advice

June 5, 2016

Normalizing the Abnormal: Making Excuses for Toxic People

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Why do we associate with people who aren’t good for us? Why do we stick with them? Here are a few of the reasons:

  • FAMILIARITY: If you were raised in a dysfunctional family, you are used to acquaintances who injure others. Their behavior is routine. To some degree you become habituated to it.
  • THE DIFFICULTY OF LEAVING: The end of relationships can be complicated and painful. Should you wish to avoid conflict or are afraid the toxic individual will lash out, all the more reason to endure the situation.
  • INSECURITY AND FEAR OF LOSS: A person with low self-esteem and few friends might accept a poor relationship despite its limitations. He does not believe he will be better off without it or capable of finding a new buddy.
  • OPPORTUNISM: Alliances can be a simple matter of taking advantage of a situation and serving your own interest. Senator Marco Rubio is being encouraged to run again for the Senate by senior Republican Party (GOP) members. Thus, he has decided to make friends with an enemy, Donald Trump, the presumed Republican nominee for President. A former supporter of Rubio, Cecilia Durgin in the conservative National Review, states: “Rubio hadn’t just disagreed with Trump on policy but had labeled him a ‘con artist’ who threatened the GOP and was too dangerous to be entrusted with the nuclear codes. Now Rubio has gone from reluctantly upholding his pledge to support the nominee, to saying he’d attend the (Republican National) convention and would be ‘honored’ to help Trump.” Durgin finds Rubio’s shift opportunistic.
  • FEAR OF THOSE UPON WHOM YOU DEPEND: A child who perceives the potential for repetitive angry and hurtful responses from a parent can learn to bury his feelings and blame himself for generating the parental danger. He has little choice. Retaliation will only bring on more injury. Unfortunately, he may accept the parent’s verdict as just. By diminishing himself, he unconsciously attempts to make his situation more acceptable. Moreover, his life then becomes less hopeless: he comes to believe that if only he can change himself, the parent will show him love. Without eventual escape from the elder and processing his own misfortune, he is liable to accept mistreatment throughout his life.
  • RATIONALIZATION: The process of growing up is disillusioning. We discover mom and dad aren’t perfect and no one is morally pure. That includes ourselves, at least if we are honest (a contradiction in terms, I know). Many of us are not and excuse the gradual erosion and transformation of our sense of right and wrong. Thus, we might note no problem in those whose misbehavior isn’t much different from our own. People salve their conscience by thinking they will be heroic and principled when faced with a major moral crisis, no matter their small indiscretions in more routine situations. Without being tested, however, you don’t know. In my experience, morality is lost by inches. Those who are not careful gradually become something they would have rejected at an earlier time of life. When the big moral test arrives, they have long since given up whatever idealism they once had.
  • BECOMING POLLYANNA: By nature or experience, it is possible to be optimistic about individuals and look at the bright side of life. This can be a good strategy for a routine sense of happiness, despite the mistakes of judgment it leads to. If you see only the best in people then it doesn’t matter too much with whom you spend your time or, within limits, how they treat you.
  • HISTORY AND INERTIA: Relationships of long-standing are hard to give up. You share a history and a body of memories with someone special. A recent friend doesn’t replace that shared experience. A new person who appears toxic will be avoided much sooner than an old buddy or family member.
  • GUILT: Society reinforces loyalty. You risk not only admonishment if you end a relationship, but violating your own internalized sense of what is proper.
  • MISGUIDED HOPE OF GETTING THE LOVE YOU WANT: When your beloved or best friend reminds you of a parent who did not love you enough, you may endure his mistreatment in the hope he will change. You are still chasing the dream of getting the kind of affection you hoped for from the parent. This is a case of unconscious mistaken identity or — as therapists call it when they are taken for someone else (metaphorically speaking) — transference. One can almost never persuade a parent or parent’s doppelgänger to be who you want. We can only work through the transference, grieve our failure to obtain the desired love, and find healthier affections.
  • NECESSITY: In a down economy one stays in jobs with abusive bosses far longer than one otherwise would. Financial dependence on a spouse (or the inability to work) creates the same constraints. Escape becomes difficult; though, over time and with preparation, effort, and courage, a toxin-free situation is possible.
  • HOPELESSNESS: Some of us are so bruised by human contact as to assume we might as well stay put, since no one better is thought to exist. It is a false, but powerful belief and likely to be associated with depression. Treat the mood disorder. Hope (and a more objective view of the future) may then return.

One key to a good life is adapting, learning from experience, and knowing how to start over. There are millions of new people you might get to know who would enrich you. Unhappy relationships need not be maintained. We are often freer than we think.

—

The top Caltrans Sign is the work of Mliu92 and sourced from Wikimedia Commons.

May 30, 2016

Speeding through Life and What To Do about It

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It is difficult to take a long view of things from a perspective free of the hurly-burly of life. We are mostly preoccupied with what is in front of our nose. Still, there are trends we might observe from a distance that may be more important than whether we get a weekend date. Here are a few impacting our lives:

  • Being with friends face-to-face is more difficult than when America was rural, cities were smaller, and cars and super highways didn’t exist. We try to substitute electronic contact, but the relationships are different, less easeful because they are hurried and perhaps shallower. Communities of friends are harder to assemble once past school years. We are more atomized, separated, and detached. The availability of email and tweets create an escape from those who are socially uncomfortable. Face-to-face contact, formerly a pleasure, has become a luxury if you enjoy it and a job you skip if you dislike it.
  • Families, too, are more distanced by geography (once the children are grown) than they were even 50 years ago.
  • Americans, especially if they are young, are less captured by a particular religion. Worship communities used to bind people together in a way seen less often today.
  • The TV and computer present us with the possibility of witnessing the “lives of the rich and famous” and comparing ourselves to celebrities in a way impossible for almost all of human history. Fewer of us might think of ourselves as a “big fish in a small pond” because such ponds have been dried up by competition and contact with the entire world. This fuels the pursuit of material wealth and power, but also dissatisfaction with our station in life.
  • As noted regularly, the income inequality between the corporate executive class and the rank and file workers is enormous, fueling further discontent.
  • We work more hours and/or travel greater distances to work than recent generations, leaving us less time for other things. On the highway of urban life we live in little boxes, whether cars or homes, and gridlock — stuckness — is the norm.
  • The creation of a volunteer army and the elimination of the military draft robbed the nation of a common experience and sense of responsibility to our neighbors and country, not to mention activities and goals pulling people together, including the families of those serving the country.
  • We are in danger of feeling smaller and less significant as everything gets bigger and change is faster. Life becomes unmanageable despite all the labor saving devices. Lifelong careers doing one task for one employer disappear as the demands of work change and computerized machines make humans expendable.

