child abuse

May 26, 2010

Fear of Change: the Therapeutic Implications of Japanese Holdouts

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Things change. The question is, do we change with them? Or, do we instead, continue to operate by the same outdated rules of conduct.

I often said to my patients that they seemed to be behaving as if the conditions of their early life still existed. They had long since fashioned solutions to problems that they faced many years ago, and continued to use the same solutions, even though those methods of living didn’t fit with their current life situation. It is as if one were born in Alaska, learned to wear multiple layers of heavy clothing and then moved to the tropics without a change of attire. The warm clothes were helpful up North, but are a disaster down South.

What does this have to do with the “Japanese Holdouts of World War II? The answer is that these men lived by an outdated set of rules with heartbreaking consequences.

If you recall your history lessons, you will remember that the Japanese soldiers of that period were trained according to the principles of Bushido, a feudal fighting code that derived from the period of Samurai warriors. Above all else, weakness was condemned and surrender was disgraceful. Death by one’s own hand was seen as preferable to permitting oneself to be captured, so as to avoid both personal disgrace and family shame.

The Allied approach to the war against these very soldiers in the Pacific was one that involved “island hopping.” The strategy passed over certain islands, both to save men and ensure that the Allies would be able  to capture those islands that were of the greatest strategic value. When the Japanese surrender came in 1945, numerous Japanese troops found themselves stranded on out-of-the-way Pacific islands, cut-off from their command, and without the capacity for communicating back home. These men neither knew the war was over nor could imagine that any honorable soldier, let alone their entire nation, would surrender. Some were in small groups who gradually died from disease or starvation; others were, at least eventually, alone.

While many never surrendered and died still waiting for reinforcements that never came, it was not uncommon in the late 1940s and 1950s to read news accounts of isolated Japanese combatants giving themselves up. The photo at the top of this page is of Second Lieutenant Hiroo Onada, who finally surrendered in 1974, and would not do so until his former commanding officer, by then a bookseller, personally ordered him to lay down his arms.  At that point, World War II had been over for nearly 30 years.

Thirty years. Yes, 30 years dedicated to a war that was over and a life of desperation that was no longer required.

But how many years, if any, have you given up to a thread-bare, bankrupt strategy of living that has long since outlived its usefulness?. And, more to the point, how many more will you endure? When will you realize that your “solution” has now become the problem?

In my psychotherapy practice I saw numerous variations on this theme. People who were abused or neglected  or criticized as children and who continued to live in terror of disappointing others. Those who found substance abuse the only available way of treating the depression or anxiety they experienced when they were young, and who continued to do so. People who avoided challenges because they were scared of failure, having failed many times in the past. Individuals who wore a chip on their shoulder, forever sensitive to insults and injuries that reminded them of long ago attacks, but now were only injurious in their imagination. And those poor souls who expected rejection because of past rejection. Like the Japanese holdouts, the years pass but the fear doesn’t, and the possibility of satisfying relationships and happiness slips away.

If you still are responding to the present as if it were the past, with solutions that solve little (even if they were once necessary), then it is time to change your life. The barricade of your life’s defenses might be protecting you only from the phantom of an enemy who lives within you, not on the other side of the fortification.

A good therapist is likely to be able to help you develop a new way of living, one more appropriate to the world as it is, not the world as it was; to set aside and heal old wounds.

Is it time?

What is the continuation of your old way of living costing you?

The war, your personal war, might just be over and you don’t know it.

September 13, 2009

Therapy, Responsibility, and the Nuremberg Defense

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Therapy, like life, requires taking responsibility for what becomes of you. But, as the comedy team Cheech & Chong famously noted, “Taking responsibility is a lot of responsibility.” What does that have to do with “the Nuremberg Defense?” Read on.

If you are old enough (or a good student of history) the word Nuremberg has a certain resonance for you. It is a German town that was a center of the Holy Roman Empire and the Renaissance; later becoming the host of Nazi Party rallies between 1927 and 1938, the site of the passage of the Nuremberg Laws stripping German Jews of their citizenship, and equally well-known for the war crimes trials that were held after WWII, in an attempt to hold Nazi villains to account. Such Nazi higher-ups as Hans Frank, Rudolph Hess, Joachim von Ribbentrop, Alfred Rosenberg, Albert Speer, and Julius Streicher were brought to justice there (see above photo); Hermann Goering escaped hanging only by committing suicide.

