compassion

October 18, 2009

Unfaithful and Feeling Guilty: Now What?

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Infidelity happens. I’m not condoning it, but humans are known for mistakes, and this is simply another example of our fallibility. Still, what should you do if you have realized the error and broken off the affair? Assuming that your spouse or significant other doesn’t already know what happened, should you confess?

Let’s add two more conditions to the hypothetical situation that I’m describing: first, that you feel guilty; and second, that you have no intention of ever violating your partner’s trust again. Let us further assume that it is unlikely that your spouse will find out about the affair from someone else.

This, in other words, is one of those moments between you and your conscience. I’ve counseled people who felt so guilty that they believed they had no choice but to confess. I’ve also treated people who didn’t tell, believing that they would injure the spouse unnecessarily.

Sometimes these affairs are very old. I remember the first patient who reported a situation such as this to me. The infidelity had actually happened years before. It had gone on for a few months, then ended. The man had been faithful ever since and, it was clear, had every intention of being faithful from then until the end of time. But he felt terrible about what he had done and couldn’t shake the feeling despite the passage of time.

One consideration that such a person needs to take into account is that, for the spouse, the event is new when it is uncovered, even if it happened years ago. The wound happens at the moment of discovery or confession and doesn’t exist until that time (assuming that no STD has been communicated). But once the indiscretion is revealed, the emotions of anger and sadness are triggered, as is the sense of betrayal, and the lack of trust. Even if the infidelity is 100 years old, it typically feels to the injured party as if it happened today. And the long climb back to marital accord now begins, with no guarantee that the summit will be reached and good relations will be reestablished.

So, what if you don’t tell your spouse? Will your guilt last forever, undiminished? That depends on an enormous number of factors, including your religion (if any), your anxiety that your husband or wife will eventually find out (no matter how unlikely that might be in reality), your need for forgiveness/absolution, your ability to rationalize mistakes, your own capacity to forgive yourself, and so forth. If you need absolution and have a religious background, confessing to a priest, or fasting and prayer on the Jewish “Day of Atonement” might be helpful, depending on your particular faith. Therapists sometimes also serve the role of unofficial confessor.

If you were hoping that I would give you a clear answer, a “right” way to handle this situation, I undoubtedly have disappointed you. I frankly don’t think there is a right or wrong way in this type of case, at least not in the abstract. There are only ways that work better or worse; well, less well, or poorly; and it will depend not only on your own psychology, but the psychological makeup of your spouse. Thus, a solution that might be effective or useful for one couple, might be awful for another and lead to the end of the marriage.

Best, of course, not ever to be unfaithful. But, as I said at the start, these things do happen and, when they do, can have an overwhelming emotional wallop on all concerned. How you handle it shouldn’t be automatic. Much depends on your decision.

Choose wisely. As carpenters like to say, “Measure twice, cut once.” And know that the news will “cut.”

—

The above image is called Pashtun Couple by Arsalan Khan, sourced from Wikimedia Commons.

October 8, 2009

Beautiful and Smart, But Unlucky in Love: The Reasons Why

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I have treated many beautiful women who reported a history of bad relationships: unfaithful boyfriends or husbands, frank physical or verbal abuse by their partners, or a loss of interest by the men from whom they most wanted that interest. There are lots of reasons for this. Here are a few:

1. If you came from a home where you were neglected, criticized, or abused, your self-worth is likely to be less than what it should be. Recall Marilyn Monroe: famous, beautiful, and talented, but insecure and unlucky in love. A woman with the background I’ve described often looks for approval from someone who unconsciously reminds her of the person who failed to love her as a child. It is as if the unconscious mind is still looking for the thing never achieved before (love or approval), and it only has value if it comes from a similar person. Since the parent in question was neglectful or critical, the chosen substitute will likely be that way as well, providing the woman with another chance to win loving attention. Given her poor choice of a partner, the sought-for affection and approval are no more likely than they were in childhood.

2. Whether male or female, if you moved too often as a youngster, the insecurity of being the new kid on the block is hard to shake. You may also feel the never-ending need to prove yourself. Once again, insecurity can lead to choosing someone less good and kind than you deserve.

3. Are you too needy? Are you dependent upon your boyfriend or husband to make decisions for you? Are you unable to support yourself financially? Can you bear to be without a boyfriend for very long? Do you need regular reassurance you are “the one and only?” This gets old. While that reassurance will temporarily calm your fears, your lover will almost surely tire of it, leaving you insecure if you don’t ask repeatedly for confirmation of his devotion (or him feeling put-upon if you do). As with a number of the concerns mentioned above, therapy is suggested if your self-worth requires an ever-present escort who constantly bolsters you; and a tendency to lose your sense of self in the relationship, forget about your friends when with a romantic partner, and give-in to the new love-interest for fear he will otherwise leave you.