Where does this leave us?

We are less interwoven with other people, for one thing. More isolated. More dependent on entertainment by ourselves, unlike those days in which others were more or less unavoidable and solo diversion consisted mostly of building or crafting something, or reading. Since we live without lots of family members around us (as was the historical standard), we spend more time alone — more time focused on ourselves. Thus, man’s innate self-interest is stoked even further.

We humans also must deal with our evolutionary baggage, including a tendency to get used to things (habituation) and want some new object or activity. We pursue money, status, and other goals which we hope will be attractive to others, but don’t counterbalance the mission with effective moral or religious messages to get ourselves “out of ourselves” and on to thoughts of being a part of something bigger. Moreover, in the absence of easy intimate contact (not necessarily sexual) we substitute sensation and material pleasures, which are only satisfying for a short period before we habituate to them and search for a new diversion. No wonder the USA is rated 18th in life satisfaction of the 38 countries measured by the Organization for Economic Co-operation and Development (OECD), despite our historical affluence.

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What can be done? Several things:

  • Join with others. This might include participating in government by attending meetings at which your elected representatives speak or legislate, finding a cause worthy of volunteering for, creating your own philanthropy, reading to children at your library, or joining a religious community or a park district sports team. Alexis de Tocquiville wrote that one of the benefits of worship was to get your mind off yourself and on to something bigger and more distant, not so focused on the day-to-day minutia and irritations we all experience.
  • Mindfulness meditation is another way to get outside of yourself and in-the-moment, accepting whatever the present conditions are, and reducing your tendency to wring your hands and worry about yourself.
  • Try to reduce your addiction to the rapid-fire stimulation of electronics. Spend a day free of your computer and phone. Read a great book. As Oscar Wilde said, “It is what you read when you don’t have to that determines what you will be when you can’t help it.”
  • Buddhist philosophy focuses on developing compassion for oneself and others, an antidote to the selfish motives residing in each of us and a mercantile world encouraging them.
  • Get away from the city. Walk more outdoors. Let yourself assume the tempo of a life more like your ancestors, the one your body was built for.
  • The liberal arts have fallen on hard times. The importance of knowing such subjects as history and philosophy are dismissed. “Be practical,” people are told. “Learn about those things you can turn into dollars.” I’m no philosopher, but I will admit that there are few fields of higher learning as hard to turn into a fortune or even a living as philosophy. Getting a tenure track university job as a philosophy professor is only a bit less difficult than flying without wings. Yet such learning has enormous relevance to our lives. Despite great technical advances, the most important issues are the same as they were 2500 years ago: life, death, love, loss, morality, and purpose. What does it mean to be human? How can one lead an honorable and productive life? Often in therapy, especially with those who are beginning to overcome anxiety and depression, these concerns arise. We can do worse than consult the wisest minds in the world’s history, an oasis in the dog-eat-dog struggle to get ahead. Getting ahead, as it is defined in the West, can leave your soul behind. If your life is focused on making money and spending it for things inessential, you will have earned whatever emptiness you find at day’s end. Should you measure yourself by the size of your bank account or reflection in the mirror, the result is the same. What have you learned from your time on the planet? What do you know about the human project that you didn’t 10 years ago? What is important to you and what are you willing to give up? The world has changed, so we all must change with it. Ask yourself similar questions and chart a new course.

It is hard to find repose — peace of mind — these days. But, I suspect, it is more necessary now than ever.

—

The first image is called Running Man, by amandasqueeze. The second is Nude Man Running, an 1887 photo by Eadweard Muybridge. Both are sourced from Wikimedia Commons.

May 22, 2016

Why You Want “More” From Your Therapist (and Why He Can’t Give It)

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You think of your therapist as a special person, at least some of you do. His kindness and attention can not only generate gratitude, but affection. You are aware of his boundaries and you can be frustrated by a professional stance limiting the kind of contact you’d like: a favored position, not someone put into a time slot with a financial transaction attached.  Perhaps, however, there is more to this than an ethical code. Why might his viewpoint as a therapist make what you want difficult to obtain? And, no, I’m not talking about sex.

Consider the role you play and the role he plays. You are likely talking about emotionally charged issues. Your feelings are front and center. His are not. Indeed, he is thinking about what you are feeling and doing.

You come to the clinician because of problems on which you are intensely focused. Thus, you are internally directed to your issues. The counselor, on the other hand, is not attending to his concerns, but to yours. He is looking outward, you are looking inward.

The counselor is not exposed. While you can find out some things about him, the treatment is not about him. You do not keep his secrets, but he wants to keep yours. You are encouraged to open yourself in order to heal. He is closed, assuming a relative position of safety and authority no matter how much he tries to be gentle and helpful.

Your session is of singular importance to you. It is one of many sessions for him, focused on you and a full complement of other patients. That makes him more important to you than you are to him. It does not mean he is indifferent to you. The doctor may well have tender feelings for you and enjoy your company, care genuinely, and approach you somewhat differently from the way he approaches others. Still, he is your only therapist, while you are not his only patient.

The counselor spends a limited time with you. He will then meet with someone else and switch his concern to the newly arrived individual. In a sense, however much he is concentrating on you while you are with him, he must develop an ability not only to be “in the moment” with you, but switch to another person after a brief interval. You do not switch. When you leave, your concern is still on yourself and the relationship with the therapist. A mental health professional is like an athlete in this way. After the game is over, he quickly puts the contest behind him so he is able to bring all his skill and attention to the next game.

To the extent that the therapist makes himself a blank slate and reveals little about his life, it is thought you will play out your emotional issues in the form of transference: experiencing him, to some degree, as similar to an important person or persons in your life, especially if your parental relationships are unresolved. Your transference toward him provides important material which he will help you work through. In doing so, you cut the trip wires of the past that continue to harm you in the present.

The counselor, of course, can also have countertransference toward you: experiencing you and reacting to you as if you are someone about whom he has unresolved feelings. However, to the extent he gets to understand the intimate details of your life, he is likely to be less prone to such emotions than you are in response to him. You are not a blank slate to the therapist. Thus, his likelihood of projecting his issues on you is at least a bit less probable.

