counseling

February 24, 2010

Performers, Priests, and Other Intermediaries

Do you remember your childhood friend, the one who knew the girl you fancied, the one who was the intermediary between you and “your heart’s desire,” who let you know if she was equally fond of you, and who passed messages and notes between the two of you? And do you remember when you asked one parent to “run interference” with the other, to shield you from the blow or scolding or grounding that you were afraid you would receive if your defender couldn’t soften the heart of the other? These were probably your first experiences with the role of an intermediary.

Putting these things in the terms of childhood memory will, I hope, help you to recall just how important that mediator was, how much you counted on her or him to put things right for you, how much dependency was involved, and how grateful you were if she was able to do the job of advocating for you efficiently and well.

As adults we still use these kinds of mediators, intermediaries, or advocates. Lawyers “make our case,” accountants talk to the IRS on our behalf, reference persons write letters or recommendations to potential employers or universities, agents negotiate salaries for us, and a marital therapist tries to help two people repair their relationship.

But the intermediaries whom we most esteem, I think, are those that perform a public form of intercession. I am speaking of musicians, actors, and clergymen.

What do I mean by this? Let’s start with musicians. They take the printed note on the page of music paper and give it life—sing it, play it, form it in the way that they understand the notation. The players interpret the music. It is said that they “recreate” it, but truly, it does not exist except as an abstraction until they begin to perform it; we do not hear it until they begin to “make” the music. They are the intermediaries between the composer (who might be long dead) and us.

So too, actors and actresses. They give life to the playwright’s or script writer’s words. These players shape the words, give them emphasis and color, drama and intensity. And they are the carriers of the playwright’s meaning, his advocates and his intermediaries in the communication he hopes to bring to us, the audience.

Clergymen and clergywomen serve much the same purpose, only with religious texts. If you believe that they serve a higher being, then you also believe that they mediate between God and man. Their sermons, if eloquently delivered, are no less moving than the sounds of stirring music or the voice that an actor gives to Shakespeare’s lines.

We esteem these mediators, in part, because (at their best) they reveal to us a higher, loftier, more intense and creatively imagined way of being; they move us to tears or to excitement or to hope; they quicken life, stimulate thought, open our hearts, teach us, and, if we are ready, change us.

Given the effect that they have on us, these mediators receive our appreciation and, sometimes, adulation. Indeed, because the composer or playwright or screen writer has given over the task of performance to these people (while he is in the shadows, even if alive), we can lose sight of the author of the creative work being presented to us on stage. And, so too, the recreative artist (the actor or musician) can get a bit too carried away with his own self-importance. Indeed, it is rare for the great conductors, singers, actors, violinists, and actresses of the world not to be at least a little full of themselves.

One who was not, however, is the subject of an excellent new biography: Serving Genius: Carlo Maria Giulini by Thomas Saler.

Giulini was an Italian symphony and opera conductor who lived from 1914 to 2005. His humility in the face of the geniuses he served, that is, the great composers, would have been for nothing if not for his own talent in giving life to their music. Giulini felt that his role was a small one, as the servant of these great men, as the mediator of something much bigger, more important, and more lasting than himself. Giulini was a man both great and good, an extraordinarily rare combination. I had the good luck to hear him perform dozens of times and to interview him once (and, in the interest of full disclosure, I was interviewed for Mr. Saler’s book).

Giulini took his role as the link between composer and listener very seriously; indeed, the responsibility to the composer, to do his art justice, was a weighty one to this enormously conscientious man. Giulini gave the concert that celebrated the liberation of Rome from fascist control in 1944 during World War II. Soon after, he was asked to play Bach’s Brandenburg Concertos, pieces he admired but did not feel ready to perform. Pressured to do so in a concert that was well received, Giulini nonetheless felt he had let down both the composer and the audience by playing these pieces before he was convinced of how to best recreate every note. It was 22 years before he finally felt that conviction and again conducted any work of Bach.

As quoted in the biography, Robert Marsh said of the conductor, “He is one of the most completely civilized men I have ever met, one who can command without every raising his voice, who wins and holds your loyalty by the nobility of his character. If music is to lead us to the fullest awareness of humanistic values, men such as Giulini will be the models we must follow.”