4. Is your beauty (or sex) all you believe you have to offer? There are tons of gorgeous, sexy women out there and, unlike you, they won’t age! (Or at least it will seem so, since, as you get older there will be a new cohort of young females who eventually will look preferable in purely physical terms). Although men can be pretty primitive in their response to the physical characteristics of women, qualities like wit, kindness, intelligence, good humor, and integrity grow in their value to all but the most unenlightened men. As someone once said, “Beauty fades, but stupid is forever.”

5. If a man shows interest in you too early, are you turned off? It’s true that there is an element of gamesmanship in dating and mating, but don’t choose the intrigue of a man who is hard to get and miss the devotion and decency of another.

 

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6. Are you entitled? Do you believe your boyfriend or husband should keep you on a pedestal, shower you with gifts, and buy the best house in just the right neighborhood? Do you value money, status, and material things too much? If you do, a well-grounded man will tire of you or avoid you. One who is less secure or less enlightened may simply become weary of your demands for “more,” and instead seek a woman who is less self-involved and shallow.

7. Are you a good listener? I hope so, because relationships demand this. If you aren’t, your partner will not feel understood. Unless you respect the differences between yourself and your lover (which very likely were initially attractive), you will find the relationship works poorly or not at all.

8. As I’ve said before on my blog, sexual interest and enthusiasm are necessary parts of a good relationship. Abandon them at your own risk. However, this is not to suggest you should have sex simply because your partner wants (or worse) demands it.

9. Do you allow yourself to be demeaned in public by the man you are with? I always ask marital couples seeking therapy what attracted them to each other. One male I recall said, “She ‘shows’ well,” about his beautiful wife. The words and tone were demeaning, in no way a compliment. Indeed, the man might have said the same thing about a show dog or show horse. The lovely lady remained silent. A more self-respecting woman might have walked out of the room.

10. Do you have a drinking or drug problem? Does your male friend? How do you know you don’t? Just because friends and acquaintances drink as much as you doesn’t mean you can avoid the alcohol or drug-driven downside of heartache, arguments, and a bad end to the relationship. Read up on alcohol abuse to get a sense of where you stand: http://www.alcoholscreening.org/

11. Do you wind up with men you feel sorry for? Not a good choice. Do you give in to men who pursue you relentlessly, even though you aren’t enormously attracted to them? Again, this is not destined to lead to a successful match.

12. Do you believe you can change the man you are with? A miraculous transformation is unlikely to occur. Meaningful alternations in any of us take their own time and much painful effort. As the old therapy joke goes, “How many therapists does it take to change a light bulb?” Answer: “One, but the light bulb has to want to be changed.” Take a measure of who you are with while you are still capable of being objective, which means your evaluation needs to be done early in the relationship. Once your heart takes over, rational judgments are either too late or altogether impossible.

13. As a father two two career-minded, married daughters, I applaud independent women who forge careers. But just as a man needs to remember his wife and children require attention, so do women in high-powered careers need to live by the same rules. If you are neglectful of your partner, mentally or physically exhausted by the work you do between 9 and 5, and consumed by issues related to your vocation, the relationship is at risk.

14. Are you too critical? If you experienced or observed a fair amount of criticism growing up, it is easy to become like the person who did this. Indeed, we are often at risk of becoming the thing we hate, or of normalizing the unfortunate characteristics we observed in our parents because we had no other family to compare them to. Compassion, understanding, forgiveness, and acceptance are needed in any good relationship, and in large quantities.

15. Do you expect your boyfriend or husband to fulfill your life and make you happy? No one can really do that for you, although having a companion can be worthwhile and important. But a relationship will not solve all problems or make life perfect. Don’t expect it to. The weight of that expectation is more than most lovers can bear.

16. One final point, and a sad one. If you are smart and beautiful, and especially if you are professionally accomplished, there are men out there who will be intimidated by your competence, intelligence, authority, and attractiveness. As a result, you might have to generate more than the usual amount of effort to find a good match. Unfair, but true.

In closing, I should say that making a good choice of mate, regardless of whether you are a man or a woman, is challenging. But there are a lot of good people out there (albeit fewer men than women), so if your history shows a pattern of failed choices, its best to look in the mirror and ask why. And, if you can’t come up with an answer or change your pattern even though you are aware of repeating the same mistakes, therapy often helps.

—

This post has generated one very heated and critical comment. You might want to read it and see what you think: Dealing with Online Criticism of that “Bald, Ugly, Old” Man: Me.

The top photo is of Marilyn Monroe, a cropped frame from her 1953 movie, Gentlemen Prefer Blonds. The second image is of Céline Du Caju, Miss Belgian Beauty 2006, taken by Eddy Van 3000 and sourced from Wikimedia Commons.

October 2, 2009

What Happens in Psychotherapy?

What does psychotherapy do and how does it do that? Good questions, and even some therapists might have a hard time answering them. Of course, some of the goals are obvious: reduce depression, have better relationships, eliminate anxiety, enjoy your life more, and stop worrying. But what are the elements that get you there? I’ll give you a sense of some of the factors that permit those goals to be achieved.