A common refrain during the testimony of the accused was the statement “I was only following orders.” This line of explanation was used so often that it became known as “the Nuremberg Defense.” It was found insufficient by the judges, who reasoned that the accused had the moral responsibility to refuse orders to commit “crimes against humanity,” even assuming that it could be demonstrated that such orders were given.

Since I don’t treat war criminals, you might be asking yourself how the failure of some of these long-dead Nazis to take responsibility applies to treating people with less dramatic problems of depression or anxiety or relationship disappointment? In the course of talking with my patients, I often discover that they have suffered from some sort of misfortune; be it inadequate, negligent, or abusive parents; accident or injury; or unfair treatment at school, at work, or in love. Sometimes the stories are heartbreaking. It is perfectly proper for patients to blame at least part of their unhappiness on these events and these people. Moreover, it is often essential that they grieve those losses, give voice to their anger and sadness, and rail against the unfairness of life. And it is important for a therapist to help them as they process their grief.

But therapy cannot end there.

The patient, if he is to improve his life, cannot simply assign responsibility to some other person as a release from the need to take charge of what becomes of himself in the future, any more than a Nuremberg defendant might hope that assignment of responsibility to the commanding officer would take him off the hook for the unspeakable acts he committed.

Put more simply, neither the war crimes defendant nor the common therapy patient can point to someone else, say “He is the one who caused this,” and leave things at that. Just as the SS criminals were asked, “And then what did you do?” so must we all, regardless of what misfortune has happened to us, ask ourselves, “Now what? Do I simply accept the injustice, forever blame others, and stay defeated and aggrieved in-perpetuity, or do I grieve my loss, take responsibility for my life, and try to get beyond the injuries I’ve suffered?”

We all know people who, however small or large the disappointment that they have experienced, never get beyond criticizing, blaming, whining, and feeling sorry for themselves. While some of this is often necessary to get past the hurt, a lifetime of it is simply a waste, a personal failure to take control and to admit and accept that if life is to have meaning and value, we all have to do something positive with that life, regardless of bad breaks. Even if fairness demands that others compensate us for our losses, if such compensation cannot be obtained, life still calls us to repair ourselves. As a therapist colleague of mine, at the risk of sacrilege, used to tell those patients who seemed to forever bemoan their fate, “Get off the cross, we need the wood.”

Shakespeare commented on responsibility-taking in Julius Caesar when he gave Cassius the words:

“Men at some time are masters of their fates:

The fault, dear Brutus, is not in our stars,

But in ourselves, that we are underlings.”

This is not always literally true. But there is no better way to live than to try to make our circumstances the best we can, however unlucky our lot. A good therapist will help you get there.

July 9, 2009

What to Expect in Your First Therapy Session

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Going to therapy for the first time takes some courage. You are about to talk about some very personal things to someone who is a complete stranger. What can you expect?

1. First of all, expect to be at least a little bit nervous at the beginning. But even before you get inside the therapist’s office, you will have to fill out some paper work. You will also receive a written description of the therapist’s practice, including such details as whether the therapist accepts your medical insurance and how he handles that. Additionally, he will give you information about how your medical records are safe-guarded and the extent to which those records are confidential.

2. The therapist should greet you, bring you into his consulting room, and sit face-to-face with you. Therapists generally want to convey “openness.” It is therefore rare for a therapist sit behind a desk, with you on the other side.

3. After a few “ice breaking” words, the counselor will ask you why you have sought treatment. If you already told him some of this on the telephone, he will want you to fill in the details.

4. Don’t feel that there is a particular “correct” order in which to tell your story. Simply tell it. Initial sessions should generally allow enough time for you not to be rushed. The therapist has probably scheduled at least 75 to 90 minutes to spend with you.

5. If it makes you feel better, it is entirely appropriate to bring an outline of the topics about which you wish to talk, and to consult this outline or read directly from it whenever you need to.

6. The counselor is likely to have some questions for you. He should want to know about your background, not only about the concerns that exist in your life at the moment. Unless he knows that history, he won’t be able to fully understand how you came to have the current difficulties and whether they represent a repetitive pattern in your life.

7. Among the topics you might be asked about are such things as a description of your parents and their approach to rearing you, relationships with siblings, the educational and social history of your school years, whether you changed residences with any frequency as a child, past and current health concerns for you and your family, the presence of any traumatic events in your life, your dating experience, the type of friendships you have or have lost, work background, alcohol or drug use, current medications, present family relationships (spouse/children), financial concerns, and past or current depression or anxiety issues.