Now let’s switch focus. Imagine what therapy would be like if these conditions were not typical of a therapeutic interaction. In which case:

  • The therapist would reveal as many of his issues as you do of yours.
  • He would be focused on himself as much as on you.
  • He would have less control over his emotions in session.
  • You might come to know disqualifying things about him.
  • The counselor might break down in session when you are overwrought or because of his own life problems outside of the office.
  • Consolation from you may well be required to stabilize him.
  • When you are in session he could be preoccupied with the last patient he saw before you.
  • Your relationship to him would approximate the kinds of contact you have with friends and co-workers.

I wrote this essay for the purpose of helping you understand a therapist’s perspective, his limitations, and his boundaries. Without those walls, little benefit comes from treatment. This is not to say your therapist doesn’t care about you. It is to say his care must remain within limits. In the absence of those limits, no matter how much you believe you’d like something more, counseling leads to something less.

Sometimes in life we do not know what is best for us. Then we are lucky — very, very lucky — that our wishes are not granted.

—

The photo of the 45 rpm disc was sourced from Wikimedia Commons.

May 15, 2016

When Sex is Too Much Trouble

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If you are young enough, the idea of sex as a chore is beyond imagining. You know you will change as you age, but the thought of sex as a job, obligation, or — worse yet — too much trouble, is inconceivable (pun intended). You’ve heard, perhaps, of those who lose interest, but don’t really think you ever will; and are too busy with the mating game to put your mind into an unattractive future (in both senses), whether due to the march of time or other factors.

Philip Roth tells us about a re-evaluation of the sexual project, as we read the viewpoint of his narrator in The Human Stain. Indeed, the character’s altered attitude toward sex drove him to move from the city to the seclusion of the countryside:

 My point is that by moving here I had altered deliberately my relationship to the sexual caterwaul, and not because the exhortations or, for that matter, my erections had been effectively weakened by time, but because I couldn’t meet the costs of its clamoring anymore, could no longer marshal the wit, the strength, the patience, the illusion, the irony, the ardor, the egoism, the resilience — or the toughness, or the shrewdness, or the falseness, the dissembling, the dual being, the erotic professionalism — to deal with its array of misleading and contradictory meanings.

The complaint is not unknown. Indeed, some men prefer sex with prostitutes because it takes care of the problems driving Roth’s narrator to isolate himself from sexual encounters altogether. For those men, the exchange of dollars for skin does away with the “misleading and contradictory meanings” and the emotional and behavioral role-playing they find so bothersome.

We do a lot for sex — at least for the connectedness and commitment we hope will come with it. Would the amount spent on cosmetics, hair supplies, skin creams, Viagra, sex toys, personal trainers, gym classes, face lifts, breast implants, hair plugs, mirrors, bar bells, watches, clothing, cars and jewelry total nearly so much without the hope of a sexual or romantic payoff?

How much time is spent choosing those items and activities? How much time in using them? How much time in wondering whether they have done the intended job? How much time observing whether anyone notices?

Sex is in the scent of perfume and pheromones and aftershave. Romance and seduction are on the air of radio broadcasts and TV programming. Sex sells cars, shoes, and itself. But don’t, please don’t point out the obvious: you would be considered crude. By comparison there is some honesty in the professional transaction of money for sex; one could argue, more than is inherent in the pursuit of a trophy spouse or the prospective mate’s willingness to become a sexual hood ornament.

Roth’s point, however, is more subtle than any of these things. He is referring to learning the steps of the mating dance and performing them to perfection, even when you don’t like the music. Part of his concern is the sheer effort involved, the fashioning of disguises, the worry that you are boring, the time to make yourself look good, the forced concentration on the other person while stifling a yawn, the calculations designed to impress, the compromises, the things said to promote yourself, and those unsaid to hide what is unbecoming.

Then there are the questions of strategies and tactics, the intracranial meeting of your own personal staff of generals to call the shots as if you were embarked on a military campaign: when to phone or text, when to touch, when to flatter or smile or laugh, when to be unpredictable and what you can predict about the target’s vulnerabilities and impregnabilities.

If one’s heart is aflutter, an attempt to comprehend what is going on in the relationship is inevitable, despite your flustered, pulsating state of body and mind. Your conception of the union’s status may not coincide with what the other thinks or hopes, but consumes much time and psychic energy. Curiously, Roth’s character does not mention the frank danger of sex. The dreaded risk of injury, the extraordinary vulnerability, the nakedness in every sense, involving every sense.

He seems more concerned with the way one is captured, thrown about, unbalanced by an enticing companion. The brain is pitched into the trash heap because there is no reasoning with all the impulses holding sway. Sex presses you to do things you wouldn’t otherwise do and experience half-crazed feelings of pre-relationship desire, early relationship passion, and end-of-relationship desperation.

How do we maintain a full-time job with all this happening?

Some don’t, you know. The burden of the sexual road show can’t bear the tumult or spare the time to do those other things.

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Should you be young enough, the excitement of the chase, not to mention your raging hormones make the carnal marketplace seem the only place to be; an arena that might define you as popular, alluring, or powerful. For a few, this comes naturally. For most, the meat market is a little like being placed on a skating rink before you’ve learned to walk; too much, too soon. Still, our genetic programming pushes us into the fray.

Time strips away the appeal and ratchets up the cost sex exacts, just as Roth suggests. The hormonal flush diminishes gradually, while the desperation mounts. The psychic scars of failed relationships make one hesitate, but the clock is running. Not just the ticking biological time bomb, but the worry you are gradually becoming invisible to members of the opposite sex because your shining externals don’t have the glow of their best years. A receding hairline, or growing waist line tell you your “use by” date is approaching much too fast. Meanwhile there appears no end of competitors who want to take your spot; less weathered or younger or richer or just simply smarter and better looking.

All this is more than enough to make one nauseous, anxious, or depressed.

Some do, temporarily or permanently, throw in the towel — give up on the sex project. You can have a rich life without lust, but it certainly is different from the wildly urgent existence of the sexual being, where youthful animal instinct meets the combustible allure of the primordial creature in heat.

Celibacy meet-up groups exist around the world, although not all of the folks in these are abstinent by choice. Some are like Roth’s fictional character, choosing to be free of the trouble of sex. A portion of those who opt for continence may resist the lure of flesh as a kind of discipline or a way to concentrate on other things and grow personally; perhaps to sublimate their sexual energies, focusing on something beyond and above the narcotic of skin and the grip of Mother Nature’s hard-wired programming.