1. Trust. Many people entering treatment have trust issues: they trust too easily or not at all, usually the latter. Trust will start with the relationship between you and the therapist. Simple things: does he listen? Does he understand? Does he seem interested and dedicated? Is he dependable? Does he care? If the answers to these questions are “yes,” then it will be a bit easier to begin to trust others. The experience of a benign relationship with one person can open you to the possibility that this experience can be achieved elsewhere in your life.

2. Validation. Many people coming into psychotherapy having been told that they should “get over it,” that they “shouldn’t feel that way,” that they shouldn’t complain or “whine;” or having been ignored, dismissed, or criticized too often when trying to express themselves. Some folks believe feelings are unimportant; others might state that it is not “masculine” to feel too much, and so forth. As a result, many new patients have so buried their feelings that they are alienated from themselves and don’t know whether it is appropriate to think or feel as they do. A good therapist creates a safe place for talking about such things (trust again), and gives the person a sense that there is value in what they feel and think. Over time, this action, by itself, can help improve self esteem and reduce sadness and alienation.

3. Grieving. If one has not had supportive relationships (with people who are both trustworthy and validating), the sense of loss or absence contributes to sadness, and sometimes to depression. The relationship with the therapist allows you to express the emotions related to loss (both sadness and anger) to someone who listens patiently and shows concern. As you process those feelings of loss, your sadness should gradually diminish. The therapist serves as a witness and again, as someone who validates your pain. Grieving in isolation too often contributes to the feeling of disconnection and alienation from the world. Grieving with someone who cares reconnects you to one of the things that can be good in life: human contact.

4. Learning new things. Any good therapist needs to provide some guidance and tools that enable change. This might come in the form of helping you learn and practice new social skills (including acting these skills out with the therapist), assisting you in changing how you think (cognitive restructuring) that helps you reduce self-defeating thoughts, training in how to be assertive (again with role playing in the therapy session), or meditation.

5. A change in perspective. A good therapist will provide you with new ways of thinking about the world and about your life. Since he can see you from the outside, he is more likely to see you in a way that you cannot see yourself.

6. Facing things, not avoiding things. We all practice avoidance some of the time, and some of the time it is a useful thing. Unfortunately, many of us practice it all too much. We distract ourselves from pain and avoid challenging situations. We can use food, TV, shopping, sex, drugs, alcohol, the internet, and computer games to get us away from whatever it is we can’t handle. We worry about problems rather than coming up with a plan of action and taking them on. We don’t ask out the pretty girl for fear of rejection, or say “no” to people who want to befriend us for the same reason. We stay at a “dead-end” job because of our insecurities. And, of course, unhappiness is the result.

A therapist can assist you in identifying the patterns of avoidance, help you to gradually become able to tolerate anxiety (by use of such things as cognitive restructuring, role playing or meditation) and give you tasks that gradually increase in difficulty so that you reduce avoidance and begin to take action that works.

7. Acceptance. By acceptance I am referring to acceptance of the nature of life and the discomfort that comes with living; acceptance of the fact that being open to life allows you to experience satisfaction and joy, but also opens you to pain; and awareness of the temporary nature of most of that discomfort. The more that you take life on its terms, the less you will be trapped by it.

Remember playing with the Chinese Finger Puzzle as a kid, the cylindrical woven structure made of bamboo, open at both ends? You put your two index fingers into it, but when you pulled hard to get your fingers out, you became more stuck. Only by releasing the tension and moving your fingers toward the center of the device, did it collapse and no longer held you tight. Life is a lot like that to the extent that we must stop engaging in behaviors that only make us more “stuck.”Acceptance allows you to free yourself, at least somewhat, from what is distressing about life.

8. Valued Action. If you are caught in the struggle with your emotions, or focused on avoidance of pain, what is good in life will be hard to achieve. Therapy can help you to think about the life you would like to lead, the life that is consistent with your values, and help to relieve you of the habits that keep you so wound-up that you don’t have time to think about what it is you would really like to do, and what it is that would lead you to a sense of satisfaction and accomplishment. What is your true self? Therapy can help you find out and encourage that person to exist in the world.

The description I’ve given you is based, in part, on my experience in life and training, especially training in such therapeutic approaches as cognitive behavior therapy (CBT), mindfulness-based behavior therapy, Acceptance and Commitment Therapy (ACT), and psychodynamic psychotherapy. Other therapists may have a different view of what is important and how to help you get to the point that your life is more satisfying and less fraught with depression, anxiety, or chronic relationship problems. But here, at least, I hope that I have given you some sense of direction and some reason to be hopeful about the possibility of change in your life.

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.

August 30, 2009

What To Do When Therapy Doesn’t Help

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Therapy doesn’t always help. That doesn’t mean that it can’t help and that a second chance isn’t indicated. But, it does mean that you will need to ask yourself a few questions about what is going wrong.

