Steven Kvaal, Ph.D.: Relationship History and Self-Assessment

An interview with Jenni Grover and Steven Kvaal, Ph.D., about the impact of past relationships on our self-assesment and negative/positive thought patterns. Dr. Steven Kvaal is an associate professor in the Department of Psychology at Roosevelt University, where he has been the Director of Training and Director of the PsyD Program in Clinical Psychology, and currently focuses on teaching and training. He began his work in health psychology in graduate school, where he provided behavioral treatments to tension and migraine headache patients and support services for hospice patients and their families.

Past and current relationships and their impact on our self-assessment

An interview with Jenni Grover and Steven Kvaal, Ph.D., about the impact of past relationships on our self-assesment and negative/positive thought patterns. Dr. Steven Kvaal is an associate professor in the Department of Psychology at Roosevelt University, where he has been the Director of Training and Director of the PsyD Program in Clinical Psychology, and currently focuses on teaching and training. He began his work in health psychology in graduate school, where he provided behavioral treatments to tension and migraine headache patients and support services for hospice patients and their families. 

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Dr. Kvaal has since been a member of several interdisciplinary treatment programs in Florida and Illinois providing treatment for back, facial and other pain problems. He also works with patients with more general mental health concerns.

Jenni: Hi everybody! This is Jenni Grover from ChronicBabe.com and we are in Lesson Three, which is all about turning around negative thinking and getting into a positive space whenever possible. Today I have with me a guest, someone I’ve worked with before, Dr. Steven Kvaal. He formerly was a clinician at Swedish Covenant Hospital in Chicago, and he’s an associate professor at Roosevelt University, also in Chicago. (Y’all might be able to tell I have a little bit of a Chicago bias, but it’s where I live, it’s who I know.)

Steven is a really interesting person and has worked with a lot of folks with chronic pain and chronic illness, so today we’re going to talk a bit about negative thought patterns and other ways to get positive. Welcome, Dr. Kvaal, how are you today?

Steven: I’m doing fine, and you?

Jenni: I’m good, thanks. I know when we were talking about this call, you had a preference for how we started it. So I’d love to hear you just jump in with your thoughts and we can get started.

Steven: OK. I was a little uneasy about the focus on negative thought patterns for two reasons, both the focus on thought patterns and the focus on negative and positive. I think the idea that we can separate our experiences into thoughts and actions and feelings is a pretty artificial separation, and I also think it’s difficult to separate all of those thoughts, feelings and action, from the relationships within which they occur—and other contexts, though I think relationships are really what’s critical for most folk.

Jenni: That’s an interesting perspective that I had not thought about when I first started planning these calls. I’ve actually never had somebody talk to me in that way about the relationship between negative thought patterns or beliefs and how intertwined they are… obviously I’ve talked to people about how intertwined they are with relationships and how connected they are, but I think in our community, at least in this culture, a lot of people are used to thinking about negative or positive, or good or bad, or things are kind of disconnected. I think about this a lot in mind-body questions; a lot of people are very disconnected. So I’m happy to talk about that with you today.

Steven: OK. I think, of course, they’ve been separated throughout history to make it easier to analyze them and think about things in different ways, but I think it’s important for us to remember that our experience might not necessarily be divisible quite so neatly.

The same with the negative versus positive; it seems to imply a clear difference or separation that I think is not usually that clear. Maybe it’s my age, but I think ambiguity, ambivalence and compromises are more characteristic of reality than negativity and positivity.

And I can see how it can be helpful, especially for some patients who are feeling very stuck, to talk about negative thoughts as a means of getting some leverage on how things could be looked at differently or starting to make some changes. But I think that forcing into negative and positive can become a bit tyrannical, and does violence to reality, just as the separation of thought and feelings.

I think as people start to become more reflective about problems and experiences or problems in living, the ambiguity in the mix tends to become more predominant or more clear. I think sometimes problems arise by trying to impose those differences of negative or positive. “Is this a good relationship or a bad relationship?” “Is my doctor a good doctor or a bad doctor?” I think the reality is that it’s going to be mixed.

Jenni: The way you say that is so true. I don’t think I’ve ever had very much in my life that’s been very clearly good or bad, that’s uniformly, “this is it, it’s good or it’s bad.” There are a lot of shades of gray and a lot of us live on a spectrum day to day.

Steven: Shades of gray, and a mix of good aspects, bad aspects, middling aspects.

Jenni: So, to maybe go a little off-script then, can we maybe just jump to one of the questions I had written but was a little further down my list?

Steven: Sure.

