therapy

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 13, 2009

“The Only Thing We Have to Fear is…”

Franklin D. Roosevelt’s 1933 inaugural address, given in the terrifying midst of the Great Depression, is quite well-known for the line: “The only thing we have to fear is, fear itself.” With 25% of the work force unemployed, there was much of which to be afraid.

Less well known, but no less eloquent and telling a comment on fear came from his widow, Eleanor Roosevelt, when she was asked late in her life to give a radio audience some guidance based on her own life experience. Recall that Mrs. Roosevelt was a timid, unattractive, and lonely child, afraid of many things; left by her widowed father to be raised largely by her severe grandmother. She eventually became world famous, not only because of her husband, but because she became a champion of the rights of disadvantaged groups and a spokesperson for the United States. Eleanor Roosevelt was a public woman known for her actions and her voice when most women stood in the shadow of a husband.

The quote? “You must do the thing you think you cannot do.”

Good advice for just about everybody.

August 9, 2009

A Few Relationship and Dating Tips

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What can one add to the guidance that people are always looking for in finding a mate? Here are a few things you might not have considered:

1. Don’t ignore all the little things. People often betray important disqualifying characteristics early in a relationship. In the heat of the sexual attraction moment, we might want to ignore those things that appear to be small problems. Does your new friend call when he says he will call? Does he show up on time? Is he really listening when you are talking? You might be able to forgive such failures now, but they can signal problems that will appear larger later on.

2. Are you attracted only to “bad boys;” or to women more concerned about how every inch of them looks in the mirror than to take the time to look at you? If so, you’d better ask yourself “why?” If you keep having bad relationships, perhaps it’s because of some of the people you are choosing to partner with. In that case, reflection on your decision-making process is in order.

3. Get past the small talk. Do you want to know someone well? You will have to ask them about more than their opinion of Michael Jackson’s death and the Cubs’ chance of getting to the World Series.

What things might you ask? If your date represents a good opportunity for a lasting and satisfying relationship, eventually you will need to know about his politics and religion, how he handles money and debt, whether he has made good decisions in life, and his capacity for emotional intimacy and openness; does he hold onto old friends and how does he treat them? How does this person deal with frustration, disappointment, and anger? Is he charitable and forgiving?

How does your companion explain past relationship failures? Can he be appropriately assertive? Is he too dependent on you and others? What are his relationships with parents and siblings like? How was he raised? Is his humor too often at your expense or the expense of someone else, perhaps including himself? You don’t have to know about these things right away, but you do need to know about them before your heart starts running the show and leaves your head behind.

4. Don’t expect your date to make you happy. You are looking for a partner and not a caretaker or parent (I hope). Don’t look for someone to make up for past injustices and misfortunes. Don’t expect him to shoulder most of the burden of bringing home the bacon (or rearing the children) alone. Don’t encourage him to make most of the important decisions for you or to expect you to make those decisions on your own.

5. Since most of you reading this are probably relatively young, its important to realize that people change. The person you are with today is not going to be the same in 10 or 20 years or longer. (It would be troubling if he is unchanged by the passage of time. Surely, in 10 years or more one should learn something new from the experiences of life).

There is an old saying that men expect their wives never to change, while women expect that they will change their husbands. If you subscribe to this theory, you are in for trouble. People change physically, and should grow in experience, knowledge, self-awareness, and compassion, but don’t always transform for the better or in a way that is compatible with the alterations that you will make yourself. Does the hot young person sitting across the table from you right now have the ability to grow and to adapt to your own growth? While you can’t know for sure, it would behoove you to have some opinion on the subject.

6. How much self-awareness does your date have? Does he understand what he does and why he does it? Does he know (or care) about how others perceive him and when (and why) he injures someone else? Can he look into the mirror and see himself for who he really is, not for who he might want to believe that he is?

7. Recognize that you are not going to change your new partner. People don’t change because others want them to, they change because they have come to recognize that their behavior isn’t working for them and the cost of continuing in the same way is too high. If you think the relationship will only work if your new love can be altered, think again.

8. How much of a role, if any, do alcohol and drugs have in your life and that of your romantic partner? People tend to minimize or deny the extent to which substance abuse is present. This is especially likely to be true if you come from a family where this kind of behavior was routine. Alcohol, for example, tends to fuel arguments as well as depression.

9. Recognize that the honeymoon always ends. The nature of new love is to see the other in an idealized state. Your friend’s self presentation, attentiveness, and kindness are not likely to increase over time. The flame of sexual intensity will not always burn so bright. Something more will need to be present for the relationship to continue to be satisfying.

10. What do your friends really think about your current romance? Sometimes they can see things that you can’t.

11. Are you looking for someone stronger than you are? Or are you looking for someone docile who won’t challenge you, but simply be devoted and doting? In either case you are almost certain to be in for trouble. Relationships based on this sort of inequity typically become fractious and unsatisfying for both partners. They can transform into hostile dependencies, where the strong, dominating partner feels unappreciated, and the yielding, self-effacing individual morphs into someone who is aggrieved and simmering, or shuts down.

12. Are you insecure? Can you bear to be without a girlfriend or boyfriend for very long? Do you need regular reassurance that you are “the one and only?” This gets old quickly. While that reassurance will temporarily calm your fears, your friend will almost surely tire of it, leaving you less secure if you don’t ask again for a sign of his devotion, and him feeling put-upon if you do.

