depression

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 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.

December 30, 2009

Hope For the New Year: Old Words After a Tough Twelve Months

Its been a tough year, but not the first in human history. These old words from the great nineteenth-century Scottish writer Robert Louis Stevenson seem just right:

“Give us grace and strength to forbear and to persevere. Give us courage and gaiety and the quiet mind. Spare us to our friends and soften us to our enemies. Give us strength to encounter that which is to come, that we may be brave in peril, constant in tribulation, temperate in wrath and in all changes of fortune, and down to the gates of death loyal and loving to one another.”

November 19, 2009

Self-Defeating Behavior and the Path to Loneliness

http://upload.wikimedia.org/wikipedia/commons/thumb/0/0b/Africa_lonely_kids.jpg/240px-Africa_lonely_kids.jpg

What price would you be willing to pay to feel that you are special? I will tell you a story of one young woman who has paid that price and then some. She is an example of how we sometimes defend our self-image at the cost of our happiness.

The patient of another psychologist, I knew this woman for about 20 years, filling-in for her therapist when he was on vacation. Gloria (not her real name) had a tragic early life. She was victimized by her parents’ verbal and physical abuse and neglect, and became an easy target for schoolmates. Gloria was unlucky, too, in that she was born with slightly less than average intelligence. Making things even worse, her body was naturally graceless and her facial features were less than attractive. But, Gloria could be sweet and socially engaging, willing and able to approach strangers and make conversation despite a long history of rejection.

Even with all her disadvantages and misfortunes, Gloria, now a middle-aged woman, might still be able to have a good and pleasing social life except for one thing: she believes that she is the world’s unluckiest person, the record-setter for having received the greatest misfortune in the history of the planet. Moreover, she feels compelled to report her tale of woe to those people she begins to get to know, very early in her relationship to them. This has the predictable result — they shy away from her, leaving her feeling rejected once more, and adding to her claim that she has been the most ill-treated human in recorded history.

I am not being facetious here; I once asked her to compare herself to various victims of misfortune including those who had been tortured, suffered in natural disasters, lived in concentration camps, or been plagued with disfiguring and painful illnesses. She assured me that her lot in life was far worse than any of them; and, that it was only fair and reasonable to expect people to be sympathetic to her and give her some of the understanding, sympathy, and support she had always been lacking.

Thus, Gloria pursues with a vengeance the comfort and affection that she believes she has coming to her. Her sense of entitlement to this, her insistence that her fellow-man should and must provide this, drives people away from her in her striving for the love she has never had. Of course, her therapist points out to her the self-defeating nature of this strategy, the need first to establish relationships based on something other than the other person’s willingness to listen to her sadness and anger. Gloria doesn’t accept this, unfortunately. The world and the rest of the human race owe her this hearing (so it seems to her), the sooner the better, and it is only fair and just to expect them to deliver what she wants.

Gloria is smart enough to understand that people she hardly knows might not have much patience or interest in accepting her premature self-disclosure. And so, you might well ask, why does she continue to do the same thing over and over with the same bad result? Why doesn’t she try something different?

After much consideration of that question, here is the best answer I can provide. First, Gloria is so desperate and needy, so starved for affection, that it is difficult for her to restrain herself from lunging at the thing she desires whenever she first sights it. But, more importantly, I think the one thing that Gloria values above everything in her life is her self-appointed status as The Most Unfortunate Person in World History.

Now, you might say that you wouldn’t want to hold that particular title. But, think about it. I suspect that this designation gives Gloria the only form of distinction she could every expect to achieve in life. Without it, she is simply a sad, angry, lonely, unattractive, unaccomplished, anonymous person; but with it, she is something special, someone who stands out from the crowd, a noteworthy individual, one in six billion, the leader in her class. And the self-nourishment she receives from licking the wounds attendant to this awful position in life almost certainly provides her with some amount of solace.

I’m sure Gloria would deny the psychological explanation I’ve just provided for her self-defeating behavior and I cannot promise you that it is accurate. But I would ask you this. Do you know people who persist in self-defeating behavior despite all the advice, therapy, or wise counsel offered by friends, relatives, and therapists? Have you sometimes wondered why they do so?