Intermediaries. They mean a great deal to us.

As you can tell, Giulini did to me.

February 14, 2010

“I Was Only Joking”

http://upload.wikimedia.org/wikipedia/commons/1/1a/Laughing_Fool.jpg

I’ll give you an example of an ill-timed joke. It happened during the oral examination for my Masters thesis at Northwestern. Oral exams tend to generate a good deal of anxiety in the examinee, and I was no exception to this. The protocol is that the examining committee first meets together and then calls you into the room to join them. After exchanging greetings, the chairman of the committee, your thesis advisor, opens the gathering to questions from the other committee members. And so it was that Philip Brickman asked me the first question, beginning just this way:

There is a very serious problem with this thesis.

Dead silence ensued. My anxiety level went up 400%. I began to imagine my future taking a very wrong turn into four lanes of on-coming traffic. And then, after a pause that seemed to last for ages, he turned to the “Acknowledgements” section of the thesis and said:

Philip is spelled with one “L.”

Philip was calling attention to the fact that I had spelled his name “Phillip,” with two “Ls.” I have no memory of exactly what happened immediately after, although I can imagine that everyone laughed. I certainly was relieved; maybe that was Phil’s intent. But, however funny or well-intentioned, it was also a bad joke, one totally at my expense and possible only because of the vulnerability of anyone sitting for an oral exam, and Phil’s authority as one of the examiners. I had no residual resentment toward Phil, who was otherwise always more than pleasant toward me and, I should add, quite a significant research psychologist. But, I give you this example to point out that humor at another’s expense is a problematic undertaking.

I am sure that there are very few of us who haven’t ever taken advantage of the insecurity, vulnerability, or anxiety of someone, to make just such a remark as Phil made. I’ve certainly done it. It is a very human thing to do. And worse if it is done in front of an audience than one-on-one. I’m raising the point only because sometimes people who are sarcastic or mean-spirited do this with regularity and glee. And often, if the target of the humor complains, the jokester will blame the alleged “over-sensitivity” of the person who is the butt of his comment with admonishing words like, “you can’t take a joke,” “I was only kidding,” or “you are too sensitive.”

Maybe, maybe not.

But, once done, we owe the person who we toyed with the courtesy to respect his wishes and whatever sensitivities he does have, whether “over” sensitive or not. To do so is the civil and polite thing to do. Children are especially easy targets for barbs of the kind I’m describing and need particular respect, I think. Life is tough enough for the little guys and girls without adults taking advantage of their unshielded tenderness. That, at least, is my 2 cents on the subject.

And, if you are curious, I did pass the oral exam!

—

The image above is that of a Laughing Fool (ca. 1500) sourced from Wikimedia Commons.

February 11, 2010

Rumor

What do you think of people who spread rumors? Are you one such?  Rumor mongers are certainly not thought of in a kindly fashion. We call them gossips or tale bearers, not words of praise. And how about those people who relish the rumors, listening avariciously, almost licking their lips at the prospect of some juicy gossip?

The best, most visually evocative description of this kind of person comes from The Aeneid by the Roman poet Virgil. Here it is in Robert Fagles’s translation:

Rumor, swiftest of all the evils in the world.

She thrives on speed, stronger for every stride,

slight with fear at first, soon soaring into the air

she treads her ground and hides her head in the clouds.

She is the last, they say, our Mother Earth produced.

Bursting in rage against the gods, (Mother Earth) bore a sister

for Coeus and Enceladus: Rumor, quicksilver afoot

and swift on the wing, a monster, horrific, huge

and under every feather on her body–what a marvel–

an eye that never sleeps and as many tongues as eyes

and as many raucous mouths and ears pricked up for news.

By night she flies aloft, between the earth and sky,

whirring across the dark, never closing her lids

in soothing sleep. By day she keeps her watch,

crouched on a peaked roof or palace turret,

terrorizing the great cities, clinging as fast

to her twisted lies as she clings to words of truth.

If you are so inclined, the next time you are about to spread a rumor (or listen to one), reflect on that image of eyes and tongues and mouths and ears.