As with a number of the concerns mentioned above, therapy is suggested if your self-worth requires the presence of an escort; along with constant bolstering and a tendency to lose yourself, forget about your friends, and give-in to your new love for fear that he will otherwise leave you.

13. Are you still in love with someone else? Is your new date on the rebound himself? The presence of strong feelings which are still attached to someone else can complicate your new relationship. You are discouraged from entering into a “rebound romance” for good reasons.

14. Do your values match up well with the your potential love? Do you share the same vision of life, the same goals; the same stance toward integrity, devotion, loyalty, work, and children? Not just in what you say, but in what you do.

15. Do you tend to be drawn to partners who are much younger or much older than you are? In the former case, this can suggest the need to dominate the less experienced partner or simply to be looking for good looks rather than something more lasting. In the latter instance, its possible that you might be unconsciously trying to find a parent figure or someone to rely on and take care of you. In either case, some honest self-reflection regarding this pattern is worth your attention.

16. If commitment is what you want, beware of the man or woman who says that he or she is not ready for a serious or long-term relationship . To date someone like this is rather like buying a shiny, dashing new car that will start to fall apart after six months.

17. Watch out when you hear yourself thinking that, although you can see that there are problems in your burgeoning twosome, you will stay a while to see if things get better since you aren’t (yet) risking a broken heart. Often your heart leaps ahead in situations like this and you discover that you are in love with the wrong person only too late.

18. Take your time! You might hear the clock ticking on the days of your life (or your life since your last relationship), not to mention the time left on your fertility, but rushing things out of desperation will prevent you from making the best possible choice. Remember, the point of this is not only to win the affection of the other individual, but to determine whether he is worth the winning!

—

The top photo is an Austrian Road Sign photographed by Pirosko. The second image is described as a “short animated gif with 2D-boy.” Both are sourced from Wikimedia Commons.

August 6, 2009

Social Anxiety Disorder and Its Treatment

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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.

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

July 30, 2009

After Life

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The subject of religion is a dangerous one. Many people have strong opinions for and against. It makes little sense to trying to persuade someone that God does exist, or that he/she doesn’t.

At the risk of offending you, I’m going to offer a few random thoughts on the subject, with particular focus on the question of whether there is a life after death and what it might consist of. I don’t claim to be strongly attached to all of these thoughts, but I do find them interesting; you might as well. If, however, you are 100% certain of the validity of your own opinions (or that of your faith or lack of faith), I’d suggest that you don’t read further.

So, if you are still with me…

When I was a kid, an athlete who hit a home run or scored a touchdown generally didn’t make an enormous deal of it. Today athletes are much more demonstrative, not a bad thing in itself. However, a good number of them point to the sky, presumably to heaven, to give thanks. In some cases it represents the same “Gott mit uns” attitude, an essentially tribal view, that some countries adopt in and out of war-time: “God on our side.” In other cases, the jocks state that they are giving thanks simply for the good health and ability that they believe they have been given by God. Well, first of all, I sure hope God has better things to do than to side with one team or another. But there is actually a pretty funny story about this, in W. P. Kinsella’s collection of short stories, The Thrill of the Grass. The story is called The Last Pennant Before Armageddon and its about the Cubs winning the pennant.

—

On the subject of heaven, it seems that we all want to go there, but we don’t have a really clear idea about what it consists of. Many references are made to deceased loved ones looking down on us and looking after us from beyond the grave. But think about that for a moment. What if heaven does consist of people who do care, and care a lot, about what is going on back on this mortal coil? How can they be living in never-ending happiness? Seeing all the unhappiness, the accidents, injuries, and disappointments of life is heartbreaking and tough enough when you live here. To think that the dead are suffering with us from afar doesn’t sound like my idea of a better world.

On the other hand, let’s assume for the moment that “the dead don’t care,” a refrain in Thomas Lynch’s book Undertakings. (Lynch is both a published poet and a professional undertaker, so he has a rather interesting vantage point on death). If our parents and loved ones no longer care about us (and assuming that they reside in heaven), they must be quite different creatures than they were on earth. And I can’t imagine the petty jealousies of life, the hunger, the (at least) occasional insomnia, the worry, and so forth, being the lot of those in any heaven worthy of the name. So, if people actually do go to such a place, I doubt that we would quite recognize them as being very much like they were on earth. And, frankly, one would be so transformed in transit to heaven as to have difficulty recognizing oneself.

—

A number of people commented on how the recent death of Farrah Fawcett was overshadowed by the death of Michael Jackson. A few of my patients expressed the fact that they felt sorry for Farrah that the media didn’t attend more to her passing. It is a touching sentiment. But, if Thomas Lynch is correct, Farrah wasn’t bothered by it.

—

I recommend that you watch a Japanese movie of several years ago, After Life. It depicts a group of recently deceased people who assemble at a sort of transit station on the way to whatever is beyond. They are told that they will have several days to decide on their own version of eternity, which will consist of living forever in whatever single moment they choose from their just-ended life history on earth. They are each assigned a counselor of sorts, to assist them in the choosing process. To live “in the moment” necessitates that they give up that part of themselves that, like all humans, allows them to look back and remember the past, as well as to look forward and anticipate the future. Experiencing whatever large or small single event is most precious involves sensations and feelings attached only to that slice of time rather than to thought, analysis, worry, reflection, or concentration on other things, even including other positive relationships, experiences, and events. And so, perhaps not surprisingly, each person in the movie struggles with giving up all of their other memories, relationships, and daily preoccupations in return for an eternity of living within a single instant in time with a single focus.

