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.

Thursday, December 16, 2010

Is it Love... or is it Wimpy Parenting?

It's easy for me to ask the question and it's even easier for me to pontificate about it as I sit in the ostensibly all-knowing-and-wise Wizard of Oz chair 50 hours each week.  The debate has strong adherents on both sides. 

Many parents explain to me that the realities today are significantly different than when I was leaving the nest of my parents’ home. Quite true.

Of course, we live in a very difficult financial environment. I'm told it is very difficult if not impossible for a young person to find employment that will cover their housing, food and other bare essentials. Also, there have been articles written suggesting that another "developmental phase" is evolving; a  "20-something phase" which follows adolescence but precedes adulthood. This argument supports the idea that it is healthy for pre-adults to stay under a protective parental wing.

I'm in agreement with the first argument; we are certainly living in difficult times - I am not so sure about the notion that another developmental phase is evolving that warrants a protracted adolescence. 

I am continually flummoxed when it's suggested life should be "easy" or "easier". I wonder, when has life EVER been easy - except for during my childhood when my mother did my laundry, prepared my meals, cleaned my bedroom, virtually did my homework and fought my battles with my father. 

Since I matured (in the last few years), I've come to "accept" that Life is difficult. As I survey the situation of others, I think others have a more difficult situation than do I. As I consider those in other countries, it is doubtless that their life is even more of a struggle.

Where did we ever get the impression that life "should" be easy?  

[Disclaimer: I have often said and it applies here also that this is my OPINION - not facts or the conclusion of research - so feel free to dissent.] 

In my professional experience, I generally find it unhelpful to allow young adults to stay in their parents’ home. Young adults are in a developmental period in which it is appropriate to make their own rules - often these rules are at odds with the parent's values and norms. If a young adult is living with parents, one party will have to adjust and often - it's the parents that capitulate. Instead of maintaining clear boundaries about their expectations and allowing the natural consequences to occur, they violate their own integrity (becoming increasingly angry and increasing helpless in the process) and unintentionally retard their child's emotional/psychological maturity. 

Why do parents, again and again postpone imposing significant consequences (i.e., booting the older-adolescent out)? Parents, frequently, will offer a litany of rationalizations - but more often, the real answer is that the parents can't tolerate their own anxiety that would escalate if they "induced labor" to get their child to leave the nest. They feel plagued by all of the "what if" questions. "What if the young adult becomes homeless? What if they turn to crime? What if they go hungry?"  These are real possibilities - but they are possibilities that the parent(s), ultimately, cannot control. The lack of control is what provokes the anxiety. The parents are exchanging a feared future “what if” for the alternative – a surly, entitled and resentful offspring who never develops a sense of competence and responsibility.

It may be worth reviewing the blog entry about the “drama triangle”. The rescuers believe they are motivated by compassion, but more often, the root motivation is their own anxiety. They engage in recuing behavior to contain their own anxiety which would escalate if they were to allow their young adult to face the harsh realities of life. As they continue to rescue, the “victim” suddenly becomes the rescuers’ persecutor who now feels like they are the victim. The familiar refrain from parents and other rescuers is, “After all we’ve done for you, this is how you repay us”?

Commonly, the young adult (or other victim) will charge the rescuers with being too controlling or unfair.

How, you may ask, does one extricate oneself from this kind of trap? The answer, I'm afraid, is not easy. And, isn’t it interesting that the initial desire to provide an easy way became the fertile feild for this very hard dilemma? 

The answer is that there is no escape from the fact that this life is hard and that we do a grave disservice to our children when we try to shield them from this fact. The way out of this dilemma is hard and heart-breaking. The way is filled with anxiety as we wonder if our children will “make it”.

There is a well-known saying – which while sounding hard-hearted is true: Life is hard, so get a helmet.

Two neighbors have a fence between their backyards.
The first man notices the neighbor got a new dog.
Over a period of weeks, as the man observes his neighbor's dog, it seem his tail is getting shorter.
One day, as the neighbors meet at the mailbox, the first man comments that he has seen the new dog.
His neighbor gushes about how cute and sweet the dog is.
The first man mentions that it seems the dog's tail is getting shorter and shorter.
Yes, says the neighbor, "The Vet said I should get his tail docked, but I love that dog so much...I didn't have the heart to do it all at once."

