therapy

November 29, 2009

The Things We All Need to Learn

The things we need to learn wait for us. They are very patient.

I think you know what I mean. At least, you have seen it in others: the angry person who never learns how to control his anger or perhaps isn’t even aware of the need to control it.

Then there is the passive person, who cannot stand up for himself easily, defers to others, and gets taken advantage of pretty routinely. And, despite this, it hasn’t changed over the years.

Some of us choose the wrong friends, lovers, or business associates, making the same mistakes repeatedly. Others continue to use failed methods in raising children. Some of us never face our fears fully (see Albert Brook’s film Defending Your Life for a funny take on this problem). And then there are the people who are impulsive and act without thinking, over and over; or the ones who are sloppy at tasks, not careful enough; or those who are too compulsive, too detail-oriented, trapped by their obsessive attention to small things.

I could go on, but instead, it’s time to ask you a question. What challenges in your life have you yet to master, the ways of thinking or behaving that don’t work for you but which you repeat? Most of us have a pretty easy time spotting the errors in others, but how about your own?

There is an old joke about how we learn:

A man walks down a road and falls into a hole. He doesn’t see it, and it takes some time to get out because it is deep.

The next day, the man walks down the same road and falls into the same hole. He still doesn’t see it, but he might just get out of it more rapidly this time.

The day after, the man walks down the same road, sees the hole, and falls into it anyway.

The following morning, the man walks down the same road, sees the hole, and this time walks around it.

And what does our hero do after the next sunrise? He walks down a different road.

Holes, like unsolved problems, have all the time in the world. They wait for us to recognize them, see the danger they pose, and change our behavior to avoid the danger. As the saying goes, “If you do what you’ve done, you’ll get what you’ve got.” Others have said that one definition of insanity is continuing to use the same failed strategy, all the while expecting different and better results.

How long will you wait to change? Your problems can last a lifetime. They have no train to catch or meetings to attend; they take their time, not troubled by waiting. Or, should I say, they take your time. All of your time.

Do you really want to wait that long?

November 19, 2009

Self-Defeating Behavior and the Path to Loneliness

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

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

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

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

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

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

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

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

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

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

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

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

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

—

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

November 11, 2009

An Inside Story on (Mental) Health Insurance Reform

There is much misinformation and misunderstanding about the workings of the health care system. Here are a few observations on how things work from the perspective of someone who is a practicing clinical psychologist with experience both inside and outside of hospitals:

1. The Doctor/Patient Relationship. In the days before managed care, doctors and patients really did make decisions without too much interference from insurance companies and the government. While insurance companies set some limits on what they would pay out (maximum benefits for mental health services were usually expressed in dollar amounts) and would pay no more than what they deemed “reasonable and customary” fees for each “service,” they did not typically require that practitioners obtain “pre-certification” (pre-authorization) of those same services. So, if you and your therapist thought you needed the treatment that he was offering, the insurance company let you obtain that care and supported it by paying in accord with the insurance contract that you held directly with them, or, more likely, held through your employer.

Managed care caused several changes. First, it required “pre-certification” for many forms of treatment, thus explaining the “managed” nature of the care. That meant that the practitioner (or a member of his staff) had to fill-out forms that explained the nature of your condition, provide a treatment plan, and justify the type of treatment that he hoped to provide.  Depending on the insurance company, sometimes pre-certification required a phone call with the insurance company’s “gate-keeper” to discuss the information just mentioned. And, depending on the length of treatment or changes in the patient’s condition, this process would be repeated so long as you were in the care of the therapist in question.

It is important to understand that the relationship between the doctor and the insurance company was (and is), at least to some degree, antagonistic. If the therapist is unfettered by the restraint of the managed care arm of the insurance company, he stands to get paid by them for as much treatment as he prescribes and the patient consents to receive. On the other hand, to the extent that the insurance company can limit or say “no” to the doctor’s plan, the company gets to keep more of the money paid to them in insurance premiums. Both sides will maintain that they only work in the patient’s best interests, but it should be easy to see the slippery slope that both parties are on, a slope called “financial self-interest.”

Another change was the establishment of panels of “providers.” The “docs” knew they were in trouble when they began being called providers, a business-type of term, rather than doctors (which would include anyone with a Ph.D. or an M.D. or a D.O or a D.D.S) or therapists or social workers. Some providers agreed to accept discounted fees (saving the insurance companies and patients some money) in return for having patients steered in their direction. Usually, the insurance companies would then give patients encouragement to use practitioners on their list of such “preferred providers,” and better insurance coverage when they consulted those individuals, rather than doctors who were “out-of–network.”