To me, it sounds like a heaven worth wishing for, one that would really be wonderful, assuming one would choose a particularly joyous or exciting or touching instant of one’s life. And it raises an interesting question: what moment would you choose?

—

Do we fear death or dying? Just asking. Shakespeare’s Hamlet clearly worries about the afterlife not being so much fun. If you haven’t read his famous soliloquy in a while, the one that starts “To be or not to be…,” you might want to take a look at what thoughts about death ultimately stopped him from taking his own life:

To be, or not to be: that is the question:
Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them? To die: to sleep;
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to, ’tis a consummation
Devoutly to be wish’d. To die, to sleep;
To sleep: perchance to dream: ay, there’s the rub;
For in that sleep of death what dreams may come
When we have shuffled off this mortal coil,
Must give us pause: there’s the respect
That makes calamity of so long life;
For who would bear the whips and scorns of time,
The oppressor’s wrong, the proud man’s contumely,
The pangs of despised love, the law’s delay,
The insolence of office and the spurns
That patient merit of the unworthy takes,
When he himself might his quietus make
With a bare bodkin? who would fardels bear,
To grunt and sweat under a weary life,
But that the dread of something after death,
The undiscover’d country from whose bourn
No traveller returns, puzzles the will
And makes us rather bear those ills we have
Than fly to others that we know not of?
Thus conscience does make cowards of us all;
And thus the native hue of resolution
Is sicklied o’er with the pale cast of thought,
And enterprises of great pitch and moment
With this regard their currents turn awry,
And lose the name of action.

—

Another film on the subject of life and afterlife is called Defending Your Life. Albert Brooks and Meryl Streep star as two forty-something, recently deceased Yuppies who meet in the place you supposedly go after you die, Judgment City. There, you are subjected to a sort of tribunal where it is determined whether you learned enough and accomplished enough in your earthly existence to win you a place on the next higher level of existence, presumably something like heaven. Streep’s character was a brave, generous, and loving person in life, so there is no question that she will go on to the next level. For Brooks’s character, however, things aren’t looking too good. He never overcame his fear of a great many things on earth, so he might just get sent back, reincarnated without memory of his past, in the form of a new-born little boy. And, if this happens, the love affair that has begun in Judgment City between him and Streep’s character will end. I won’t spoil the rest of the film for you, but it is a very funny, entertaining, and wise movie about the need to learn and progress and grow throughout our lives, and to be brave in facing whatever is difficult for us.

And, who knows, maybe there is something like a Judgment City ahead for all of us.

—

The above image is Stratocululi. Source: German Wikipedia, original upload 3. September 2004 by de: Benutzer. Living Shadow. Courtesy of Wikimediacommons.

July 23, 2009

How to Choose a Therapist

Most of us are not at our best under pressure. Similarly, when depressed, anxious, or otherwise stressed and in crisis, the patience and clarity of thinking needed to choose a therapist might well be in short supply. So here are a few pointers, things to consider, when you decide to consult someone for psychological assistance:

1. Ask a friend if he or she can recommend a therapist with enthusiasm. Also, be sure to request that your acquaintance explain “how” the therapist was helpful. Not all counselors are equally adept at treating every problem, so your friend’s recommendation should be carefully considered in light of whether your issues are different from your friend’s. You might also ask your physician for a recommendation. A good way to phrase the question is, “If you needed to get a therapist for someone you loved, who would you choose?”

2. Internet searches of various kinds can help find a good person. Various organizations list therapists who perform a certain type of therapy or work with certain types of problems. An example would be the Association For Behavioral and Cognitive Therapies: www. abct.org/ The National Register of Health Care Providers in Psychology is another such group: http://www.nationalregister.org

3. Some information about the therapist is usually available on web sites such as those mentioned above. If the therapist has a web site of his own, you will usually find out a good deal more.

4. What kind of therapist are you looking for? There are many choices. Clinical Psychologists are doctoral-level professionals (Ph.D. or Psy.D) who typically have completed four years of training beyond their college Bachelors degree and had additional instruction and supervision in the form of a year-long internship, often within hospitals or clinics. In most states psychologists cannot prescribe medication, but have received more graduate training in psychological evaluation (testing) and therapy than is typical of any of the other disciplines who perform therapy.  Psychiatrists are physicians trained in medicine, who also receive specialized training during a psychiatric residency. They can and do prescribe medication and a number of them also do therapy. Clinical Social Workers generally have a Masters Degree obtained in the course of two years of post-college study, in addition to practical experience and a history of supervision. Marriage and Family Therapists usually also have a Masters Degree and may have a similar amount of training as do the social workers, although their education is not identical to that group. All of these disciplines encourage and sometimes require therapists to continue their study via post graduate course work, supervision, and reading.

