A Conversation Between Caleb Birkhoff, LMFT, and Laurel Roberts-Meese, LMFT

LRM: I’m so happy today to be talking to my friend and colleague Caleb Birkhoff. Caleb is a licensed marriage and family therapist and he specializes in working with substance use and addiction treatment. He has a private practice in San Francisco, and also works in a clinic. Today we wanted to talk about healthy coping. It’s been a topic that has come up a little more than usual because people are stuck at home and a lot of their normal coping strategies are not available, or they’re getting worse. So we wanted to talk about the abstract concept that is healthy coping, what does it look like, why is it hard, and what are some things we can do. Welcome, Caleb.
 
CB: Thank you. I’m excited.
 
LRM: So what comes to mind for you when someone saying “healthy coping”?
 
CB: So much. In general, as therapists, we tend to deal with all the unhealthy things people do to cope, especially working in add*ction, subst@nce use, and harm reduction. For most of my clients, substances are the primary coping strategies, and that has wildly diminishing returns. So when I think about healthy coping, I really think about figuring out a way to manage or regulate or enjoy, sit with, and tolerate emotions and discomfort, primarily. I think there are also ways that our interactions with particular people, events, foreseen or unforeseen in our life, circumstances, sometimes places and times of day, year, anniversary, that have difficult or challenging or maybe exciting feelings that bubble up. We have to figure out how to mitigate some of the damage we could do to ourselves, manage our risk well, but also expel some of that energy and find out some of the ways we can be as healthy as possible knowing that we can’t possibly be 100% happy or 100% healthy all the time.
 
LRM: A comprehensive definition! It’s abstract, but we all know that experience of that discomfort, that “ugh, I don’t want to feel like this,” and you’ll reach for whatever is closest, if it’s a drink or food or sex, or whatever it may be.
 
CB: Internet wormhole!
 
LRM: Yep, or your phone!
 
CB: Instagram, Facebook, Twitter.
 
LRM: Totally. It will have a numbing effect, but it doesn’t actually address the underlying issue that is causing the discomfort. They may help you cope, but they may not be the most effective in terms of actually reducing and identifying the source of the discomfort, which isn’t always possible, but can be addressed more often.
 
CB: One of the key features of [coping] being healthy is the level of sustainability and reliability. A lot of [coping strategies] sort of gloss over or numb our experience, or as I like to think of it, writes checks for Future Caleb to deal with. I may feel good now, and that guy will worry about that. It diminishes our ability to do this comfortably and consistently and therefore we have a really uneven experience and our tools get washed over and forgotten about. Most often we have an answer; most people who show up to something like therapy probably has some answers, things in your life that have worked in the past but drift away. Having someone remind me helps me realize “oh, I can do that.”
 
LRM: We all have more coping skills than we realize, it’s just being able to utilize them in a time when you’re elevated, when you have a higher level of stress, when you are really uncomfortable, you’re not necessarily going to be able to think, “Oh yeah, I know going for a run always makes me feel better” or “calling my friend Shannon is going to make this feel way more manageable.” When you’re at the SOS level, you can’t think through what a sustainable, healthy response is.
 
CB: I think also building in some daily practice and routine is really helpful. It’s like “I just do these things because work for me and they make me feel good on days that I feel good, and on days that I don’t feel good.” It takes some of the guess work out. If I always go for a run at 3 o’clock, on days I feel good I’m excited about putting on my tennis shoes, and on days I’m not feeling good it’s like “well, I have to go on this run.”
 
LRM: The structure and routine highlights that there’s such an overlap between self-care and healthy coping. That run could be preventative care and coping, like “I know that if I don’t go for a run, I’m gonna feel real bad in a couple days because I need to move my body.” Or it could also be responsive self-care, also known as coping. So there’s preventative self-care, which should be thought of as coping.
 
CB: Correct!
 
LRM: Would you say that the preventative coping measures tend to be healthier? Things like running, creative practices, spiritual practices, or would you say that there are also preventative unhealthy coping?
 
