grieving

June 3, 2010

The Limits of Reason: How to Think about Your Date, Your Boss, Your Mom, etc.

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As a therapist, I hear a lot of concerns from my patients about parents, bosses, romantic partners, and so forth. The thoughts often take the form of “Why did he do that?” or “What was he thinking?”

Some of this is worth questioning. In life it is useful to take the role of the other person, to look at things from his or her perspective, to try to “understand” that individual’s motivations and reasoning process.

But, there are limits. Here are just a few that make understanding difficult:

1. People don’t always carefully weigh their decisions before making them. We humans frequently think and act impulsively or emotionally. It can be a bit harder to fathom an ill-considered act than one that is carefully reasoned.

2. The person whose mind you wish to enter may not know himself well at all. When you recall what he says are the reasons for his actions, you need to be aware that he may be fooling himself. Alternatively, he might be dishonest with you, giving you less than a full set of data, trying to prevent himself from looking bad in your eyes, or attempting to protect you from being hurt by the truth.

3. We all act in self-serving ways much of the time. The same person who says that he hates it when someone ends a relationship without explaining why — not even making contact or returning phone calls — might well avoid the discomfort of a final farewell or confrontation himself when he decides that a relationship should end, thereby doing the very thing that has been done to him.

4. Most people, in or out of therapy, are often indirect in expressing their unhappiness with you or their disappointments about your behavior. (Marital conflicts and parents talking to children can be noteworthy exceptions to this general rule). But, in the absence of direct communication, it is difficult to be a good mind reader. Indeed, crystal balls are in short supply whenever I go shopping.

5. When trying to understand others, we look for some form of logic. To seek something that is often missing within the person is a pretty big misunderstanding of how people think and act.

6. You may not have enough history and background information to make an accurate analysis of what drives this individual to do what he does.

7. Do you really know the person well “under the skin?” There is often a mismatch between what is happening on the inside and what is occurring on the outside. Put differently, the contradiction between surface appearances and internal truth often affirms the old saying, “Don’t judge a book by its cover.”

Too much time trying to figure out another person is unproductive. For this reason and those cited above, I encourage my patients to set some limits on the amount of time they spend attempting to get into someone else’s head. At bottom, I think, what most of us are looking for is the understanding that will allow us to return to the relationship and put it right, now that we have found the “answer” to what transpired. Or, something that will console us or produce the closure that we are hoping for at the relationship’s end. By attempting to “understand,” we are frequently seeking a sense of intellectual control, partially to acquire information that will prevent future disappointments, but also to compensate us for our loss and to silence the nagging internal voice that asks “What happened?” and “Did I do something wrong?”

It is better, beyond a certain point, to consider several things about oneself:

a. Why did I choose that person to be with? (Obviously this doesn’t apply to your parents; nor does it always apply to bosses or co-workers).

b. How did it happen that I missed the early warning signs of trouble? Oh, I know that you might think that such signs didn’t exist, but it could be that you ignored them, minimized them, or had a blind-spot for them.

c. Why didn’t I set some limits on the relationship in order to prevent the other person from injuring me? And, if I tried, why did my efforts fail?

d. Why didn’t I leave the relationship earlier?

e. What, if anything, did I contribute to the problems that occurred between my friend/partner/lover/boss and myself?

f. Have I grieved the loss or disappointment fully (including attention to both my sadness and my anger)?

g. What do I have to do differently in order to minimize or avoid problems like this in the future?

Instead of addressing the situation in these ways, with these questions, most of us spend no small amount of time ruminating, and then looking for something we can say to the other person to get them to behave as we wish. With some individuals that is possible, but not with everyone.

Jackie Robinson’s breaking of the baseball color-line is instructive in this regard. As you might know, Robinson and his boss, Branch Rickey, agreed that he would not respond to the abuse from fans, players, and coaches that both expected he would receive when he became the first black man in the 20th century to play in the Major Leagues. But, despite two years of taking every racially demeaning insult known to mid-century white males, he succeeded in playing well. Moreover, by this time there were other blacks in the Major Leagues and a great experiment in civil rights had succeeded.

If the story I’ve heard is true, Robinson and Branch Rickey had a conversation at the beginning of Spring Training at the start of Robinson’s third year with the Brooklyn Dodgers. They agreed that Robinson could now be himself, and fight back with words or fists, if necessary. Soon after, the Dodgers played the Philadelphia Phillies, who did not know that Robinson was no longer on a leash. The middle-aged man from the deep south who coached third base therefore once again began the verbal onslaught that he had performed with impunity for the two previous seasons. Robinson called time and walked over to the third base coaching box.