There are several possibilities:

1. Misdiagnosis. If, for example, you have an alcohol or drug problem, but the therapist wasn’t told about it or didn’t realize its significance, treatment is almost certain to fail. Similarly, if you have a Bipolar (manic-depressive) Disorder that goes untreated (these can be difficult to diagnose), it will be hard to profit from therapy. I have seen many adults, for example, who have the inattentive form of ADHD and have never been diagnosed and treated for the condition, even though they have seen more than one therapist.

2. Insufficient motivation. Have you been giving therapy your best effort? Do you go to sessions religiously? Do you follow through on any “homework” assignments that you and the therapist discuss? If you are not adequately open and dedicated to getting better, then treatment is likely to fail. Defensiveness in the treatment process and inconsistent attendance are major problems. With respect to lack of effort, the old joke goes: “How many therapists does it take to change a light bulb?” Answer: “One, but the light bulb has to want to be changed.”

3. The therapist/patient match. Do you feel comfortable with the counselor? That doesn’t mean that therapy will never make you uncomfortable (change isn’t easy and it is often painful), but it does mean that the therapist is someone you can trust, who is sincere, and who is competent. Does the therapist have sufficient understanding of your life circumstances? This doesn’t necessarily mean that he has lived through a similar situation or has an identical background, gender, age, or religion; but he will need to understand where you are coming from.

4. The tempo of therapy. Does the therapist push too hard? Do you find yourself too often overwhelmed by the issues and feelings being stirred up in your sessions? Or perhaps, do things seem to go too slow? Are the sessions becoming boring and unproductive?

5. Activity level of the therapist. Is the counselor too active and probing for you? Does he seem to have a plan and a direction for your treatment (he should)? Is he too controlling, seeming to follow an agenda that is inflexible and ignores what you need? Or, alternatively, is he too passive, simply waiting for you to talk about whatever you want, regardless of how far afield this might lead the treatment?

6. Is the therapist too friendly? Does he want (or is he open to) a friendship or anything other than a therapeutic relationship (he shouldn’t be). Or, is he too distant and uninvolved?

7. Type of therapy. Therapists are not all equally comfortable and competent at the multiple types of treatment available. Some problems have been subjected to well-documented and researched treatments (Obsessive Compulsive Disorder, for example). If your therapist is using the wrong treatment approach, you are not likely to benefit as much as you could.

8. Medication. Would you do better if you were on medication? If you are on medication, might you improve more with a different medication?

9. The therapist’s problems. Does the therapist seem stable? Does he act in an inappropriate way in the sessions? Does he become angry and critical? Is he judgmental rather than supportive? Does he talk about his own current problems?

If you are still in therapy and you have concerns about its effectiveness or any of the issues mentioned above, it is usually best to voice those issues to your counselor. He should not only be open to hearing what you have to say, but want to be responsive.

Therapists are not mind readers and won’t always figure out what you are thinking or worried about unless you say it. Do your homework and try to find out what therapeutic approaches might be more appropriate for you (your therapist should be able to describe at least some alternatives).

If he cannot provide you with the kind of treatment you are asking for, he should be able to come up with some very good reasons for what he is doing. Should those reasons be unconvincing, perhaps a second opinion is indicated and he should be open to this idea, as well. If you remain sure that this therapist is not the right one for you, getting a referral from him to someone else is entirely appropriate.

If, on the other hand, you have had unsatisfying experiences in therapy before and are not now in treatment, but are thinking of trying again, make sure that you have attempted to investigate your potential new therapist’s background and experience. Also, when you talk to him on the phone, ask about his therapeutic approach. If you do decide to see him, talk about the things that didn’t work in previous therapy attempts, as well as those that did.

Be as informed as you can be. Unlike brain surgery, you aren’t going to be passive and unconscious during treatment. You are going to participate and interact with someone who, you hope, is well-trained and dedicated and compassionate. Evaluate what is going on in treatment in an open and thoughtful way; collaborate with the therapist.

You will be glad you did.

—

The Red Woman by Neuthaler is the name of the above image, sourced from Wikimedia Commons.

August 16, 2009

The Problems with On-Line Therapy

It is tempting to think that therapy might be done on-line with the same effect that it can be done face to face. Unfortunately, most of the time, this probably isn’t true.

Some people are certainly more comfortable with the computer and that can be part of the problem. The face-to-face contact, in a supportive environment, is something that is beneficial. By pursuing therapy without direct human contact they may be avoiding something about which they are afraid. If that is the case, the therapy will, by definition, miss dealing with the very thing that the patient needs to tackle and confront.

Then, too, part of the therapy process involves having the courage to be with the therapist, alone in the same room with one other person and the words and feelings that are the substance of your life; to make the effort to come to his or her office; to be on time and value the human contact together in a setting where one learns that it is safe to discuss the most intimate, personal things in one’s life.

If you have been to an extremely moving or exciting concert you probably known what direct contact with the event means. Music that can overwhelm in the concert hall is likely to be less powerful when heard in a recording of that concert in your living room. Something inexplicable but precious and unreproducible can happen in the few moments of connection between the human beings who are musicians and the human beings who are the audience. Just so, between the therapist and the patient, something remarkable and fragile is too often missed when the medium that carries the message is electronic.