4. What kind of therapy do you want? In part, that might depend on what kind of problem or problems you have. Psychodynamic psychotherapists will tend to pay much attention to early life issues including unresolved feelings toward one’s parents, and the potential impact of additional events that occur during the growing-up years in an attempt to free you from repetitive patterns of behavior that might have started at that time. Cognitive behavioral therapists use CBT to focus more on present day concerns, attempting to help you take steps to alter the automatic and self-defeating thoughts that influence your mood and fuel your depression and anxiety, as well as assisting you in changing your behavior. They spend much less time on early life events as a rule, and do not usually consider “insight” into the causes of your troubles to be crucial to assuaging your emotional pain. Marriage and family therapy aims to treat couples and family systems, usually meeting with the marital pair or family group rather than with one person at a time.

5. Try to determine how much experience your potential therapist has with a given kind of problem. Some therapists specialize, for example, in treating alcohol and drug abuse and are certified in this field (CADC or certified alcohol and drug counselor). If you have anxiety issues, on the other hand, ask your therapist how many people he has treated with this condition. Similar questions might be asked of someone who you wish to consult for the treatment of depression or schizophrenia. Don’t be afraid to ask. Any reasonable professional in the health care field will welcome your making an informed decision.

6. Other factors might be considered. How active do you want the therapist to be? Some tend to direct the therapy, while others are more comfortable listening to you and responding to just those issues that you believe are important. Some people choose therapists based on gender, believing that they will feel more comfortable with one or the other sex. Age of the therapist is important, since it tends to be correlated both with professional experience and life experience. If you believe that not everything in life is learned in a classroom, you will probably want to see someone who has a few gray hairs and who has been married with children.

7. Financial considerations often enter into the choice of a therapist. MDs are usually the most expensive people to see and Masters level professionals are the most economical. Ask your therapist about what he charges for his services and what portion, if any, of his fee is covered by insurance. Some communities have public mental health agencies that offer therapy at a heavily discounted price, although they often have long waiting-lists. A portion of therapists will discount their fees if you can make a good case for such a discount.

If you go through your insurance company, it is likely that they will steer you toward a practitioner who has a contract with them and has agreed to discount his fee to you. Understand, however, that the discount also typically benefits the insurance company, since they will have to pay less money in benefits if you choose a provider who is in their network. Therefore, their recommendation comes with a degree of self-interest.

Be aware that (as the old saying goes), sometimes “you get what you pay for.”

8. Some people choose not to use their medical insurance to pay for counseling. They make this decision because they have concerns about the impact of a mental health diagnosis on their future ability to get life or disability insurance, and the possibility that having a “pre-existing (mental health) condition” will complicate their medical coverage should they ever change jobs or go for a period without insurance and then attempt to obtain it again.

9. Remember that the most important element in obtaining a therapist is getting a person who is accomplished, talented, experienced, and a good fit for your therapeutic needs. You should also have a sense that he really cares and wants to help. While some of the other considerations mentioned previously might be important, if the therapist can’t help you, nothing else really matters. When you meet the therapist (see my blog post “What to Expect in Your First Therapy Session“) he should be able to convey expertise, compassion, and competence, as well as giving you a sense of hope. Don’t settle for less.

July 16, 2009

Infidelity and Its Treatment

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The names don’t really matter. Today they are Tiger Woods; Mark Sanford, Governor of South Carolina; and John Ensign, U.S. Senator from Nevada. Tomorrow they will be someone else. Every day, there are other names, little known, but causing no less pain.

How does it happen? How does it happen that people who claim to live by well established moral norms, who have taken a public oath to remain faithful to their spouse, violate that promise? There are several reasons:

1. Power and celebrity = opportunity. People in positions of power and celebrity have more opportunity than most to be unfaithful. They are surrounded, sometimes literally, with admiring and attractive younger people. As Oscar Wilde said, “I can resist anything, except temptation!” The famous and powerful have plenty of that.

2. Contiguity. You might think that the separation of sexes in some religious fundamentalist societies is unfortunate or wrong, but it does keep opportunity at a minimum. In modern Western secular civilization, men and women work together, eat together, and travel together on business. Repeated contact with a sympathetic business associate, pulling together with that person as a team on a business project, creates not just the opportunity for sexual contact, but the chance to get to know and like one another. Perfectly moral and decent folk can find themselves stirred by the presence of a person to whom they are not married, even though they weren’t looking for anything outside of the marriage.

3. Disinhibition. Alcohol and drugs. If you are around sexually attractive people in a party atmosphere or when you are “under the influence,” your judgment and hesitation are more likely to be set aside.

4. The “Great Man” rationale. More than once, I’ve heard men justifying the concept of infidelity in the case of those who are accomplished and powerful. Often, the rationale includes reference to the role that “the great man” plays in benefiting society. According to this line of reasoning, the “heroic” figure is thought to have earned the right to live by a different set of rules than the common man, and should be given the chance to be compensated for his contribution to society by being allowed multiple sexual partners.

5. The “It won’t hurt anyone” rationale. The faithless sometimes persuade themselves that there is nothing wrong with their behavior so long as anyone who might be injured (spouse/children) never knows about it. This is akin to the old philosophical question, “If a tree falls in the forest, but no one is present to hear it, does it really make a sound?” What the argument ignores is that the transgressor is changed by his act of betrayal, that he must tell a continuing set of lies in order to maintain the fiction of his character, that he risks his partner’s physical health in the event that he has become a carrier of a sexually transmitted disease, and that it is impossible to guarantee that the secret will never be revealed.