Remember that Robinson had lettered in four sports at UCLA, including football (as a running back). More than most, he radiated intensity, strength, courage, and intelligence. So it was that Robinson moved within inches of the bigot, looked straight into his eyes, and said: “If you ever say anything to me like that again, I’ll kill you.”

Now, I bring this up not to recommend death threats, but rather to point out that Robinson knew exactly who he was dealing with. He knew this man was not going to be persuaded to behave himself by high-flown verbal eloquence; he knew that spending much time thinking about this man’s character was a waste. What Robinson knew for certain was that there was only one thing he needed to understand about his nemesis (his intolerance) and only one approach that would work:

  • I’m bigger and stronger than you are, so if you don’t stop, I will beat the crap out of you.

Everything changed that day as others quickly realized that Jackie Robinson was not a man who could be insulted any more.

Of course, we all need to spend some time thinking about others and why they do what they do. But, endless rumination on the subject rarely is enlightening or successful in making us feel better.

Some people are like boulders. They are big, hard, insensate, obdurate, and potentially damaging objects. It is essential to see their potential to injure and realize that when you are downhill from such a human bolder, you are in danger.

If you understand how gravity works and get out-of-the-way, that is all you need to know and do — all you can do.

A shame, but true.

—

The image above is The Thinker by Auguste Rodin.

May 2, 2010

Lost and Forgotten Loves

Do you remember, perhaps wistfully, someone who has long been out of your life? The person might be a first love or a romantic interest who came along at a vulnerable moment. That individual provided something timely and touching, perhaps a feeling that you thought you would never have. Usually it was the possibility of love — the possibility of being loved and feeling loveable — something that hadn’t been experienced recently if at all; something that seemed hopelessly out of reach. And so, this person who opened the door to embracing that feeling — to a sense of being worthwhile and valuable — acquired a special value herself. She brought the “music” into your life and might continue to hold a special place in your heart.

Perhaps you felt that the lost love was too good for you — at least so you thought. The interest she had in you seemed a bit astonishing to you. And you were enormously grateful for her interest and the pleasure that she seemed to take in your company. If you were lucky, the relationship lasted long enough to change you for the better. And even though it ended with your heart breaking, you still carry inside of you a sense of gratitude and an enduring soft-spot for this person who you’ve likely not seen for many years.

There are ironies here, at least two I can think of. First, that your gratitude just might be a bit misplaced. You probably thought too little of yourself and too much of the object of your affection. Perhaps you placed her on a pedestal. You might have dismissed what you brought to the relationship: your good nature, your wit, your humor or kindness, or  your own physical attractiveness. And so, whatever affection or interest you experienced that felt to be more than you deserved, might in fact have been just what you were entitled to: you were better than you thought.

Another irony is that, as much as you might still think of this individual from time to time, it is entirely possible that she almost never thinks of you. You did not change her life, even if she changed yours. Your role was more peripheral, less important. To her, you are another relationship in a history of such contacts, not the one that made an enormous difference in her life, as she did in yours. It seems a bit unfair, doesn’t it? Yet that is the way life works.

But I think that the ultimate irony in these unequal pairings is that there is probably someone out there whose life you did alter, to whom you meant everything, and who you now hardly ever think about. In other words, the roles described at the start of this essay are reversed. And you may not even know (or remember) just how profound your impact was on that lover of the moment. For him or for her, that time together with you was much more special, decisive, and profound than it was for you.

It helps to see both sides of this. Both the over-valuing of another and the impact we make on people without really trying — just by showing up in their lives at the right moment and being ourselves. The most dramatic impact outside of a romantic relationship (and indeed one that has more influence) is surely that between a parent and a child, but bosses and friends can sometimes approach the importance of a romantic partner.

Therapists and teachers need to be mindful of this too, in their relationships with patients and students, respectively. Whether you help or you hurt another can be of enormous importance. And, if you’ve done your job especially well or especially poorly, you will probably be recalled long after the relationship has ended.

My high school friends and I take part in something called the Zeolite Scholarship Fund, about which a search of this blog’s archives will reveal more. One of the things we have done in addition to giving scholarships at our alma mater is to honor our old Mather High School teachers. We let them know how much they meant to us, at least those who made an important difference in our lives and are still living. Even decades later and long since they might have recalled any of our names, we remember them and their influence.