Additionally, expect to be questioned regarding any evidence of mood fluctuations, sleep, digestive problems, headaches, caffeine use, suicidal or homicidal thoughts or actions, difficulties in maintaining attention, hyperactivity, hallucinations, delusions, hobbies, religion, how you feel about yourself, whether you can be assertive in your life (say “no” or ask for things), diet and eating/weight problems, obsessive thoughts, compulsive actions, and what you hope to get out of therapy.

Of course, the first session won’t have time to touch on all these areas in the initial session. A counselor will proceed gently.

8. You should not feel that you must discuss topics that are too uncomfortable for you. A sensitive therapist will give you permission to cover only the ground you wish to and a sense of control over the session’s progress so that you don’t become overwhelmed.

9. The therapist might well ask you what challenges you’ve had in life and how you have managed to overcome them. This kind of question helps you to know what strengths you have and to help you remember that you have surmounted past difficulties and therefore can rely on those strengths to help you surmount the current problems.

10. By the end of the session, the therapist should provide feedback about what you have said. This is, in part, to help you and the therapist know if he has heard and understood you and whether his initial impression of you seems appropriate.

11. The counselor, to the extent that he offers interpretations of the material you have presented, should let you know that this is a first impression and therefore not necessarily perfectly accurate. An expert therapist needs to hear your concerns about him personally, his ideas, the therapy approach he is recommending, and his effect on you. Such a person will not be offended by your concerns and wants to hear from you what feels right and what doesn’t feel right about the therapy process.

12. The counselor will normally allow a good deal of time to answer any questions that you have about him and his approach. Although most people usually do, it is not essential that you make another appointment at that time. If you already believe that this therapist is not the right one for you, it is perfectly appropriate to say so and ask him for a referral to another professional.

13. By the end of the session you ought to have a sense of direction and at least an initial treatment plan as articulated by the counselor. The therapist is likely to remind you of the importance of regular attendance and that your dedication to your own healing is essential to obtaining the results you want. Therapy, unlike medical intervention such as brain surgery, requires effort and activity on your part. It is also essential that you have the courage to look at yourself honestly, recognizing that in order for your life to be better you will have to be willing to change some things about yourself.

14. At the end of the first session you might feel exhausted, in part because talking about big emotions is hard work! You are likely to be less anxious than you were when you came into the session. You may feel some amount of relief at having talked about things that you have rarely if ever discussed before. If the therapist has done his job, you should have a sense of hope.

15. In the days following the first psychotherapy encounter, you might well find yourself still processing the material you discussed. This can be unsettling, but it is quite normal. Additionally, a person new to therapy can feel that he has said too much and made himself too vulnerable to the therapist, especially if he (the patient) is a private person. Some people will therefore not return to therapy after the first session. If you have this hesitation, however, remember that it is in your interest to persist despite your discomfort if you sincerely wish to change your life. Good luck!

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The above image is the entry to Sigmund Freud’s office at Berggasse 19 in Vienna, Austria. It originally was posted to Flickr by James Grimmelmann and was sourced through Wikimedia Commons.

June 25, 2009

Anger Anyone?

Some of the very logical or morally upright folks out there believe that you should never get angry. Never ever.

I’m not one of those folks. First of all, we are all human, and to be human means to have emotions. Second, it is hard to imagine a humanity capable of defending itself, the spouse, and the kids, who can’t get in touch with some needed anger when we or our loved one’s are imperiled.

When danger appears, we are built to fight or flee. The sympathetic nervous system readies you for action. Adrenaline starts to pump, the big muscles of our body receive more blood as the heart rate increases, breathing becomes more rapid, the pupils widen (the better to see danger, my dear!), and sweat gland activity heightens to keep you cool in the event of a major exertion of energy (as well as to make you slippery, so that an aggressor can’t get a firm grip on you).

All of this has been “selected for” in the Darwinian sense: if our ancestors hadn’t successfully fled the tiger or defeated the enemy with the help of these physiological changes, we’d not be here and their genetic line would have stopped.

The same logic suggests that the female of the species historically tended to choose males who were capable of defending her and the kiddies, especially when pregnancy and child-rearing made them particularly vulnerable. But, since the female couldn’t always depend upon the male when he was out hunting and gathering, she needed some anger too.