They are all yours if you want them!

February 7, 2010

Are You Narcissistic?

http://upload.wikimedia.org/wikipedia/commons/thumb/b/b0/Fran%C3%A7ois_Lemoyne_001.jpg/500px-Fran%C3%A7ois_Lemoyne_001.jpg

Have you ever been called a narcissist? What does that mean? Let me offer you an image that might help you understand it.

Imagine that you are standing in front of a mirror, but at some distance from it. You can see yourself, but you can also see a great many other things around and behind you. Now envision yourself walking toward the mirror.

If you get close enough, you will see only one thing: yourself. It is not necessarily that you are indifferent to whatever else might be behind and around you; rather, you are so taken with your own likeness, that you become unaware of other people nearby and how they might be faring.

That is narcissism: a fascination with and almost exclusive focus on yourself. The word comes from the Greek myth about an unusually attractive young man named Narcissus, who falls in love with his reflection in a pool, not aware that he is looking at his own image. Inevitably he perishes because he cannot get over this preoccupation.

At the extreme, too much narcissism becomes a Personality Disorder. That means it is a pattern of behavior and internal self-involvement that is rigidly pervasive and leads to problems in relating to others. People who suffer from Narcissistic Personality Disorder tend to lack empathy for others; they are grandiose in their inclination to overestimate their worth. They usually assume that others will not only share in this high appraisal of their value, but treat them accordingly. Indeed, they expect to be admired and take that admiration as an entitlement.

The word insufferable comes to mind.

http://upload.wikimedia.org/wikipedia/commons/thumb/d/de/Michelangelo_Caravaggio_065.jpg/240px-Michelangelo_Caravaggio_065.jpg

Such people believe that the rules that apply to most others might not apply to them because of their special qualities. Nor do they clearly see the injuries that they inflict on others; or show empathy even when such injuries are brought to their attention. If you are useful to a narcissist, able to help him advance his agenda, then he will probably want you around.

At the moment that you are no longer of value, however, or have been replaced by someone deemed better or more useful, you are in danger of being set aside or discarded.

The narcissist tends to have fantasies of great achievement or idealized love and exploits others. And when his behavior fails to lead to the result that he believes is his due, it is rare for him to fully recognize and take responsibility for that failure. Without that awareness, circumstances and other people are blamed, and he is likely to continue on the same unfortunate path indefinitely.

And to answer the question posed in the title, given the blind spot just mentioned, if you are narcissistic, it is unlikely that you will so identify yourself.

Initially, you might find such a person dashing, enormously self-confident, and appealing, perhaps even a visionary — definitely a big personality. Closer and more frequent contact, however, begins to reveal the dark side. Loving someone else is difficult for the narcissist, who is already in love with himself.

Do you need an example?

At least as he has been represented in the press, the Governor of South Carolina will serve that purpose. Obviously, one cannot diagnose him or anyone else on the basis of news accounts, but they suggest that he might fill the bill.

He is said to be taken with himself, preoccupied with his achievement and appearance, and fancies himself (and his South American lover) as sharing some sort of idealized, almost mythic love. Meanwhile, in the course of his affair, the wife and kiddies back in the States were set aside; even his responsibilities to his constituents were ignored, as he took secret trips to visit his girlfriend, leaving South Carolina without anyone in charge while he was away.

I suspect that you know some people who are pretty full of themselves and might have some of the other characteristics I’ve mentioned.

Want to change them?

Good luck.

Personality Disorders of this kind are not easily altered. Indeed, such people rarely see the need for treatment — their reflection in the mirror looks more than good enough to them. Self-awareness is not one of the narcissist’s strengths.

No, change won’t come easily.

A better question to ask yourself would be the following: why would you WANT to be with him?

—

The painting at the top of this essay is Narcissus by Francois Lemoyne, from 1728, sourced from Wikimedia Commons. The second image is Caravaggio’s take on the same subject (1594-1596), from the same source.


February 4, 2010

What I Learned About Therapy From Frankie Avalon

http://upload.wikimedia.org/wikipedia/commons/thumb/3/3a/Gluehlampe_01_KMJ.jpg/240px-Gluehlampe_01_KMJ.jpg

Now, you might not think about Frankie Avalon in connection with psychotherapy. But, in a peculiar way, he taught me a bit about treatment many years ago.