HMOs (Health Maintenance Organizations) worked a bit differently. The care was usually even more strictly managed. There were fewer doctors and hospitals from which to choose, and typically smaller co-payments (the amount the patient paid out-of-pocket to the healer). Even more services were managed and required a referral from the patient’s “primary care physician.” Depending on the nature of the contract between the doctor and the HMO, he or his medical practice might lose money to the extent that he authorized too many referrals and too much treatment. This was clearly another step in the conflict between getting treatment and the ability of the insurance company (and sometimes the docs) to make money.

At present, there are relatively few insurance policies (very, very expensive ones) that don’t attempt to limit your choice of doctors or hospitals, or manage your care in some fashion. So, when you hear some politicians say that they don’t want the government to interfere with the doctor/patient relationship, be aware that your insurance company almost certainly already does that.

Negotiated Fees for Services. I’m always amused when the press, insurance companies or politicians refer to the “fact” of doctors and insurance companies “negotiating” fees for the healer’s services. Understand that doctors have virtually no leverage in these situations. If they wish to participate in “preferred provider” panels in the hope of obtaining more patients, they are typically given a fee schedule as part of the contract that they are offered. Large institutions may have some leverage (hospitals or very, very large practices), but solo practitioners and small practices, which make up most of the providers you would routinely consult, are pretty much told to “take it or leave it” in terms of the contractual conditions and the fee schedule by which they will be compensated. Again, if politicians tell you that they are defending the rights of doctors to negotiate such fees, I’m not exactly sure who they have in mind. Most of the psychologists, psychiatrists, and social workers I know must choose either to take what the insurance company or PPO (Preferred Provider Organization) offers, or to be “out-of-network.” As an out-of-network professional, you can set your own fees, but don’t benefit from the PPO or insurance company’s efforts to send you patients.

Parenthetically, it should be noted that few if any of the healing professionals I know got into this work for the purpose of making tons of money. Indeed, most of us didn’t think much about the business-side of our work when we chose to pursue our vocation. As you doubtless have already concluded, the business-end can’t be ignored easily.

Covered Services and Pre-Existing Conditions. Insurance companies aren’t all alike. Some have larger provider panels, some cover more services, etc. Depending on your policy, psychological testing, neuropsychological testing, individual psychotherapy, family psychotherapy, alcohol/drug treatment, and marital therapy, might or might not be covered. Indeed, some insurance policies do not cover mental health services at all.

Pre-existing conditions are those from which you suffered prior to the start-date of your insurance contract. If your insurance company excludes pre-existing conditions, it usually does so in one of two ways. It can have a waiting period (perhaps one year) before it will cover you for treatment of that condition. On the other hand, some contracts require that you have not been treated for the condition for a specified period (again, perhaps one year) before they will pay for treatment; this is based on the assumption that if you have not had treatment in that time, any future therapy will probably not be for precisely the same condition.

You should be aware that when you submit an insurance claim, or ask your doctor to do so, you have now been marked down in a sort of “permanent record” kept by the insurance industry. Whenever you apply for insurance on an individual basis, you are routinely asked to sign a waiver that allows the insurance company in question to consult your life history of insurance claims and your past medical records. If they find something that is not to their liking (meaning that it causes them to believe that you are a bad risk), they may deny you coverage either for the particular condition in question or simply refuse to issue you an insurance policy. This can apply not only to health insurance (the topic I’ve been talking about until now), but also disability and life insurance. As a consequence, some people (if they are able) prefer to pay for certain types of health care out of their own pocket, rather than creating a record of illness that might be used against them by insurance companies at a later time.

Needless to say, one of the most consumer-friendly features in the health care legislation just passed by the House of Representatives is the prohibition of pre-existing condition exclusions. The Republican alternative does not have such a provision.

The Efficiency of the Private Sector. My office manager could give you an ear-full about the difficulties that she has in getting insurance companies to do what they are contracted to do; that is, pay bills promptly and correctly. The number of “lost” claims that require resubmission, delayed payments, and incorrectly paid claims give the lie to the notion, at least among the mental health professionals who I know, that the private sector is to  be preferred in this arena to the performance of Medicare. Of course, some companies actually are quite efficient, while others are frank disasters.