So, if you get angry, as you almost certainly do, you have come by at least some of it honestly and through no particular effort of your own.

That said, how do you know when your anger goes over the top? Some people will tell you when that happens, of course, and sometimes the authorities will in the form of police. If you are no longer a child and get into fist fights or find yourself yelling a lot, you’ve almost certainly got a problem, either as an aggressor or as a victim. Alcohol might add to your combustibility since it tends to disinhibit people, making big emotions more likely. For some otherwise mild mannered men and women, drinking turns them to the dark side. As the old Chinese saying goes, “first the man takes the drink, then the drink takes the man.” Substitute the word “anger” for the word “drink” and you have an equally valid way of looking at anger. Do you have the anger, or does the anger have you?

On the subject of old sayings, there is an Italian saying that also applies to this issue: “If you want revenge, you should dig two graves.” This means, of course, that revenge is likely to consume you (and perhaps even lead to your demise) just as much as it is likely to succeed in hurting the other party. Lives have been eaten-up and made perpetually miserable by the preoccupation with righting wrongs. Think of the centuries long enmity that exists in the Balkans or the long standing animosity between the Greeks and the Turks. Numerous other examples could be cited. One act of revenge causes the victim to look for his own revenge and back again in a circle without end.

Anger is often the result of a real injury, but the danger is in becoming the thing that you learn to hate because of that injury. The data on the likelihood of child abuse being perpetrated by parents who were themselves abused  is fairly well known. Such a parent is much more likely to abuse his children than a parent who was not himself abused as a child. When I tell people this they often find it puzzling. Surely, they say, the abused child would learn what not to do from the parent’s bad example. But think of cigarette smoking or drug/alcohol abuse. Again, the child raised by an addicted mom or dad is at greater risk of duplicating the parent’s behavior than one raised by parents who are abstinent. Not only does the child have the model of the parent as a bad example in these homes, but, in the case of abuse, the youngster has to deal with the anger and hurt inside of him, which comes from being targeted. As children these kids can rarely succeed in retaliating against their parents, but they can take their feelings out against other smaller children (including their siblings) or against their own helpless children when they have become adults. Indeed, unless the abused child is able to obtain relief from the feelings of anger and sadness that come with abuse (and this usually takes therapeutic intervention), he is likely to carry some of these emotions and their behavioral consequences into adulthood. A good book on the subject is For Your Own Good by Alice Miller. A first class movie that depicts exactly what I’ve described is Good Will Hunting.

Back to the question of how you might know whether you have an anger problem, there are a few additional indicators. Do you (or do people tell you) that you react out of proportion to events that are not seen by others as being that big? Do you find yourself feeling angry or irritable much of the time, or awakened by resentments in the middle of the night? Do you have road rage? Have you every punched a wall or thrown an object due to this sort of upset? If you are an athlete in a contact sport, do you enjoy inflicting pain on the opposition?

Even if none of the above apply, there might be other ways that you express your resentment. Do you intentionally delay or put off tasks that others (a spouse or a boss) want you to do, but you don’t believe are that important? Are you sarcastic to others, rather than direct? Do you grumble in discontent or talk behind the back of others at what they’ve done (or not done) or complain about their personal qualities, but put a friendly face on in front of them? If you’ve answered “yes” to some of these questions, you might just be “passive aggressive,” expressing your ire indirectly.

Again, I’m not saying that all anger is inappropriate. And, certainly, one shouldn’t always turn the other cheek, lest one regularly get taken advantage of. But anger can be a problem for you and for those around you. Like a big dog, it should be kept on a short leash. If you can’t manage that, think about counseling.

A recent review article in The Behavior Therapist by Kulesza and Copeland concludes that cognitive behavior therapy is the current treatment of choice for anger problems. The authors emphasize the need for both training in behavioral skills and the use of cognitive restructuring to insure the best results. Therapy for anger issues is therefore likely to include direct instruction about antagonism and its management; self-monitoring of angry feelings, thoughts, and behaviors; relaxation training; assistance in new ways of thinking about the events that trigger rage episodes; social skills/assertiveness training; direction as to how to think about and undercut anger when it does occur; and practice in being exposed to triggering events so that new skills can be employed and the patient can learn to tolerate or diffuse the emotional intensity and stop short of vehement outbursts.

Among self-help books, one of the best is Stop the Anger Now: A Workbook for the Prevention, Containment, and Resolution of Anger by Ronald Potter-Efron.