Frankie Avalon was performing in Chicago and appeared on a late night local program on Chicago’s ABC affiliate TV station; as did I and two other mental health professionals. Avalon was talking about his career as a singer and one-time pop-idol of the 1960s. The rest of us were speaking about hypnosis. Frankie Avalon was to appear on the first half of the program, while the mental health section was scheduled second.

The program was taped on Thursday for broadcast the next day. And, as things worked out, both the legendary singer and the shrinks all spent a few minutes together in “the Green Room” before the taping began. Avalon asked us a bit about ourselves.  When he discovered that we would be talking about hypnosis, he posed the following question: “Hey, can you guys stop me from smoking?”

One of my fellow-therapists responded, “Do you want to stop?”

“No,” Avalon replied.

We all laughed, but in truth, the singer had demonstrated something very important about therapy. To wit, not everyone who comes to therapy wants to change. Or, at least, they might not want to change the particular thing about themselves that is causing their unhappiness, or suffer the pain of making that change, or explore the unsettling emotions that sometimes surface in treatment.

This often happens in marital therapy too, when one member of the couple doesn’t think he or she is doing anything that bad, and so has no reason to adjust.

Therapists often can help those who recognize that their problems are severe enough to require “whatever it takes” to change. But, we are not much good when working with someone who, like Frankie Avalon, really doesn’t want to do anything different.

Those adults who are forced into therapy, pressured into treatment, or who go because they think that they ought to, are usually setting themselves up for failure. A wise therapist will usually identify this quickly and ask those individuals if they really want to be there — or point out that they don’t seem ready, and that premature therapy would be a waste of their time and money.

As the old joke goes, “How many therapists does it take to change a light bulb?”

One, but the light bulb has to want to be changed.

—

The above image is an Electric Light Bulb From Neolux in Studio by KMJ, sourced from Wikimedia Commons.

January 28, 2010

Do You Understand Me? On the Dangers of the IM

In the course of conversation, serious or casual, we often ask, “Do you understand?” The conventional wisdom tells us that if the question is followed by a “yes” answer, then real understanding exists.

I say, not so fast. Let me give you an example.

I remember treating  a family that included a son and a daughter. I don’t recall the precise ages of the children, but the boy was probably between 10 and 12, his sister much younger. I’d been seeing the family for some time when the parents came to their appointment in a state of more than usual alarm. The father first wanted to talk with me alone. He said that his son had threatened to “rape his sister.” I asked for the details, including whether the father had questioned his son as to his understanding of the word “rape.” “Yeah, I asked him whether he understood what that meant,” the father told me, “and he said that he did.” I then spoke with the son alone. This gentle but troubled and ashamed boy recounted the incident. Then I asked him to tell me, in his own words, what rape meant. And what came out was some version of “beating-up” his sister because she had been teasing him. Where had he heard the word “rape?” “On TV.”

Not that wanting to beat-up his little sister was a thing to be encouraged, but still, it wasn’t rape that he wanted to do, and everyone was pretty relieved once I explained the details to the parents. The point of this is that it isn’t as easy as we think to achieve “understanding” of what we are saying; indeed, if you think it is easy, you are probably creating a certain number of misunderstandings.

Consider how many serious attempts at communication are done in the form of email. Too many people routinely hit the “send” button before they have carefully reflected on how their message will be understood, and how they will feel about having sent that message in an hour or a day or a week.

What is the best way to be understood on any subject, and especially on a subject of importance? Be in the same room as the person with whom you would like to communicate, having first gathered your thoughts; and with the time to explain them and the opportunity to see if the other person can accurately paraphrase what you’ve said back to you. In this situation you will have several sources of information that can be helpful in making yourself understood, and are also available to inform you if your message has been received in the way that you were hoping. You will have words, of course, but also body-language, facial expressions, eye contact, tone of voice, inflections, the volume (loudness) of your speech, the speed with which you utter the words–all of these things, which you can vary as needed.

