even larger on the horizon.  Our parents may have been a type of psychological buffer between us and death.  Once they are gone, we realize, we are next.

With retirement, there is opportunity for more recreation, and for fortunate retirees, they discover new sides of their personalities that they never knew existed.  However, there can be disappointment as well.  Retirement may bring boredom.  Moreover, if there wss a plan to travel with one's spouse, the health of one or the other may prevent that from actually occurring.

Erik Erickson refers to the final stage of life as being Ego Integrity versus Despair.  As the body deteriorates, persons have to decide if they are still worthwhile and whether their life still matters.  If they were the smartest, they likely no longer are.  If they were the most beautiful, now they must find a new source of self esteem.  If their job made them powerful, that too no longer provides self esteem.  Victories against old age may be won, but the person realizes that all victories now are temporary and partial.

The physical drives diminish in this age.  Some find this a blessing that they no longer have to cope with sex or anger as much as they used to.  On the other hand, some persons find the absence of sex to leave a great hole in their life.  And anger may become a different kind of problem. If there is any frontal lobe impairment, irritability and anger may become stronger rather than diminishing.

Many persons at this age now turn toward grandparenting as their primary source of meaning in life.  They find great enjoyment in it.  They also want to pass on their values to the second generation down and worry that some values may be lost.  

On the other hand, they often worry that society is losing its most important values.  They see a world that is changing so much that it is starting to feel that it is not THEIR world anymore.  It begin's to feel that their world is receding, and they may mourn for it.  At the same time, they see glimmers of hope--new developments in medicine and the humanities which give them hope for humanity.

As their physical bodies fail them, they have to turn to other resources.  Some focus more on their intellect.   Some focus on spending or managing their money, and some on spending time with their family.  The equation of life has to be re-solved.  One person once joked that this age person checks their stocks in the morning and plays golf in the afternoon.  

Loneliness begins to be a major problem for many, as significant others pass away.  For other couples, both are still alive but there is a change in personality due to changes in the brain.  Some spouses, for example, are in chronic pain or experiencing a mild cognitive disorder.  There may even be the beginnings of dementia.  

The onset of chronic physical disorders and cognitive problems leads to another issue--the ascendence of the younger generation.  Older persons may both enjoy the help they receive and resent the increasing dominance of their children.  In a best case, the adult child assists them in their goals.  In a worst case scenario, the elder finds themselves explicitly or implicitly demeaned, and their autonomy taken away.

The elder struggles to preserve autonomy.  It had been hard won in the first 20 years of life.  Now there is the threat of it being taken away, if not by one's own children then by physical illness or cognitive impairment.  It may also be taken away by financial restrictions.  

The elder may look to preserve a sense of worth by being a source of knowledge for younger generations.  This may work.  On the other hand, they may find that there is no interest in their life wisdom.

*************

Then there are the tasks of adulthood.  These tasks go on more or less perpetually throughout the adult years and are not limited in time as stages are.

Identity development--This begins in the adolescent years but never stops.  The sense of being a unique person with one's own values, goals, strengths, and weaknesses continues to develop.  But it is not only thoughts and actions.  As much as anything it is a feeling of being integrated.  It is a feeling of "I exist, and I know who I am."  But as we age, the question is less and less "Who am I?"  Rather it becomes,  "How do I fit this self that I think I am into a new world of change and loss?"  It becomes partly a question of, "Does the world around me want or need the self that I have become?"  Or to put it differently, "Does my identity make sense in a world that has changed?"  In one sense our identity becomes more fixed as we get older.  But it is always capable of change.  And who we are in relation to the world has to change as the world changes around us.  Take, for example, a person who was a colonel in the army.  He had a job to do.  People looked up to him and respected him.  They looked to him for orders and direction.  After retirement, however, those relationships do not exist.  He or she must define an identity in relation to the people and circumstances surrounding them now.  

Interconnectedness--being known, having friends.  This task never stops because we lose friends as well as make frinds as time goes on.  Friendship patterns can stabilize from 30-65 but then they destabilize also as time goes on.  People move, and they die.  And unfortunately friendships are sometimes tossed aside for no good reason.  They may be lost because of resentments.  There is a danger of losing our interconnectedness with others.  Relationships have to be nurtured and maintained.