CB: We do a lot of anticipation with anxiety. If you’re future-oriented and worried, we gear up for those things, and we notice behavioral and emotional relapses and destructive skills and habits showing up ahead of time. An example a lot of people can relate to is public speaking; it’s most people’s worst fear, they would rather die than have to talk in front of people! It’s not inconceivable before having to give a presentation to have that worry in your head and start doing things ahead of time. The more proactive and planned we can be, the more we can anticipate responding to things to things instead of reacting to things. Responding to things [rather than reacting] gives us a little bit of space to think about and plan, and we’re closer to our baseline and therefore thinking clearer and more open to accessing resources, asking for help, running that by somebody. Giving ourselves a reality check isn’t easy to do when you’re all fired up.
 
LRM: Oh yeah, when you’re at an 11, you can’t do that self-resourcing, you just need relief.
 
CB: The hard thing, culturally, especially with something like drugs or alcohol, or food, or escaping into the internet, is that the primary coping skill of that nature will get us from a [discomfort level of] 6 or 7 [out of 10] down to a zero pretty quick, so we have this expectation that other things we do will work that way, and it really doesn’t. But we can get from a 6 to a 5, and a 5 to 4, etc, gradually work our way down, and it will require more effort and time and planning and execution of more skills. And in the long run, you’ll be able to feel really proud and accomplished in those areas, and like we were talking about before, being proactive and doing that maintenance piece. We might cut off that anxiety flight at the pass because we went for a run before even realizing we’re anxious.
 
LRM: What do you think are some barriers to healthy coping?
 
CB: How long do you have? (Laughs) In the context of COVID shelter-in-place, realistically, outside is a barrier, health is a barrier, diversity and intersectionality is a barrier. It’s like, “how safe do I feel doing these things?” If the gym is a primary coping skill, well, where I live they’re not open right now. Nature is lovely, but if you’re not supposed to be outside that’s really challenging. We have these patterns that we’ve established, these things work for a long time until they don’t, and we don’t always see that part coming. For a lot of people, there’s learned behavior that seemed to work for a while and now it doesn’t. Rigidity, tradition.
 
LRM: Lack of motivation, too. A lot of us are experiencing at least some level of anhedonia, which is an inability to connect with joyful things. It’s not a full-blown depression, but we’re not motivated to put on our shoes and go for a run. We’re like, “yeah, I’d feel better if I called my friend, but I could also not…”
 
CB: And we’re social beings, so feeling not safe or comfortable to interact with other people really does add a level of loneliness. Some people are fortunate enough to be able to work from home, but that brings a whole other host of things; having those demarcations of work and not work make a big difference for people. If you’re not working, there’s a lot of time to fill, and that can be really challenging. Especially now, there’s this real pressure, mostly false, to have done something productive with your quarantine, and to leave with your new Etsy shop or six pack abs. Realistically we’re facing a global health pandemic, along with a lot of other pretty scary and frightening things with social justice, and so our job is to survive.
 
LRM: Survive, yes.
 
CB: To survive with some level of dignity and grace, with our emotional and social health intact. To feel involved and engaged without being overinvolved, over-engaged, and overwhelmed, and that’s a really delicate balance. That’s where having resources, places to turn to, people to turn to, even virtually [matters]. I hate the phrase “make the best of it,” but really, it’s about knowing that yeah, I’d love to go get a sandwich with you, but realistically what we can do right now is FaceTime or Zoom or sit six feet apart and talk through our masks.
 
LRM: The toxic productivity message out there, well, we’ve done somewhat of a good job walking it back a little bit. I saw some fitness place that said in their marketing, “if you were telling yourself you weren’t going to get in shape because you didn’t have the time, and now you still don’t, it was never the time that was the issue,” and I was like, That is such a horrible message to put out there! Unless you are someone who has always coped by being productive, by being a taskmaster and creating structure for yourself, and genuinely feel very positively about doing home projects; if that has always been your strategy, great! You’re probably doing a little better during the pandemic in terms of ability to divert your attention to projects and that productivity that is being suggested. But if that is not how you’ve ever coped before, how can you expect yourself to cope that way now with all the additional stressors that are going on? The toxic productivity messaging out there is really hurtful and it’s adding shame and guilt to people who are already struggling.
 