Even with the aid of video communication between the therapist and client, it is too easy for the counselor to miss the subtle signs of discomfort or sadness, the body language, the perspiration, the incompletely formed tears in your eyes, the ever so slight furrow of your brow; the subtle vibrations, tremors, and eye movements; the nervous bouncing of a leg, or sometimes the disinterest or boredom that it is crucial for the therapist to observe. Equally, the patient cannot see the intensity and concern and dedication of the therapist, or, more appropriately, cannot so easily “feel” them as when he is seated only a few feet away looking directly into his eyes.

A famous musician once described the difference between a “live” performance and a recording as like the difference between “sleeping with Bridget Bardot (a famously beautiful movie star of 1950s and 1960s) or sleeping with her picture.” A crude comparison, perhaps, but it does get to the human contact that happens between two people when they are face-to-face, versus the more artificial quality of that interaction when they might be separated by thousands of miles and living in different time zones.

Of course, one might add that medical insurance may not pay for such an electronically mediated encounter as on-line therapy, but that is not the essential point. The essential point is that the best of life and healing occur in the context of a caring professional who you get to know in a personal way and who gets to know you in the same way. However advanced technology becomes, at least until it allows a convincing hologram of you to be in the same room as the therapist, something will be missing and lost in media-mediated encounters.

That said, if you live at a significant distance from a good therapist, therapy over the phone or on-line might be your only alternative. Still, it is important to recognize that there will almost certainly be something lost. And, depending upon what you need, what is lost may well be the crucial element in your healing.

July 23, 2009

How to Choose a Therapist

Most of us are not at our best under pressure. Similarly, when depressed, anxious, or otherwise stressed and in crisis, the patience and clarity of thinking needed to choose a therapist might well be in short supply. So here are a few pointers, things to consider, when you decide to consult someone for psychological assistance:

1. Ask a friend if he or she can recommend a therapist with enthusiasm. Also, be sure to request that your acquaintance explain “how” the therapist was helpful. Not all counselors are equally adept at treating every problem, so your friend’s recommendation should be carefully considered in light of whether your issues are different from your friend’s. You might also ask your physician for a recommendation. A good way to phrase the question is, “If you needed to get a therapist for someone you loved, who would you choose?”

2. Internet searches of various kinds can help find a good person. Various organizations list therapists who perform a certain type of therapy or work with certain types of problems. An example would be the Association For Behavioral and Cognitive Therapies: www. abct.org/ The National Register of Health Care Providers in Psychology is another such group: http://www.nationalregister.org

3. Some information about the therapist is usually available on web sites such as those mentioned above. If the therapist has a web site of his own, you will usually find out a good deal more.

4. What kind of therapist are you looking for? There are many choices. Clinical Psychologists are doctoral-level professionals (Ph.D. or Psy.D) who typically have completed four years of training beyond their college Bachelors degree and had additional instruction and supervision in the form of a year-long internship, often within hospitals or clinics. In most states psychologists cannot prescribe medication, but have received more graduate training in psychological evaluation (testing) and therapy than is typical of any of the other disciplines who perform therapy.  Psychiatrists are physicians trained in medicine, who also receive specialized training during a psychiatric residency. They can and do prescribe medication and a number of them also do therapy. Clinical Social Workers generally have a Masters Degree obtained in the course of two years of post-college study, in addition to practical experience and a history of supervision. Marriage and Family Therapists usually also have a Masters Degree and may have a similar amount of training as do the social workers, although their education is not identical to that group. All of these disciplines encourage and sometimes require therapists to continue their study via post graduate course work, supervision, and reading.

4. What kind of therapy do you want? In part, that might depend on what kind of problem or problems you have. Psychodynamic psychotherapists will tend to pay much attention to early life issues including unresolved feelings toward one’s parents, and the potential impact of additional events that occur during the growing-up years in an attempt to free you from repetitive patterns of behavior that might have started at that time. Cognitive behavioral therapists use CBT to focus more on present day concerns, attempting to help you take steps to alter the automatic and self-defeating thoughts that influence your mood and fuel your depression and anxiety, as well as assisting you in changing your behavior. They spend much less time on early life events as a rule, and do not usually consider “insight” into the causes of your troubles to be crucial to assuaging your emotional pain. Marriage and family therapy aims to treat couples and family systems, usually meeting with the marital pair or family group rather than with one person at a time.

5. Try to determine how much experience your potential therapist has with a given kind of problem. Some therapists specialize, for example, in treating alcohol and drug abuse and are certified in this field (CADC or certified alcohol and drug counselor). If you have anxiety issues, on the other hand, ask your therapist how many people he has treated with this condition. Similar questions might be asked of someone who you wish to consult for the treatment of depression or schizophrenia. Don’t be afraid to ask. Any reasonable professional in the health care field will welcome your making an informed decision.