Intimacy--This is interconnectedness at the closest level.  It involves both sexual intimacy and emotional intimacy.  In fact it involves a variety of types of intimacy--too much to go into here.  We learn to approach "the other," sometimes to the point of feeling that we are merging and becoming one.  But we discover that merging is not really what we want and that there is a need for distance as well.  We learn to back away and protect a sense of selfhood separate from the other person..  

Assertion and boundaries--Learning to draw boundaries in a healthy manner can be a difficult task.  We have to learn how to say no to others.  Similarly, we have to learn how to handle our anger in a healthy manner.  Anger is such a powerful feeling that employing it in a healthy manner requires adjustments and tweaking throughout the lifespan.  Anger and assertion are not the same thing, but they are linked.  If we create healthy boundaries and assert ourselves, then anger is less likely to build up and get out of control.

Contributing to society versus meeting our own needs--This also continues throughout the lifespan.  Do I give of myself to others and to society?  And if so, how much?  How much do I hold back for myself?  Not just my money, but my time and my emotional energy?

Coherence--Finding a meaning for life.  This involves spirituality, or if not that, then at least a philosophical view of what my life and Life in general are all about.  Is there meaning to my life?  If so, is it purely a meaning that I create out of thin air, or does my life's meaning come from a higher power?

Keeping a sense of hope--Faith, hope, and love are mentioned by the apostle Paul as the greatest of human aspirations.  There must be something to live for.  Just living is not a solution. It is static.  Either we are reaching for something that gives our lives meaning, or we are just marking time until we die.

Dealing with deterioration--dealing with illness and with aging.  We begin to noticeably decline even in our 30's with a few gray hairs or being short of breath climbing a hill.  For some persons, illness leads to decline even earlier.  We are forced to adjust our self view every time we notice a new phase of decline.  We notice gray hair, and then we adjust our self view to that.  We notice less muscle strength, and we adjust to that.  If our doctor gives us a chronic diagnosis, then we have to adapt to that also.  This is both a practical and a psychological issue.  How do I function now that I have arthritis?  Or who am I if I am not able to function sexually anymore as a man or as a woman?  Our "self" has to absorb not just one blow to it, but multiple blows--indeed many blows.

Establishing Financial independence--For some people this is a stage; for others it is an ongong task.  It has been said that making money is easy, and keeping it is hard.  Many persons enter retirement with very little cushion and mainly have just their Social Security retirement income.  

Coming to grips with "the real world" and not just an ideal illusory world--There is a danger at all ages of living in an fantasy world.  This may be an illusory view of ourselves or of the world around us.  We may all be prone to this--liberals and conservatives, religious and non religious.  And yet we cannot live without hopes and dreams.  And we cannot be absolutely sure of the ultimate nature of reality.  We must have dreams of who we are and what the world can become, and these dreams must exceed what we have now.  But also these dreams must remain sufficiently rooted in reality.

Psilocybin for Depression?

Research is beginning to accumulate indicating that the psychedelic psilocybin (think "magic mushrooms) may be helpful for depression.  Ketamine, another hallucinogen, is FDA approved to treat depression, although it is generally not paid for by insurance.  Studies have thus far been with small numbers of subjects.  It had been previously studied in individuals with life threatening cancer.  The most recent publication was in the prestigious Journal of the American Medical Association (Psychiatry).  Treatment effects were rapid; patients were given two separate treatment sessions, a very brief and relatively inexpensive treatment.  

One drawback was that there was only a four week follow up of results.  I have had patients who were referred by their psychiatrist for ketamine treatment.  (I am a psychologist, and I was not involved in the process.)  Most did not find it helpful.  The one who did started needing booster treatments after a few weeks.  Thus, I do not see hallucinogens as a magical answer.  

However, I believe that it is a shame of U.S. drug development policy that these substances have not been seriously investigated before now.  If a substance was labeled as being a street drug or as an abusable drug, it was hard for investigators to get approval to do serious research with it.  

We now need to move rapidly forward to know whether these substances have any legitimate medical value.  Here in Oklahoma, cannabis products are readily available.  Unfortunately, we now have a thriving street corner industry rather than a more traditional model of going to a pharmacy to get medication.  But at least there is a new openness to considering that psychoactive chemicals found in the natural world might, just might, be useful medications, even if they are sometimes abused and sold on the street.