Jenni: When we think about relationships, and how they impact our tendency to maybe think negatively or have maybe unhealthy behaviors that have come from those relationships, can you talk about how it’s important for people with chronic illness to look at those relationships? Or look at the behaviors and thought patterns and where they came from? What’s the value of doing that?

Steven:I think there’s value in two different ways.

Number one is, at least in virtually all of the patients I’ve worked with, the chronic illness has had a huge impact on their relationships. When I do an interview with folks I ask them to describe their pain or other medical condition, but probably the most important part of the assessment for me is to ask about what impact it’s had on their views of themselves and on their relationships. And that’s what we usually spend a lot of time talking about. Most patients say they’ve never had the opportunity to talk about such things before, and many tear up, both because it’s a tender spot in their lives and because they appreciate the opportunity to share such experiences.

Because relationships often suffer when people have developed chronic illnesses, because they can’t do the things they used to do, perhaps, which changes their views of themselves, and that can affect the relationship. People in their lives may not understand the impact of the illness.

Most of the people I’ve worked with have chronic illnesses and their experience is that it’s very difficult for others to understand what it’s like to have a chronic problem. They will often say friends and family can be very patient for weeks, maybe months, but then many start to get impatient and wonder why you’re not feeling better, why aren't you over this yet?

Jenni: Do you feel like when people are in relationships like that, does that kind of experience then generate some kind of negative thoughts or negative self-perspective or behaviors?

Steven: I think so. Just the other day in our pain group, we were talking about this issue. And even folks who’ve been working with a pain problem for a long time, and recognize that it’s not their fault that their problems still persist, will also say that it’s hard not to internalize those judgments, implicit or explicit, that other people are making, and at times wonder, well, could I be doing more? Am I not exerting my will enough? Am I not motivated enough? Could that be the problem?

Or, I’ve even had people go so far as to doubt whether they're actually disabled and wonder how much of their problem might be just in their mind. Even folks who’ve had five or six operations, transfusions and hardware. It can be difficult not to see yourself reflected in other peoples’ views of you.

Jenni: So when people have that kind of experience—and I know it’s hard to generalize, because everybody’s different in how they’re going to process this and work through it—where do you start with your guidance for them on how to get past that?

Steven: I think it has to do with the second part of the importance of relationships, and that is the extent to which our early and most formative relationships have affected how we see ourselves and others and what we expect of others, especially when we’re in need or in distress.

Often people will have a more severe vulnerability to feeling at blame or guilty or as if they’re not motivated enough, if some of their early experiences with parents and other people who were close in their life weren’t very supportive, weren’t as supportive as they could be, so they don’t have as strong a sense of confidence in who they are and their value.

So the intervention then begins with reflecting on those experiences and the impact they’ve had. It takes a huge amount of emotional resources to cope with a chronic condition, and especially a chronic painful condition.

And if you’ve been through a lot of emotional difficulties early in your life, adding a chronic and painful condition can make those vulnerabilities come to the surface again, even though in some ways people might have learned to adjust and adapt very well, and develop a stronger sense of self-worth and value and confidence. It can be shaken even in folks who had a very supportive childhood with very loving parents.

Jenni: I had a very rocky childhood and upbringing, and I’ve learned to be very resilient. I’ve written about this a lot at ChronicBabe.com and that’s something I’ve worked on a great deal, but I still have moments where, you know, I’ll feel like I’ve tried everything, I’m doing everything my doctors are telling me, and I’m working really hard on it… and even though I’ve surrounded myself with very supportive people, I’ll have moments where I think, am I just not doing this right? Am I not working hard enough on this? You know, why am I failing?

I can still slip into that space of very intense self-judgment and that’s a tough space to get out of. I think a lot of us with chronic illness wind up getting our heads there.

Steven: Yeah, and I think what you just described also connects back with what I talked about earlier with my problems with the emphasis on negative versus positive. In that, some things are going to be negative and remain negative and can’t necessarily be overcome. In my classes, the students always chuckle nervously when I say this, but we’re all gonna get sick and die.

Jenni: It’s true, it’s kind of an inevitability. I think what you say is very challenging for some people when you say that there are negative things that we can’t overcome. I think that doesn’t necessarily have to mean that you can’t have a happy life or learn different ways...

Steven: True.

Jenni: For example, if I observe something about myself, like I’m having self-judgment, and I’m almost 20 years now living with fibro, and certainly many years with therapy and other advice. If I’m still having moments of self-judgment, then I know that’s probably never gonna stop. But there’s a difference in how I act when I have those moments, right?

Steven: Yeah, definitely. Especially if you can catch yourself in the act, and then of course that gives you another opportunity not to judge yourself for being self-judgmental.