If you choose not to use face-to-face communication or simply can’t, due to circumstances of time or distance, perhaps a phone call will do. But understand that what you and your partner in conversation might be able to see has now been lost to you. Without the eye contact, body-language, and facial expressions to help you interpret the words you are hearing, the chance of misunderstanding grows.

Worst of all is the written word. True, if you have time and are a thoughtful person who is good with language, you might have added time to craft your written message that isn’t available when simply speaking in conversation. But, once the back-and-forth of an instant-message or text-message communication occurs, one usually loses the time for careful consideration that one had in the days of letter-writing. And you have lost not only the possible message-clarifying assistance of what you can see of the other person’s expressions and posture, but also all the things that a telephone still conveys in sound: inflection, emphasis, strain or ease, intensity, urgency, and so forth. Now your chance of being misunderstood has increased even more.

A very clever old book, How to Make Yourself Miserable by Dan Greenburg with Marcia Jacobs, puts it very well in Exercise #4 from a section called “Seventeen Masochistic Exercises for the Beginner:” “Write a letter to somebody, mail it, then figure out which part could be most easily misunderstood.” Greenberg wrote the book well before the days of IMs and text-messages, so one can only imagine what an update might look like given the destructive possibilities inherent in those speedy missives.

Sometimes the oldest advice is best: when you want to talk about something important or emotionally charged, take a deep breath and wait. Write if you need to (just to get your feelings out–don’t send it), talk to friends or a counselor, but take time before you address the issue to the person himself. And, when you do, if at all possible, do it face-to-face with lots of time to sort out the details. Beware of the IM and the text-message.

And if you are old enough, remember back to the Cold War days when the initials often heard in daily conversation were not IM, but ICBM–meaning Inter-Continental Ballistic Missile.

An IM can be a little bit like that, but might just blow up in your face.

January 24, 2010

Can You Sleep At Night? Being Ashamed and Feeling Guilty

There is an important distinction between being ashamed and feeling guilty. Both are connected to wrong doing, errors, mistakes, or failures. Both involve emotions. Feeling guilty, however, unlike being ashamed, doesn’t require an audience.

A person typically feels guilty almost automatically when he believes that he has done wrong. It matters not whether anyone else knows or finds out. Often, it doesn’t even matter that others might forgive the transgression. Thus, a sense of guilt is an internal state connected directly to an act thought to be wrong.

Shame, on the other hand, requires an audience, or at least, others’ knowledge of the inappropriate behavior or failure, even if they did not directly witness it.

By these definitions it is possible to feel guilty without being ashamed. One need only believe that one has done wrong. But someone who has been shamed (in other words, found out and condemned) might only come to feel bad if his behavior is widely known.

You might think that this always happens, but it doesn’t. Take the recently removed Governor of Illinois, Rod Blogojevich, who has yet to admit any guilt and who certainly doesn’t act ashamed; indeed, who appears quite shameless. Shamelessness is never a compliment, but rather a statement about someone who has no “shadow,” no sense of ever doing anything inappropriate.

To cite a couple of other examples, one a therapist and one a minister, neither felt guilty even after having their iniquity publicly exposed. In both cases the misbehavior was of a sexual nature that involved infidelity, as well as a violation of the code of ethics of their professions.

In the former case, the therapist had sex with ex-patients; in the latter example, the clergyman had sex with parishioners. Both were married (not to each other) at the time of these acts. The public exposure of their actions and ensuing humiliation mortified each of them and, indeed, each one contemplated suicide. But neither really believed what had happened was terribly wrong, and rationalized the transgressions in defense of his own self-image. In both cases the rationale involved holding the sexual partners largely responsible for the romantic encounters.

The connection between shame and suicidal depression is interesting and can be found even in the epics of Greek mythology. When Achilles died in battle, the Greeks held a vote to decide who among them should be awarded the splendid armor of Achilles, which had been fashioned by the god Hephaistos. Ajax (Aias) the Greater, the best warrior after Achilles, lost this competition to the cleverest of the Greeks, Odysseus, who had designed the Trojan Horse strategy that won the war. In his humiliation, Ajax went mad and eventually killed himself. Such is the devastating effect of a “loss of face.”