After initial studies of the effects of an hallucinogen by itself are completed, a second wave of research will be needed.  At that point, we will need to look at combining psychotherapy with the experiences patients under its influence, experiences that may break through their normal psychological defenses and set them free from old, repetitive ways of thinking.  I believe that such combined treatment could produce synergistic effects that would be the real value of such drugs.

The Word "Just"

My patients in cognitive therapy know that I am very averse to ever  using or hearing the word "should," except in limited situations.  Here is another word that is on my blacklist--"just."

I don't avoid this word entirely, but it can be destructive at times.

Here are some examples that I think are very unhelpful:
To an ADHD child--"If you would just sit still..."; "If you would just pay attention..."
To an obese person--"If you would just eat less..."; "If you would just exercise..."
To a depressed person--"If you would just start thinking positively..."; "If you would just get out and be around people..."
From one spouse to another: "If you would just try to remember what I tell you..."

And so on.

The fact is that oftentimes, if people could do one of these actions, they would.

What do all of these have in common? They imply that there is a kind of moral failure of willpower which could be remedied by turning on or off a switch.  They ignore the complexities of the brain, of past learning history, of the overall body physiology and chemistry, and of reinforcement patterns in the home.

That is not to say that there are not problems that need to be solved.  However, using the word "just" does not solve the problems and make them better.  It can do the opposite; it can make problems worse by evoking shame in the other person.  

When can the word be used?  I think it can be used in an encouraging way rather than as a put down.  For a child trying to learn fraction division, it might possibly be helpful to say, "All you have to do is just turn the second one upside down and then multiply them."  This could encourage the child to see it as easy extension of something they already know how to do rather than having the mindset that it is hard.  However, if the child has difficulty with math, then this statement could also become somewhat of a put down.

The word is sometimes helpful in our self talk.  For example, if I were anxious about going into a job interview, it might be helpful for me to say to myself, "All I have to do is put on a cheerful face, take a deep breath, and answer his/her questions."  In other words, the word "just" can be a way of telling myself that I am making a mountain out of a molehill.

So be careful with the word "just."  Use it wisely and carefully; and pay attention to how it affects other people when you use it with them.

Coping with COVID

It has been a long time since I published my last blog.  I guess I thought that I had run out of things to say.

Well, I haven't.

COVID came along and my patients have run into many new problems, including and above all, problems with interpersonal isolation.

I have become convinced that we are creatures evolved for close, intimate contact, such as one would find in tribal and village life.  City life with its anonymity is relatively new (in the last 100-200 years).  We are suited for interpersonal contact and interactions.  Our brains function optimally when we have to look each other in the eye and have to talk to each other.

Now even before COVID, there were some problems with people being too isolated.  People stayed in their homes with central heat and air and rarely acknowledged each other on the street.  But COVID has created isolation on steroids.  We are more isolated than we want to be, than we should be.  The effect on most of my patients has been lethargy (a blah feeling) and depression.

For that reason, I am encouraging my patients to see me by Zoom rather than by telephone.  I want them to look me in the eye, and I want to do the same.  I want to experience the illusion that we are in the room together, and I want them to have that, too.

(However, if Zoom and Facetime are not available then telephone is the next best thing.)

Our physical bodies need to distance from each other, but isolation is terrible for our minds.  Our brains need the stimulation of being right there with someone.

I am very fortunate.  I am able to practice what I preach.  Here is what I might be able to experience in a week:

Sunday: Zoom Sunday School

Monday:  3-5 hours therapy by telephone or Zoom

Tuesday:  3-5 hours therapy by telephone or Zoom

Wednesday:  3-5 hours therapy by telephone or Zoom

Wednesday evening:  Sunday School socializing

Thursday:  3-5 hours therapy by telephone or Zoom

Friday: Psychologist consultation and support group by Zoom

Saturday: My wife's extended family meets on Zoom

I am not trying to toot my own horn here.  I am simply saying that I practice what I preach.  I know that I need the interpersonal contact, and I believe that my patient's need it, too.

There are exceptions.  Some of my patients with agoraphobia find it easier to tell others why they stay home so much.  They feel less need to explain themselves.  Other than that, most of my patients appear to be negatively affected.