Resisting temptation is always an interesting and difficult project, so there is doubtless knowledge to be gained in it, much as any kind of philosophical or religious abstinence provides, like a day of fasting.

How long would you travel this solitary highway?

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There are as many ways to live as people who are living. One such way could include a span of time without sex. The world is beautiful and forever new if you only look hard enough. Intimacy does not require some sort of penetration of bodies.

For myself, if I were to take a break, I’d schedule a winter in a forbidding place where everyone is covered up.

I’d have lots to do — things of importance to me.

When spring comes and the comely shed their coats?

That would be another matter.

—

The images, in order: Sexy Secretary Drawing by Dimorsitanos, With Reference to Sexy by Mickey esta en la casa, and Monique Olsen by Christopher Peterson. All are sourced from Wikimedia Commons. This essay is a revised version of The Emotional Cost of Sex, published in 2012.

May 8, 2016

What Gets Under Your Therapist’s Skin?

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Many patients worry about alienating their therapist. Will he dump me? Am I wearing him out? Is my progress too slow?

Several behaviors can get a counselor irritated, though patients aren’t always aware of them.

Here are a few:

  • The Hand on the Door Disclosure: Therapists attempt to be mindful of the time left in your session. When possible, they hope to wind down the emotional intensity of the meeting so they don’t leave you in tatters. Clients who are hesitant to talk about something important will often wait until the very end of the meeting before dropping the bomb. Suicidal ideation or plans, sexual indiscretions, and self-harm are sometimes revealed in this way. The counselor now is faced with the dilemma of trying to deal with a fraught issue and insufficient time to do so. Mental health professionals do, of course, push back their schedules, ask the patient to wait in another room until the counselor is free, etc. Those clients who spring late surprises repeatedly do themselves and their clinician a disservice.
  • Failing to Work Between Sessions: Some patients don’t attend to homework the therapist and client agreed upon before the next meeting occurs. A few don’t even recall what was discussed. The doctor’s job is to determine why this recurs and try to create conditions in which the patient succeeds. A client who is dissociative, for example, may be unable to remember an unsettling conversation topic. Still, some people aren’t prioritizing their treatment and taking responsibility for their own healing. A therapist can be frustrated by this and should call attention to the troublesome behavior pattern.
  • Lateness: The session is the patient’s time. Every second. The counselor is expected to start on schedule, to be alert, and focus on his client. He should review his notes before opening the door. Yes, unexpected events happen in every life, but the client needs to be ready to go, not chronically missing. Even those diagnosed as ADHD, who therefore have an “excuse” for lateness, cannot be helped if absent. Everyone is tardy occasionally. The chronicity of such behavior, however, can erode the counselor’s patience.
  • I Must See You Today: New patients who believe they are in crisis sometimes plead for a same-day appointment. Therapists are inclined to help, both by nature and training, so they do what they can. Those who are experienced, however, know an urgent request from a new patient is potential trouble: he frequently doesn’t show up. Why? Since practitioners never meet the no-show new client he speculates that they may be narcissistic, histrionic, and self-indulgent; or so disorganized, erratic and impulse-ridden that the appointment takes second place to something else.
  • Money: Among the worst examples of a patient’s abuse of a therapist’s trust is financial irresponsibility. On occasion an insurance company will send reimbursement for the doctor’s services to the client, even though he assigned payment to the mental health professional. I recall a couple of egregious examples, one involving a psychiatrist and the other a psychologist, who treated two different people during long psychiatric hospital stays. Their fees amounted to thousands of dollars each. Although neither of the inpatients reported being unsatisfied with the treatment they received, both used the unexpected wealth to take vacations.
  • Overuse of Telephone and Email Contact: Clients need to realize their doctors have other patients, and their own lives outside the consulting office. Genuine emergencies justify telephone calls. Changes in scheduling are useful to complete by email. That said, many therapists direct patients to the emergency room if a crisis develops. Counselors are wise to talk about out-of-session contact with the patient and agree upon what does or doesn’t constitute overuse of the doc’s electronic time. Some therapists stipulate that any phone conversation lasting more than a few minutes will generate a fee. Over-reliance on being able to reach the therapist can also result in both over-dependence on the counselor and a failure to give oneself the opportunity to develop resilience and alternative coping mechanisms.
  • Appointments Made by Relatives: No one will be surprised about spouses urging their mate to go to therapy. Many of those reluctant clients hesitate. Thus, mental health professionals get calls from the non-patient to book a meeting for the future client. Ambivalence or disinterest by the latter points to a lack of motivation and the probability of a poor therapeutic result. The easiest part of treatment is to call the therapist, even if this isn’t easy. Doctors are smart to require the patient himself to arrange the appointment.
  • Passivity or Passing the Buck: The oldest joke about treatment is this: “How many therapists does it take to change a light bulb?” “One, but the light bulb must to want to be changed.” If you don’t desire change enough to give your best effort, the chance of a successful outcome is small. Patients who expect the doc to do all the heavy lifting should consult psychiatrists for the purpose of medication. They can then be passive, with the exception of remembering to take their meds. Therapists love patients who work hard and assume responsibility. The others, not so much.
  • Termination Issues: Termination in therapy is a bit like a romantic break-up. Assuming the therapist has not been inappropriate and the relationship has lasted several weeks, a face-to-face conversation concerning the end of treatment is usually best for both parties. The golden rule applies: do unto others as you wish them to do unto you. I’ve written about all the ways terminations are mishandled here, as well as the value of walking away with your head held high and a sense of mutual respect, even if the treatment didn’t achieve what you hoped.

A good therapist is one who will tell you if something is troublesome about the therapy relationship (from his end) and try to work the issue out. His default stance is not to give up on you. Misunderstandings are in the nature of human contact, not necessarily deal-breakers. If you think you offended your doctor or caused upset, raise the issue. Psychotherapy depends on words — those you say and he says. A mute conversation partner makes for a long and unproductive 45 or 50 minutes.

It doesn’t have to be.

—

The smiley is called Thumbs Down by Cäsium 137 (T.). It is sourced from Wikimedia Commons.

May 1, 2016

Can You Always Trust Your Therapist?