It should be said that the therapist and the minister I have referred to were quite narcissistic people who saw themselves through a very forgiving lens. Both terminated contact with old friends following their public embarrassment, in order to avoid facing them. In a sense, the self-love and lack of a well-developed conscience of the two people in question set the stage for their wrong doing — they believed that they were without moral flaws and therefore that anything they thought to do would automatically be a morally acceptable behavior.

Beware of those who say that they can sleep easily at night and use this standard as their primary method of judging or evaluating their own behavior. I doubt that the worst of the totalitarian rulers and despots of history would have failed this test of moral correctness, despite the murder, unhappiness, and genocide they created.

In the USA, on the political front, we have seen lots of people who don’t admit wrong, who rationalize what they do, and who serve themselves while claiming to be acting “on behalf of the American People.” I’m sure some of them come to believe their own story, their own rationale — shameless, as I said before; indeed, almost a kind of self-delusion.

In my experience, people who come to psychotherapy because they feel ashamed (but not particularly guilty) don’t usually take responsibility for their actions in the course of treatment. Rather, if the process follows the typical course, they will recover from the injury to their ego and be able to go on with life, still guarded against significant self-awareness. Moral self-reflection doesn’t seem to come easily or naturally to them.

By contrast, individuals who experience guilt that causes them to enter counseling often can learn to forgive themselves and recover from the depression that usually accompanies their guilt. For them, however, the risk is in taking too much responsibility and being too severe in their self-judgment, exactly the opposite of the person who is only ashamed.

It is useful to be capable of feeling guilt, to admit wrong doing, and to feel ashamed; that is, if one is to lead a moral life. On the other hand, it might be argued that those who are shameless and who rarely feel guilt probably have more fun in life and are less troubled — the mirror reflects their image back to them in the way that they want to see it, and not in the way it actually looks. They live in a state of ethical blindness. Whether that permits a satisfying life is another story.

You be the judge.

—

The above image is Shame by Libertinus Yomango, sourced from Wikimedia Commons.

January 16, 2010

How to Grieve, How to Live

grieving-parents-side-view

You might think that grieving is not an uplifting topic. But there are ways in which that is precisely what it is.

We start with the pain of loss, specifically a loss of something of value. If you lose a penny, you won’t much care. But if the loss is of something of great importance to you, you will care greatly. The pain of loss points to the value of the thing that you have lost; and the value you place on a thing points, at least potentially, to the pain to which you are vulnerable.

What are the things we value? A job, a relationship, friends and family, a promotion; our physical-self, which can be defaced or damaged… many things: money, status, a good name, a pet, and power, too. Take your pick. You decide what is important and whatever is inside the basket in which you put your emotional pain or your vulnerability to such pain — that item has value.

Grieving involves opening yourself to the pain. Now, you might think, “It must be only a recent loss that causes the hurt.” But the heart has no clock attached to it, no timer reading off the digits of distance between you and the loss; so, if you had a difficult childhood, you might still be holding the pain inside even though it is decades old.

Not only must you open yourself to the pain, but you must do it with a witness, a listener, someone who cares and who is present, who is “there for you.” This is necessary to reattach you to human contact — to life, to intimacy — rather than closing off and pulling away from people. And in this sharing — this openness, this talk and tears and gnashing of teeth — the pain eventually subsides. It’s a little bit like kneading dough — you continue to work it until it changes. The story of your feelings will be repeated by you, if necessary, dozens of times in different ways, until the emotions are changed and the excruciating intensity of the loss passes.

How long does this process take? Six months to a year would not be unusual, although it can be longer. The first anniversary of the loss is often especially hard; so are birthdays and holidays in the first year and sometimes beyond. But if you do not do the grieving “work,” the process can be extended and a sense of melancholy or a lack of vitality can follow you relentlessly.

To grieve doesn’t mean you will forget what you have lost. And, indeed, if it is a loved one, certainly you will never forget and you will never be untouched by the memory. There is a dignity in this. We honor the loved ones who are lost in this way and perhaps they live, metaphorically speaking, inside of us. As the Danes say, “to live in the hearts that you leave behind is not to die.”

