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Friday, August 17, 2012

Emotional Maturity

The other day, I was having a conversation about what constitutes “emotional maturity”. I discussed the topic with a number of people and no one seemed to have a very clear idea about what defines emotional maturity or how one becomes emotionally mature.

Several years ago, a patient/teacher made a comment leading me to write the following definition which, upon further reflection, seems lacking.

A Definition of Maturity:
  • The ability to discriminate between reality-based thinking and fantasy/wishful thinking - followed by...
  • choosing the reality-based choices/decisions because you recognize that what you wish/want just isn’t based on the real-world reality - and...
  • the willingness to tolerate/accept the predictable emotional fallout from your choice.

I suppose that is one definition.

I was told by others that emotional maturity is achieved when one doesn’t always have to be “right”; that one has transcended the right/wrong paradigm. Does this suggest that the Israelis and Palestinians, as cultures, aren’t emotionally mature? They’ve been debating who is right or wrong longer than I can remember.

Another told me that emotional maturity is exhibited in empathy – the capacity to vicariously experience the feelings and experience of another.

There was an interesting article in SLATE magazine in 2007 discussing what the author called the “Mind-Booty Problem”. William Saletan, the author, discusses the idea of the age of consent (regarding sex). He comments that in English common law, later adopted by American colonies, the age of consent was between 10 and 12. In 1885 the age was raised to 16. One might suggest that physiological maturity naturally occurs around age 12-13. Some research suggests that intellectual maturity seems to level out around the age of 18; but intellectual ability or physiological maturity has little or very little or nothing to do with emotional maturity. Most of us recognize that teenagers engage in frightening and too often tragic risk-taking behavior. This tendency seems to level off in the early 20s.

These qualities seem biologically determined. Emotional maturity, however, seems to be mediated more by life experience and one’s ability to be truly consitutionally honest with one’s self and one’s thinking and behavior.

I’ve sometimes commented that if one has a lot of money, emotional maturity can be avoided till the day one dies – because having a lot of money (power) means, for some, that they may seldom if ever have to experience the limits of their “control”. Perhaps developing a realistic sense of how much power/control one reasonably can expect is correlated with emotional maturity.

I can’t say, definitively, what constitutes emotional maturity – but I do think the question is important. (My old teacher was fond of saying, “Why ruin a perfectly good question with an answer.” He valued questions more because it continued the conversation. Defining answers tend to end conversations.)

Here are a few other qualities that might be expressed in emotional maturity:
  • The ability to “handle” one’s own emotions without making another responsible for them. How often have you noticed someone else (or yourself) blaming another person or situation for emotions that are experienced.
  • The ability to allow others to have emotions without giving in to some inner or out influence to “fix” the other's troubling emotions.
  • Emotionally mature people understand (hopefully by their mid-20s) that the world DOES NOT revolve around them. Sometimes, therapists like to describe such self-absorbed people as “entitled”.
  • Emotionally mature people can be independent but also have the ability to be partners in relationships without being dominant or submissive.
  • Emotionally mature people are honest, sensitive and don’t bring “drama” into relationships as a manipulation.
  • Emotionally mature people communicate as clearly as they can (understanding that the act of communicating itself is fraught with error). They don’t engage in mind-games and are not passive-aggressive.

These are just some of my random thoughts on the matter (helped along by my friends and patient/teachers). I challenge you to answer the question. What defines emotional maturity? What experiences encourage emotional maturity? I challenge you to ask your own friends to see what they say.

And please – tell me what you learn because it will help me be more useful to others.

Here’s a related question that I won’t write about now – but equally important. What is SPIRITUAL maturity?

Saturday, August 4, 2012

The Disease of Abnormal Integrity

For B&J

The disease of abnormal integrity is an expression coined (I believe) by my mentor, Carl Whitaker, M.D.

Carl was part physician, part psychiatrist, part obstetrician and gynecologist, part philosopher and part dairy farmer. Being a grandfather taught him to be tender and playful. Being a farmer taught him to be ruthless.

Carl was raised on a dairy farm and he never seemed far from the no-nonsense, plain-spoken and unapologetic manner one might expect of an earthy farmer. As a young man, he was encouraged by the town doctor to go to medical school – and not knowing any better, he did. After medical school, he continued his residency to become an obstetrician/gynecologist, but with the outbreak of the Second World War, there was a demand for psychiatrists – and so, he was deemed a psychiatrist.

The majority of Carl’s clinical work was with psychotic patients. In that era, schizophrenia was understood VERY differently than it is today. When Carl practiced, there were only the most basic anti-psychotic medicines that invariably had terrible side-effects and so whether patients had schizophrenia (as we understand it today – a brain disease) or their behavior was, for reasons not understood, bizarre or psychotic, psychotherapy was the treatment. 

Psycho-dynamics (unconscious influences) were typically thought to explain a patient’s bizarre language and behavior. Today, most clinician’s would agree that schizophrenia (the brain disease) should be primarily treated with medications, but there are still many patients who do not have a brain disease – and their behavior is judged bizarre or inappropriate by the so-called “normal” culture.

Carl developed an unusually keen understanding of his patients’ psychotic language and behavior. Just as one takes on a regional speech accent after years of living in the region; Carl lived in the neighborhood of psychosis for decades – and his language and theories reflected that. I vividly remember how difficult it was for me, initially, to understand his arcane and seeming idiosyncratic expressions and descriptions of an individual’s or family’s problems. His language often sounded bizarre and frequently was laced with Freudian theory and obstetric and gynecological metaphors. Frankly, it was shocking.

I suppose I became enamored of Carl partly because he was famous but also I secretly enjoyed his outrageous comments. Carl had another quality that really enchanted me; he was one of the only people I’d ever meet who had no pretenses – or none that I discerned. He had nothing to prove, was unconcerned with others’ opinion of him and was thoroughly unimpressed with himself.

The concept of a disease of abnormal integrity is one of Carl’s often puzzling expressions. Carl believed in what he described as dialectics. At one end of a continuum, some people are so direct, unvarnished and/or unaware of social convention that their behavior and language seems “crazy” or bizarre - it violates societal norms – leading to the individual being excluded from the culture – a culturally instinctive shunning. At the other end of the spectrum are individuals who apparently have no sense of integrity with an abiding inner sense of core values. Carl would describe such people as “sociopaths”.