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Any seasoned therapist knows a fair number of other counselors, some casually, some quite well. We refer patients to a few of these people and steer clear of making referrals to others. The reason for the latter is pretty simple: doubts about their skills. That raises a second question: should their patients have the same uncertainties?

Going to the doctor in the days before there were lots of different types of medical professionals was a no-brainer. The doc was the expert. The medical model required the patient to submit to the physician’s ministrations. You were passive, he was active, and everything was supposed to work without much thought on your part.

No more.

To begin, there are many different types of counselors: clinical psychologists, psychiatrists (some of whom only prescribe medication), psychiatric social workers, marital and family therapists, licensed clinical professional counselors, and other titles. The first two are doctoral level practitioners, the rest most often hold masters degrees. The type and extent of training varies.

Then there are an enormous number of therapeutic approaches. Here, for example, you will find descriptions of 30 different kinds and this list does not include all the specialities within each type: http://www.counselling-directory.org.uk/counselling.html

The plethora of therapy modes creates a dilemma for the patient. At bottom, the issue is trust:

  • Is the doc expert at the precise model of treatment best suited to my condition?
  • Is the type of therapy he might recommend for me empirically validated? Empirical validation refers to a large body of well-controlled research demonstrating that therapy approach X for diagnosis Y produces better results than either no treatment or a placebo.

If you multiply the number of diagnoses by the number of approaches to treatment, you come up with a number so large as to confuse many patients. Indeed, we can say with certainty that there is no therapist who is expert in each approach for every type of diagnosis. Mental health professionals must therefore narrow their focus to a limited number of diagnoses and a small selection of approaches to those diagnoses.

Most practitioners possess training and experience in one or more forms of healing Depressive and Anxiety Disorders. They may not be prepared, however, to take on all subtypes under these headings. Thus, for example, a person who accepts patients with Anxiety Disorders might not be prepared to work with all 10 of the coded diagnoses listed below the broad descriptor “Anxiety Disorders:”

ANXIETY DISORDERS:

  • 309.21 Separation Anxiety Disorder
  • 312.23 Selective Mutism
  • 300.29 Specific Phobia
  • 300.23 Social Anxiety Disorder
  • 300.01 Panic Disorder
  • 300.22 Agoraphobia
  • 300.02 Generalized Anxiety Disorder
  • 293.84 Anxiety Disorder Due to Another Medical Condition
  • 300.09 Other Specified Anxiety Disorder
  • 300.00 Unspecified Anxiety Disorder

Why an Empirically Validated Treatment is Important? An Example:

Given all the issues mentioned, consulting a therapist who can diagnose and recommend the treatment most likely to help is crucial.

Here is an example of how this might best work in practice. The recommended and empirically validated treatments for Obsessive Compulsive Disorder (OCD) include Exposure and Response Prevention (ERP) or medication, with a 70% effectiveness rate overall. Our hypothetical patient is hamstrung whenever leaving his home, his office, his car, etc. He checks over and over whether he has locked everything for fear of an irrational catastrophe. This causes him to waste an hour or more a day. Our friend is late for appointments, work, and social events, angering many people and placing his job and family relationships in jeopardy.

If one were to treat this gentleman with ERP, the therapist and patient would together rank those situations that are the least anxiety provoking to the ones most upsetting. The client would then be exposed to a fear-inducing event at the low end of the list, having agreed not to engage in his usual compulsive checking despite his turmoil. The patient’s fight against the urge to check is the portion of treatment called response prevention. The expected outcome is a diminution in his fear and checking as he repeats these exposures without confirming the security of the lock. The patient gradually faces the more unsettling items on the hierarchy until the troubling behavior is eliminated.

Traditional talk therapy, designed to uncover the underlying “reasons” for such compulsivity, is ineffective in treating OCD. At this point in the history of this condition, if a therapist chooses to provide a treatment not meeting the standard for “best practices,” he risks not only his patient’s well-being, a waste of his money, and a squandering of his time, but a malpractice suit.

What Increases the Risk of a Therapist Not Choosing an Empirically Validated Treatment (Assuming It Exists)?

At least three possible reasons:

  • He is unaware of the research pointing to the recommended approach.
  • He doesn’t “believe” in the validated mode of therapy.
  • He doesn’t possess the training to deliver it properly.

As noted above, therapists are not schooled in every method of doing their job. They perform in a competitive field, especially in large urban areas, and are under downward pressure from insurance companies regarding their fees. There is the possibility of unconscious self-persuasion of the knowledge and skill to treat a wider range of conditions than close scrutiny would justify, thus enlarging the potential pool of patients who might consult them. All health practitioners are required to spend more time documenting their work than previous generations of peers. Therapy clients also often desire evening or weekend appointments, creating an incentive for the doc to be available for sessions during “leisure” hours. Any of these factors can unintentionally limit the time needed to keep up with the latest research and receive the necessary training.

Depending on the practitioner’s location and discipline, there are requirements for continuing education. Licensed psychologists in Illinois must take at least 24 hours of continuing education every two years to maintain their practice. At least three hours cover professional ethics. No other directives point him toward a particular area of knowledge. In other words, these requirements are not guaranteed to remedy any shortfall in competence to treat OCD or any other particular disorder.

What You Can Do:

Where does this leave you, the present or future patient?

Counselors almost all mean well, but we all should recognize “the road to hell is paved with good intentions.” It is in your power to do the following:

  • As early as possible, understand what the initials after your therapist’s name mean, e.g. M.D., Ph.D., L.C.S.W., etc. This is not meant to disparage any particular group, all of whom include excellent practitioners. Rather, knowing this gives you the most basic information about the counselor’s background.
  • Learn about the kind of training he received subsequent to his degree and what he specializes in, both in terms of diagnosis and approach to treatment.
  • Ask him why he is suggesting a particular approach and find out what other approaches exist, and, especially whether they have been empirically validated. It should be noted empirically validated therapies do not exist for every diagnosis.
  • Be sure to confirm, as much as possible, whatever you are told by doing your own research.

Once again, I’m not assuming any wrong doing by your counselor. However, remember, you are dealing with another human being, no matter how kind or intelligent.

As an old Russian proverb tell us, “trust but verify.”

 

April 24, 2016

On the Need for Reassurance: What Do You Do After Therapy?