Tuesday, December 14, 2010

Living Vicariously

Recently, I was asked if I’d written about “living vicariously”. The question has prompted me to write about it. (Most of what I write is directly or indirectly in response to questions my patients/teachers present to me.)

Let’s begin with a definition of "vicarious" that I’ve appropriated from

  • performed, exercised, received, or suffered in place of another: vicarious punishment.
  • taking the place of another person or thing; acting or serving as a substitute.
  • felt or enjoyed through imagined participation in the experience of others: a vicarious thrill.
  • Physiology . noting or pertaining to a situation in which one organ performs part of the functions normally performed by another.

Often the way we use it in the vernacular is when we suggest that one person has consciously or unconsciously avoided the challenges of Life and hope to experience the good parts (Who would want to experience the painful parts?) through someone else. Perhaps some of the better known examples of vicarious living are (please forgive my sexism) the “stage mother” who always wanted to be a performer but for various reasons turned away from their dreams – now, they push their child with a peculiar relentlessness. Another familiar expression is the “sports dad”; when their son or daughter is still a toddler, they begin shaping them into an image that the father wants. More subtle expressions are found in the inverse. Parents who have lived an indentured life of their parents morality – and then they are shocked when their own children express the “hell-raiser” that the parent was afraid to express. Had the parent expressed it (not necessarily in outlandish fashion) the child wouldn’t need to so vehemently express the parent’s unlived life.

There’s something quite narcissistic about this dynamic. Instead of trying to be aware of what talents emerge organically, the parent imposes an image which is not natural for the child. Often as the child matures, the child sometimes doesn't express their own native identity but accepts the image the parent imposes. 

I’m reminded of chánzú – foot-binding of very young girls practiced in China for almost a thousand years. – because small feet were considered more desirable. It was a form of mutilation. Consider the word, “mutilation”. To me, it suggests the act of muting another’s expression. When we force our children into an environment that extrudes some reflection that we wanted to see when we looked into a mirror. When we indulge in this kind emotional mutilation we are violating the unique character of the child.

I am not suggesting that children should not be socialized to be responsible citizens; that is our responsibility as parents – but it is also our responsibility to nurture their unique character.

Most children (I’m thinking about my own son.) despite our best efforts, become their own persons.

I’m concerned for those young people who have demurred individuating because they fear disappointing their parents.

I’ve often said I used to be threatened by a person’s threat of physical suicide… today; I am more horrified by one who commits psychological suicide or psychological homicide. Abandoning your self is gruesome beyond words.

I believe that it is each person’s SACRED OBLIGATION to live their own life with all the integrity they can.

Again, from


  • reverently dedicated to some person, purpose, or object:
  • regarded with reverence: the sacred memory of a dead hero.
  • secured against violation, infringement, etc., as by reverence or sense of right: sacred oaths; sacred rights

If we abdicate this central task, it becomes the seeds of all manner of problems. If we are parents, I believe we are obligated to create the environment wherein our children can express their unique character and gifts. That means we are not to enable them to remain perpetual adolescents. It means we prepare them for the realities of living in a difficult world. We do what we can to prepare them for the disappointments that are inevitable. We communicate (more so in our behavior but also with our words) that their supreme task is to express their Spirit (not yours), as fully as possible. We communicate that we (their parents) are not the most important ones to please – they must live, as much as possible, a life of integrity.

My teacher, Carl, used to refer to the “disease of abnormal integrity” a mode of functioning wherein one acts without regard to societal expectations, violating any or all cultural norms, having no apparent respect for the feelings of others. A more modern description might be "sociopathy". The opposite is someone who has no integrity; they are people-pleasers in extremis. Neither is the desired state. Finding a balance between them is the trick… and it is quite a trick. 

There is an inherent tension between the two impulses. Knowing (through trial and error), how to navigate between the dangers of these two positions largely is the functional definition of emotional/psychological maturity.

