One of my mentors (TE) was a psychiatrist of immense intellect and a laser’s capacity to cut to a psychiatric diagnosis. His brilliance as a diagnostician, however, did not extend to gently bringing his well-defended patients down the therapeutic path.
This man was a surgeon of the mind.
Surgeons leave scars.
Think of psychotherapy’s beginning as a kind of dance, with the patient in motion like Salome, covered with seven veils. Her wraps and shifting movement are for protection, not seduction. The client, female or male, is wary, and the covering — any covering — guards against invasion.
Should a doctor rip the gauzy garments away, he does an injury. Without a shield, the individual is exposed, terrified, and likely to flee treatment.
Too much too soon.
A thoughtful mental health professional doesn’t drain a protective moat until the client develops the courage to take on the scary world outside his castle (or inside his head). The counselor must avoid retraumatizing the sufferer, in effect flooding him with emotions he is unprepared for.
The irony of hurting when you mean to help could not be more poignant or more terrible.
Young therapists can miss this. So do managed care companies when they want you to push treatment as fast as possible (to cut its cost) or medicate the insured party for the identical reason. TE was guilty of ignoring the same therapeutic speed bump.
The challenge of focusing on life’s dark side was understood by the mathematical genius Blaise Pascal, who died just before the age of 40 in 1662. The Frenchman recognized the need to divert oneself from contemplation of the human condition. Students of clinical psychology might still benefit from his words. For example:
Being unable to cure death, wretchedness, and ignorance, men have decided, in order to be happy, not to think about such things.
Or this:
I have often said that the sole cause of man’s unhappiness is that he does not know how to stay quietly in his room.
In short, the world can overwhelm creatures as small and vulnerable as ourselves. Those in most need of distraction are among the least inclined to make use of this necessary method in the pursuit of equanimity.
Pascal again:
However sad a man may be, if you can persuade him to take up some diversion he will be happy while it lasts, and however happy a man may be, if he lacks diversion and has no absorbing passion or entertainment to keep boredom away, he will soon be depressed and unhappy. Without diversion there is no joy; with diversion there is no sadness.
I’d say Pascal goes too far, but his point is a worthy one. I can name many people who seem content (at least for the moment) because they don’t think about the shadow following them down the street. Perhaps trouble at work or home, with children, or the big concern:
Death.
A memorable patient of mine found escape in distraction and denial, eating enough carbohydrates to push her well into obesity and diabetes. Yet, while feeding, she felt at peace. During stressful moments, this lady believed she deserved a treat as compensation for her upset.
The therapist seeks a balance between accepting the other’s ever-ready psychological defenses and gradually helping them to recognize the long-term damage they are doing to themselves by not facing problems. With the sizable woman in question, it was quite a tightrope walk.
I find myself on both sides of the balance beam.
Socrates was right when he said, “The unexamined life is not worth living.” So, however, was Pascal, by implying the deleterious effects of too much examination, rumination, and painful memory. The truth is hard to swallow, as the kid in the top photo is about to discover.
Were I to create my own mantra, I’d alter the inscription on the Temple of Apollo, which reads: “Know Thyself.”
A less pithy version would be:
“Know thyself, but not all in one bite.
“Remember: Your potential for self-awareness is bigger than your stomach for it.”
While I have great respect for Rogerian (client centered) therapists, and those who are followers of “focusing,” which is partially based on Rogerian principals, I myself spent about 8 years with a well known therapist known for his skills in focusing, Then I spent perhaps two more years with a “pure Rogerian”. After many years, I have come to regret this. I was allowed all the denial I needed, in fact way too much. I determined the “course” of therapy and the therapists practiced active listening and made very few directive interventions.. They didn’t bother with “corrections” if my ideas and thoughts were leading me down some very non-productive paths. Rogerian therapy can take you so far, and then you need someone who can say “Well don’t you think you need to change this,”, instead of being so “accepting” about your own beliefs about yourself. .
When I mentioned to the Rogerian therapist that I was depressed and sleeping 16 hours a day, I remember that his reflection was “so you are sleeping 16 hours a day.” It went on like this, and my depression worsened to the point where I eventually needed hospitalization.
Never once did he say, “you know you really need to get out of bed, and start functioning” or something similar. “Active listening” should be a technique, not the be all and end all of therapy. This may vary from patient to patient, but some patients denial or lack of self-awareness about some issues is very profound and much more active techniques are necessary to break through their defenses.
Absolutely, Rick. Extremes are always dangerous. You’ve described very well the risk of allowing the “veils” to remain on permanently.