I suppose that the most appropriate metaphor for the way in which we unknowingly impact others negatively (and this can apply to teachers who were particularly poor or nasty) is one of walking down the street, being unaware and unconcerned (as we all are) of the very little creatures (bugs) that we might be treading upon. I know that this is an exaggerated comparison to the way that we are affected by others. But the point is that we are all pretty fragile, easily hurt by those who care less about us than we do about them.

Just something to be mindful of in any relationship, whichever end of it you are on. Like throwing a stone into a pool of water, the ripples can go on for a very long time.

Be nice.

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A cropped version of the painting at the top of this page: The Kiss by Gustav Klimt

April 28, 2010

Two Americas, But Not the Two You Think

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Before his marital infidelity discredited him, John Edwards spoke eloquently about “two Americas.” He talked of differences between the health care, financial stability, education and housing available to these two different parts of our society.

But there is another American divide that has created two other Americas: on one side the fighting men and women in our armed services (along with their families) and the rest of us on the other.

If you are unhappy about the polarization of our society, look no further than the differences that have been institutionalized by the volunteer army. However much good was achieved by the decision to eliminate the military draft, surely the absence of shared sacrifice has contributed to the ease with which we take opposing positions to our fellow-citizens on matters that have to do with national security.

No longer does the USA pull together for the long haul in the way that was possible during World War II. In part, “the Good War” was good because enough people believed in the values for which the USA fought, knowing that their children, husbands, and brothers would defend those same values with their lives; and it was good because the people of this country (regardless of class) shared in the rationing of goods and the sheer terror of having their loved ones abroad and in harm’s way.

If a war is worth fighting, it should not have merit only because the children of other people are fighting it, even if they do so voluntarily.

These thoughts occurred to me as I listened (on CD) to the book Final Salute by Pulitzer Prize winning author Jim Sheeler. This book is about the officers who inform families that they have lost a loved one, and of the families who suffer the unspeakable pain of the death of a son, a husband, a wife, a brother, or a sister; a dad or a mom.

The book takes no sides on the question of the War in Iraq. Yes, you will hear occasional comments in support or opposition, but you will not think as much about these policy questions as about the human beings you meet along the way. Several families will become your acquaintances as well as the warriors — the Marines — who died serving our country. And you will also get to know Major Steve Beck, a Marine tasked to inform the families of their loss, the man who delivers a message nearly as shattering as the projectile that killed their loved one.

Major Beck and the Marines live by the creed that they shall leave no comrade behind. And, consistent with this value, Major Beck leaves no family behind, providing comfort and support long after the knock on their door that changes everything, that creates a “before and after” without end.

I wish I had the words to convey what is in this book. I don’t. But I can say that it is plainly written, eloquent in its simplicity, aching in its beauty, profound in its impact. It does not work to make melodrama of what is already poignant enough. Rest assured that you will think about war, any war, differently after reading or listening to Final Salute; unless, of course, you are a member of the “other America,” the one that fights the wars and sends its loved ones into conflict. If you belong to the bereft group within that group, then there is nothing contained in this book that you do not already know at a level too deep for words.

If you have lost just such a one as the young men portrayed in Final Salute, I can only give my condolences to you and your loved ones. It is thanks to the willingness of the few to serve on behalf of the many that the rest of us are safe.

We — those of us in the non-fighting America, those of us for whom the wars in Afghanistan and Iraq are abstractions — perhaps remain too comfortable, too detached from something of desperate importance: the work done far from home in our name by the children of other people. And too removed and distant from how these “best and brightest” of their families risk and sometimes give up everything they hold dear.

We need to remember that, for these families, the human cost never fully goes away.

They are out there, these inhabitants of “the other America.”

We walk by them unaware every day…

Kafka said that “a book is like an ax, to break the frozen sea within us.”

This is such a book.

—

The maps above are the work of Allstrak, courtesy of Wikimedia Commons.

March 4, 2010

The Upside of Depression and the Downside of Medication

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Are there advantages to being depressed? Something good about something we think of as so bad? A recent New York Times Magazine article by Jonah Lehrer makes just that case: Depression’s Upside.

The essence of the argument is that some episodes of depression allow for and encourage a kind of analytic rumination that is productive. Put another way, the tendency in depression to focus on a problem, mulling it over to the exclusion of other thoughts, permits the sad person to find a solution to his difficulty and change his life in a positive way.

The counter-argument, however, is that the ruminative process is both painful and unproductive — that it often creates a kind of self-flagellating preoccupation with one’s trouble rather than a process that leads to something good; that unhappiness and focusing on pain and its concomitants simply feed on themselves to no helpful end.