6. Mid-life crisis. Poor humanity. Poor man. We age, we lose our youthful good looks, sometimes our hair, our virility, our energy, our strength, our stamina. The antidote? A youthful or new sexual partner who, for a time, can help us shut out the dreaded and self diminishing passage of time.

7. Solace. The ups and downs of life are inevitable, even in the luckiest of lives. The best marriages are not immune to the daily stress that  takes a toll on a spouse’s ability to be compassionate, encouraging, and supportive. Financial worries, business reverses, family illness, house keeping, and child rearing soon diminish the “date night” and honeymoon atmosphere of the early days of the relationship. A fresh and sympathetic set of ears, all understanding and acceptance, often develops into something more, and something sexual.

8. “It’s not natural.” Some people, mostly men, justify infidelity with the notion that man was not meant to be a monogamous creature and the flowers of the field (i.e. the opposite sex) were meant to be enjoyed.

9. Longevity. At the turn of the last century in America, that is, about 1900, the average life expectancy was about 50 years. By that standard it was usual for marriages to be relatively short, 25 to 35 years at the most, many much shorter. No longer. Many now last 50 years and more. What happens in that time? People get older, their bodies change, and their personalities alter as well. When I do marital therapy, I usually ask couples what initially drew them together. The most frequent answer I get is something like, “He was hot and we had a lot of fun.” Thirty years on, it goes without saying, he isn’t so “hot” and they sure aren’t having fun.

In order for marriages to thrive into mid-life and beyond, the couple has to work very hard at the relationship, to keep the sexual spark alive despite physical changes and familiarity, and to see to it that personality alterations are compatible or synchronous. Too often one partner wants the marriage to be exactly as it was at the beginning and believes that both the personality and physical changes in the other person amount to a breach of contract. Meanwhile, the other might feel held to a contract that is no longer appropriate to the current state of the couple’s life together and to their age, personality, and experience. One or the other very well may see infidelity as tempting under such circumstances.

10. The scoundrel factor. Although an injured spouse sometimes believes that “evil”  is the most likely explanation for her spouse’s betrayal, in most cases it really isn’t. Most people don’t set out to behave badly and many feel guilty when they do. That said, there are certainly more than a few cads among us, and they do with impunity what others only do with hesitation, a troubled conscience, or not at all.

11. Boredom. Boredom doesn’t cause anyone to stray, but it does set the stage for the temptation. Routine can kill even the things that we love. The pattern is well-known: wake up, go to work, come home, play with the kids, do the bills, and collapse from exhaustion. Or, the stay-at-home parent’s version: wake up, make food, shop, make food, take care of the kids, do the housekeeping, make food, clean, and collapse from exhaustion. Either way, the routine is deadening and there is little room for excitement.

12. A lack of sex. Again, this doesn’t cause infidelity, but can set the stage for it. A warning here: cease sexual contact at your own risk and at the risk of your marriage. But, this is not to suggest that you should have sex only because your partner wants to.

13. Cruelty, sarcasm, and a lack of appreciation. If the marriage has turned into a battle ground, with gratitude replaced by indifference or hostility, infidelity is more likely on either side.

—

When the infidelity is exposed, the result is devastating to the victimized spouse. Rage, sadness, a loss of self-regard, and feelings of inadequacy are common. What did I do? What didn’t I do? Why did he do that? If he felt that way, why didn’t he leave first before he took on another partner? The devastation occurs whether the infidelity is fresh, or the betrayed person discovers it years after it occurred. The emotional clock of devastation only begins to run from the point that one becomes aware of what happened.

If a couple comes to therapy in the wake of such news, several factors go into the therapist’s evaluation of the situation. First, is the infidelity over or is it still going on? If the marriage is to have any chance, the “other” relationship has to end. Moreover, it has to end because the spouse having the affair wants it to end and believes that the marriage is worth saving, not because his marital partner is threatening to leave or because of the fear of financial devastation in the course of a divorce.

The therapist will try to gauge what still binds the marital couple together, if anything. Do they still have positive memories of their courtship? Do they have children and are they concerned about the effects of a divorce on their offspring? Are they still in love? If there is no love on the part of even one partner, therapy is almost certain to fail to recreate it.

If the both parties want to save the marriage, have positive memories of the start of their relationship, and if loving feelings still exist between them, treatment often can help to repair things. One of the first items in need of attention will be allowing the injured spouse to grieve. This will require both tears and anger, but will need to be time limited. That is, however great the injury, the victimized spouse must understand that he cannot forever bring up the infidelity to be used as a weapon when he feels unhappy or aggrieved in the future. As the old farm expression goes, “Don’t burn down the barn to kill the rats.”

Of course, apology by the roving partner will be necessary and it will take time to rebuild trust. Once the immediate crisis is over, the couple needs to look at what contributed to their estrangement and what changes need to be made in their relationship. They have to reaffirm a set of values by which to live and goals for their relationship and for the family. Changes in patterns of communication will likely be necessary, as will time and attention to each other. Serious self-reflection and responsibility-taking will be particularly important for the unfaithful member of the relationship, but the partner too must be willing to look at the possibility that he contributed to his spouse’s feelings of disaffection.

Such situations aren’t easy, but they can come out well. Good will, sincere contrition on the part of the person who strayed, and emotional generosity on the part of the victim are all key. The betrayal is never forgotten, of course. But time does its work on the scar of infidelity, just as bodily scars tend to soften and fade over time, even if they never fully disappear. Happiness and love may yet flourish.