Jenni: (Laughs) Right! Judging judge-y-ness is not the hottest idea.

Steven: Not so good. You were asking about how to work on these things, that’s where in psychotherapy—and I don’t really draw a clear line between psychotherapy and psychological pain management—that’s another area where I think the boundaries are very blurred.

Jenni: For me, they have been one and the same really.

Steven: That’s where it can be helpful to look back and think about, how did I develop this tendency to use judgment to motivate myself and to evaluate my experiences? And judging myself, in particular.

Although some people may tend to be more judgmental of others, others are more judgmental of themselves. Some tend to wield that judgment stick indiscriminately. It’s a tough one. It often has clear sources in that people learned to do that to cope with a difficult situation.

So for example, if someone had very critical parents, being judgmental could be one method of trying to avoid parental criticism, by judging yourself first, maybe even more harshly. At least that way you might be obviating your parents’ judgment, or you might not have to deal with the anxiety and uncertainty of wondering when that stick of judgment is gonna come down, if you’re applying it yourself.

Jenni: So if someone’s listening to this and it’s resonating for them—and I have a feeling it’s going to resonate for just about everybody who’s listening to this—how can folks begin to consider their current relationships and their past relationships, and look for origins of some of these behaviors or thoughts to try to address them or at least become aware of them? How can someone get started if they’ve never been to therapy or they haven’t thought about this stuff before?

Steven: One way is to think about how they’re feeling in a particularly troubling situation and maybe think back to the times when they’ve felt that way before. Or another approach, not so very different, is to think about what they’re troubled by or what they’re wishing for from others, or are afraid will happen. What do they expect others will do in response to their need or their wish, and what has happened before? How did they come to expect those kinds of responses from others, and how did they come to act in a certain way in response to what they expect?

Steven: It sounds maybe too abstract or too contorted, but I think the basic point or premise for me is that we learn about ourselves based on how others treat us, and certainly when working with a chronic pain problem, you’re interacting with others, with your family, with physicians, with people on the job if you’re still able to work, so you’ve got those personal interactions.

But as you mentioned, dealing with conditions like that also can affect how you think about yourself, which can also lead back then to thinking about, how did I come to see myself in this way? How did I come to act towards myself in this way? Because my premise in working with people on their relationships—and especially troubling relationships, and especially when people are puzzled by how they have trouble changing and continue to act in ways that don’t seem very helpful—is that, going back to this premise again, those ways of acting served a purpose at some point.

I don’t think anyone willfully acts irrationally, or against his or her best interests. With everyone I’ve worked with so far, having ways of treating oneself or thinking about oneself or other people, usually made sense at some point and usually earlier in life when one was more vulnerable and had to adapt to circumstances.

Jenni: Yeah, I feel like I’ve definitely spotted those patterns in my own life for sure. And it’s hard to see those things about yourself, but I think they can lead us to learning better ways to handle our circumstances. By being honest with ourselves about where those tendencies may come from or where those perspectives may come from, I think it has to lay the foundation for change.

Steven: I’d like to add a caution though, in that some folks who’ve had very, very troubled lives may find their distress increasing as they start to think back about these things. In that case, it’s very helpful to have a supportive, caring, therapeutic relationship with someone, to help work through those periods. And also someone who can say, let’s back off from this for a little bit, let’s think about something concrete, about what you might do tomorrow or the next day. To prevent those recollections from being overwhelming sometimes, it depends on the individual.

Jenni: That makes a lot of sense. Because I know that for some people, things are so intense that the last thing they want to do is send themselves into a flare-up because they’ve spent the afternoon reliving in their mind terrible things that happened when they were a kid. That’s not productive.

But I like what you’re saying for folks who know that this is a very challenging thing to do: getting some professional help to get through that process makes so much sense. And I’ll speak from experience and say that it’s a great idea if folks can do it. ‘Cause that person is like, your guide through the jungle.

Steven: Yeah, I think so. And I think it also helps to see the fallibility of those guides;  that’s another way to learn, maybe, to be less judgmental about yourself, too—to see how a caring and well-meaning therapist or physician can also make mistakes.

Jenni: Yeah, because they're human too, it’s not like they’re impervious to flaws. They’re part of the community and we all have from some weird things in our background that are going to affect how we are. So...

Steven: Yes. There’s one more thing I wanted to say and that is, although it may sound like I’m encouraging people to feel worse about their situation, I hope it’s not exactly that way.

That’s not been my experience working with a lot of patients or working with myself; I also have a couple chronic pain problems, although not very severe. My experience is that although people may, with reflection, understand how they’ve been shaped by important relationships and that may lead to sadness or even grief, most people I’ve worked with feel that that feels more real and less frightening, in a way, than being anxious or worrying or having difficulty facing uncertainty. It provides a little more solid sense of reality than having avoided thinking about those incidences for a long time.