In my clinical experience, therapy with people who are depressed over loss or injury often breaks down into two phases. The first of these is a grieving process, where the person expresses and processes (or sometimes purges) the feelings of anger, sadness, emptiness, desolation, and hopelessness that come with the loss of something of value — a love, a job, high social status, a capability, a fortune, etc.

The second phase involves learning from one’s painful experience about how to live differently, make different decisions, associate with different people, become more assertive, overcome fear; value things differently in life such as money, material things, status, accomplishment, friendship, and love.

Naturally, neither of these two phases is absolutely discrete — they blend into each other and overlap each other. As a practical example, someone who has had a series of bad relationships will typically need to grieve the unhappy end of the most recent one and, in the process, learn how he happened to choose a person or persons who made him so miserable; then changing whatever needs to be changed internally and externally so that different and more satisfying choices occur in the future.

People who are like the hypothetical individual just cited usually come into therapy in emotional pain and seek relief of that pain as promptly as possible. This desire is entirely reasonable — who wouldn’t want this? Some of them request medication, which is often the fastest way to “feel better.”

But many are leery of psychotropic drugs and see them as artificial, hoping that therapy will produce a more lasting fix without dependency upon a foreign substance. Indeed, while a good therapist will strongly encourage the use of medication for someone who is seriously depressed, i.e. suicidal, unable to work, sleeping away the day away (or almost unable to sleep); that same therapist will also know that medication sometimes serves to “de-motivate” the patient, giving him or her a relatively quick solution that allows that person to tolerate an intolerable situation. In the New York Times Magazine article mentioned above, Dr. Andy Thomson describes this problem eloquently:

I remember one patient who came in and said she needed to reduce her dosage. I asked her if the antidepressants were working, and she said something I’ll never forget. ‘Yes, they’re working great. I feel so much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.’

Clearly, this woman was aware that she needed to be in some amount of discomfort in her relationship with her husband in order to be motivated to get out of it. The drug made her feel better, but, it also reduced her incentive to change herself and her life. It was, in effect, a kind of band-aid, rather than a real cure. It anesthetized her and, in so doing, robbed her of something that was essential for new learning and behavior change to occur.

Unfortunately, most people who come to therapy are neither as courageous or insightful as the woman just described. Once they feel significantly better, whether due to therapy or medication, it is common for them to be less interested in continuing treatment. They have recovered from the event that precipitated their entry into therapy, but they might not yet have learned enough to avoid making the same mistakes that contributed to the problem in the first place.

Such a person can reason that the cost of therapy (both financially and in terms of time, effort, and the difficulty that comes with changing one self) is now greater than emotional pain from which they might still be suffering. Put another way, at this point, doing therapy “causes” more difficulty and pain than not doing therapy, just the reverse of what seemed true when they started the treatment process.

At this stage, those who continue in therapy have something that an old mentor of mine, Truman Esau, used to call “therapeutic integrity.” What he saw in some of his patients was an almost heroic desire to make themselves better regardless of how much the actual process of doing so was difficult, uncomfortable, or painful.

These patients didn’t shy away from problematic truths about themselves or others. They worked hard to stretch and challenge themselves, knowing that it was crucial to improve. They didn’t simply want a quick fix. Like the woman in Dr. Thomson’s example, they recognized that some pain was essential to being motivated. They knew that there was no such thing as “a free lunch,” and were willing to do whatever it took to repair and better their lives.

If you are in therapy now, it will be important for you to be sensitive to this shift from the often intense distress that brought you into therapy, to the point when the therapy itself might seem distressful. This can mean that the therapist is not skillful or that he is pushing you too much, but it just might also signal that some of the most difficult life changes you need to make are still ahead of you, even if the cost of making those changes seems greater than when you started treatment.

If you leave therapy because it is hard and unpleasant work, the problems you have won’t care. They will simply continue to reside in you, work on you, and trip you up. It is not enough to get over your last disappointment or unhappiness, but to change yourself enough to avoid future problems.

Few things that are worthwhile come to us for free.

—

The above image titled Depression is the work of Hendrike, sourced from Wikimedia Commons.

January 16, 2010

How to Grieve, How to Live

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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 23, 2009

When the Lover is Ready the Soul Mate Will Appear

Mel Nudelman and Sally

I’ve read or heard two different meanings attributed to the Buddhist saying, “When the student is ready the master will appear.” The first suggests the universe is ordered in such a way that things happen when they are supposed to:  knowledge will be offered by events in the universe (or God) at the right time. If I am allowed to amplify the meaning slightly, the saying would also refer to the idea that when you are ready, the right person for you might also appear, not just a teacher, but your future love.