Mandatory Insurance and the Idea of a National Health Insurance or “The Public Option.” In order to get a sense of how a mandatory health insurance program might work, it is useful to look at how a similar approach has fared for automobile insurance. Virtually every state in the union requires that drivers have auto insurance. There are reportedly a number of problems that have occurred with this. First, stipulating that there is a requirement doesn’t necessarily get people to buy car insurance–you need an enforcement mechanism to make certain that they follow the law. I’ve heard stories of people who didn’t have insurance and were brought to court after an accident without being required to pay the expected penalty, but instead were ordered to buy a policy and return to court with it. Doubtless, having done this, those folks might then cancel the policy, especially if they couldn’t really afford it. The expense of creating a data base and monitoring all drivers to determine whether they have current auto insurance is costly and perhaps inefficient, since most people who can afford it will probably buy it on their own without threatened penalties. Some states have chosen to attempt to single out “high risk” drivers for particular scrutiny and oversight, presumably at reduced costs.

Almost certainly, some of the same complications would be present in any national health insurance program. Without going into all the arguments for and against, it should at least be noted that we already have a form of national health insurance. Its called Medicare, and the people who have it apparently like it quite well; but it does cost a fortune and creates an enormous weight on the generations who will have to continue to pay for it.

Thus, the moral and practical dilemma: providing coverage for people who need it (before Medicare, for example, it wasn’t unusual for the elderly to live in poverty, having been wiped out by medical bills) vs. the cost of such a program in dependency and dollars.

I hope that I’ve offered at least a little bit of useful information.  Here is hoping that you will, if needed, learn more and weigh-in with your Congressman or Senator; decisions with far-reaching consequences are being made right now.

November 6, 2009

On the Fort Hood Tragedy

What happened at Fort Hood? Why would a psychiatrist, a physician trained in the treatment of “mental and nervous” disorders, go on a rampage against his own comrades? I suspect we will be reading about the following in the days ahead:

1. Did Major Nidal Malik Hasan, the accused murderer, have proper supervision of his work and his own fitness for duty? Did he suffer from a psychiatric disorder of his own and was he being treated? News accounts suggest that he was terrified in anticipation of an expected deployment to Iraq or Afghanistan.

2. To what extent did he feel marginalized within the Armed Services? He is said to be a man born in the USA, the son of immigrant parents. It is also reported that he had become increasingly devoted to his Muslim faith and might have experienced some harassment from other soldiers because of his religion.

3. Was the Major marginalized in other ways? He is described as a 39-year-old bachelor who had been looking unsuccessfully for a mate.

4. Major Hasan is believed to have treated numerous veterans suffering from PTSD (Post Traumatic Stress Disorder) returning from the Middle East. Is it possible that he suffered a form of vicarious trauma from hearing the disturbing, if not tragic stories of these young people?

5. To what degree have the Armed Services been able to reform an organizational culture that discourages soldiers from showing emotional vulnerability and seeking treatment before they become dysfunctional? It is one thing for the returning wounded veterans to get psychiatric services; it is another for them to believe, early on, that their anxiety, worry, and depression will not be seen as a weakness by their comrades, make it harder to perform their duties in war-time, and cause them to be ridiculed? Did Major Hasan, who apparently had not experienced combat himself, believe that his own inner-turmoil was acceptable and would have received support from his superiors?

6. Did Dr. Hasan have a history of having received treatment prior to his entrance into the military? If Dr. Hasan did seek treatment at any time, what was the result? Is their any routine assessment of the psychological status of both the soldiers and those who are given the task of treating them? Does the military realize that the nature of their work puts virtually all personnel at psychological risk?

7. What security procedures exist in military installations such as Fort Hood?

8. Is the military sensitive to cultural conflicts that are experienced by its uniformed personnel?

Most of us assume that mental health professionals have their own personal lives well under control. Unfortunately, such is not always the case. For more on this subject, please read my recent blog: “When Helping Hurts: Therapists Who Need Therapy.”

October 8, 2009

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

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

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

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

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

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

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

 

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 20, 2009

To Wait, or to Wait: That is the Question

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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 16, 2009

What Should be the Last Word on the Question of Civility and Rudeness?

Memo to Kanye West, Serena Williams, and Representative Joe “You Lie” Wilson:

If you do not wish to be treated offensively, do not give offense.

In other words, live by the Golden Rule.

September 13, 2009

Therapy, Responsibility, and the Nuremberg Defense

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

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

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

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

But therapy cannot end there.

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

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

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

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

“Men at some time are masters of their fates:

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

But in ourselves, that we are underlings.”

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