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When we go to the doctor our expectation is to receive a cure: something to finish off the illness. We might expect a similar result from a therapist. He will apply the magic ointment to make our hurt go away. Typically, however, we are not offered a fix with a lifetime guarantee, but guidance in developing a method — a way of living “differently:” a “practice” designed to enable a more satisfying and manageable life.

Perhaps our desire for someone to “make it better” goes back to childhood. Indeed, depending on people is, for many, an endless and desperate project. We look for them to put things right, whether to captain our team, lead our country, or reassure us everything will be OK. Unfortunately, however, there are no magicians, only experts. They cannot be with us forever and, even if they could, our excess dependence would transform them into the human equivalent of a security blanket.

If life is to be lived with adequate confidence we need a method to practice regularly, not another human as our permanent rabbit’s foot or talisman. Not a replacement for an inadequate parent. Not excess dependency, but self-reliance coming from the development of a new “groove:” a repeatedly rehearsed approach to the challenges particular to our life.

How can we carve out such a path?

This is a big question. Usually, however, other questions take precedence. Will I wear out my therapist? Will he leave me? Will he ever say he cares about me in a convincing way?

The unstated belief is that the mental health professional is essential for my well-being; and the hope he will be there as long as I need him. In effect, he possesses the magic, I don’t. You hear this in the lament of the lonely, as well: I cannot do this by myself and my life can only be better when I find “the one.”

Therapists, at least with most of their clients, recognize they need to be transitional objects. A portion of what they do is to enable the patient to develop a method of living designed to make him (the doctor) unnecessary. Put differently, the client learns to master his problems most of the time.

Many patients resist the notion to the point of hoping to become the friend (or lover) of the counselor after treatment ends. Just as we look to our aged parents for wisdom or reassurance, we want not only the therapist’s attachment, approval, and security, but his guidance, as if he can never be replaced, least of all by relying on ourselves.

The idea of “a practice” is not always mentioned by counselors. Oh, the clinician will assign homework, but he might never say homework must continue when treatment ends. Leaving the therapist’s office upon termination is not enough. Rather, the client must continue to do work on himself, climb even higher, take on different versions of the same challenges, and bounce back when thrown to the floor. He needs to remind himself of his strengths, his successes, and what he must do now. This is a practice: “repeated exercise in or performance of an activity or skill so as to acquire or maintain proficiency in it,” according to the Google online dictionary.

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Your program might involve regular, organized self-reflection; journaling, mindfulness enhancement, recitation of those people and things for which you are grateful, time set aside to challenge negative self-talk, a plan for increasing your compassion, writing down all those difficult moments you’ve overcome; and a step-wise, graduated list of challenges you want to take on and a chart of your progress.

You may already engage in other such practices. Daily meditation would be one. Daily reading of passages from a religious text is another. Professional athletes and body builders maintain a regular workout routine, even in the off-season. The goal is to solidify your thought and action, create a habit, improve your focus, rely on yourself, and beat back whatever might encroach on past gains.

One of the best examples of this idea is found in Plato’s Phaedo, the story of Socrates’s last day. Knowing that he will shortly drink hemlock to fulfill the state’s death sentence, it is perhaps unsurprising that Socrates speaks with two younger philosophers (Simmias and Cebes) on the subject of mortality and whether an afterlife for the soul can be foreseen. Despite his attempt at philosophical “proofs” of the likely existence of an eternity, they acknowledge the extent to which they (and we) are like children in search of a magician for reassurance. They despair that once Socrates is gone, no such person will be able to provide his kind of logical, well-reasoned, persuasive confidence in the possibility of a life after death.

Socrates gives Cebes the following advice, as applicable to therapy as to facing one’s mortality in a philosophical way, in both cases to dispatch fear:

What you should do, said Socrates, is to say a magic spell over him (the scared child in each of us) every day until you have charmed his fears away.

Cebes persists, believing only Socrates, soon to be dead, has the necessary sorcery.

Greece is a large country, Cebes, he replied, which must have good men in it, and there are many foreign races too. You must ransack all of them in your search for this magician, without sparing money or trouble, because you could not spend your money more opportunely on any other object. And you must search also by your own united efforts, because it is probable that you would not easily find anyone better fitted for the task.

Thus, Socrates has advised these well-trained philosophers to repeat their own magic spell over the child within them: to seek the wizard in themselves to calm their anxieties by way of what he has taught them and whatever further ideas they can reason out on their own. In effect, to develop a practice maintaining or enhancing proficiency in dealing with this challenge of life.

The proper approach for the therapy patient might be said to take whatever he has learned in treatment and make it a practice. Yes, this is lots of work, but what is the alternative? Life will not hesitate to provide you with more challenges. We stop growing at our own peril, just as the athlete risks getting out of shape by abandoning his practice routine. Concern for your psyche is not like a diet, to be ignored and replaced with poor nutritional habits once the target weight is achieved.

Whether you maintain a practice or not, your counselor will still be there in most cases. But don’t you think you would be more secure by taking your life in your own hands once he passes the baton?

Your therapist does.

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The top sculpture is The Thinker by Auguste Rodin, sourced from Hiart at Wikimedia Commons. The second photo is of Baseball Hall of Fame pitcher Bob Feller.

March 27, 2016

Can a Therapist Know How You Feel? Must He Have Courage? Thinking About Essential Qualities in a Counselor

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Does a therapist “know how you feel?” No. How could he?

But he may still be able to help you even without such knowledge.

Why don’t I know how you feel? I am not you. I am not your age or perhaps your gender. We may not share the same faith. I wasn’t born in the same place under the same circumstances. My parents made more money or less than yours, lived with extravagance or pinched pennies. They survived the Great Depression well or badly or not at all; and so forth.

A counselor is not in your skin, so can’t know the sensations which comprise your life. Yet he can have some idea, perhaps even a good one. What might that idea be based on?

First of all, you are both human and have a certain set of shared, although not identical experiences. Speaking for myself, as a seasoned counselor I talked to thousands of people who told me what they thought, revealed how they reasoned, and explained how events influenced their mood. I therefore became familiar with the range of what is possible in reaction to an enormous number of circumstances. I also read text books, received instruction from teachers, and shared in the richness of emotion, perception, joy, and adversity found in stirring memoirs, novels, plays, and movies.