6. Other factors might be considered. How active do you want the therapist to be? Some tend to direct the therapy, while others are more comfortable listening to you and responding to just those issues that you believe are important. Some people choose therapists based on gender, believing that they will feel more comfortable with one or the other sex. Age of the therapist is important, since it tends to be correlated both with professional experience and life experience. If you believe that not everything in life is learned in a classroom, you will probably want to see someone who has a few gray hairs and who has been married with children.

7. Financial considerations often enter into the choice of a therapist. MDs are usually the most expensive people to see and Masters level professionals are the most economical. Ask your therapist about what he charges for his services and what portion, if any, of his fee is covered by insurance. Some communities have public mental health agencies that offer therapy at a heavily discounted price, although they often have long waiting-lists. A portion of therapists will discount their fees if you can make a good case for such a discount.

If you go through your insurance company, it is likely that they will steer you toward a practitioner who has a contract with them and has agreed to discount his fee to you. Understand, however, that the discount also typically benefits the insurance company, since they will have to pay less money in benefits if you choose a provider who is in their network. Therefore, their recommendation comes with a degree of self-interest.

Be aware that (as the old saying goes), sometimes “you get what you pay for.”

8. Some people choose not to use their medical insurance to pay for counseling. They make this decision because they have concerns about the impact of a mental health diagnosis on their future ability to get life or disability insurance, and the possibility that having a “pre-existing (mental health) condition” will complicate their medical coverage should they ever change jobs or go for a period without insurance and then attempt to obtain it again.

9. Remember that the most important element in obtaining a therapist is getting a person who is accomplished, talented, experienced, and a good fit for your therapeutic needs. You should also have a sense that he really cares and wants to help. While some of the other considerations mentioned previously might be important, if the therapist can’t help you, nothing else really matters. When you meet the therapist (see my blog post “What to Expect in Your First Therapy Session“) he should be able to convey expertise, compassion, and competence, as well as giving you a sense of hope. Don’t settle for less.

July 16, 2009

Infidelity and Its Treatment

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The names don’t really matter. Today they are Tiger Woods; Mark Sanford, Governor of South Carolina; and John Ensign, U.S. Senator from Nevada. Tomorrow they will be someone else. Every day, there are other names, little known, but causing no less pain.

How does it happen? How does it happen that people who claim to live by well established moral norms, who have taken a public oath to remain faithful to their spouse, violate that promise? There are several reasons:

1. Power and celebrity = opportunity. People in positions of power and celebrity have more opportunity than most to be unfaithful. They are surrounded, sometimes literally, with admiring and attractive younger people. As Oscar Wilde said, “I can resist anything, except temptation!” The famous and powerful have plenty of that.

2. Contiguity. You might think that the separation of sexes in some religious fundamentalist societies is unfortunate or wrong, but it does keep opportunity at a minimum. In modern Western secular civilization, men and women work together, eat together, and travel together on business. Repeated contact with a sympathetic business associate, pulling together with that person as a team on a business project, creates not just the opportunity for sexual contact, but the chance to get to know and like one another. Perfectly moral and decent folk can find themselves stirred by the presence of a person to whom they are not married, even though they weren’t looking for anything outside of the marriage.

3. Disinhibition. Alcohol and drugs. If you are around sexually attractive people in a party atmosphere or when you are “under the influence,” your judgment and hesitation are more likely to be set aside.

4. The “Great Man” rationale. More than once, I’ve heard men justifying the concept of infidelity in the case of those who are accomplished and powerful. Often, the rationale includes reference to the role that “the great man” plays in benefiting society. According to this line of reasoning, the “heroic” figure is thought to have earned the right to live by a different set of rules than the common man, and should be given the chance to be compensated for his contribution to society by being allowed multiple sexual partners.

5. The “It won’t hurt anyone” rationale. The faithless sometimes persuade themselves that there is nothing wrong with their behavior so long as anyone who might be injured (spouse/children) never knows about it. This is akin to the old philosophical question, “If a tree falls in the forest, but no one is present to hear it, does it really make a sound?” What the argument ignores is that the transgressor is changed by his act of betrayal, that he must tell a continuing set of lies in order to maintain the fiction of his character, that he risks his partner’s physical health in the event that he has become a carrier of a sexually transmitted disease, and that it is impossible to guarantee that the secret will never be revealed.

6. Mid-life crisis. Poor humanity. Poor man. We age, we lose our youthful good looks, sometimes our hair, our virility, our energy, our strength, our stamina. The antidote? A youthful or new sexual partner who, for a time, can help us shut out the dreaded and self diminishing passage of time.

7. Solace. The ups and downs of life are inevitable, even in the luckiest of lives. The best marriages are not immune to the daily stress that  takes a toll on a spouse’s ability to be compassionate, encouraging, and supportive. Financial worries, business reverses, family illness, house keeping, and child rearing soon diminish the “date night” and honeymoon atmosphere of the early days of the relationship. A fresh and sympathetic set of ears, all understanding and acceptance, often develops into something more, and something sexual.