According to Carl’s reasoning, if a person with schizophrenia “hears voices” – because they have abnormal integrity, they answer the voices - even if they’re in the middle of a supermarket. Bystanders will likely describe this person as “crazy”. While many of us may freely admit we hear voices, we normally believe that the thoughts, really, are our own. Most importantly, WE DO NOT ANSWER OR ARGUE WITH THE VOICES AS WE STAND IN THE MARKET. This is an extreme example but more subtle examples are all around us. A person who naively makes a comment that is entirely unacceptable in polite society might be one such example. The majority of people may rightly wonder, “What’s wrong with that person? Don’t they KNOW how unacceptable their comment is?”

Carl urged us to have the flexibility to be unusually honest (he would probably call it, “crazy”) when called for but also know when to “play the game” that society expects (he’d probably call it, psychopathy). He’d argue that being too one-sided either way would be problematic. If we’re too honest, the culture (which is inherently duplicitous) will punish us – by social shunning, being arrested or psychiatrically hospitalized. If we’re too much of a game-player then we have no soul – no core integrity. (Actually, Carl would have said it in a more seemingly vulgar way – he’d say then you’re just a “mechanical f**ker” – a “crazy” way of saying you’re like someone that has sex the way animals do, mechanically – with no heart, with no soul.

Carl told the story (I’m assuming it’s true.) of when he was appointed chairman of psychiatry at Emory University. For Carl, it was an undreamt achievement. One of his first decisions was that all medical students would be required, for their first two years, to participate in weekly group-psychotherapy. Probably a great idea – but he succeeded in alienating the rest of the faculty which led to his dismissal. It was a crushing professional and personal blow to Carl. He had acted with abnormal integrity either unaware or unimpressed that his behavior violated the established “norm”. It didn’t matter that it was probably a good idea – because it was intolerable to the dominant culture. He was pushed out the same way the human body will produce antibodies that attack a virus or bacteria that is experienced as “foreign”.

How often do we see that the culture, (whether it’s the culture in a family, the workplace, the legal or political system) is dishonest and we rail that, “it shouldn’t be like that”. If we “speak truth to power” (as some like to say) we will assuredly be eliminated. But, if we are “tricky”, if we know how to work within the system, so as not to alert the “normative obedience-dogs”; perhaps we can bring a change. 

Of course, some find some smug sense of self-righteousness as they enact the role of martyr. This is often the tact of the immature or otherwise uncontrolled-impulsive. (Those aspiring to martyrdom should carefully contemplate the first criteria for being a martyr.)

I often think that one’s reasonable expectation of integrity can be thought of as a set of concentric circles. (Like a bulls-eye target.) In the center, one might have one or two extremely close individuals – you can most likely expect integrity from them. In the next circle are very close friends – but capable of betraying your trust. The further we go to the outer circles the less we can reasonably expect integrity. When we function in the outer circles we need to be “tricky”, we need to “play the game” for the sake of self- preservation.

Carl’s cautionary admonition: “Learn to be as tricky as you are crazy.”

Monday, April 16, 2012

The Story of You (and Me)

[Standard Disclaimer: Psychology and its sibling, psychiatry are not nearly the science that too many believe they are. Psychology and psychiatry have more in common with philosophy and religion. Psychology and psychiatry present a model and models are limited, imperfect explanations.
In 1931, Alfred Korzybyski, commenting on models and theories observed that (a)  maps may have a structure similar or dissimilar to the structure of the territory and that (b) the map is not the territory. Applied to psychology and psychiatry, Korzybyski’s statement suggests that while the models may be presented as reliable explanations, they are in fact limited and sometimes inaccurate. Many have had the experience of trying to use a map that just doesn’t accurately reflect the terrain we’re trying to navigate. I say all of this to disabuse anyone reading that the foregoing is a fact. What follows is a theory, a map – a belief. It is valid only to the extent that it is useful in helping us understand and navigate our lives.]

In the last 20 – 30 years a fairly new school of psychotherapy has hatched from the mother nest of philosophy. This newish belief system, the progeny of subjectivism, is often labeled, “Narrative Therapy”.

I don’t present myself as an authority on Narrative Therapy but it does present a number of ideas that help me understand myself as well as many patients. In this brief essay, I will try (albeit imperfectly) to put forward some of the ideas of Narrative Therapy. I invite you to ponder the ideas yourself – to see how it fits (or not) with your own experience of Life.

Basically, the narrative approach suggests that humans organize our lives and our relationships with others based on “stories” (i.e., accepted explanations). The stories may be “authored” by “authorities” (sometimes our parents, our families, our culture, or professionals). Sometimes, but not often, we are authors of our own life. I sometimes ask the question, “Are you living the autobiography – or are you living an unauthorized biography?”

Forgive me while for a moment, I use myself as an example. How did I come to the beliefs I have about who I am? Many years ago, I believed I was stupid, perhaps intellectually impaired… how did I come to believe that? I don’t recall anyone explicitly telling me that. I do seem to have a distinct impression that the belief was widespread and generally accepted – so I believed it too. I probably believed it for 35 years.

How many of us have had the experience of helping our son/daughter with homework and because they are frustrated (or tired or bored) they exclaim, “I can’t do it.” Or “I’m just not good at this.” Sometimes, this develops into a broader belief about themselves. They begin to “believe” they are generally incompetent. This narrative or story that “I can’t” becomes a “dominant narrative” that overshadows other possibilities. So when we encounter a situation, we invoke the dominant narrative, “I can’t”. The dominant narrative becomes a template for our lives. We use it to explain out past (I’ve never been good at math.) It colors our present experience and predetermines how the future will be experienced.

The narrative approach suggests that along with the familiar dominant narrative, there is a “competing narrative”, a narrative or story that contradicts the dominant narrative. Some say that the competing narrative is “marginalized”. As an illustration think of a large group of people, the great majority believe in the XY political position (the dominant narrative) a few believe in the PQ political position (the competing narrative). The PQ believers will likely feel it is better to not voice their beliefs too loudly because they might be overwhelmed by the XY believers – so the PQs are marginalized. Rarely, the PQs might be particularly courageous and voice their beliefs. There may be consequences for saying something unpopular. They may be told they’re wrong – stupid – immoral, they may be shunned. They may feel pressure to conform to the dominant belief to be accepted by the group.