Despite all of this, I am open to surprise. An example: my father died abruptly in the year 2000 at the age of 88. I’d known he was mortal at least since the time of his heart attack when I was a boy. Prior to his death I counseled many people who were suffering from loss. Still, despite dad’s advanced age, his demise was shocking. Like the flick of a switch — the “here today, gone tomorrow” unreality was too true. Unexpected fatigue lasted for months, as though the life force taken from him had been emptied from me as well. Even now, years after this loss, I can’t say for sure “I know how you feel” if you tell me about the death of your father. Your relationship with him and the circumstances of each of your lives might cause me to rely more on imagination than something closer to your lived experience.

I would argue we cannot even recall how our own pain felt once the distress recedes into the moderate or distant past. Big events do not remain unaltered in the museum of the brain. Rather, they are like a photo faded by the sun. We need painful memories to diminish, which would otherwise leave us in a perpetual state of agony. Even splendid, heavenly recollections, if remembered with their original impact, would compromise our ability to attend to the most crucial elements of each new day. To some degree we must unconsciously forget or transform our life history.

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You might ask me: “How then can you help me grieve my loss if you can neither ‘know how I feel’ nor retain an unaltered remembrance of your own loss?” In several ways. I can listen to you and bear witness to your pain. I can be sympathetic. I can accept the emotions and stories you share: the varied combination of sadness, anger, exhaustion, and sense of separation from the world accompanying the death of a loved one. I can abide with you, acknowledge your suffering, and “be there” until it passes. If you will accept the comfort, our relationship will help to reattach you to life, even while you are grieving something that rends the same cord of attachment.

You will never be what you were before your loss, of course. But, you are more likely to heal if you share your grief. Holding it in or trying to “move on” too quickly — or shedding your tears only in private — can cause your sadness to pass by inches or not at all. Human contact in the aftermath of loss is crucial. A supportive spouse, friend or therapist can help. Time does the rest.

My sympathy for you doesn’t require I first possess knowledge of your internal life any more than enjoying milk requires a prior existence as a cow. Best not to say you know how another experiences his suffering. It is enough to tell him you care. Indeed, were you to fathom every detail of the emotions passing through another without caring, absolute understanding of his pain would count for nothing. Genuine concern — not some magical power to read another’s heart — is what counts. A patient will often forgive a therapist’s momentary failure to grasp his upset, but ought not to accept his indifference even if his knowledge of the patient’s emotional state is exact in every aspect.

The counselor carries an imperfect bag of tricks. Like the wounded soul who comes to treatment, he risks failing at the task he shares with his client, even if the courage demanded of the patient is greater. The therapist also assumes the frightful responsibility of caring for another with no certainty his effort will avoid tragedy, even if his burden and terror are less than the patient’s own.

The practitioner is always practicing. He must work to learn more and attempt to heal you no matter how much knowledge and experience he has. His therapeutic arsenal is never complete. Psychotherapy research is forever making new discoveries. Fortunately, if the therapist has the knowledge, dedication, and experience along with the courage to allow your heart to touch his, what he has tends to be enough.

In accepting you as a client, he risks injury to both you and himself. Why? In short, because you do matter to him. In treatment with the best healers, that is the one thing of which you can be certain, however much your relationship history causes doubt.

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The top photo is Misty Morning by flagstaffotos.com.au/ The second image is Cirrus Clouds with 3-D Look by Simon A. Eugster. Both are sourced from Wikimedia Commons.

February 21, 2016

Why Loved Ones Refuse Therapy and What to Do About It

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You’ve tried — with your friend, your spouse, your adult child. You made the case for counseling. Some hem, some haw, some say they will, but don’t. Others just refuse.

Why?

A few reasons to consider and what you might do about it:

  • Stranger danger. Suspicion of strangers is deeply rooted in the human race, derived from our primitive beginnings and ever-present con-artists. Your friend’s personal experience of betrayal may be a key factor.
  • Saving face. Much in life depends on reputation. How many of our parents admonished us to hide the family secrets and “be sure you don’t tell the neighbors!” Men, in particular, want to project strength, the better to succeed in the world of work and win a desirable spouse.
  • The doctor doesn’t care. He is only in it for the money and measures his patients’ value by the size of their bankroll. Should counselors then give treatment away and make their living after hours by standing on street corners with hat in hand?
  • I’m afraid my employer will find out. I can’t risk it. If you use insurance, the insurer will know your diagnosis, as will every such company in the linked system. They are not supposed to reveal anything to your employer. However, if you work for someone with few employees and his premiums go up the next year … ?
  • Therapy is for the weak, a crutch for the spineless. A therapist argues instead that facing your demons and working to change are signs of strength, not evidence of frailty: an indication of courage, not its absence.
  • I don’t believe in the value of looking back. Sometimes therapy doesn’t require it, but a historical evaluation can remove the bolder from your backpack and allow you to move ahead with pace. On the other hand, baseball’s Satchel Paige said, “Don’t look back, something might be gaining on you!”
  • Emotional pain. Whatever reasons are given, the prospective client can be unconsciously timorous at opening painful issues — digging up a grave bursting with undead horrors of the heart and memory.
  • I’m a logical person, not into feelings. I can solve this logically. Such statements are uttered most often by those who aren’t as logical as they think.
  • A real man does things, he doesn’t talk about them. But what if he doesn’t know what to do after trying everything?
  • Fear of change. Most of us find discomfort in new challenges, in or out of treatment. Yet change can’t be avoided unless you want to wear the same clothes in the same size and color the rest of your life; and continue to travel to the same job site even after your employer bars the door.
  • Fear of the mystery. The counseling office is a bit like the inner sanctum of a haunted house — a place of strange rites and secrets, incense and shadow play, frequented by the ghost of Sigmund Freud. The person who wants control will find few guideposts. Will a wizard cast a magic spell on him?
  • Fear of medication or hospitalization. Though you can’t be forced to take meds as a rule, some are terrified they might hear the doctor recommend it — or worse, a hospital stay.

What’s to be done? I received calls from spouses who wanted to make an appointment for their mate. This is rarely useful. If the individual lacks the courage or motivation to seek treatment himself, the likelihood of his appearance at the appointment is a coin flip at best.

Begging and pleading have their limits, too. The more you push, the more therapy becomes your agenda, not the person you care about. You own it, he doesn’t want to buy it. The more you pester or threaten, the faster he runs. If he does attend a session, his motive is to placate you, not heal himself.