—

The image above is a cropped screenshot of Lana Turner from the film The Postman Always Rings Twice, sourced from Wikimedia Commons.

July 9, 2009

What to Expect in Your First Therapy Session

http://upload.wikimedia.org/wikipedia/commons/thumb/6/6c/Freuds_House.jpg/256px-Freuds_House.jpg

Going to therapy for the first time takes some courage. You are about to talk about some very personal things to someone who is a complete stranger. What can you expect?

1. First of all, expect to be at least a little bit nervous at the beginning. But even before you get inside the therapist’s office, you will have to fill out some paper work. You will also receive a written description of the therapist’s practice, including such details as whether the therapist accepts your medical insurance and how he handles that. Additionally, he will give you information about how your medical records are safe-guarded and the extent to which those records are confidential.

2. The therapist should greet you, bring you into his consulting room, and sit face-to-face with you. Therapists generally want to convey “openness.” It is therefore rare for a therapist sit behind a desk, with you on the other side.

3. After a few “ice breaking” words, the counselor will ask you why you have sought treatment. If you already told him some of this on the telephone, he will want you to fill in the details.

4. Don’t feel that there is a particular “correct” order in which to tell your story. Simply tell it. Initial sessions should generally allow enough time for you not to be rushed. The therapist has probably scheduled at least 75 to 90 minutes to spend with you.

5. If it makes you feel better, it is entirely appropriate to bring an outline of the topics about which you wish to talk, and to consult this outline or read directly from it whenever you need to.

6. The counselor is likely to have some questions for you. He should want to know about your background, not only about the concerns that exist in your life at the moment. Unless he knows that history, he won’t be able to fully understand how you came to have the current difficulties and whether they represent a repetitive pattern in your life.

7. Among the topics you might be asked about are such things as a description of your parents and their approach to rearing you, relationships with siblings, the educational and social history of your school years, whether you changed residences with any frequency as a child, past and current health concerns for you and your family, the presence of any traumatic events in your life, your dating experience, the type of friendships you have or have lost, work background, alcohol or drug use, current medications, present family relationships (spouse/children), financial concerns, and past or current depression or anxiety issues.

Additionally, expect to be questioned regarding any evidence of mood fluctuations, sleep, digestive problems, headaches, caffeine use, suicidal or homicidal thoughts or actions, difficulties in maintaining attention, hyperactivity, hallucinations, delusions, hobbies, religion, how you feel about yourself, whether you can be assertive in your life (say “no” or ask for things), diet and eating/weight problems, obsessive thoughts, compulsive actions, and what you hope to get out of therapy.

Of course, the first session won’t have time to touch on all these areas in the initial session. A counselor will proceed gently.

8. You should not feel that you must discuss topics that are too uncomfortable for you. A sensitive therapist will give you permission to cover only the ground you wish to and a sense of control over the session’s progress so that you don’t become overwhelmed.

9. The therapist might well ask you what challenges you’ve had in life and how you have managed to overcome them. This kind of question helps you to know what strengths you have and to help you remember that you have surmounted past difficulties and therefore can rely on those strengths to help you surmount the current problems.

10. By the end of the session, the therapist should provide feedback about what you have said. This is, in part, to help you and the therapist know if he has heard and understood you and whether his initial impression of you seems appropriate.

11. The counselor, to the extent that he offers interpretations of the material you have presented, should let you know that this is a first impression and therefore not necessarily perfectly accurate. An expert therapist needs to hear your concerns about him personally, his ideas, the therapy approach he is recommending, and his effect on you. Such a person will not be offended by your concerns and wants to hear from you what feels right and what doesn’t feel right about the therapy process.

12. The counselor will normally allow a good deal of time to answer any questions that you have about him and his approach. Although most people usually do, it is not essential that you make another appointment at that time. If you already believe that this therapist is not the right one for you, it is perfectly appropriate to say so and ask him for a referral to another professional.

13. By the end of the session you ought to have a sense of direction and at least an initial treatment plan as articulated by the counselor. The therapist is likely to remind you of the importance of regular attendance and that your dedication to your own healing is essential to obtaining the results you want. Therapy, unlike medical intervention such as brain surgery, requires effort and activity on your part. It is also essential that you have the courage to look at yourself honestly, recognizing that in order for your life to be better you will have to be willing to change some things about yourself.

14. At the end of the first session you might feel exhausted, in part because talking about big emotions is hard work! You are likely to be less anxious than you were when you came into the session. You may feel some amount of relief at having talked about things that you have rarely if ever discussed before. If the therapist has done his job, you should have a sense of hope.

15. In the days following the first psychotherapy encounter, you might well find yourself still processing the material you discussed. This can be unsettling, but it is quite normal. Additionally, a person new to therapy can feel that he has said too much and made himself too vulnerable to the therapist, especially if he (the patient) is a private person. Some people will therefore not return to therapy after the first session. If you have this hesitation, however, remember that it is in your interest to persist despite your discomfort if you sincerely wish to change your life. Good luck!

—

The above image is the entry to Sigmund Freud’s office at Berggasse 19 in Vienna, Austria. It originally was posted to Flickr by James Grimmelmann and was sourced through Wikimedia Commons.