One may wonder how the XYs came to believe in the XY position. Often we believe something because authorities (authors) have authoritatively stated the position and the author/experts have a valence of unquestioned credibility. How do these “experts” come into possession of so much power? Why do they have greater credibility than we do? Why did I believe that I was stupid? I believed it because a competing narrative (I’m smart) was marginalized. I believed it because unquestioned authorities said so. But… something didn’t go according to “the plan”. Gradually, the dominant narrative came under scrutiny and as the competing narrative gained ground, I became the author of my own life. I was no longer living a biography written by others.

Some of you may remember the 1944 movie, “GASLIGHT”. The concept of the movie is similar to what is suggested above:

Why does the flame go down? Lights in the London house are from fixtures with gas flames, and when you light one light, it reduces gas supply to the other lights in the house that are close by, and the light dims. But no one in the house has lit any other lights! And there are also footsteps overhead, from a nailed closed attic. Neither of the two servant ladies sees or hears either of these signs. Paula Anton (Ingrid Bergman) thinks she is losing her mind, just as she has lost the broach her husband Gregory (Charles Boyer) gave her. Her new marriage is falling apart; she cannot go out lest she make another embarrassing scene. Is it the house? The house where her aunt, a famous and beautiful concert singer, had been murdered when the young Paula was actually in the house. What does her new husband, who plays the piano beautifully, do for a living? Nothing. Why does he go out every night and leave her alone, alone to fret and worry? Who is the man who sees them at unexpected times and places, a man we the audience soon learn is Brian Cameron (Joseph Cotton), a Scotland Yard detective. He is curious about the unsolved murder of Alice Alquist, the aunt who looked a great deal like the beautiful Paula does now; it was a murder that defied the investigators. No motive, no suspects. No clues. (IMDB)

The movie portrays a person’s perceptions being supplanted by another narrative. In the movie, the plot is intentionally driven by malicious intent. In our daily lives, our own native narrative is replaced, ostensibly, by well-meaning experts and authorities – but the net-effect is that our own experience is replaced with a culturally ordained norm.
  • How do we reclaim what has been appropriated by an unquestioned, ostensibly authoritative culture?
  • How do we free ourselves from identities that others (sometimes well-intentioned - sometimes not) decided for us?
  • Do we have the courage to “speak truth (the truth of who we are) to power (the dominant culture)?

I never cease to be inspired when I witness a marginalized culture “stand up” to speak their truth to the dominant culture. Here, I must admit that while I am inspired, I am not always comfortable with it. I’m not always comfortable because I am part of the dominant culture. I am Caucasian Christian heterosexual and male. I make no apology for it but when others, different than me, speak their truth, sometimes it conflicts with mine. Nevertheless, I am inspired by their courage and their commitment to authenticity.

If we want to speak our own truth – our own personal truth – perhaps we can borrow a page from those who, for so long,  have been disenfranchised and excluded.

I like learning new words. Learning new words contradicts the narrative that suggests that I’m stupid.

Hegemony is one of the words I like. Wikipedia says of hegemony:

In the practice of hegemony, the leader state (hegemon) formally establishes indirect imperial dominance (rule) by means of cultural imperialism, which dictates the internal politics and societal character of the sub-ordinate states that constitute the hegemonic sphere of influence. The imposition of the hegemon’s way of life — its language and bureaucracies (social, economic, educational, governing) — transforms the concrete imperialism of direct military domination into the abstract power of the status quo, indirect imperial domination. In the event, rebellion (social, political, economic, armed) is eliminated either by co-optation of the rebels or by suppression (police and military), without direct intervention by the hegemon; the examples are the latter-stage Spanish and British empires, and the unified Germany (ca. 1871–1945).

Hegemony is what many (sadly, sometimes myself) would seem to prefer. It seems we want others to reflect our standards, tastes, beliefs and values. It seems there is less and less tolerance for variation.

Can you say who you are without being seen as a monolith?

If I say I am Republican, that also means ________________ (fill in the blank)
If I say I’m Gay, that also means _______________________ (fill in the blank)
If I say I’m a Jew, that also means _____________________ (fill in the blank)
If I listen to NPR, that also means ______________________ (fill in the blank)

Can I be a Gay, Republican Jew that listens to NPR and Rush Limbaugh while eating red meat and drinking green tea?

Who tells the story of you (and me)?
What do we do if it's unpopular? Who will speak the truth?

Monday, January 9, 2012

I have noticed a stunning irony when it comes to the treatment of alcoholism.

In my work I regularly encounter individuals suffering the ravages of alcoholism. 

Whether it is late or early stage alcoholism, I explain that alcoholism is a disease for which there is no “cure” but with proper treatment, the progression of the disease can be arrested. I explain that if left untreated, alcoholism is more lethal than cancer, particularly when one considers the societal costs. 

  • Roughly 25% of hospital beds are filled by alcohol related conditions 
  • 50% of emergency room visits are alcohol related
  • over half of domestic violence is alcohol related 
  • over half of child abuse/neglect is alcohol related and almost 50% of traffic fatalities are alcohol related 
  • Lost wages resulting from hangovers in the U.S. alone was $148 BILLION in 2005.

The implications are staggering.

If most patients I see were diagnosed with cancer, and were told that a near certain cure was possible but the patient would have to travel a thousand miles, be financially ruined, undergo perilous surgery and followed by chemotherapy with it attendant side effects, they would gladly endure the gauntlet. If those same patients were told there was a slim chance that eating a macrobiotic diet has been reported to help but there was no evidence to support it; they’d probably pass (though, in Santa Barbara, I’m unsure).

But, if my patients are diagnosed with alcoholism (more lethal than cancer) and told that the disease is treatable with good success – and the treatment is essentially free and the treatment is local, with few side effects … and the treatment is AA… probably half my patients will find reasons to avoid treatment for this deadly disease which will effect generations.