I prefer, however, another, more psychological way of thinking about this aphorism: there are always available “masters” or other persons who might be important in your life, but the “student” doesn’t notice the presence of those persons until he is ready. Or, to look at a different aspect of this notion, important knowledge is always or almost always available to us, if only we are open to it, prepared by experience or mind-set to receive it.

In other words, we must be ready to learn, to think and feel differently than we have before in order to recognize there is something important to be learned.

Those in life who have all the answers — certain of everything — will never learn anything new. Those afraid to do new things are unlikely to learn, since in order for the “master to appear” one must have one’s eyes open and actually get out of the house — the master being unlikely to call you to make an appointment, unsolicited.

But if you are humble about what you know, humble in the knowledge there is always more to learn, you might just learn something. Branch Rickey, the baseball executive, said “luck is the residue of design.” I’d add to that, so is learning the residue of design. And part of the “design” or preparation is to put yourself into situations where it is possible to be enlightened, whether by people or events or your actions; by books or theater, music or child-rearing or romance.

A good therapist is enlightened by his patients. He experiences a whole world, the world of the patient, seen through the patient’s eyes. His patients also inform him, directly or by their response to him and to the therapy, what works and what doesn’t.

People in less formal relationships than therapist and client teach us too, and enrich our lives. For example, some people believe there is only one person who represents our romantic destiny. When the person comes along they might say, by the first definition I gave you at the top of this essay, the universe or God put this person in our lives at just the right time. There is a Yiddish word that captures this notion nicely: “bashert” or “beshert.” In other words, to be “fated.” It is used when someone tries to say an event was “meant to be,” and is often employed with respect to a reference in the Jewish Talmud that God has chosen your soul mate.

My own opinion, however, is that most of us might have met, fallen in love with, and married any number of good people and had equally good lives as we have with the person whom we did marry; different, certainly, but just as good, more or less. That we didn’t marry someone else might have been due to a lack of maturity when the “other” person appeared, poor judgment about the value of the qualities in a person, or fear of rejection and heartbreak, to name just a few possible reasons.

If you protect your heart against the poisonous arrows that can harm it, you also might prevent Cupid’s arrow from reaching it.

One must be open, then, for the right person, for the master, for whatever knowledge or experience might enrich us. Vincent Van Gogh wrote the following to his brother Theo in 1880:

Many a man has a bonfire in his heart and nobody comes to warm himself at it. The passers-by notice only a little smoke from the chimney, and go their way… I am drawn more and more to the conclusion that to love much is the best means of approaching God. Love a friend, anyone, or anything you like, and I tell you, you will be on the right road to learn more. You must love with a high and intense determination, with your will and your intellect, and seek always to deepen, expand, and improve your knowledge. …”

Which makes me think of my late friend, Mel Nudelman. Mel was an old friend in both senses of the phrase — I’d known him since the ’70s and at age 87 he lost his wife of 50 years and was devastated. But, to his credit he fought through and grieved his broken heart to the point of making a new girlfriend! (A lovely woman, by the way). And so, Mel lived as he always did, learning, taking classes, counseling others, being with his children and grandchildren, making friends young and old; ever curious about politics, music, sports, medicine, and the world. All this until near the end of his days in his 90s.

Put differently, Mel was open to life and whatever it would reveal to him.

My advice then, to you and to myself, is to keep learning and keep being open to “possibility,” including the possibility there are things yet unseen, unexpected, or unacknowledged to enlighten us if only we keep our eyes open and look.

We are all students of the greatest teacher of all: life.

—

The photo above shows Mel and Sally Nudelman.

November 25, 2009

Forgiveness: If and When?

Much is made, especially by the religious, about the importance of forgiveness. But the topic is worthy of some discussion before one gives a blanket endorsement to forgiveness of everyone and everything. Should all acts be open to forgiveness? Is apology essential before there is any forgiveness? Are some offenses unforgivable? Are some people permitted more leeway to act inappropriately and exempt from the expectation of apology?

First off, who has the right to forgive? Only those who have been injured. I have no right to forgive your mistakes unless you have done me harm in some fashion. Certainly, this right might include an injury done to someone I love, if I too will have suffered pain due to the harm done to the other person. The idea that I can’t forgive you for an injury you did to someone I don’t know, for example, is allied to the notion of legal standing. I can’t bring a law suit against you unless the court agrees that I have a stake in the matter. As the old saying goes, “I don’t have a dog in this race.” That doesn’t mean that I don’t care about what happened; rather, it means that in matters of injury, compensation, or apology, I’m not directly involved.