8. “It’s not natural.” Some people, mostly men, justify infidelity with the notion that man was not meant to be a monogamous creature and the flowers of the field (i.e. the opposite sex) were meant to be enjoyed.

9. Longevity. At the turn of the last century in America, that is, about 1900, the average life expectancy was about 50 years. By that standard it was usual for marriages to be relatively short, 25 to 35 years at the most, many much shorter. No longer. Many now last 50 years and more. What happens in that time? People get older, their bodies change, and their personalities alter as well. When I do marital therapy, I usually ask couples what initially drew them together. The most frequent answer I get is something like, “He was hot and we had a lot of fun.” Thirty years on, it goes without saying, he isn’t so “hot” and they sure aren’t having fun.

In order for marriages to thrive into mid-life and beyond, the couple has to work very hard at the relationship, to keep the sexual spark alive despite physical changes and familiarity, and to see to it that personality alterations are compatible or synchronous. Too often one partner wants the marriage to be exactly as it was at the beginning and believes that both the personality and physical changes in the other person amount to a breach of contract. Meanwhile, the other might feel held to a contract that is no longer appropriate to the current state of the couple’s life together and to their age, personality, and experience. One or the other very well may see infidelity as tempting under such circumstances.

10. The scoundrel factor. Although an injured spouse sometimes believes that “evil”  is the most likely explanation for her spouse’s betrayal, in most cases it really isn’t. Most people don’t set out to behave badly and many feel guilty when they do. That said, there are certainly more than a few cads among us, and they do with impunity what others only do with hesitation, a troubled conscience, or not at all.

11. Boredom. Boredom doesn’t cause anyone to stray, but it does set the stage for the temptation. Routine can kill even the things that we love. The pattern is well-known: wake up, go to work, come home, play with the kids, do the bills, and collapse from exhaustion. Or, the stay-at-home parent’s version: wake up, make food, shop, make food, take care of the kids, do the housekeeping, make food, clean, and collapse from exhaustion. Either way, the routine is deadening and there is little room for excitement.

12. A lack of sex. Again, this doesn’t cause infidelity, but can set the stage for it. A warning here: cease sexual contact at your own risk and at the risk of your marriage. But, this is not to suggest that you should have sex only because your partner wants to.

13. Cruelty, sarcasm, and a lack of appreciation. If the marriage has turned into a battle ground, with gratitude replaced by indifference or hostility, infidelity is more likely on either side.

—

When the infidelity is exposed, the result is devastating to the victimized spouse. Rage, sadness, a loss of self-regard, and feelings of inadequacy are common. What did I do? What didn’t I do? Why did he do that? If he felt that way, why didn’t he leave first before he took on another partner? The devastation occurs whether the infidelity is fresh, or the betrayed person discovers it years after it occurred. The emotional clock of devastation only begins to run from the point that one becomes aware of what happened.

If a couple comes to therapy in the wake of such news, several factors go into the therapist’s evaluation of the situation. First, is the infidelity over or is it still going on? If the marriage is to have any chance, the “other” relationship has to end. Moreover, it has to end because the spouse having the affair wants it to end and believes that the marriage is worth saving, not because his marital partner is threatening to leave or because of the fear of financial devastation in the course of a divorce.

The therapist will try to gauge what still binds the marital couple together, if anything. Do they still have positive memories of their courtship? Do they have children and are they concerned about the effects of a divorce on their offspring? Are they still in love? If there is no love on the part of even one partner, therapy is almost certain to fail to recreate it.

If the both parties want to save the marriage, have positive memories of the start of their relationship, and if loving feelings still exist between them, treatment often can help to repair things. One of the first items in need of attention will be allowing the injured spouse to grieve. This will require both tears and anger, but will need to be time limited. That is, however great the injury, the victimized spouse must understand that he cannot forever bring up the infidelity to be used as a weapon when he feels unhappy or aggrieved in the future. As the old farm expression goes, “Don’t burn down the barn to kill the rats.”

Of course, apology by the roving partner will be necessary and it will take time to rebuild trust. Once the immediate crisis is over, the couple needs to look at what contributed to their estrangement and what changes need to be made in their relationship. They have to reaffirm a set of values by which to live and goals for their relationship and for the family. Changes in patterns of communication will likely be necessary, as will time and attention to each other. Serious self-reflection and responsibility-taking will be particularly important for the unfaithful member of the relationship, but the partner too must be willing to look at the possibility that he contributed to his spouse’s feelings of disaffection.

Such situations aren’t easy, but they can come out well. Good will, sincere contrition on the part of the person who strayed, and emotional generosity on the part of the victim are all key. The betrayal is never forgotten, of course. But time does its work on the scar of infidelity, just as bodily scars tend to soften and fade over time, even if they never fully disappear. Happiness and love may yet flourish.

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The image above is a cropped screenshot of Lana Turner from the film The Postman Always Rings Twice, sourced from Wikimedia Commons.

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.