CB: There’s no simple way around the fact that this is hard. It’s hard for different reasons for different people, but in general this is hard. Figuring out a healthy and sustainable way to cope in your life is challenging even under ideal conditions, and we’re certainly not living in those at present. Effort is important, persistence is key. I think there’s a lot of space for goal setting, but keeping them realistic but a little challenging. We can rely on things like determination. If I waited for the day where I woke up and felt inspired to go for a run, that would never happen. I’ve never woken up that way. But I can set a goal to go for a walk for 30 minutes three times a week. Check off that list! Those things build momentum and counterintuitively build motivation down the road. When we wait for that divine inspiration, well, I haven’t gotten it.
 
LRM: What you’re speaking to is the power of habit. When you create structure, when you create routine around healthy coping, it becomes easier and easier. There’s a story I heard that I love to repeat: there was a woman who every year would set a New Year’ resolution to run a marathon. She had never done it before, and every year she didn’t. Then one year her resolution was to put on her running shoes and leave the house every single day to either walk around the block or go for a five mile run, and by the end of that year she did run a marathon because she made it a routine, a small, achievable goal to put on her running shoes and leave the house every day. She was able to build on that by structuring it in and making it manageable.
 
CB: They’re called SMART goals: small, measurable, achievable, reasonable, and timely, or something like that. The smallest pieces should be a little outside our comfort zone, but if it’s way outside our comfort zone I’m not going to do it. From zero to running a marathon is not going to happen; it’s like, yeah I’ll figure out how to fly to Mars too. Why would I ever be able to do that? But I can put on shoes. That’s a good plan.
 
LRM: I think something that’s worth mentioning is how difficult it can be to cope when we don’t have social activities available to us. Some people really cope through physical touch. Just getting a hug or a backrub or sex – in moderation – can be healthy coping depending on how you’re going about it and how safe you’re being. Some people don’t have those available to them right now and it’s worth mentioning that we are social beings and to be physically distant from people is very hard and limits the ways we can cope, healthily or unhealthily.
 
CB: Canada is rolling out this concept they call the double bubble, which where we can merge our quarantines. Most of us have spent a fair amount of time at this point managing our own family space and living space and the people that exist in that that we’re comfortable seeing, and the concept that [Canada is] championing that we might take some ownership and agency of ourselves in merging my quarantine with someone else’s, therefore doubling our quarantine contacts, while managing risks. I think we’re in a delicate position where we’re trying to manage public health with our personal health, and that’s a really interesting intersection with a lot of friction. But knowing that if I don’t go see someone, I’m going to lose it, might outweigh the potential risk of infection. Obviously this isn’t going to be one of those things where every day the risk is bigger and greater and I’m going to see 100 people over the course of the week – that’s not what we’re talking about – but having that quarantine shelter-in-place buddy, where it’s like “this is a person I feel comfortable hugging, or holding hands with, or going for a walk with, or maybe sitting in their house for a short period of time, but I also trust that if they are not feeling well, they will tell me about that, that there’s accountability to help us manage risk. We’re not going to throw caution to the wind and talk to everyone and touch everything, but to make a concerted effort think about, “What is my NEED around this – not my want, but my need – to help manage my health and wellness, and how can I responsibly integrate that with somebody else?”
 
LRM: With that, the absolute necessity of clear, honest, direct communication, expectations about risk management, knowing who they’re in contact with, how often are they going out; all that needs to be figured out on an individual basis. But I do think, in terms of healthy coping, that Canada might be on to something. So my final question is: how do you know when you’re coping well?
 
CB: When I’m not exhausted by it. There’s a lot of things that are healthy for me that I could be doing, maybe some I should be doing, but if I feel too drained to do it again, [it won’t work.] Something I talk a lot about with clients is that there are all these great general recommendations of things that you can do to take care of ourselves, and realistically I could probably cross 25% of those things off the list because I’m just not going to do them. But also not being too proud to try them in a pinch. For example, I’m not a meditator. I never have been. I’ve tried, I really do try, but it’s just not something I take too. It’s uncomfortable.
 