Your last sentence really struck me, and I think it’s certainly true of me at times, in therapy. I can be disappointed in my therapist for not going deep enough, quickly enough, or when she is trying not to intrude or not to move too quickly, or trying to give me the tools to cope, before proceeding further. Thank you for another excellent post….
You bet. Glad it made an impact. Retraumatization by the one who is trying to help repair the trauma is a great risk and a terrible irony.
There is no question, the truth hurts. It is far more palatable in small doses and served with a spoonful of honey. Rumination, self-examination are forms of curiosity that can drive you mad. I am guilty of this, but not sorry for it.
Also, thank you for explaining that sick feeling in the pit of my stomach the last several months. 😉
You gave me a smile, since I know of what you speak. 🙂
Dr. Stein, is that why so many of us have difficulty in accepting the reality of climate change? Is it too terrifying to comprehend and take action?
I am no expert on that subject, Rosaliene, but I’ll offer some thoughts. Perhaps part of it is “diffusion of responsibility.” There was a major research article years ago by Darley and Latane prompted by the murder of Kitty Genovese in Brooklyn. Numerous people heard her scream, but did nothing. The idea of responsibility being diffused among those who thought someone else would take action was raised. Another avenue, closer to what you have already suggested, involves “Terror Management Theory.” That large body of research was prompted by the book “The Denial of Death” by Earnest Becker. The general notion is that our fear of dying (mortality terror) influences how we live and react to threats. Although I support environmental/climate change action, I wonder if the organizations I donate money to spend any of it on research that might suggest the best method of attempting to influence public opinion. Thanks for your provocative question, Rosaliene.
One other thought, Rosaliene. You might find this anecdote about the US Supreme Court Justice, Felix Frankfurter, informative. He was approached by an eye witness to the ongoing Holocaust in 1942. Though himself a Jew, he was so staggered by what he heard that he could not believe the story. You can read the details here: http://www.jewishhistory.org/felix-frankfurter-the-other-jewish-justice/ Perhaps the denial and inaction we witness regarding climate change is akin to this.
Thanks for sharing your insights on the question I raised, Dr. Stein.
“I wonder if the organizations I donate money to spend any of it on research that might suggest the best method of attempting to influence public opinion.”
~ Perhaps you should raise this matter with them. I face this challenge with members of my own family.
Thanks for the Jewish History link. Will check it out now.
Hey, doc – where’s the normal photo credit?
Good catch, Scott. This comes from Jeffreysharrison.com/ I am not sure, however, that he is the photographer. There is no credit listed for the photo there.
“Without diversion there is no joy; with diversion there is no sadness.”
This is so true of PTSD sufferers. WWII combat veterans returned from war and returned to life rebuilding the U.S.’s economy following a decade+ of depression and then five years of war. These men were immersed into life, separating themselves from the trauma of their service. They enrolled into college or went straight to work. For years they provided for their families yet they dealt with terror in the silence of night. They went to work, worked hard, multiple jobs, played hard…they raised their families. When they retired, the led active lives. When the silence of old age commenced and the diversions faded, the war returned and with it the intense nightmares and very real pain. Though the book was not written as a treatise on PTSD, my friend, Author Marcus Brotherton penned the book, “We Who Are Alive and Remain” (http://amzn.to/1FLYJUZ) about several men who served in the famed “Easy Company” of the 506th PIR/101st Airborne Division and their lives after the war. When the veterans became idle, life became difficult.
Yes, I am one of those who deal with combat-related PTSD and the nighttime silence is near-deadly. When I do sleep, the nightmares are horrific. When I was between jobs, I was miserable as the flashbacks, nightmares and memories dominated me. I did find a therapist who was also a psychiatrist and, because of all the issues that you cite with various clinicians and their quick-fix, pill-pushing track-records, I went into that with Fort Knox-like defenses that took months for me to let down. In reading this post, I realize now that he allowed me to take my time to let them down. I never felt pushed or pressured to allow access. I see now that he knew that 20 years of existing and suffering following combat was going to require me to build trust, not only in him, but also in that side of myself. I still lack even the most basic trust for therapist, psychiatrists, counselors, etc. (yes, you included).
Thank you for this very honest post. I appreciate your perspective and am left wondering how many of your ilk would be bothered (angered, even) by what you published.
Thanks, Will, for taking the time to write this enlightening comment. Thanks, too, for the book recommendation. Your distrust is understandable, ironic because it is also a part of the cost of your honorable service. As to what other therapists might think, I’m not too concerned. Writing anything on the internet puts one in a much diminished line of fire from what you saw at close range. I also know that many counselors would agree with what I’ve written, for whatever it is worth.
The book is a very enjoyable read. I was a weepy mess when I read through it…especially when I read about what the families of these veterans endured as their soldier struggled.