Another consideration is whether the injury is ongoing. If someone is in the process of playing practical jokes on you day after day, to take an example that is relatively small, would you forgive his poor taste or judgment? He’d probably laugh at you if you did, because that individual sees nothing wrong with what he has done. Better to get him to stop or get out of his way, than to consider any generosity of spirit on your part that is likely to go unappreciated.

Then there is the question of apology. Let’s assume the joker just mentioned has a moment of self-awareness, or perhaps has been persuaded that his actions are rude. What must he do to apologize? According to Aaron Lazare’s book On Apology, he should acknowledge what he did to hurt you, say that he is sorry, and attempt to compensate you in some way. In the case of public humiliation caused by the practical jokes, for example, it would be appropriate (although perhaps impractical) for the prankster to make a public admission of his foolishness in front of the same people who were present when he embarrassed you. Moreover, he must do his very best to make sure that his boorish behavior isn’t repeated. Simply saying “I’m sorry” isn’t enough. Nor is it sufficient to state, “I’m sorry if I’ve hurt you,” a turn-of-phrase we hear from public figures, but one that is absolutely inadequate. According to Lazare, it is crucial that the transgressor be precise in admitting what exactly he did that caused harm, leaving no ifs, ands or buts, and making no excuses. This is the same sort of thing that happens in court, when, after a plea bargain, the accused admits exactly what he did without excusing it away, and recounts the consequences that followed from that behavior. In legal terms it is called “allocution.”

With respect to the question of some offenses being unforgivable, that is for the injured party to decide. Murder, rape, torture–all terrible–still permit the possibility of forgiveness if it is in the capacity of the afflicted to give it. The same answer would apply to the question of having a different standard for the behavior of one person than for another. We all do this in practice, accepting the failures and misbehavior of those we love when we aren’t so generous with a stranger who does exactly the same thing; and we often let things go without apology.

Forgiveness, however, is not the same as forgetting. If you have been injured, it is most often worth remembering who did what to you, lest you put yourself at risk of being hurt once again. Nor does forgiveness require that you continue your relationship with the person who harmed you; it is sometimes good judgment to forgive the person at the same time that you end the relationship with him.

Relationships are messy and we all can do better and be kinder. Many people have trouble telling others when their actions have caused an injury. The victim can suffer silently or in grumbling discontent, and passive-aggressively try to pay-back the injurer in some indirect fashion. Often, the hurt that the injurer caused is inadvertent and might be easily remedied if the one who has done the harm is told gently but firmly that he caused unhappiness.

Of course, some relationships, if they regularly cause injury, can be quickly dispensed with at little cost. But for those closest to us, we usually will suffer more and longer before limiting contact or severing the bond with that individual. And contact with parents or siblings, for example, cannot be replaced. So, for most of us, we will usually put up with some measure of unhappiness in order to keep a place in our lives for even the unrepentant relative. And, in part, it depends on how much one is willing to put up with.

There is at least one additional very important and useful reason to forgive. It follows from the old Italian expression, “If you want revenge, you should dig two graves (one for yourself and one for the object of your revenge).” The point here is that carrying anger is costly and letting go of that anger might allow you to be happier and more at ease in the rest of your life.

But, be careful not to let go automatically and too soon. Anger is often a necessary part of getting over an injury. While it doesn’t always have to be expressed at someone else, neither is turning the other cheek invariably the best policy for your psychological well-being. Writing about your feelings will oft-times help, and talking to a friend or counselor can be useful. But once you are through the stage of anger, forgiveness is at least a possibility.

Still another reason for accepting an apology and forgiving is that the relationship can be continued and sometimes improved by the act of mutual understanding that is involved. Life is full of disagreements and differences, in addition to unintentionally hurt feelings. Those parties who can survive conflicts, communicate about them, and come to a point of acceptance, understanding, and appreciation often are bonded together more strongly by the experience.

It takes maturity to know when to ignore something and when, instead, to confront the person who has injured you. Most things probably aren’t worth the trouble of a conflict, lest one always be fighting and accusing others. Best to wait for a cool and calm moment to decide whether confrontation is worth it, than to act in the over-heated instant. That is nothing more than common sense.

But, as a wise man once said, common sense is rather uncommon.

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.