Let me return to “vicarious living”. Vicarious living is dishonest living. Whether we are trying to coercively scapegoat our children into living the life we didn’t have the guts to live ourselves – or whether we are psychological/emotional parasites, getting our thrills voyeristically from another’s life, it’s dishonest and reflects our own failure to mature while simultaneously planting seeds of problems in our children.

I am reminded of a fragment of a letter that Paul wrote to the Philippians, he says, “…work out your own salvation with fear and trembling.” The Greek word for “salvation” is soterios – it means WHOLENESS, COMPLETENESS or HEALING. Note that Paul tells them to work out their own wholeness (not someone else’s) and that it’s a scary process – not for the faint-of heart.

Living a life of integrity – honesty – not shirking our obligations – not drafting our children into living a life from which we turned away, is our endeavor.

Is it easy? No, it’s the hardest thing I can imagine – something I strive to do – something I fail to do – but I keep trying. I hope you keep trying too.

Saturday, December 11, 2010

Where is Chistmas? (Hint - look in a mirror.)

Most cultures celebrate the advent of “God” being manifest in the world. In the Western culture, it is virtually impossible to escape the commercialized expression of Christmas. Probably, the number of people who celebrate a secularized Christmas out-number those who celebrate Christmas as a sacrament. Paul Tillich believed a sacrament was an outer expression of an inward Grace.

During a recent conversation with a theologian, he commented on the dynamic tension between psychology and Faith. Probably, I would think they share more in common than he would but for the purposes of this brief comment, the differences are not so important.

Many who know me, already know that I have some formal training in the Christian tradition, so please forgive me if it seems the Christian tradition is more prevalent in my comments. I don’t mean to “dis” other faith traditions – it’s just easier and more familiar for  me to speak in my “first language”, the Christian idiom. Other traditions, whether they be tied to a faith-tradition or other-cultural tradition also have expressions of the Divine being expressed in the material world.

For those readers with an antipathy towards Christianity, try to imagine my references as an allegory like an impressionist painting.

Consider the medieval arcane practice of Alchemy; the over-arching idea was to transform a “lower” substance to a “higher” substance – the “philosopher’s stone” of Harry Potter fame. The transformation was thought to be brought about by strange, often tortuous procedures of heating, cooling, pulverizing or combining with other substances. We find a similar motif in Shakespeare’s “The Tempest”; Ariel is the spirit (a higher substance) liberated from the tree (lower substance) in which he’d been imprisoned. In Alchemy, the lower, base substance is often called Prima Materia. In the practice of psychotherapy, the patient comes with a “presenting problem” which is the Prima Materia – it is the beginning base element which we hope to transform to something better and higher.

In the Christian narrative, God is expressed in human form. (Remember… ALLEGORY) The angel Gabriel tells Mary, a virgin, 

“Do not be afraid, Mary; you have found favor with God. You will conceive and give birth to a son, and you are to call him Jesus. He will be great and will be called the Son of the Most High."

Here, we find another example of the Divine (higher substance) being expressed in a human womb (lower substance). I don’t think it is just an interesting coincidence that “mother” and “matter” come from the same root, in Latin, Mater and Sanskrit, Mata.

Later, as Mary is ready to deliver the child, we read:

"While they were there, the time came for the baby to be born, and she gave birth to her firstborn, a son. She wrapped him in cloths and placed him in a manger, because there was no guest room available for them. And there were shepherds living out in the fields nearby, keeping watch over their flocks at night. An angel of the Lord appeared to them, and the glory of the Lord shone around them, and they were terrified. But the angel said to them, “Do not be afraid. I bring you good news that will cause great joy for all the people. Today in the town of David a Savior has been born to you; he is the Messiah, the Lord. This will be a sign to you: You will find a baby wrapped in cloths and lying in a manger.”

Do you see the leitmotif? The Sublime presented in very crude surroundings.

Many times through Christian writings we find God’s will expressed through less than revered forms; from the mouth of an ass, from a bush and others. We are told that God uses the foolish to confound the wise. We are told of a "building block that was rejected" and how it becomes the cornerstone of a new epoch.