I hope that what I wrote was truly enlightening for you. The Vietnam vets whom I call friends and brothers are the ones responsible for shining the floodlights on PTSD and how debilitating it is. When they returned home, not only were they rejected by their country, but also by WWII and Korean War vets. They “lost” their war or they were seen as not having fought in a “real war” by their fathers’ generation. Nothing good awaited them which made dealing with the PTS that much more troublesome. The VA rejected them and their combat-related issues for many years. They turned to each other, instead and forged a new pathway to healing that my generation and the current one now benefit from.
I think what was powerful about what you wrote was the “realness.” I treated some Vietnam vets and dealt with PTSD due to a variety of awful conditions. I remember the politics of the Vietnam War and the shameful way the returning vets were treated. Perhaps you read Studs Terkel’s “The Good War,” about WWII. One of my favorite movies is probably the first effort to portray the complications of returning home: “The Best Years of Our Lives.” I’ve made only one attempt to write anything about war in these posts: https://drgeraldstein.wordpress.com/2010/04/28/two-americas-but-not-the-two-you-think/ You are qualified to write and say things about war and its aftermath that I am not. You lived it.
The Best Years of Our Lives is one of my all-time favorites and considering the denial that Americans lived with in the postwar era, that film pushed the envelope with PTSD awareness and the struggles of reentry following war.
Yes, I read Terkel’s book.
I doubt that my combat experience gives me much in terms of qualifications to write or speak on war. I was but a peon.
Such a thought provoking post.
My first thought is that working with my therapy dog and linking the healing of the human animal bond with those who want and need it, is my own healing force. It keeps me looking outward.
My second thought was about those seven veils .
I am pretty sure my veil #6 of the 7 veils in my own therapy may not have been totally protective__I am pretty sure it may have been intended as one of those “seduction “ones. Fortunatetly my dancing veil technique was sufficently lacking in mystery, actual dancing, actual veils and generally not so subtle , it turned out to be simply amusing and entertaining (for me at least.) I’m sure my good therapist really filled up his note pad on me that day.
Let keep dancing, Dr S.
J
Yes, by the time you reach the sixth veil, anything is possible! Another blog for another day. Thanks, Jill.
Forgive my inexperience but are you saying that the therapist walks a fine line between not pushing a client enough and pushing a client too much? How does a savvy client know if he or she is being challenged enough? Seems as if that would be difficult to assess from the client’s perspective. Thanks for the thoughtful piece (if only I had a better grasp of the concept…..)
Yes, JT, I think you understand this as I intended it. It is not only difficult to assess from the client’s perspective, but from the therapist’s. The guiding but imperfect principle is the patient’s reaction to what is happening in treatment and the counselor’s sensitivity to that. You don’t want people in therapy to shut down and flee, you want them to discover they can tolerate difficult memories and challenges. Yours is an insightful question for which there is no “one size fits all” answer.
Therapy seems like an art more than a science then. Scary business. As you say, quite a tightrope walk and there is potential for more damage than healing. Risky business too….
The previous comment re: PTSD made me think of my father. He served as a medic in the South Pacific – a very young man far away from home putting his friends’ body parts into bags to send home. Although he rarely talked about those experiences, it is clear to his children that he suffered from PTSD. We have speculated that some of his PTSD lives on in his children. Doesn’t Jung have something to say about that? Nothing has more importance in the life of a child than the unlived life of the parent? Not that my dad didn’t live his life but that his life was forever affected by those years and so his children carry his pain as well.
Human beings bring such interesting pieces to the puzzle table.
Thanks, again, for the reflective writing.
I’d say therapy is an evolving science, JT. That we have not yet formulated precisely what is the best tempo for treatment and for whom it might be best, doesn’t mean we won’t. There are treatments that have been very thoroughly studied in well-controlled research and have demonstrated their effectiveness for certain diagnoses. Even in medicine one can have the experience of doctors being quite uncertain what is the cause of a serious condition and how best to treat it. (I’ve had this experience myself, now thankfully resolved). Re: PTSD and other traumatic events in our parents’ lives, I’d agree about possible second generation effects. A groundbreaking book on the subject is “Children of the Holocaust” by Helen Epstein, the first effort to look at the common psychology among the kids of Holocaust survivors. You see this too, in the kids of people who had a tough time in the Great Depression.
http://prisonerofherpast.kartemquin.com/
A look behind the curtain of a Holocaust survivor and her family
Thanks, Harvey. Hope you are well. I remember this from Reich’s Tribune writing. Well worth looking at if one has the stomach for it
[…] Dr Stein recently published a post called ‘The Unsung Value of Denial and Distraction: Where Therapists Can Go Wrong‘. It illustrates just how difficult it is for both therapists and clients to tread the line […]
Reblogged this on Darque Thoughts.