July 2, 2009

A Few Good Books

You won’t be looking at this unless you are a reader. So here are a few brief recommendations of books that have made a lasting impression on me. Most are not new and I suspect that some are out of print, but are likely to be obtainable by a search on the Internet. In no particular order:

1. Frauen by Allison Owings. Owings comes as close as anyone to answering the question, “How did the Holocaust Happen.” An American journalist who studied in Germany, she returned there to interview mostly gentile women who had lived through the period of the Third Reich. Owings summary does an extraordinary job of describing the psychology of the bystanding German population.

2.  A Prayer for Owen Meany by John Irving. Irving gives away the plot of his novel early on: Owen Meany will die an unusual death. But rather than destroying the tension of the book, this puts the reader in Owen’s shoes as a man who knows that he will come to an untimely end, but doesn’t know exactly how. As the book progresses and that end comes closer, the terror is almost unbearable.

3.  Agitato by Jerome Toobin. The story of Toscanini’s NBC Symphony Orchestra in the one decade that it attempted to survive after his retirement. If you enjoy anecdotes about famous musicians, this book is for you. The tale Toobin tells is both funny and sad, since the orchestra did not last. Jerome Toobin, by the way, is the father of Jeffrey Toobin, the legal scholar and public intellectual.

4.  Regret: the Persistence of the Possible by Janet Landman. A book about the title emotion, viewed from literary, psychological, and other perspectives.

5.  What is the Good Life? by Luc Ferry. A very good attempt to answer the biggest question of all: what is the meaning of life?

6.  The Long Walk by Slavomir Ramicz. The author tells the true story of his escape from a Siberian prison camp. He and his compatriots, with almost no equipment, food, or appropriate clothing, attempted to walk to freedom and Western Civilization, which took them as far as India. As you can imagine, not all of them made it. That anyone at all did is astonishing.

7.  Anna Karenina by Leo Tolstoy. This story of an unhappily married Russian woman touches on almost all that is important in life: love, friendship, obligation, children, religion, the value (or lack) of value to be found in work and education, death, and the meaning of life. None of that would matter much without the author’s gift of telling his story and allowing these issues to flow out of the human relationships and events he describes.

8.  The Boys of  Summer by Roger Kahn. Kahn’s classic tribute to the Brooklyn Dodgers baseball team of the 1950s, the team that had Jackie Robinson as its central figure and leader.

9.  War Without Mercy by John Dower. Dower describes the racism that underpinned the Pacific theater of World War II. Unlike the war in Europe, each side viewed the other as less than human and treated the enemy with a brutality consistent with that view.

10.  The Culture of Narcissism by Christopher Lasch. Although the book is now a few decades old, the writer’s message is still spot on. He looks at the empty pursuit of happiness in material things and acquisitions, driven by the increasingly disconnected nature of social relationships in this country, and the promise of the media that happiness lies, not in fulfilling human contact, but in the goods that come with “success.”

11.  The Time Traveler’s Wife by Audrey Niffenegger. A fantastic and touching creation about a man unstuck in time, thrown forward and back, and the woman who loves him. Its being made into a movie, I’m told.

12. Patrimony by Philip Roth. Roth’s account of the illness and death of his father.

13.  The Denial of Death by Ernest Becker . More than one person has told me that this is the finest nonfiction book they have ever read. It is a meditation on what it means to be mortal, and how the knowledge we all have of our inevitable demise influences how we live, in both conscious and unconscious ways. Becker’s book has lead to an entire area of psychological research called “Terror Management Theory.”

14.  For Your Own Good by Alice Miller. Miller is a controversial Swiss psychiatrist who looks at the effect of harsh upbringing on the welfare of children. If you believe that children should be seen and not heard, this book might make you think twice.

15.  A Tale of Two Cities by Charles Dickens. A story of self sacrifice and heroism set in the French Revolution. If you can read the last few pages without tears, you have a firmer grip on your emotions that I have on mine.

16.  The Glory of Their Times by Lawrence Ritter. Ritter was a college professor when he began to travel around the country in the 1960s, tape recorder in tow, to obtain the first hand stories of the great baseball players of the first two decades of the 20th century, who were by then very old men. Probably as great an oral history as any of those written by Studs Terkel, and perhaps the greatest baseball book ever.

17.  American Prometheus: the Triumph and Tragedy of J. Robert Oppenheimer by Kai Bird and Martin Sherwin. Oppenheimer is the man who brought the Manhattan Project to fruition, that is, helped create the bomb we used to end World War II in 1945. But more than that, this book is a wonderful biography of a complex, peculiar, and brilliant man, who was brought low by those who wished to discredit his opposition to nuclear proliferation in the period after the war.

18.  The Mascot by Mark Kurzem. A story that is beyond belief, but turns out to be true. The central figure of the story, when he was a little boy, was adopted as a mascot by a Latvian SS troop after surviving the murder of his family. Why beyond belief? Because he was Jewish. The book reads like the most extraordinary mystery.

19.  All Quiet on the Western Front by Erich Maria Remarque. The most famous anti-war novel ever written. The book is told from the standpoint of a young German infantryman during World War I.