Often the answer isn’t “logical” in that it doesn’t “make sense” intellectually. But, it just might make sense emotionally, as I believe it does for Gloria. If, somewhere deep inside, she doesn’t really believe that she can achieve the life she wants, her behavior suggests that she has found a method, however self-defeating it is, to give herself some of the sense of status and recognition that life hasn’t and probably won’t provide to her.

Gloria was dealt a bad hand in life. Her response to that deal of the cards is instructive. She seems to have chosen a sort of fantasy, a story about herself that compensates her for her misfortune, just as it simultaneously fuels her continued loneliness. But be careful should you wish to dismiss her behavior as “crazy” too quickly. We all do self-defeating things in life.

Before you condemn her, check yourself out in the mirror.

—

The drawing above is called Africa Lonely Kids by Myfacebook. It is sourced from Wikimedia Commons.

November 14, 2009

Making the Same Mistakes Over and Over: How to Learn From Childhood

There are few perfect childhoods out there. Indeed, it’s the nature of childhood to have some tough times. You are small, you don’t know anything, everything has to be learned for the first time. No wonder its a challenge! The adults tower over you and the big kids can belittle you, push you around, and trip you up. Literally.

So what do we do to survive childhood? Well, we figure out some strategies to deal with the problems that we face. For example, if you have an angry parent, you might learn to be sensitive to signs of upset in someone else, know when to keep your head down, try not to ruffle feathers. On the other hand, if you had a parent who only gave you attention when you were helpful and solicitous, doing things like looking after your younger siblings, you could have learned how to take care of others and seen that quality as, perhaps, one of your only virtues.

Often, the solutions that were necessary early in your life don’t work very well in the “older” (which is to say “current”) version of you. Being sensitive to possible anger in friends, lovers, and coworkers could well find you cowering unnecessarily, accepting half-a-loaf because your are afraid that if you speak up, you will get none. Being a care-taker as an adult might get you some initial approval, but it can prove unsatisfying when the person you are with expects that you will do all the caring and give all the help in the relationship, but doesn’t think to give much back to you.

It’s a little bit like this: Imagine that you were born in Alaska, learned to wear heavy clothes and multiple layers. It was a solution that was necessary and one that worked. If you continue to live in Alaska, you will find success if you use the same solution forever. But, should you move to South Florida and operate by the same set of internalized rules, now you will have quite a problem!

Childhood solutions only are useful to adults if you continue to live in circumstances similar to your childhood. But, by definition, most of us live in different circumstances. We are not any longer so small and defenseless, so unworldly and innocent. We now have much more capability to change the world around us. Unfortunately, some of us don’t know it.

Are you doing the same things that you did as a kid, using solutions that haven’t solved anything for a while? Are you suppressing emotions because that  was a good strategy in an uncaring childhood home? Are you still afraid of situations that resemble your early life challenges? Do you still avoid difficulties, never having figured out how to face them?

It’s worth taking an inventory of your early life and, even more importantly, your current life.  Look frankly at what did or didn’t work as a kid (and what does or doesn’t work now), asking yourself whether youthful difficulties produced a way of being that isn’t helpful. If you keep using failed solutions, you will likely continue to experience failure. Most of our problems are patient. They wait for us to recognize them and then to solve them. They can wait a lifetime.

Is that how you want to spend the rest of your life, making the same mistakes, accepting less than what might be possible and good for you? If you are willing to wait in that way, don’t call a therapist; you are too patient and not sufficiently motivated to change. But if you are beginning to be aware of how unsatisfying your way of living is and have the courage to face that fact, do call. That’s what therapists are there for.

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

http://mburgan.files.wordpress.com/2008/12/nuremberg_defendants.jpg

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

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

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

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

But therapy cannot end there.

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

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

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

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

“Men at some time are masters of their fates:

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

But in ourselves, that we are underlings.”

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

July 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.