So, in summary, get on Zoom.  If you can't, then get on the phone with people.  Get out of the house and drive around.  (You can keep your distance or even roll up your windows to be safe if you like).  Stay out of stores if you can, but be creative in how you can interact with others.  Get some visual stimulation.  Drive some places that you haven't been before.  Give your brain something new to look at.

Social contact is not so much like a drug that makes you feel better immediately.  It is more like a vitamin.  If you don't have it, you eventually start to pay the price after awhile.

Is There Such a Thing as Positive Denial?

Positive denial

Denial is considered one of the most primitive of the defense mechanisms.  It is usually thought of as a distortion of reality, and therefore as being very unhealthy.  To put it bluntly, denial sometimes involves a person lying to themselves.

But I am now wondering if there is a healthy form of denial.  Or another way of putting it is, maybe there is a role for extreme optimism which is not fully justified by the evidence.

The issue came up with a patient of mine with Parkinsons.  (I have permission to share this.)  This patient is aware of all of the statistics about the disease's progression.  He is seeing all the appropriate doctors and taking all of the appropriate treatments.  Therefore, the denial in question is not the same as ignoring the warning signs of a disease; this is quite different.

An article came out in JAMA Neurology which suggested that some persons with Parkinson's remain stable, or even get better, over a six month period of time when they have sufficient vigorous exercise.  My patient has seized on this as a touchstone, figuring that he, too, will remain stable, or even get better, as long as he exercises enough.  This may be denial because Parkinson's is always a progressive disease; it's just that sometimes it progresses very slowly.  This person's "denial" is helping him to exercise 75 minutes a day, which will almost undoubtedly help the Parkinson's.  Without this optimism, he might crater, go into depression, and hence might give in to the disease.

Is there a down side to the denial in this situation?  Or is it even denial?  Maybe it's just taking optimism to its ultimate lengths, extrapolating in a very hopeful way on some of the research available.

Now, it could be argued that a slightly toned down optimism might be just as useful.  That is, believing that vigorous exercise will slow the disease rather than keeping it totally stable, might be more realistic and still motivate the required level of exercise.  However, for this particular person I'm not so sure that a toned down level of optimism would be nearly as effective in motivating him.

Moreover, we can't overlook the role of the placebo effect.  If you believe a medicine is extremely powerful, then it is more likely to be.  Placebo effects have been demonstrated even in the treatment of cancer.

So, it is still true that some forms of denial are destructive and prevent growth.  However, I am now seeing that extreme optimism (even up to involving some denial) may be just what the doctor ordered in some situations.

States of Mind: Active versus Passive, and Doing Versus Being

Many of us like to be doing things.  America was built on doing things.  Getting things done and accomplished is usually a good thing.  But there are other useful--and pleasant--states of mind as well.

Primarily I want to talk about "doing" versus "being."  Another way of thinking about this would be active versus passive mental activity.

First, let's start with what is positive about "doing."  The "doing mind" is active.  I sometimes refer to it as "active ego" (as opposed to passive ego).  Passive ego occurs when we are aware of thoughts and feelings, but they just wash over us.  We may be overwhelmed with good feelings (as on the beach) or worry (as when a family member is sick).  We just worry and worry and worry.  I sometimes see passive ego manifested as a neutral emotional state in the state of hypnosis (which I used to do, but hardly do anymore).  In hypnosis, the patient is not actively directing their own thinking, and the mind is in a receptive state to suggestion.   The opposite then is what I refer to as "active ego."  In active ego state, the mind is ready to solve problems and is actively considering options.  In this state, it appears to be less susceptible to worry and rumination.  That can be very helpful when there is anxiety.  The thoughts associated with this mental state may be, "What can I do about this situation?  I can do something to fix it!"

There is also an in between state--neither clear passive or clearly active.  When we appreciate what is around us (nature, people, even the feel of the air in the room), there is a kind of activity, but it is not visible to  others.  We are making a choice to focus our minds.  While we do not appear on the outside to others to be doing anything, we are actually expending mental energy.

Is there anything negative or self defeating about the active/doing mind?  On the negative side, the "doing" frame of mind can become overly habitual, and maybe even addictive.  We "do" out of habit, or because we are afraid to be alone with ourselves and our feelings.

Mindfulness therapy generally points out the value of the opposite of doing, which is learning to simply "be" or to appreciate what is around us.  Mindfulness tends to play down the role of actively achieving goals.  To the degree that it promotes doing, mindfulness therapy creates an awareness of the thoughts and feelings associated with it, so that the person is not "doing" purely out of habit.