Jenni: That makes sense. I can imagine being alone in the middle of the night and really not feeling well and then starting to get really self-critical. Instead of swirling in that storm of fear or anxiety and Where’s this coming from? What do I do? I don’t know why I’m like this! I would prefer to think, Oh, you know what, I’m being self-critical because I have a history of that that stems from this long relationship and...

I feel like then, I can start to tackle that, I can start to say, Okay, I see that about myself. Awareness is so much a part of caring for ourselves. Now I see that I can think about how I want to be different, or remind myself of what’s in the past and that I’m in the present. And in the present I have a lot of tools to take care of myself, and people who love me and support me, you know?

Steven: And think about the troubling relationships as well.

Jenni: Yes, because there are so many positive relationships that have taught me how to take care of myself. And I know it behooves our listeners to think about those as well. They’re just as powerful, I think, as the ones that taught us some bad habits.

Thinking about these ideas and how large a role past and current relationships affect how we look at ourselves and how we think about our life with illness, for someone then who’s just kind of starting on this journey, is so valuable.

I’m wondering if you can leave us with a kind of best “next step” for someone who’s newly diagnosed, or maybe this is the first time they’ve ever really thought about the genesis of some kind of negativity or behaviors that they’ve had that aren’t the most helpful to them? I’m wondering if you could give us your best advice for those folks to get started on a journey of self exploration that might lead them into more positive territory.

Steven: I’m assuming you mean besides the obvious psychotherapy, both individual and group?

Jenni: Well, that’s a great place to start for sure.

Steven: Especially group. And I’m saying that because many—I would venture to say nearly all—of the chronic pain patients I’ve worked with have at some point wondered whether they were different or crazy in some way because of the things they were experiencing, which were in reality the most common experiences of someone who’s coping with a problem of pain that doesn’t go away and that interferes with life in all its aspects.

Jenni: So being in a group of people where you can say that and everyone nods their head and says, “Yes, I’ve been there too,” that’s got to be very empowering, I think.

Steven: Yes, I think so.

Jenni: I’d say a lot of people could benefit from that kind of work for sure. I think if someone’s listening to this right now and they want to ask themselves: What’s something I could do tonight with a spare twenty minutes of my time, or hour of time… what can I do right today to get started on this and start thinking about it? Do you have any tips for that?

Steven: A way to start might be to think about one’s thoughts and feelings, not just specific to the chronic pain or chronic problem, medical condition. And think about: Am I feeling frightened? And what am I frightened of? And am I feeling that I need help from others? And am I afraid I’m not going to get it? Am I afraid that I might lose others’ love? Or am I afraid that I might—and this is a big one, I think—I might lose myself or who I am?

Jenni: And identify those, because those feelings are there whether or not they’re caused specifically by your illness or something else, right?

Steven: Yes. And I think it can be more productive to work with some more general questions. Because these days I—maybe I’m oversimplifying, maybe my memory is deteriorating so I’m trying to reduce what I need to keep in mind to be helpful—but more and more I think that how one manages with chronic pain or other chronic medical conditions isn’t essentially different than how one manages with any of life’s difficulties, although it can be among the most severe of difficulties and the most intense. I don’t think it’s different in kind from dealing with, say, a divorce, or the death of someone close to you, or a job loss, or other kinds of disappointments.

Jenni: I actually really agree with that. I think it’s such a big thing but I feel like you definitely got us thinking about some new ways to think about coping, and even getting beyond coping to coming back to a place where we’re really thriving in spite of it. So, I want to thank you so much for all your time today!

I think you’ve definitely given me a lot of things to think about and I know that everyone listening has been challenged, and has some advice to take away that they can use to think about how they can work on themselves. Thank you so much for being here with us today Dr. Kvaal, it’s really been a treat to talk to you.  

Steven: You’re very welcome. I appreciate being asked, and I hope I made sense or could be helpful—and if there were parts that didn’t make sense or don’t seem helpful, just let ‘em go.

Jenni: Ah, yeah. I’m sure there was a lot in there for people to really get something from. For our listeners, if you joined us a little bit late, you’ve been listening to Dr. Steven Kvaal. He’s an associate professor at Roosevelt University. And if you didn’t catch this whole audio broadcast I hope you’ll go back to the beginning and really give it a good listen, there’s so much here to take in. Thanks again and this has been Lesson Three, talking about heading from the negative into the positive. Thanks again for your time and we’ll talk to you soon!