psychotherapy

October 18, 2009

Unfaithful and Feeling Guilty: Now What?

http://upload.wikimedia.org/wikipedia/commons/thumb/5/56/Pashtun_Couple.jpg/256px-Pashtun_Couple.jpg

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

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

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

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

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

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

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

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

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

—

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

October 8, 2009

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

gentlemen_prefer_blondes_movie_trailer_screenshot_16-1

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

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

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

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

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

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

 

http://upload.wikimedia.org/wikipedia/commons/thumb/5/5b/Du_Caju_%28miss_Belgian_Beauty_2006%29.jpg/500px-Du_Caju_%28miss_Belgian_Beauty_2006%29.jpg

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

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

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

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

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

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

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

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

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

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

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

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

—

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

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

October 2, 2009

What Happens in Psychotherapy?

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

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

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

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

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

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

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

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

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

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

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

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

September 27, 2009

The Meaning of Life is…

Thoughtful people since the beginning of time have looked for the answer to the biggest question of all: what is the meaning of life? But recently I’ve begun to wonder whether perhaps it is the wrong question. The existentialists have long suggested that it is our job, each of us, to find our own meaning. But even if you believe in the idea that we must take responsibility for the one life that we have and view it as a creative act, to make what we can of it, I’m still not convinced that the question is the best one available.

What then might be a better question? The question I’m thinking of is, what are the meanings of a life, the purposes to which one puts that life? In other words, the meaning of a life, its target or goal, would be viewed as a changeable and changing thing, not just different from one individual to another as the existentialists suggest, but different depending upon the moment that the question is asked of any single life. It might be one thing when you are 15 and quite another when you are 50, still another at 75.

But first let us consider very briefly the answers to the original question, what is the meaning of life? One could go on at length about the various “isms: hedonism, stoicism, and so forth. I will not do this. Others know more about them and have already discussed them at great length. Still, one must give a nod in the direction of the meaning of life being the simple biological fact of procreation, continuing the human race. The religious might argue that the will of God for each individual as the meaning for that particular person, along with doing honor to God’s law. Then there are those who believe that life is intended to increase one’s understanding and knowledge, or to have the maximal amount of pleasure, or to perfect oneself by fulfilling your innate talents and capacities, or to make the world a better place than you found it, or quite simply to love in a deep and abiding fashion.

But, my current thought is that there is no single meaning for all persons, but changing meanings as we grow up and age. Early-on, the meaning of our lives is perhaps to be found in discovering what we can do, who we are, and mastering the extraordinary number of things any little person has to learn just to get out the door and off to school. Not far into the process one must determine how to relate to people, how to honor yourself without disrespecting others, figuring out where you stand in the pecking order of athletic, intellectual, and social competition. Discovering one’s vocation must be on the list, since most of us take so much meaning from what we do for a living, be it as a captain of industry, a scholar, a salesperson, or parent. All the better if what we do for a living provides a sense of fulfillment, creativity, acknowledgment, accomplishment, and growth.

Meaning is to be found in a life-partner too, in love, in family, in raising a child, and in risking your heart. And over time, friendships, especially if they are life-long, have great value and define us as people and as members of a tiny group of two or more friends or part of a community, pulling-together to do something worthwhile.

In war-time, loyalty, comradeship, and courage take special meaning; even to the point that, a few years before World War II, the Japanese government proclaimed loyalty as essential to the national morality. And, in the war itself, the idea of behaving honorably in the face of certain death, never allowing himself to be captured, guided the Japanese soldier and gave meaning to his service. Emperor, country, and comrades counted for a lot; even the importance of family sometimes diminished in the heat of battle, by comparison, when it was necessary to steel one self against the terror of combat.

Under less severe circumstances, learning is something that gives purpose as we work to understand ourselves and the human condition, as well as particular things about the world. Later on in life, for many people comes a certain generosity of spirit, a desire to help those who are coming after us, to lend a hand. And the shortness of time contributes to intensity of feeling, making the beauty of the earth, a smile, a song, an act of kindness, or an embrace all the more touching because we know that before too long, the sweetness of life will no longer be ours to savor.

Having taken all this time on the question I’ve raised, I think there is danger in spending too much time on trying to answer the question, “What is the meaning of life? If one has learned anything from life itself, it is that the time is precious and waiting in contemplation for a revelation of what we should do risks squandering the time we have. But most of us are comforted by a sense of direction, and one should try to determine what is of value, and to conform one’s behavior to what is important and worthy of effort and time. Indeed, mindfulness and commitment-based psychotherapies work very hard to encourage the person to become detached from things that are not important, and instead to focus him on his values and how to “live” them.