July 2, 2009

A Few Good Books

You won’t be looking at this unless you are a reader. So here are a few brief recommendations of books that have made a lasting impression on me. Most are not new and I suspect that some are out of print, but are likely to be obtainable by a search on the Internet. In no particular order:

1. Frauen by Allison Owings. Owings comes as close as anyone to answering the question, “How did the Holocaust Happen.” An American journalist who studied in Germany, she returned there to interview mostly gentile women who had lived through the period of the Third Reich. Owings summary does an extraordinary job of describing the psychology of the bystanding German population.

2.  A Prayer for Owen Meany by John Irving. Irving gives away the plot of his novel early on: Owen Meany will die an unusual death. But rather than destroying the tension of the book, this puts the reader in Owen’s shoes as a man who knows that he will come to an untimely end, but doesn’t know exactly how. As the book progresses and that end comes closer, the terror is almost unbearable.

3.  Agitato by Jerome Toobin. The story of Toscanini’s NBC Symphony Orchestra in the one decade that it attempted to survive after his retirement. If you enjoy anecdotes about famous musicians, this book is for you. The tale Toobin tells is both funny and sad, since the orchestra did not last. Jerome Toobin, by the way, is the father of Jeffrey Toobin, the legal scholar and public intellectual.

4.  Regret: the Persistence of the Possible by Janet Landman. A book about the title emotion, viewed from literary, psychological, and other perspectives.

5.  What is the Good Life? by Luc Ferry. A very good attempt to answer the biggest question of all: what is the meaning of life?

6.  The Long Walk by Slavomir Ramicz. The author tells the true story of his escape from a Siberian prison camp. He and his compatriots, with almost no equipment, food, or appropriate clothing, attempted to walk to freedom and Western Civilization, which took them as far as India. As you can imagine, not all of them made it. That anyone at all did is astonishing.

7.  Anna Karenina by Leo Tolstoy. This story of an unhappily married Russian woman touches on almost all that is important in life: love, friendship, obligation, children, religion, the value (or lack) of value to be found in work and education, death, and the meaning of life. None of that would matter much without the author’s gift of telling his story and allowing these issues to flow out of the human relationships and events he describes.

8.  The Boys of  Summer by Roger Kahn. Kahn’s classic tribute to the Brooklyn Dodgers baseball team of the 1950s, the team that had Jackie Robinson as its central figure and leader.

9.  War Without Mercy by John Dower. Dower describes the racism that underpinned the Pacific theater of World War II. Unlike the war in Europe, each side viewed the other as less than human and treated the enemy with a brutality consistent with that view.

10.  The Culture of Narcissism by Christopher Lasch. Although the book is now a few decades old, the writer’s message is still spot on. He looks at the empty pursuit of happiness in material things and acquisitions, driven by the increasingly disconnected nature of social relationships in this country, and the promise of the media that happiness lies, not in fulfilling human contact, but in the goods that come with “success.”

11.  The Time Traveler’s Wife by Audrey Niffenegger. A fantastic and touching creation about a man unstuck in time, thrown forward and back, and the woman who loves him. Its being made into a movie, I’m told.

12. Patrimony by Philip Roth. Roth’s account of the illness and death of his father.

13.  The Denial of Death by Ernest Becker . More than one person has told me that this is the finest nonfiction book they have ever read. It is a meditation on what it means to be mortal, and how the knowledge we all have of our inevitable demise influences how we live, in both conscious and unconscious ways. Becker’s book has lead to an entire area of psychological research called “Terror Management Theory.”

14.  For Your Own Good by Alice Miller. Miller is a controversial Swiss psychiatrist who looks at the effect of harsh upbringing on the welfare of children. If you believe that children should be seen and not heard, this book might make you think twice.

15.  A Tale of Two Cities by Charles Dickens. A story of self sacrifice and heroism set in the French Revolution. If you can read the last few pages without tears, you have a firmer grip on your emotions that I have on mine.

16.  The Glory of Their Times by Lawrence Ritter. Ritter was a college professor when he began to travel around the country in the 1960s, tape recorder in tow, to obtain the first hand stories of the great baseball players of the first two decades of the 20th century, who were by then very old men. Probably as great an oral history as any of those written by Studs Terkel, and perhaps the greatest baseball book ever.

17.  American Prometheus: the Triumph and Tragedy of J. Robert Oppenheimer by Kai Bird and Martin Sherwin. Oppenheimer is the man who brought the Manhattan Project to fruition, that is, helped create the bomb we used to end World War II in 1945. But more than that, this book is a wonderful biography of a complex, peculiar, and brilliant man, who was brought low by those who wished to discredit his opposition to nuclear proliferation in the period after the war.

18.  The Mascot by Mark Kurzem. A story that is beyond belief, but turns out to be true. The central figure of the story, when he was a little boy, was adopted as a mascot by a Latvian SS troop after surviving the murder of his family. Why beyond belief? Because he was Jewish. The book reads like the most extraordinary mystery.

19.  All Quiet on the Western Front by Erich Maria Remarque. The most famous anti-war novel ever written. The book is told from the standpoint of a young German infantryman during World War I.

June 25, 2009

Anger Anyone?

Some of the very logical or morally upright folks out there believe that you should never get angry. Never ever.

I’m not one of those folks. First of all, we are all human, and to be human means to have emotions. Second, it is hard to imagine a humanity capable of defending itself, the spouse, and the kids, who can’t get in touch with some needed anger when we or our loved one’s are imperiled.