I think if I were told I had cancer which had a good cure rate if I converted to Judaism – I would convert in a heart beat. If they told me I could be successfully treated by converting to Roman Catholicism, I'd be saying my Hail Marys now.

I do not understand the aversion people have to AA. 

Some say that AA is religious (it’s not) or is a cult (it is) – I’d be the first to sign up for the religious cult if it would treat my condition. If I converted to Catholicism, it might take a while to learn the theology – I probably wouldn’t agree with every belief – but if it treated my condition, I'd eat fish on Friday, go to Mass twice weekly, go to confession and say the rosary.

(By the way – a cult – the root word for culture – is ANY group with a shared set of ideas, that use language that is characteristic to the group, that have rituals that help people feel like members of the cult. This would include therapists, physicians, chefs, or AAers.)

Really; I wish someone would tell me, what’s the big resistance… particularly when one considers the alternative?

I tell my patients, “If a person is drowning they ought not to be picky about the color of the lifeboat.” If they’re picky, it means to me that (a) they don’t really believe they’re drowning or (b) they are REALLY confident a different colored lifeboat is close behind.

I’ve been singing the praises of AA for years. 

Believe me, I think I’ve heard every criticism of AA; that it’s religious, that it’s founded on Christian thinking, that’s paternalistic, that it’s a cult ad nauseum. Some of it MAY be true – but if it will successfully treat a lethal condition, sign me up.

If all of my patients (whether they have a substance abuse problem or not) practiced the 12-Steps of AA, I believe I’d have 80% fewer patients – but I guess that would make them feel like they’re just “garden variety” humans.

I quote the below from AA’s “Big Book” – it’s in the back of the book; many think it should be in the front.

Appendex I I

The terms “spiritual experience” and “spiritual awakening” are used many times in this book which, upon careful reading, shows that the personality change sufficient to bring about recovery from alcoholism has manifested itself among us in many different forms.

Yet it is true that our first printing gave many readers the impression that these personality changes, or religious experiences, must be in the nature of sudden and spectacular upheavals. Happily for everyone, this conclusion is erroneous.

In the first few chapters a number of sudden revolutionary changes are described. Though it was not our intention to create such an impression, many alcoholics have nevertheless concluded that in order to recover they must acquire an immediate and overwhelming “God-consciousness” followed at once by a vast change in feeling and outlook.

Among our rapidly growing membership of thousands of alcoholics such transformations, though frequent, are by no means the rule. Most of our experiences are what the psychologist William James calls the “educational variety” because they develop slowly over a period of time. Quite often friends of the newcomer are aware of the difference long before he is himself. He finally realizes that he has undergone a profound alteration in his reaction to life; that such a change could hardly have been brought about by himself alone. What often takes place in a few months could seldom have been accomplished by years of self-discipline. With few exceptions our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves.

Most of us think this awareness of a Power greater than ourselves is the essence of spiritual experience. Our more religious members call it “God-consciousness.”

Most emphatically we wish to say that any alcoholic capable of honestly facing his problems in the light of our experience can recover, provided he does not close his mind to all spiritual concepts. He can only be defeated by an attitude of intolerance or belligerent denial.

We find that no one need have difficulty with the spirituality of the program. Willingness, honesty and open mindedness are the essentials of recovery. But these are indispensable.

“There is a principle which is a bar against all information, which is proof against all arguments and which cannot fail to keep a man in everlasting ignorance—that principle is contempt prior to investigation.”
—Herbert Spencer

Tuesday, November 29, 2011

How Do I Motivate My Family to Help Around The House?

It has been a bit since I’ve written but this morning brought an all-too-common problem.

My patient, I’ll call her Jane, is middle-aged, she’s in a long-term marriage and her 30ish son, daughter-in-law and grandson live with her. Jane has her own medical concerns which are not minor. Her concern is not unusual. She is consternated that she seems to be the only one to do any work around the house. Everyone in the home is either unemployed or on disability.

The other adults in the home are entirely able to be responsible for a division of household chores – but Jane tells me that they are indifferent to the clutter, dirty dishes and trash.

Jane feels guilty that she is so often “nagging” others and it seems to have no effect on anyone else’s behavior.

As I already said, Jane has her own medical problems which probably make her LESS able to do the household labor, “…but if I don’t do it, it won’t get done.

How often have you been in a similar situation?

Like many others in her place, Jane feels angry and defeated. She frequently reflects that the situation is not “fair”. I think most of us are well aware that life is not fair, but why should we have to endure the kind of inequity that Jane lives every day?

The Solution
The solution is very simple but also very difficult. The solution involves developing the ability to TOLERATE (not enjoy) one’s anxiety. When I use the word “anxiety”, I refer to a general discomfort. When a person feels extremely hungry, it is a feeling of anxiety. When one wants to buy something but can’t afford it, they experience anxiety. Sometimes when my wife is in the passenger seat of my car, she experiences anxiety.

It is entirely natural that we all would avoid anxiety if possible. The problem is, it cannot be avoided – and if we try, our sphere of existence will become smaller and smaller until we cannot tolerate even the smallest perturbations. The difficult task is to learn to tolerate anxiety.

In Jane’s case, her anxiety is greater than everyone else’s at home. The clutter and trash accumulate and Jane’s anxiety triggers her to control the anxiety by cleaning. Unfortunately, this leaves Jane feeling used and resentful – it leaves the rest of the family to be do-nothing lumps. In order to change, Jane must be able to tolerate her anxiety. The expression of tolerating anxiety may take a variety of forms.
  • In the extreme, Jane may choose to move out of the home for six months. Jane might object to this. (Why should I have to move?) If, however, Jane left, she wouldn’t have to see the clutter and probably the other’s anxiety would rise to a level that motivates them.
  • Jane did try another method which showed some effect. She dumped the trash, dirty dishes and laundry into each one’s bed. This worked for a brief time but Jane had trouble tolerating her anxiety about such “mean” behavior – the result was predictable. Soon after the beds stopped being a trash cans – the husband, son and daughter-in-law reverted to their thoughtless slovenly behaviors

You may have heard of similar behaviors being characterized as “learned helplessness” or enabling. At the heart of both is a RESCUER who hasn’t developed the ability to tolerate his/her anxiety.