There is worth, then, in simply knowing that the clock is ticking and that the day is short; but only if that knowledge creates a sense of urgency in you and the desire to make the most of the time.

As John Donne wrote so long ago:

“Therefore, send not to know

For whom the bell tolls,

It tolls for thee.”

September 20, 2009

To Wait, or to Wait: That is the Question

http://upload.wikimedia.org/wikipedia/commons/thumb/a/a7/Hesitation.jpg/256px-Hesitation.jpg

I was taught a valuable lesson by a bunch of inner-city kids when I was their 20-year-old summer camp counselor. The lesson was about when and whether to take action; and when and whether to do nothing and wait. But let me tell you the story…

The job was in Cambridge, Massachusetts, the home of Harvard and MIT. Although I was attending the U of Illinois, my friend Rich Adelstein was then involved in something called the “MIT Science Camp.” I never really found out what science had to do with it, because it wasn’t much different from any other summer camp, but for a few things having nothing to do with science. First, of course, it was at MIT, one of the world’s premier institutions of higher learning; a place where only the elite young minds already proficient in science were allowed to matriculate. And because of that, it was not an “outdoor” oriented summer camp, although we did do the usual things like playing baseball. But perhaps the most important distinction between this summer camp and most of those you might have heard about or attended, was the fact that it was for underprivileged kids from troubled homes and tough neighborhoods. Most of them were in the 12 to 15-year-old range. Some were shy, some were petty criminals, some were learning disabled, some were angry, and some were lost. But, it was thought that all of them might still benefit from the camp experience.

The counselors were all about my age, and all of them were MIT undergraduates with two exceptions: myself and a Harvard student. The kids were recommended by their schools. The project was funded by money then available as part of the “Great Society” vision of LBJ, otherwise known as President Lyndon Baines Johnson. The camp itself was supervised by a psychiatrist, Dr. Warren Brody. The year was 1967.

Many of the activities of my group of six kids were done in cooperation with another counselor, Geoff Smith. Geoff was a swell fellow, smart and easy to get along with, and we worked well together. We had money for some outings with the boys (all the kids in the camp were male) and even took them on a day trip to Martha’s Vineyard and another excursion to New York City, where we watched the Rockettes in Radio City Music Hall at Rockefeller Center. As I said, we played some baseball and also put on a play under the direction of a Boston College undergraduate theater major, Betty Rose. It was “Twelve Angry Men.” We had just enough players, and these kids were thereby exposed to performance. A fun summer was had by all.

On the day in question Geoff had a morning dentist appointment, so I was in charge of both of our groups. Depending on the day, not all the kids would necessarily be there. I imagine on this particular day, there were probably 10 of them present.

I was walking with the kids through Building 7 when one of the older ones quickly instructed the others to run in different directions. We had come to a four-way intersection, so there were four possible flight paths down which each kid could escape. In a flash they were gone. As I stood at the intersection and looked in each direction not one was to be seen.

Remember, I was 20 years old and in charge of these lives. Their safety was my responsibility. But what was I to do? Even though I was rattled, I was still smart enough to know that any direction I chose would, at best, avail me the possibility of finding only two or three or four kids. For the life of me, I didn’t know what to do, so I did nothing. Not because I thought that was a clever idea, but because I couldn’t think of any good solution.

Perhaps you’ve guessed that I had stumbled upon precisely the right course: inaction. In fact, it was the only solution. If I had started running down any one of the corridors, I’d probably still be running. But because I didn’t, the kids found that the “chase” they’d hoped for hadn’t materialized, and they weren’t having any fun. In the space of 10 minutes they were all back where they started and we proceeded on to our appointed destination.

Sometimes life is like that. If you stop chasing a thing or a person, it stops running away from you. You can drive people away in your pursuit, be it romantic or angry.

Slow down. Be patient. See if you can live with uncertainty. Don’t act impulsively. Wait, wait, wait and see… Take a breath. Action for the sake of action doesn’t make sense. You can actually make things worse. Assertiveness is not always the answer. Sometimes inaction is better — much better — than action.

A lot of things in life, like those kids, are like boomerangs — they come back to you.

At least, they sometimes have for me.

—

The top image is called Hesitation by Alfred Garth Jones, sourced from Wikimedia Commons.

September 17, 2009

What Children Need From Parents: Part I

A 15-year-old treated by me many years ago is a good example of one of the things that parents need to provide their children.