But “how” to do this grieving — that is the problem. If you have lived your life trying to be tough, you will find that the toughness might prevent you from doing the emotional work that will allow the grief to end. If you maintain that “toughness,” you might find yourself living as if you are numb, or displaying a sunny disposition totally at odds with what is felt deep inside, in the place where you have buried your hurt. And if you have deadened yourself enough, you will have a hard time “living,” since you will be closed-off to feelings. Joy, abandon, and spontaneity will be harder to achieve. Instead, the time ahead of you would be better called “existence” than “life.”

But perhaps you are afraid that if you allow all the pain to come out, you will be overwhelmed to the point of being unable to function. And, indeed, this can happen, at least temporarily. Or perhaps you are afraid of what others might think of you if they see you without your typical emotional control, and you are afraid of their negative judgments.

And so, grieving involves having the emotions without the emotions having you; accepting them and not struggling with them; metaphorically speaking, it is like driving a car with the radio on, but not so loudly that you are overcome by it. In other words, you will have the emotions but still be able to drive — still be able to lead your life.

To do this you must open the pain in a place that is safe and in a way that it is neither deadened or perpetually out-of-control. You must hold the hurt not too tightly and not too loosely, but gently, since it is precious; not walling the emotions off or letting them carry you away from active life for days at a time. Part of this is simply allowing yourself to be human, to honor the injury, not judging or trying to change what you feel (the change will happen by itself if you allow it), but permitting yourself to do what our mammal relatives do — to lick your wounds (metaphorically speaking) and accept the support of others, whether they are friends, lovers, relatives, or therapists.

And, in the end, if you have grieved and have the courage, good luck, and time to continue the human project that we all have been given, you are likely to heal enough to venture forth into the world, again putting yourself into the things and people you hold dear, risking injury once more, not hiding from the dangers that life brings, but also experiencing what is good in life — all the things you still value.

You will be alive again, and the grieving process will have led you there.

—

The above image is The Grieving Parents, Kathe Kollwitz’s 1932 memorial to her son Peter, who died in World War I.

January 14, 2010

Psychotherapy Humor

Hoping that the above title is not a contradiction in terms, I’ll tell you a little story.

Before I get to the funny part, however, this appeared very early in my blogging life and was ignored by almost everyone. If, after you read the story, you care to let me know why, I’d be interested. The tale is true.

First, to set the stage, I am a man of conservative appearance; quiet, thoughtful-looking, definitely not a hell-raiser. My picture, I suspect, gives this away. With that in mind …

A few year back I was treating a retired woman. She was a bit hard of hearing, but quite pleasant. I typically saw her on Monday afternoons and she always asked me what I’d done over the weekend. On one particular day, I answered this way: “Oh, my wife and I went to a tapas place.”

“A topless place!” she shrieked, almost hysterical. Well, eventually I was able to calm her down and explain to her that it was a Spanish-style tapas restaurant at which my wife and I had eaten, not a burlesque show.

But still, I’m not sure that she ever again looked at me in quite the way she had before her innocent inquiry regarding my weekend activity.

January 10, 2010

What Do Antidepressants Really Do?

I believe that the oldest reference to an antidepressant medicine comes in Homer’s Odyssey, which “could not have been completed much before the end of the eighth century B.C” according to Richmond Lattimore. The reference occurs when Menelaos (brother of Agamemnon),  Telemachos (son of Odysseus), and others are grieving the loss of friends and relatives in the Trojan War. Helen, the wife of Menelaos, is also present. It was her departure to the walled city of Troy with Paris that triggered the assault on that fortress to retrieve her. Having since returned to her husband, she wishes to salve the emotional pain of the men who are gathered at her home. The passage reads as follows in Lattimore’s translation:

“Into the wine of which they were drinking she cast a medicine of heartease, free of gall, to make one forget all sorrows, and whoever had drunk it down once it had been mixed in the wine bowl, for the day that he drank it would have no tear role down his face, not if his mother died and his father died, not if men murdered a brother or a beloved son in his presence, with the bronze, and he with his own eyes saw it.”