Is it “fair” that Jane needs to tolerate more anxiety? I’m not sure. All of us (if we will continue to become more mature) will learn to tolerate more anxiety because there is so much over which we have no control. Not having control leads to anxiety and attempting to escalate our control tactics lead only to more anxiety.

A former patient told me, “Life is hard, get a helmet.”

Wednesday, August 10, 2011

Worthy of repeat - Boundaries!!!!

Having practiced psychotherapy for more than two decades, I’ve noticed that certain themes or topics seem to be perennial. I infer that these themes are reflective of certain common human foibles.

The theme that has come up again is in the top-ten “golden oldies”, maybe in the top five. Can you guess what it is? If you guessed BOUNDARIES, you’re right!

Before I wrote this column, I checked in past blogs thinking I’d probably written before about this and sure enough I had. Almost one year ago I wrote a small commentary called, “Uhhh…. Can You Say No?”. I’ll try to not be redundant in this commentary but if you find this of some interest then you may want to click the link to read that posting also.

Some of you know too well that I apparently enjoy using shocking analogies and metaphors. I always say I do it because it creates a more enduring impression. It’s probably equally if not more true that I do it for the reason my mother always suggested – I just like getting others’ attention. With that admission out of the way, let’s begin.

Recently, I’ve talked with people upset about feeling violated because others (family and friends) either don’t notice boundaries or their boundaries are too permeable – too diffuse.

This morning, Jane (not her real name) tells me that a sibling feels free to make “constructive criticism” about Jane’s parenting methods.

I can’t think of anyone I know who kindly receives such unsolicited critiques. Why does the sibling feel free to poke their nose – especially uninvited, into concerns that are Jane’s?

The answer is _______________________ .

  1. wanting to be helpful 
  2. wanting to appear superior 
  3. diffuse interpersonal boundaries.

If you said 1, you may be correct – but I doubt it. If you said 2, you may be right and if true, the person is a jerk. If you said 3, I think you’ve won the brass ring!

(WARNING – shocking analogy follows.)

Let’s take the above situation and change one quality about it to see how it might change your answer.

This morning, Jane (not her real name) tells me that a sibling feels free to make “constructive criticism” about Jane’s sexual behaviors with her husband.

Why does the sibling feel free to comment on Jane’s sexual activities with her husband?

The answer is _______________________ .

  1. wanting to be helpful 
  2. wanting to appear superior 
  3. diffuse interpersonal boundaries.

In the latter example, I think most would recognize that opining about another’s intimate activities is violation of normal boundaries. It’s a no-brainer.

In this morning’s conversation, Jane was quite understandably insulted and justifiably angry. These are normal and healthy responses after being violated.

It was interesting that soon after Jane related her sister’s major misstep, she went on to tell me about how she (Jane) sometimes calls her mother to k’vetch about her (Jane’s) husband.

I asked Jane if she would ever consider discussing with her mother the dimensions of her husband’s (Dick – excuse the pun) reproductive anatomy. Jane appropriately said she wouldn’t dream of disclosing such personal and inappropriate information.

In my comments referred to earlier, I quoted Robert Frost’s familiar maxim, “Good fences make good neighbors.” But it is true that all good fences don’t look the same. Like so much in life, boundaries are described as being a spectrum from too permeable and flexible on one extreme to too rigid and completely impermeable on the other extreme. Usually, neither extreme is good (perhaps there are some exceptions). At times, my own boundaries have been too permeable. Other therapists (usually those more psychoanalytically inclined) have chastised me because they believe I disclose too much of a personal nature during the course of therapy with my own patients. I believe that patients should have unrestricted access to their own medical records. HIPAA laws dictate otherwise. If I want to maintain my employment at the Clinic and retain my license, I have to put HIPAA laws above my personal opinions.

My patients/teachers who are members of Alcoholics Anonymous remind me of the danger of being too private. They tell me that one is as sick as their secrets. (A variant of this says, “You’re as sick as you are secret.”)

How do we know if our boundaries are too much one way or the other? The simplistic but very true answer is, if it causes a problem it is a problem.

In my example cited at the beginning, Jane’s sibling’s sense of boundaries is too diffuse, too permeable. The result is Jan is angry, hence it is a problem. Jane’s complaints about her husband put too much burden on Jane’s mother, hence it’s a problem.

The permeability of ones boundaries should be adjusted based on communicating clearly with the parties involved. Instead of giving unasked for advice, ask first if it is wanted. Consider the “Golden Rule”; how would you want to be treated.

I conclude this short reminder about boundaries with a book recommendation. The book is written for women but is equally applicable to men. The book title is:

My Answer is No . . . If That's Okay with You: How Women Can Say No with Confidence" by Nanette Gartrell, MD

Wednesday, April 6, 2011

Why – How –What

No, this is not an essay on important aspects of journalism. Rather, this is a brief essay about “change”. Some may say it is an essay about “psychotherapy”. Arguments can be made that the two are different or similar.

Historically, psychotherapy has focused almost exclusively on the “why”; the personal, emotional archaeology; a sort of psycho-Darwinism that suggests that what we do (presently) is largely informed, if not dictated, by past experiences.

I decided to write about this after a conversation with one of my patient/teachers today. He, like many others I’ve talked with, has an important task he wants to accomplish. The task is personally important to him. The task is not odious; it is not difficult, but for reasons which elude us, he does not perform the task. Like many therapists might, I have discussed with him, “why” the task is not done. Let me emphasize that many (myself included), have experienced a similar phenomenon. Almost reflexively, we pursue the answer to “why”.

I’ll offer one of my own experiences as an example:

For probably thirty years, I have been over-weight. As a therapist-in-training, I completed perhaps ten years of psychotherapy as the patient. You might well imagine that many years were spent therapizing “why” I am over-weight. I suppose the theory was (and is still popular today) that if I understood, “why”, that would lead to the “cure”, (i.e., I would lose weight.) Well, guess what; I’m still overweight, perhaps more so. I do have several interesting theories (we therapists do love our theories) about “why” I am over-weight.
  • I have a protracted adolescent rebellion against my father who, as a restaurant owner, made sure everything was the correct portion size.
  • I’m afraid of intimacy.
  • I’m trying to fill some deep psychic void with food.