I’ll call him Ike (not his real name), a slender, silly kid with sandy hair. His family was middle class, hard working, and honest. Unfortunately, Ike lacked the latter two qualities. He was a minor league juvenile delinquent, prone to shop lifting, cutting classes, curfew violations, and occasional drug use. Ike was a poor student thanks to a lack of effort,  an Attention Deficit Hyperactivity Disorder condition that featured notable impulsivity, and the unfortunate fact that he wasn’t very bright. This teenager treated school as  diversion from his major life tasks of having fun and causing trouble. He rarely thought of the long term consequences of his behavior, instead choosing to do whatever felt right in the moment and whatever action seemed likely to produce some immediate payoff, the future be damned. Outpatient therapy had failed to make a dent in any of this, so his parents ultimately brought him in for whatever a psychiatric hospital could do to redirect Ike’s life and get some control over things.

Years ago it was often possible to keep a teenager in the hospital for several weeks or months if he needed it. Insurance policies were different and more generous then. And so, given the total control over someone’s life that a psychiatric adolescent treatment unit provided, you could produce changes in some very rebellious, out of control kids. Ike was like that. Eventually he figured out that the only way to get out of the hospital was to conform his behavior to the required standard.

While his parents participated in family therapy during his hospital stay, they remained uncomfortable with the job of setting limits on Ike. Neither one was very secure or self-confident and Ike fueled that insecurity by his behavior. Both parents were prone to feeling guilty when they punished him because of their own unresolved childhood issues, and Ike knew how to “play” them and get them to back off of threats and attempted punishments. These adults needed their son’s approval and good will too much for his, and their, good. Ike was running the show before his hospitalization. He knew it, they knew it, and his “will” was stronger than their wills were. If he complained and pleaded long enough, one or the other parent would typically break down and give him what he wanted. Despite the fact that family therapy hadn’t succeeded with the parents, Ike ultimately behaved himself in the hospital and had to be discharged even if his parents didn’t seem to have a better handle on how to deal with him in the real world. So, I crossed my fingers and hoped for the best.

As often happens after an adolescent is discharged from a psychiatric hospital, Ike and his folks went through a honeymoon period. But after a couple of months, he resumed his misbehavior and things weren’t much different from the way they had been the moment that Ike had first stepped into the hospital. So it was on the first day of his second stint in confinement (yes, his parents took him back and readmitted him), that I recall having the following conversation with Ike:

GS: “So, Ike, how does it feel to know that you can pretty much do anything you want when you are at home? How does it feel to know that your parents really can’t control you?”

Ike: “Terrific!” (Said with a big smile).

Silence ensued. I was quiet and just sat there with Ike for perhaps 30 seconds. Then, Ike spoke again and surprised me.

Ike: “And scary.”

This was the truth of it. Even Ike, who was one of the least thoughtful and least self aware patients I’ve ever treated, realized that if he could get away with anything he wanted, that wasn’t a good thing. Even Ike knew that if he was driving the bus, the bus was in trouble. Even Ike knew that he needed someone to rein him in, to set a good example, to steer him in the right direction, and to prevent him from doing some of the things he would do impulsively, recklessly, and thoughtlessly.

What then do children need? Parents with the will power, strength, consistency, motivation, intelligence, resilience, and the self confidence to set and stick to limits, take charge, and make sure that the combination of a child’s poor judgment and impulsive or rebellious behavior doesn’t rule the day. Ike was the problem, but without his parents getting a grip on their own lives and finding the strength and confidence to assume the proper role in the home, Ike wasn’t going to get better any time soon. And even though Ike would have and did resist a more assertive, consistent, and confident approach from his parents, he knew that he needed it.

Some children are easy, some more challenging for parents. It is our job in the latter role to figure out what each of our children need and provide it. Not all children are the same and not all of our children need an identical approach from us. Ike would continue to misbehave until his parents figured this out.

The strength that I’m talking about isn’t the only thing that children need from parents, and from time to time I’ll write about some of the other requirements. The good news is that if Ike, at age 15, was able to figure out what he needed, nearly all adults can too. From that point on, good things are possible.

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.

August 30, 2009

What To Do When Therapy Doesn’t Help

http://upload.wikimedia.org/wikipedia/commons/0/06/Rote_Frau.jpg

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

There are several possibilities:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You will be glad you did.