When danger appears, we are built to fight or flee. The sympathetic nervous system readies you for action. Adrenaline starts to pump, the big muscles of our body receive more blood as the heart rate increases, breathing becomes more rapid, the pupils widen (the better to see danger, my dear!), and sweat gland activity heightens to keep you cool in the event of a major exertion of energy (as well as to make you slippery, so that an aggressor can’t get a firm grip on you).

All of this has been “selected for” in the Darwinian sense: if our ancestors hadn’t successfully fled the tiger or defeated the enemy with the help of these physiological changes, we’d not be here and their genetic line would have stopped.

The same logic suggests that the female of the species historically tended to choose males who were capable of defending her and the kiddies, especially when pregnancy and child-rearing made them particularly vulnerable. But, since the female couldn’t always depend upon the male when he was out hunting and gathering, she needed some anger too.

So, if you get angry, as you almost certainly do, you have come by at least some of it honestly and through no particular effort of your own.

That said, how do you know when your anger goes over the top? Some people will tell you when that happens, of course, and sometimes the authorities will in the form of police. If you are no longer a child and get into fist fights or find yourself yelling a lot, you’ve almost certainly got a problem, either as an aggressor or as a victim. Alcohol might add to your combustibility since it tends to disinhibit people, making big emotions more likely. For some otherwise mild mannered men and women, drinking turns them to the dark side. As the old Chinese saying goes, “first the man takes the drink, then the drink takes the man.” Substitute the word “anger” for the word “drink” and you have an equally valid way of looking at anger. Do you have the anger, or does the anger have you?

On the subject of old sayings, there is an Italian saying that also applies to this issue: “If you want revenge, you should dig two graves.” This means, of course, that revenge is likely to consume you (and perhaps even lead to your demise) just as much as it is likely to succeed in hurting the other party. Lives have been eaten-up and made perpetually miserable by the preoccupation with righting wrongs. Think of the centuries long enmity that exists in the Balkans or the long standing animosity between the Greeks and the Turks. Numerous other examples could be cited. One act of revenge causes the victim to look for his own revenge and back again in a circle without end.

Anger is often the result of a real injury, but the danger is in becoming the thing that you learn to hate because of that injury. The data on the likelihood of child abuse being perpetrated by parents who were themselves abused  is fairly well known. Such a parent is much more likely to abuse his children than a parent who was not himself abused as a child. When I tell people this they often find it puzzling. Surely, they say, the abused child would learn what not to do from the parent’s bad example. But think of cigarette smoking or drug/alcohol abuse. Again, the child raised by an addicted mom or dad is at greater risk of duplicating the parent’s behavior than one raised by parents who are abstinent. Not only does the child have the model of the parent as a bad example in these homes, but, in the case of abuse, the youngster has to deal with the anger and hurt inside of him, which comes from being targeted. As children these kids can rarely succeed in retaliating against their parents, but they can take their feelings out against other smaller children (including their siblings) or against their own helpless children when they have become adults. Indeed, unless the abused child is able to obtain relief from the feelings of anger and sadness that come with abuse (and this usually takes therapeutic intervention), he is likely to carry some of these emotions and their behavioral consequences into adulthood. A good book on the subject is For Your Own Good by Alice Miller. A first class movie that depicts exactly what I’ve described is Good Will Hunting.

Back to the question of how you might know whether you have an anger problem, there are a few additional indicators. Do you (or do people tell you) that you react out of proportion to events that are not seen by others as being that big? Do you find yourself feeling angry or irritable much of the time, or awakened by resentments in the middle of the night? Do you have road rage? Have you every punched a wall or thrown an object due to this sort of upset? If you are an athlete in a contact sport, do you enjoy inflicting pain on the opposition?

Even if none of the above apply, there might be other ways that you express your resentment. Do you intentionally delay or put off tasks that others (a spouse or a boss) want you to do, but you don’t believe are that important? Are you sarcastic to others, rather than direct? Do you grumble in discontent or talk behind the back of others at what they’ve done (or not done) or complain about their personal qualities, but put a friendly face on in front of them? If you’ve answered “yes” to some of these questions, you might just be “passive aggressive,” expressing your ire indirectly.

Again, I’m not saying that all anger is inappropriate. And, certainly, one shouldn’t always turn the other cheek, lest one regularly get taken advantage of. But anger can be a problem for you and for those around you. Like a big dog, it should be kept on a short leash. If you can’t manage that, think about counseling.

A recent review article in The Behavior Therapist by Kulesza and Copeland concludes that cognitive behavior therapy is the current treatment of choice for anger problems. The authors emphasize the need for both training in behavioral skills and the use of cognitive restructuring to insure the best results. Therapy for anger issues is therefore likely to include direct instruction about antagonism and its management; self-monitoring of angry feelings, thoughts, and behaviors; relaxation training; assistance in new ways of thinking about the events that trigger rage episodes; social skills/assertiveness training; direction as to how to think about and undercut anger when it does occur; and practice in being exposed to triggering events so that new skills can be employed and the patient can learn to tolerate or diffuse the emotional intensity and stop short of vehement outbursts.

Among self-help books, one of the best is Stop the Anger Now: A Workbook for the Prevention, Containment, and Resolution of Anger by Ronald Potter-Efron.