LRM: It’s hard!
 
CB: I’m ADHD enough to have struggles with that. However, if I’ve run through all the things that usually work for me and I’m still feeling  a little squirrely, I’m gonna try it, and I’m probably going to try it with what we call in therapy some “scaffolding;” I’m going to get some assistance around it. There are fabulous apps, guided imagery, sometimes I go sit and stare at the ocean because that’s the state of mind I’m shooting for rather than sitting there and being one with my thoughts and myself and the universe. I also know that I’m coping well when I feel content, when I feel that things, both good and bad in my life, are manageable. I also think that when I’m coping well, my ego is out of the way enough that I can ask for help and talk to people about things that are working or not working, and also be open to doing that for other people because I’m not tapped out, and I have the bandwidth. In therapy we call it the “window of tolerance;” my window has enough room to take on somebody else. And having boundaries where I can say yes or no to things and feel comfortable with that. And coping is a practice, much like meditation. Some days I do it well, other days there’s room for improvement and recalibration based on what’s happening in the world. With the recent Black Lives Matter movement, having to balance that with my family and our health, I don’t have the luxury to go out and participate in the way I would have 10 or 15 years ago, or maybe 5 years in the future; the cost-benefit analysis of my health versus public health was just difficult.
 
LRM: And that was a common thing people were struggling with; feeling so called to [participate] but being uncertain about health risks. It was a hard one.
 
CB: And finding a place where I do feel empowered and safe, and where I do have agency, and that may not be being out in the streets, but donations of food, money, blood, time, phone calls; there’s so many ways to feel good about being engaged in the work and the way it’s happening without feeling overwhelmed and not necessarily having to feel disappointed about lack of engagement. It’s a balance; some days I have to do more and some days I have to do less.
 
LRM: I know I’m coping well when I’m coping rather than numbing. Numbing is very different for me, it’s just a checking out, whereas with coping I’m emotionally and mentally engaged with something and it feels sustainable. Like, “okay, I could do this regularly and be okay, and it’s not going to have an adverse effect on my sleep, my health, my social life, and it’s something I can integrate that gels well with everything else.” And as you mentioned, that ease and ego not getting in the way of reaching out to others.
 
CB: I haven’t been able to touch my toes since I was about 12, and it turns out yoga is pretty good for you, but if I thought about how I look doing yoga, it’s not gonna happen. And one last thing I want to add about coping is that sometimes the best thing we can do is do nothing. We live in this culture that is a mile a minute. That toxic productivity is everywhere. Turns out sometimes I can just take a deep breath and sit on my couch and fifteen minutes later I feel a lot better; turns out “nothing” is the thing I did about it and it feels pretty good.
 
LRM: And that’s a clear marker that you’ve done your own work because you’re able to sit and tolerate the discomfort, which is the goal with therapy, to widen that window of tolerance so you can tolerate the discomfort without acting out, without doing something that is self-destructive, without doing something that’s numbing. When you’re like, “Oof, this is REAL uncomfortable… AND, I know I can sit with it for a little bit of time.”
 
CB: Turns out my feelings don’t kill me.
 
LRM: They don’t! They might feel unmanageable, but they will not kill you, and they WILL change. Well thanks so much for being here Caleb. If someone wants to work with you, how do they get in touch?
 
CB: I have a phone number and website. Call me, text me, email me. I love being a therapist. It’s been the best decision I’ve made and I relish the opportunity to be able to help people.
 
LRM: What kind of issues do you like working with?
 
CB: Subst@nce abuse and recovery offers so much opportunity [for growth]. I like when people are ready to make a change, to climb over the wall they didn’t think they could. Transitions in relationships, family, jobs, and setting boundaries and establishing agency and a sense of self and assertiveness. Unfortunately our families of origin and life experiences sometimes zap us of those things.
 
LRM: Great! And if people want to work with my, I have a website too. I love working with motivated young professionals around anxiety, trauma, and transitions and life events like you mentioned. Even the positive ones can be very stressful.
 
CB: Change is hard!
 
LRM: It is. Thanks for being here, Caleb, and I look forward to more conversations.