While all of these why-theories have their germ of truth, none of it has helped me to lose weight.

Steve de Shazer, a former teacher wrote a book, “Words Were Originally Magic”. One chapter of the book was entitled “Getting to the Surface of the Problem”. Steve was a proponent of finding a solution to a problem; he was not particularly interested in finding a cause or a “why”.

Here’s another example of my quirky behavior:

Years ago, I despised the voicemail on my office phone. I had absolutely no problem with the voicemail at my private practice. For years I forwarded all my Clinic calls to my receptionist. “Why?” one might ask.
Honestly, I haven’t a clue. I can’t even make up a reason which, for a therapist, is remarkable. Then, about two years ago, a memo was issued from HQ stating unequivocally, that all providers were REQUIRED to respond to voicemail messages within 24 hours.

My “voicemail phobia” was instantly “cured”. No insight or introspection was needed. I did not seek help from a therapist. I now regularly and without hesitation respond to all voicemail messages.

Other patients have complained of cluttered homes, unpaid bills and derelict lawns. Without exception they have told me they don’t “understand” (i.e., have insight) about “why” the various activities remain untouched in their “in” box. Often it may be suggested they are “avoiding” the activity for some hidden reason. It is sometimes conjectured that the reason for not completing the task is due to an unresolved fear that almost always originates in early adulthood or childhood. These are attempted explanations to satisfy the "why" question.

It seems that while understanding “why” may take the patient on an interesting psycho/archeology dig and may yield interesting theories, it will probably not result in the expressed desire for changed behavior.

Let’s shift the focus from “why” to “how and what”. How can change be induced? What is associated with behavioral change?

Frequently, I consult with couples who explain that they frequently have “stupid and hurtful arguments”. Sometimes, one blames the other – sometimes they want to know “why”.
Sorting through the possible “whys” and trying to educate a couple that blaming is never useful, may go on for months. If however, I can convince them to audio record arguments – almost magically, the terrible arguments cease. I’ve listened to some recorded arguments – what I hear are two adults with mildly raised volume respectfully disagreeing. There is no name-calling, no cursing, no door-slamming. The “whys” can be various but more important was “how” the arguing changed or “what” changed the arguing. Alternatively, I may ask the couple to continue the arguing but I ask them to solemnly agree that one will begin the argument on even-numbered days and the other will begin arguments on odd-numbered days. 99% of the time, the couple stops arguing. Some will tell me that my suggestion was so absurd, they refused to do it… and didn’t argue.

Again we can generate numerous “whys” that attempt to explain but the truth is, explaining, understanding and insight have little or nothing to do with the change. More important was “what” and “how”.

The patient/teacher I initially referred to had, months earlier, done the needed task. I asked him to do it in my office. (It involved a brief computer task.) He immediately performed the task without a moment’s hesitation. Though the patient/teacher was equipped with at least four “whys” (involving his insecurity, childhood traumas and past failures) – he did the benign task. Those “whys”, regardless of their validity, did not stop him. Again, we may speculate a dozen “whys” but the how and what changed the behavior.

What then, is the “take away” from this brief essay? 

“Why” may be interesting (and be alluring to one's intellect) but it doesn’t lead to change – if you want change, think about “what” will change the behavior.

Tuesday, January 11, 2011

Concerning power and "therapy"

[Note: In these comments, I have offset some words with quotation marks. I do this to denote that the word, so marked, has meanings that deserve careful questioning. The meanings of these words are sometimes undeserved and frequently driven by the politics of the culture. If the quoting seems excessive, then it only further illustrates how virulent the effects of "professionalized languaging" has infiltrated and influenced the culture.]

Today, I spoke to a "patient", a very nice, bright woman. A year or two ago she was very upset by a variety of events. As she sat in my office, she was clearly very distressed. Because I work in a traditional medicalized system, I did what is expected and required of me in this context. I referred her to a psychiatrist. If I did not make the referral, I could be found guilty of malpractice due to the system of health-care (the context in which I work). Not surprisingly, the psychiatrist arranged for hospitalization and the patient remained in the hospital for over a week. When she was "released", not surprisingly, she had been “diagnosed” with a “mental disorder” and the treating psychiatrist had prescribed several medications. The patient was “released” from the hospital with an entirely inadequate understanding of the “diagnosis” and much less of the medicines prescribed. Because she was a "compliant" patient, she took the medicine as prescribed.

I’m commenting on this because, as I have opined previously, I am troubled by the inherent problems that accompany power discrepancies found in many professions between the “professional” and the “nonprofessional”. Particularly, I think of the medical profession and more so, psychology and psychiatry. The psychological/psychiatric “profession” has appropriated the “authority” to "diagnose" and treat “mental disorders”. It is almost unknown that descriptions of unusual behaviors and experiences that a person may have (other than those in the domain of “health-care professions”) exist. The dominant belief is that only psychiatrists/psychologists/therapists can appropriately "diagnose" and treat these "conditions" or dis-eases.

The Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV) allows only five of its more than 800 pages to acknowledge that there are “culturally-bound syndromes” that are briefly described. The implication is that these culturally-bound syndromes are quaint descriptions originating from less progressive (i.e., less educated) cultures. A patient’s descriptions and explanations of their experience are expected to yield to the more learned (and ostensibly, more accurate) “professional” descriptions. Descriptions that are indigenous to the one experiencing the unusual or troubling feelings/experience often become quickly converted to an alien medicalized idiom. Automatically deferring to the “professionals” is not always a good idea. Monthly, I receive journals that report legal/ethical violations by “professionals”. I am flabbergasted by some of the deplorable behaviors of some in the “profession”.

My concerns are not original and hopefully shared by many others. Perhaps the first to discuss the problems of power discrepancies was the highly controversial French philosopher, Michel Foucault (1926 – 1984). While Foucault probably would have objected to my use of parts-only of his thinking while excluding other portions – I’ll do so anyhow.