I think that Americans sometimes get into "doing" mind so much that they miss out on some of the other aspects of reality. Back in the sixties and seventies there was a clash of cultures in America, between the "establishment" and the "hippies."  One aspect of this clash was the disagreement about the value of turning inward and meditating.  This was disparagingly called by some "navel gazing."  This pejorative term implied that people would focus too much on themselves and their feelings, to the exclusion of taking positive action in their lives or helping others around them.  Fortunately, we have progressed beyond that dichotomy.  We no longer see life as either/or in that regard.  We can be energized by our times of quiet and reflection to go out of our own personal sphere and accomplish goals.

So, let's summarize.  Here are some different states of mind that we have available as human beings:

Doing mind--planning and getting ready to cope or to execute a plan of action

Active (but not doing) mind--focusing intentionally on what is around oneself, or maybe focusing intentionally on clearing the mind.  An example would be some forms of meditation or prayer.

Passive mind--Letting ideas wash over  you.  This can be good, such as on vacation and in creative states of mind; but it can also be negative as when we succumb to runaway rumination and uncontrolled worry.

You may want to reflect on which of these three states occurs the most with you.  Do you need to ruminate less and be more actively in problem solving?  Do you need some calm down times when you are more focused (meditating and/or praying)?  Or is it even possible that you need some more time for thoughts just to wash over you, when you can be open to creative states of mind?

States of Mind: Gratitude and Thankfulness

In the past, psychology has been very focused on what was wrong with people.  It was not unusual to hear terms such as "overly dependent," or even more negative terms such as "orally fixated," "anal," and so on.

Fortunately, now, clinical psychology can talk about people's strengths as well.  Being educated in my Ph.D. program in the seventies, I can throw around negative terms with the best of them.  But I usually don't find that to be useful (except sometimes in psychological testing, but that is a different matter).

Many times issues bring with them to therapy can be normalized to a great degree.  For example, instead of saying to a person in therapy that they have a dependent personality, I might say that they simply are not in a good balance between depending on themselves and depending on others.  It is in fact somewhat normal to have difficulty finding just the right balance in life.

But that is off the point.

Focusing on the positive can mean focusing on growth.  Many situations that bring people into counseling are crisis situations.  Crisis doesn't feel good; but it does one positive thing: it breaks up  old, ensconced behavior patterns and potentially allows for new growth.  It is like breaking up hard, parched ground and letting new seedlings come through.

Early counseling sessions often focus on putting out fires; but often there is often eventually an opportunity in therapy to start looking for new directions in life.  One new direction can be bringing new positives into our lives--looking for what is good, looking for where we have been fortunate.  Gratitude is easier when we have a lot to be thankful for.  But that doesn't always have to be the case.  Even in bad situations, there may be persons who have given us a helping hand, or fortunate turns of events.  When we look for the positives we are likely to find them.

There is a school of therapy that focuses a great deal on reframing.  For example, in losing a job where one was subjected to a tyrannical boss, a reframing interpretation might focus on the possibility that the client has been unconsciously wanting an impetus to move on to something better.  A child who is being "bad" in their behavior may actually be wanting attention to deal with grief or anxiety.  And so on.  There are almost a limitless number of different counseling situations and possible reframes.  The interesting thing to me is that when I work out a reframe with a patient, even if it doesn't seem too plausible at first, I often eventually see it as very plausible.  Reality is a very slippery thing.  We think we have it well in hand until we begin to look at situations from different angles; and then we may begin to realize that we were overly committed to one particular view (e.g., the "bad" kid) and closed off to wider views of reality.

So even in tough situations, they may not be the pure calamity that we think they are.  They may offer the opportunity for growth, and that is something to be thankful for.

With other clients, there is no particular calamity they are facing.  They suffer from depression, anxiety, or perhaps some other emotional state.  But their lives are just normal otherwise.  With these types of clients, there is no struggle to find something for which to be grateful.  But there may be a lack of gratitude simply because that faculty of the mind has not been used  much.

Think it over.  How would it feel to be thankful today?  Are there negative thoughts and emotions that you could set aside for a little while and replace with gratitude?  And if so, why not?  What do you have to lose?