That would be a potent brew indeed. But the idea of it prompts me to say a few words about what an antidepressant can and cannot do, for there is much misunderstanding on this point. And, by the way, the first real antidepressants only became available in the 1950s.

An antidepressant does not make you giddy about your life or impervious to emotional pain; it doesn’t make you forget bad things. In other words, it is not what Helen of Troy administered. If an antidepressant is working well, it helps put a floor under you. That is to say, many people with depression feel as though there is nothing holding them up (metaphorically speaking), no bottom to their suffering.

An effective medication creates that bottom, relieving them of the sense that they are without any support underneath them. It reduces their suffering too, makes them less prone to crying, less exhausted, and less subject either to over-eating or having no appetite, and usually able to sleep better. In other words, the medicine helps you tolerate life and helps normalize that life.

Some people, including quite a number who shy away from psychiatric medications or medication or any kind, actually are attempting to “doctor” themselves with drugs or alcohol.

There is danger here, naturally.

You probably know some of the dangers, but one I want to mention in particular is the depressant-effect of alcohol. It might make you feel better in the short-run, but in the long-run it is likely to fuel your depression, not to mention create a dependency.

As the old Chinese expression goes, “First the man takes the drink, then the drink takes the man.”

I suspect that you know someone who believes that psychotropic medication (and perhaps psychotherapy too) is a crutch. There is no denying that being treated for emotional problems can produce negative judgments and a stigma. Moreover, historically speaking, insurance companies have paid less well for therapy and psychotropic medication than for “physical” illnesses. That has just changed in 2010, but the stigma won’t be legislatively erased by the US congress, as was achieved by “parity” legislation that now requires equal insurance coverage of both physical and “mental or nervous” conditions.

Yet some categories of depression are certainly just as “physical” as an imperfect gall bladder is, for instance. Specifically, Bipolar Disorder, also called Manic-Depressive Disorder, is one such biologically-based psychiatric category where medical intervention is often enormously helpful, if not essential.

Would you want your severely diabetic loved-one to avoid the “crutch” of necessary medication? If your answer is “no,” then you shouldn’t be put-off by treating a biologically-based depression with a proper medication to stabilize his mood.

Nonetheless, it is true that many depressed individuals do not have any biological flaw or chemical imbalance, but rather are reacting emotionally to difficult life circumstances such as repeated losses (e.g. divorce, job loss), unfinished grief, or abuse of one kind or another. Very often psychotherapy is able  to successfully treat these people without the benefit of medication. Indeed, sometimes patients are too quick to obtain antidepressant prescriptions which take the edge off their feelings enough to reduce their motivation to address difficult life circumstances, including repetitive patterns of behavior that lead to unhappiness.  In that event, they will risk having to stay on antidepressants lest they fall back into depression.

For those patients, on the other hand, who successfully address their issues in psychotherapy, antidepressants may never be needed or, if they are used, might be required only temporarily.

If you are seeing a therapist for depression, talk with him about medicine for your condition, especially if you feel that you need immediate relief or are having suicidal thoughts. Beware equally of therapists who never want their patients to go on medication, as well as those who always do.

I should mention that while many depressed people obtain medication from their family or primary-care physician or general practitioner (GP), this isn’t always the best source of psychotropic mood-altering substances. While some GPs are both comfortable with and experienced in prescribing such medication, some are hesitant or unsure. The latter group may be less adept at identifying the precise antidepressant which is best for you given your particular symptoms; moreover, their hesitation can cause them to give you too low a dose to obtain a therapeutic benefit.

A good psychiatrist, by contrast, is absolutely up-to-date on everything about the medications available to treat you, adept at identifying which of the available antidepressants is the best fit for your particular situation, and knows how to get you to a therapeutic level of the medicine as quickly as possible. Since those in pain so often feel as if there will be no end to their suffering, and since antidepressants often take a several weeks to produce relief, getting the medicine right as quickly as possible is very important.

If you do choose to obtain medication, be sure to educate yourself about your condition and the possible side-effects of the medication being suggested. Not all physicians are good about describing those side-effects before-hand, even including the sexual side-effects produced by some antidepressants. Be your own advocate. Don’t be passive in treatment. It is your body, it is your life.

Last I heard, you only get one of each.