A significant portion of Foucault’s work focused on how power is virtually inseparable from knowledge. In fact, in much of his writing he would often speak of a hyphenated power-knowledge, thus acknowledging the reflexive nature of the two, or as some might say, “two sides of the same coin.” I’ll try to briefly sketch the basics of the Foucault’s concept and show its significance in medicine and psychology/psychiatry.

As any type of specialized knowledge develops, so too “experts” emerge. The “experts” develop special (typically unusual) language and concepts that are familiar only to the “experts”. The specialized language, perhaps intended to help “experts” better understand, has the effect of creating a widening disparity between the individual’s experience and the “professional”. (Consider the influence of the Roman Catholic Mass when it was said only in Latin and the separating effects it had on the laity.) Power and control are natural attributes of specialized knowledge. One can easily see how this dynamic lends itself to many professions and disciplines. Let’s look at how this is expressed in today’s culture.
  • In medicine, physicians invest much time to learn and become “expert” in “curing” “illness”. In the process of their education, physicians learn a language that is specialized and unfamiliar to the layman. Physicians are generally held in high esteem. They wear a mantle of god-like authority and power symbolized by their white frocks. Is it only coincidence that these garments share common qualities as the vestments of the clergy? They have the authority to diagnose and prescribe powerful drugs. If the laity (the unordained) question a physician they may well be rebuked, “And what medical school did YOU attend?” If a psychiatrist decides (Remember, there are no tests to diagnose mental illness; no x-rays, no blood tests, no brain imaging.) one is alcoholic and dictates that into a patient’s medical record, it is in the record virtually forever. It is illegal to remove it. It doesn’t matter if the psychiatrist is misinformed. Now, the patient will be labeled and other ordained experts will read that assessment and will almost certainly be influenced by it. If medicines are prescribed and the patient exercises their own prerogative to not take the medicine, they may be labeled as “non-compliant” (a variant of “hostile”) When I see a patient for a first visit, the power dynamic is set in motion long before I ever meet the patient because they assume the posture of one needing help and I in turn posture myself as one who can help. I am ordained by my education, the State of California and the Clinic by which I’m employed. Because my name (with the requisite initials) is on the door, because I have an office, because my chair is different than their chair, because I have a desk, because they must make an appointment with me, because they pay to speak with me and many other reasons, the power dynamic is set. They need help (have less power) and I am expected to provide help (have more power).
  • In a closely aligned profession, the clergy has invested much time becoming experts in the history, liturgy and traditions of their faith. They are “ordained” by governing bodies to be “shepherds of a flock”. They are authorized to perform the rites of sacraments. When members of the congregation are ill, the pastor is called to offer prayers for the afflicted. Priests, rabbis and pastors are also “ordained” by the state to solemnize weddings and bless other events not within the purview of the unordained. The Roman priest can forgive sins, hear the confession of the penitent and is the sole mediator between man and God.
  • Academia is another profession sharing many of the same qualities. The academician invests years of training, studies the works of expert predecessors, writes exhaustively so that other experts might determine if entry may be granted to the rarified air of the ordained. Titles are bestowed: master and doctor and if one is fortunate, they will become an assistant professor and then full professor. Like physicians, no longer are they called by their birth name; now they take the appellation of achievement and expertise – they are referred to as “Doctor” or “Professor”. The professor stands before the class of students and if the students are to become themselves experts, they must learn from the professing expert and pass examinations.

Foucault wrote and spoke about the problems of power, control and knowledge quite a bit. You may find yourself wondering what all this blather has to do with “therapy”. It has quite a lot to do with it. “Therapists” are in the same (dare I say it) game as those mentioned above. My own language shows how much I have been influenced by my heady “profession”. I talk with PEOPLE but often, I will call them “patients”. I am not a doctor but many of my “patients” will call me “doctor”. I correct the misnomer many times. Some tell me they understand I am not a doctor but they feel better calling me doctor. Psychology/psychiatry is not a hard science (yet). Simply reading the “patient” information sheet on a prescription medicine will illustrate the fact. When explaining the pharmacologic mechanism of the drug, the manufacturer typically says, “It is believed …” i.e., it is not KNOWN. Therapists offer beliefs and opinions; frequently with a mantle of undeserved “authority”. Therapists position themselves as relational “experts” (but no one asks how many times the therapist has been divorced), we present ourselves as experts in family matters (but no one is present to see us during family get-togethers).

In large measure, the culture has benignly conspired to rob individuals of their autonomy. Often, those labeled “patient”, have the ability to deal with and understand the meaning of the challenges encountered. As “professionals” we thoughtlessly impose our “clinical” diagnoses and assessments rather than LISTENING to the language and descriptions used by those sitting in the “patient” chair.

It is an act of self-betrayal when any of us abdicate our personal agency and carelessly turn it over to one deemed to be “expert”. When we hire an expert we should always retain ownership of our own personhood, it is after all, sacred.

Addendum: Recently, I spoke with the person referred to in the beginning of this column. I had asked for his/her comments and their comments are an important counterpoint to my comments. They made the point that when one is as "clearly very distressed" as they were, one is not carelessly turning over their personhood - because in that moment, they have lost touch with the sense of personal agency. In that moment, they would like nothing more than to have a sense of ownership of their life.They have sought the help of "professionals" because of the overwhelming distress. 

Again I thank those who help me to understand more clearly the human experience.

Wednesday, December 22, 2010

Trust - Control - Anxiety - Fear

I just finished speaking to a young woman (between 17 – 23), she made a comment that was the essence of a comment I’ve probably heard every day during the course of my professional practice.

Basically, she told be that since a certain event, (Not an uncommon one – but one that is hurtful and involves loss as well as a sense of betrayal by one who she’d considered trustworthy.) … she “can’t trust anyone.” As I said, I hear this or close variants almost every day as I sit in my chair. (Maybe, instead of sitting during appointments, I should be on an elliptical machine during appointments?)

What does the statement suggest? Probably there are some different meanings but there are also shared implications.

Throughout my blog columns, probably the most common and central themes are the concepts of power – control – trust – anxiety and fear. These are all points of a loop of experiences. All are natural but when there is a distortion of one or more, it becomes the likely (not always) source of problems. 

For those with an unusual desire to read more of my comments on the matter, refer to the links below:

How things get off-track
Anger Management
Fair Fighting
Your Anchor
Who are you

In these columns, I discuss various ways these issues become problematic.