Sometimes it helps to enlist the persuasive talents of one who is respected by the prospective patient: a clergyman, best friend, or close relative. The danger here, however, is an unauthorized revelation to a third-party interpreted as a breach of trust. A similar risk occurs when you plan an “intervention:” getting several friends and family members together to encourage and explain their concern to the doubtful potential client. This technique is more often used with alcohol and drug abuse problems, and is easier to rationalize when the person’s life is out of control and in danger.

I am not speaking here of people who are at risk of harming themselves or others. Thus, legal remedies to force the issue are not available. If your steady expression of loving concern cannot turn the tide, waiting might be the only alternative. The accumulation of pain perhaps will do what you can’t.

You are left in a difficult situation: straining your patience when everything in you wants to scream.

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Most of us spend a good part of our lives wishing others were different: more loving, kinder, attentive to us in a way rarely offered; with an intensity and compassion that finally permits the auditor to “get us.” We want the love of this one, the respect of that one, and wish another would take our words to heart. We think and plot about attracting the dark stranger, selling the human product (ourselves), and winning the vote of the crowd.

The good news here is the presence of one person we tend to ignore. While we work on others to change, he remains in the shadows. We don’t need to run after him, persuade him, make an appointment to meet six weeks in advance, and cause his face to turn in our direction. His visage greets us in the mirror every morning.

When others resist our efforts to influence them we are left to change what we can about ourselves — what we may and what we must: our attitude, emotions, and reactions to the one who refuses treatment — and to the rest of life as well.  The transformation begins whenever we want. The process of self-modification can persist as long as we live. Unlike changing the loved one, however, the necessary alterations are in our hands.

The most important opportunities in life sometimes have been there all along. We wait for the other to wake up while what is changeable in ourselves awaits its own awakening. Imagine standing at a crossroads: one path leads to a darkling state of perpetual hope or desperate preoccupation with a person you can’t control. You pass the time alternately gnashing your teeth or imagining what life might be like if only he changes. The other road directs you to a house of natural light and mirrors revealing all sides of the one human you do control. This workshop evokes the hard work of the master sculptor in everyone, the painstaking job of reshaping our basic stuff.

Become your own work of art.

050613102055--Bristol RWA gallery starting point for Festival of Stone Sculpture Trail

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The second image is a Ladies Watch Case photographed by Zeigerpaar and sourced from Wikimedia Commons. The bottom photo comes from the Bristol RA Gallery Festival of Stone Sculpture.

 

February 14, 2016

A Therapist’s Dilemma: Telling the Whole Truth vs. Healing the Wound

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Does anyone tell the “whole truth” all the time? No one, I suspect. There is a difference between answering direct questions honestly and offering opinions not requested. The therapist lives in the space between. He does not tell his patient everything he thinks about him.

This is no surprise. His job is to heal, not harm. Our best friends, for example, are careful not to say too much unless the information is essential. Indeed, many people will not offer any hard “truth” ever. Some are afraid of hurting the friend even if the buddy’s mate is having an affair of which he is unaware. As Shakespeare’s Othello says when he is led to believe his wife is sleeping with Cassio:

What sense had I of her stolen hours of lust? I saw ‘t not, thought it not, it harmed me not. I slept the next night well, fed well, was free and merry; I found not Cassio’s kisses on her lips. He that is robbed, not wanting what is stolen, let him not know ‘t and he’s not robbed at all.

Simply put, ignorance of the offense is bliss. Othello maintains the injury is not so much the infidelity, but the knowledge of betrayal. This is doubly true in his case, since the report of his wife’s affair is false.

To the extent a therapist is viewed as an authority, his opinion carries particular weight. Patients will, on occasion, request reassurance or ask what his assessment of them is. The counselor’s answer might be any of the following:

  • “Why are you asking?” The healer attempts to turn the conversation to the client’s motives.
  • “My opinion isn’t the one that counts.” The doc deflects the question, pointing out the need for self-esteem independent of anyone else’s viewpoint.
  • The shrink offers a few positives and tactful negatives (not couched as weaknesses or personality flaws), thus addressing the request as a diplomat might.

What if the therapist is in a position to provide information crucial to the patient’s well-being that he might not otherwise receive? For example, let’s say the client has body odor of which he is unaware. I suspect some therapists would shy away from anything as personal as this, but I recall an occasion with a supervisee when I dealt with it head on.

The trainee in her late-20s appeared well-groomed, but the scent always trailed her. Indeed, others on the hospital staff suggested I address the problem for the individual’s good, as well as to make contact with her less noxious.

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Making matters even more delicate was the gender difference between this lady and me. Still, it was essential my supervisee be informed how others reacted to her. I was not eager to impart the information, but my responsibility was clear. This decent and intelligent young clinician could serve her patients well only if she knew what was common knowledge. Failure to inform her would have been a disservice.

Now imagine she’d been a patient in treatment because of dating failures and loneliness. Would it have been responsible to shy away from any mention of a body odor?

A very different situation is more typical. I treated many middle-aged people who were concerned about how an adult child, now out of the home, turned out. Some of these parents felt rejected by an offspring, were depressed, or angry at the child or former spouse to whom they assigned responsibility. Often these folks found little fault in their own errant parenting.

If the patient wanted to improve his relationship with his adult child, the conversation would then involve what he might do differently now. If the offspring blamed the parent for historical wrongs, then self-reflection would be grist for the mill. But what if the relationship was over? Would the patient profit from awareness of his imperfect parenting? What gain might follow from a fresh and excruciating knowledge of the irreparable harm he’d done? Most therapists, I suspect, would allow the person’s rationalizations about his behavior to go unchallenged.

A therapist is not a palace guard barring the way to some heavenly reward, weighing the good and evil in any life, opening or closing the door to the pearly gates. He is not a moral arbiter. The job of harvesting or harrowing souls is left to “fire and brimstone” preachers and others who claim a divine purity far above the counselor’s pay grade.

The healer must keep in mind what the client came for. Most likely he did not ask for administration of an ethical purgative designed to expunge imperfection and cleanse his soul of sins past and present. If the counselor does not remember that, then the therapist, not the patient, has lost his way.

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The top photo is called The Mouth of Truth, located near Lipnice nad Sazavou in the Czech Republic. The author is Jarda 75. The second image shows “Michele Linger, left, Sexual Assault Response Coordinator (SARC), lending an ear to a Joint Task Force Guantanamo service member during a counseling session at Guantanamo Bay, Cuba, March 25, 2010.” It is the work of Army Spc. Juanita Philip. Both photos are sourced from Wikimedia Commons.