In 14 years of dealing with chronic PTSD, I have seen multiple therapists and doctors, but it was psychiatrists who were a special kind of crazy. For example, one psychiatrist told me the reason I had PTSD was because I was a “coward.” Can you imagine?! Another psychiatrist at Kaiser would never wear anything but velour track suits. I have had several therapists and psychologists who were wonderful, but as I told my primary doctor about psychiatrists: “I have my problems, but some of these people are crazier than I am.” 🙂 Thank you again for a thought-provoking essay, Dr. Stein. 🙂
Funny, but no joke, Harry. When I was in practice, one of the hardest things for psychologists and social workers to find was a psychiatrist who they were confident in with respect to medication and clinical judgement. It was possible, but not always easy. I am glad you endured the helping profession despite its challenges. Be well.
I love the image you used for this post, Dr. Stein. An overeager little one, ready to take big bites with abandon…and yet…pacing matters. I’ve encountered students and clients who’d like to move rapidly (eat the whole watermelon, spit out the seeds and move on) but belly aches and other miseries might arrive, running alongside, skewing the original ambition and/or revealing new topics and challenges.
Yes, I am sure you faced this dilemma in your practice, Vicki. I suspect it remains an inescapable part of our job as healers.Thank you.
Indeed, indeed. Thank you.
my takeaway from this is that the job/mission of a therapist is to find that balance, each patient being unique, and will most likely be a moving target. the science is there, and the art is in the recognizing the sweet spot and the timing of when to try to help the patient to move deeper or to hang back until they are ready. to act as a knowledgable guide, and let the patient show you where they need to go, is to understand the human condition.
I could not be more eloquent, Beth. Both beautiful and spot-on. I would add only this. In my opinion, no matter how long we live or how knowledgeable we become, there will always be some people who we are slow to fathom in their completeness and some who surprise us because they are facing a new situation that causes them to act in a new way. Thank you, Beth.
I couldn’t help smiling at the captioned photo of the toddler with a slice of watermelon 😀 Lost in the joy of consumption without a thought of its consequences. We humans carry so many layers of protection that it can take a lifetime to know oneself. Other times, with disastrous results, we can go through life believing that we know it all, that we are in total control–creating our own alternate reality based on denial and distractions galore.
Yes, Rosaliene. No one knows it all though many believe they do, comforting themselves against the nature of living a the world of change. The ancient play “Heracles” of Euripides offers a provocative, brilliant, and insightful lesson about how we humans can get rocked by external forces we never anticipated. I think you know this lesson well. Thank you, Rosaliene.
🙂 <3
What an interesting balance a therapist walks. Almost like peeling a fruit before it’s ripe. Fascinating, essay, Dr. Stein and I love the quotes from Pascal!
Thanks, Wynne. In my opinion we are always walking the tightrope, even in my moments we feel at ease and safe from change. In an instant fate can enter and explode our equanimity and more. The death of your father comes to mind. Meanwhile, despite that, we must do our best to honor the wisdom Pascal offered and find life’s joy and richness, as well as providing kindness to others so long as we live.
Great post as always, Dr. Stein. Socrates was right, and we definitely need to spend some time examining our lives. We don’t need to go down a rabbit hole examining every little aspect, but it’s definitely worth looking over the important areas of our lives.
The subject of death, oh my goodness. How difficult it is for some people! My mom refuses to talk about estate planning and funeral arrangements, so that is one of those things that I need to plan the best I can and hopefully everything works out in the end.
Last night, I was talking with another person who was asking for advice to deal with a 92-year-old veteran who also refuses to talk about arrangements. So I sent the person some resources from Veterans Affairs, and hopefully someone can sit down with him and do some planning for him and his wife. Not thinking or talking about something isn’t going to make it go away.
Yes, it is problematic, Edward. Often what happens is that the one who won’t deal with estate planning leaves a world of difficulty and family conflict for those they leave behind. Both those who believe in an afterlife and those who don’t often seem to deliver the same amount of unhappiness in this way to the ones they say they love.
“Unhappiness”—that’s a great way to put it, because that’s how I’m going to feel. You said something to Rosaliene about the “diffusion of responsibility.” Maybe that is a factor in these cases.
Well, it does more than diffusion of responsibility, I think, becoming an embodiment of an ostrich, one who wishes to dodge thinking about the inevitable. If you go back and read Hamlet’s famous “To be or not to be” monologue, he goes through some of his fears about death, and this causes him to put the idea of suicide aside. Good luck with your mom, Edward.
Thank you! I’m going to need luck and more.