When people tell me about their difficulties in trusting, I am inclined to ask the following:

Regarding trust, what are your expectations?

Let’s assume a relationship (any manner of relationship: mother/daughter, employer/employee, marital, close friends or casual friends). What are the trust expectations? Let’s look at some different scenarios.

  • My colleague and I want to get coffee and catch-up. Personally, I am an early-riser; he is not. I suggest 7AM, he offers 9AM. We agree on 8AM. I arrive at the shop at 7:45AM and wait… he arrives at 8:10. Is this a breach of trust? Perhaps his watch is set differently than mine. Perhaps my watch is set early. Perhaps there were exigent circumstances with his family which delayed him. Perhaps the traffic was unusually bad. Perhaps our coffee-date temporarily slipped his mind. Perhaps he got lost. Perhaps he couldn’t find a parking space. What are my expectations and what do I infer from the fact that he arrived later than I? Do I assume he doesn’t consider my time important? Do I believe he’s just being “passive aggressive”? Do I become agitated? Has he violated some rule that I think EVERYONE must know – ALWAYS be on time. Are my expectations reasonable?
  • A married couple has a heated argument which is not resolved. During the emotionally-loaded argument, both say things that the other experiences as hurtful. While in the moment of the argument, both felt upset but nevertheless believe their own comments were warranted. Now, hours (or sometimes days or even years) later, one or both think, “I cant believe (s)he said that – or did that.” When I discuss it with the couple, they each have their own differing perspectives of what transpired. One or both suggest, “Until you can ADMIT to what you said/did, I can NEVER trust you again – and without COMPLETE TRUST, there is no foundation for a relationship”. REALLY?                                                                             Considering that many of us believe we are mature and reasonable, do we still expect that someone MUST agree with us? If they have a different perspective are they necessarily lying? If they see events differently does is necessarily mean the other is in DENIAL? If the other sees events differently, can we accept that people can see things differently without being WRONG? If the other says they have been hurt by our words or actions, can we sincerely and contritely apologize? I have talked with so many who insist they were NOT WRONG and therefore no apology is warranted. REALLY? Is your sense of being right (i.e., self-righteousness) so important and certain, that you prefer to let the harm stand instead of doing what you can to repair the damage? PLEASE, don’t say “Well what about what they said…” (It sounds a bit childish, doesn't it?) I agree; they assuredly share responsibility for the damaged relationship – but waiting for the other to be contrite will forever create a stalemate (pun intended). Some will go on to use these hurts as an ever-ready moral caudul, bringing it up at every opportune moment, like a trump card, to WIN a disagreement.
  • Assume a relationship between a father and son. The father has reared his son to be a responsible citizen. As the son assumes his role as an adult, can the father accept that the son may have very different values without resorting to suggesting that “something has gone wrong”? My own son decided to be tattooed. Had he asked my advice, I would have suggested that he not get a tattoo – but he didn’t ask (Indeed, it was appropriate for him to not ask – he is an adult, not living under my roof.) Can I accept that his wishes and decisions are his – that he needn’t seek my permission or approval? Can I tolerate the anxiety that we have different values? Must I insist that MY VALUES are RIGHT and that he must conform to MY standards? By living his own life, expressing his individuality and values, does he violate my trust? Do I suggest that because he has chosen a certain behavior that my trust is forever broken? Do I live the life of a victim (a very powerful role) telling any who will listen (or reciting it to myself like an emotional prayer) of my victimhood which I insist was first perpetrated by him – but which I now daily resuscitate? Will I forgive? Will I accept that he has become what I prayed for – an individual – not a carbon copy of myself? (A close expression of narcissism.)
  • Last for consideration, a 50ish mother with an adult daughter. Mom is a devoted evangelical Christian. The daughter is lesbian. I think most understand that the mother would have a difficult time accepting that her daughter is lesbian. Probably, this is not what she had in mind when the daughter was a five year old. The daughter states that she too is a Christian. The mother INSISTS that the daughter is WRONG and sinful. During a conversation with me, it seems what the daughter does in bed and with whom precludes any other conversation the two might have. It seems there is no room for, “How was your day? What are your hopes and dreams for the future? What kinds of projects are you pursuing? How do you feel?REALLY? Is the daughter’s sex-life the most important thing to discuss? I wouldn’t dream of asking my son about his sex-life – it would be a gross boundary violation. If he ever asked me about my sex-life, I’d tell him it’s not his concern. PERIOD.

Does all of this mean that we should continually tolerate UNREASONABLE violations of our relationships? Absolutely not. 

What are unreasonable violations? That can be difficult to answer. Some more obvious violations are blatant. When a person REPEATEDLY violates our relational boundaries resulting in EGREGIOUS DAMAGE and demonstrates no willingness to change behavior... self preservation prevails - but if there is a willingness to change, we must carefully examine our motives to leave.

(excuse my religious-sounding spin: REPENT, GR: metanoia suggests that one changes their direction/behavior. If one was traveling North, they turn around and travel South.) 

What if the violations are minor injuries, unintentional insults and differences in opinion? What if a couple has agreed to an austere budget and one party spends money beyond what is agreed. Is that a reason to cast the entire relationship in jeopardy? What about if one party in a relationship has an affair – the unfaithful partner apologizes, insists it was a horrible human failing and promises to change. Should the injured party accept the apology and continue in the relationship or is this violation too much? 

It is possible to forgive but also decide the relationship cannot continue. 

I have worked with many couples who decide to maintain the relationship. They decide that there is much in the relationship that they want to save. Rebuilding the trust takes time – perhaps a year or more. Forgiving does not mean forgetting. We do not forget terrible injuries. But if we forgive, we agree to not repeatedly bring up the issue.

(Here is an excellent article - thank you BN Forgiving.)

Going back to the beginning of my rant: Continually portraying ourselves as a victim can only result in the suspension of our emotional and spiritual growth. If we are victims, we are not taking responsibility for our life. We suggest that someone else has dictated our fate. 

Who is in the driver’s seat of your life – someone else, your ego – your parent’s expectations. Blame is a game that keeps us in everlasting ignorance.