—

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

August 16, 2009

The Problems with On-Line Therapy

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

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

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

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

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

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

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

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

August 6, 2009

Social Anxiety Disorder and Its Treatment

http://upload.wikimedia.org/wikipedia/commons/4/43/VER_model.gif

Social anxiety isn’t unusual. Since you are reading this, you might well be wondering whether your own experience of anxiety (or that of someone you love) constitutes a Social Anxiety Disorder.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), such a condition exists when someone experiences a “marked and persistent fear of one or more social and performances situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The person fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.”

The essence of this condition is a preoccupation with what others might think of you.

Now, we all are concerned with this some of the time.

Think of hoping to get a job promotion or wanting to impress a potential romantic partner. But consider the language of the diagnostic manual carefully, especially the words “marked and persistent fear.” One hallmark of this disorder is avoidance. When the anxiety is so great that you do your best to get out of doing something (e.g. asking someone on a date, giving a speech, attending a party, returning an item to the store, etc.) then you very well may have a clinically significant condition that can benefit from treatment. In effect, you are trying to avoid both the uncomfortable situation and the feelings that you believe will come with it.

In addition to avoidance, the individual will commonly be aware that his fear is greater than that which would be experienced by most people in a similar set of circumstances, and that the condition is very distressing and/or interferes with his life in significant ways. In fact, one of the ways that Social Anxiety Disorder complicates one’s life is by making it difficult to do the things and have the relationships that would make that life interesting, enjoyable, and fulfilling.

Is it hard to take a compliment, be the center of attention, or talk to a stranger? Do you worry what others will think of how you look and sound? Is it hard to be spontaneous in a conversation and are you too distracted by your own worries to fully concentrate on what the other person is saying? Do you get tongue-tied when trying to make an impression or have the sense that your voice is quivering or that you are perspiring too much?

Do you hesitate to state a strong opinion for fear of sounding stupid or being rejected for your ideas? Do you try to prevent others from getting to know you very well because you believe they will eventually conclude that you are inadequate and reject you? These kinds of preoccupations are typical of Social Anxiety Disorder.

The good news is that with persistence, an accomplished therapist, and the right program of treatment, you have an excellent chance of significant improvement. On the order of 80% of those who receive a systematic cognitive-behavioral (CBT) program will likely experience such change.

A good CBT counselor first makes sure that social anxiety is your major problem. For example, its not unusual for people with a Social Anxiety Disorder to have had one or more panic attacks. If those episodes occur outside of social or performance situations and lead the person to focus on their physical health, they likely indicate that a Panic Disorder is present and that the panic itself should be the focus of treatment.

However, about 50% of people who have clinically significant social anxiety also have had panic attacks. Therefore, if your preoccupation is more about how you look to others and what they think of you than it is about the symptoms of panic, treatment is likely to target your social issues.

CBT assumes that bodily sensations (such as shakiness, blushing, or a lump in your throat), behavior (such as having difficulty making eye contact or avoidance), and thoughts (such as the belief that others will reject you or that you will lose your job) all interact to fuel your social anxiety problems.

Thus, for example, the more your thoughts focus on the belief that you need to be perfect or the likelihood that you will fail, the more you are likely to experience physical manifestations of your anxiety and behave in a way that betrays your insecurity. As a result, CBT attempts to help you change physical symptoms, behavior, and cognitions.

A good cognitive behavior therapy program for social anxiety will help you learn to counter irrational thoughts that tend to be self defeating (this is called cognitive restructuring), and gradually practice with the therapist (this is called role playing) those situations that are difficult for you, beginning only with those that produce a relatively small amount of anxiety, and then try out your new skills in the real world, again beginning with relatively easy kinds of social interactions and working toward the ones that are harder for you.

And, you will discover that if you can tolerate small amounts of anxiety rather than flee them, you will “habituate” to the anxiety in much they way that your nose adapts to a foul odor by adjusting so that after a short amount of time the smell is not nearly so strong; similarly, your anxiety will weaken if you stay in the uncomfortable situation, usually within 45 minutes.

Treatment typically takes somewhere in the neighborhood of three to four months, although it can take longer if other issues also need attention. When it is successful, the patient usually finds himself less troubled by physical symptoms, more assertive, less preoccupied with other people’s opinions, more optimistic, less awkward, able to receive compliments without discomfort, able to look people in the eyes, and less avoidant.

It can feel enormously freeing and lead to much better things in life, including more and better friendships, greater vocational success, and a more satisfying romantic life.

Persistence is essential and the program takes some courage. But if you want to change your life and be less encumbered by social anxiety, CBT for Social Anxiety Disorder has much to offer.

—

The image above is described as Template: VER model created by Braintest. It is sourced from Wikimedia Commons.