I point to these to set the stage for my “Christmas” message – that it is within YOU that the Divine is expressed, not in those who outwardly appear spiritual. Eckhart tells us that God is found in our weakness. It is when we are most broken that we find the Divine is with us and around us, in fact, IN US.

Are you feeling rejected or demoralized? We all, I am sure, have our psychological low place, our emotional manger; that is the more likely place we will find the cornerstone of our Spiritual emergence.

Forget material riches – forget what you think you know. Be honest about where you are the most broken… and then, get ready for Christmas!

Wednesday, November 17, 2010

In Appreciation of Duets

In Honor of SD & BS - Mazel Tov!

I’ve been re-reading parts of Carl’s writing about marriage (He’d be nearly 100 by now so it’s probably safe to now say “committed-long-term relationship”. From here forward, when I say “marriage“ feel free to paste in CLTR; to me, they are nearly synonymous.) Carl viewed marriage as the most natural venue where emotional growth could blossom. Granted, things were so much different even 40 years ago but in many ways we are so much the same in our psychological makeup.

Like Carl, I’ve long been an advocate of marriage. I’m certain there’s much to be said about the merits of singleness and even serial monogamy but that is not my focus in this column.

The thesis of this column is the idea that “maturity” is only half accomplished when we are physically and intellectually mature – the rest is a process that happens in the context of a marriage. Perhaps an apt metaphor is the event of two compatible DNA strands meeting and the explosive proliferation of Life that comes from it. One strand is insufficient (unless we dare venture into the world of cloning). While we are initially attracted by preliminary dynamics, we soon find ourselves on the launching pad for the ride of our life – and like a rocket launch, the ascent is not a cushy ride, but bone shaking. The ride will test our fortitude and endurance. Here, we discover if we are still in an adolescent stage of insisting that Life conform to what “I” say, or have we matured enough to accept that our partner is different and often sees things differently – not wrongly.

Carl likened marriage to the tennis player who decides that playing doubles is more enjoyable because of the creative interplay that develops. Learning when one should  hit the ball for the other and admiring the other’s abilities. Playing as a twosome is entirely different than being the staring monad. “… the simple joy of teaming becomes more important than whether we win or lose”.

I’ve talked with many couples who seem to be under the impression that marriage is about winning. The partner is seen as an opponent. The couple is playing singles against each other. When they are in my office it sometimes seems I should be wearing a black robe as I listen to attorneys for the prosecution and the defense. I often wonder, “Where is the jury?”

If we successfully graduate from our family of origin, we might be ready for the challenge of marriage. Successfully graduating helps to make it more likely that we won’t have to re-enact old unfinished familial battles with our mate – somehow again proclaiming our independence and worth, but this time, to the wrong ears. If we have successfully matriculated, we won’t be forced to complete our adolescence in our marriage.

Often couples present the bi-lateral pseudo-therapy model. In this set-up (pun intended), there is a covert awareness that HE isn’t quite right in his current form but SHE will subtly shape him into the man SHE knows he can be. HE temporarily tolerates HER inconsistencies with the intent of “helping” her become the woman HE thinks she should be. This is an idea that borrows the dubious notion that a therapist is going to change another.

Marriage is not a long-term remodel job on your partner. Marriage is teaming.

For certain, there will, in marriage, be trying moments, there will be moments of “blah” and there will be moments of great joy. Carl spoke of “…[a] whole-person to whole-person relationship…” It is a more mature love that hopefully develops. Of that stage of relational development he commented, “It is independent of sexual stimulation or sexual attraction [do not infer sexual abstinence].”

A marriage, like a swinging pendulum, increases one’s capacity for being part of a WE.  A thriving marriage allows for the increasing ability to express each party’s individuality and reflexively, each increases their capacity for togetherness.

This increasing back and forth arc describes the growing development of the WE co-created by the He and SHE.  

(Please forgive the limitations of my sexist language. I do not intend to exclude those too often marginalized. Specifically, I mean to include the wide spectrum of gender preferences) 

In this way, a marriage naturally has the movement of Life. The tides come in and go out; the heart contracts, and relaxes. In this manner we develop our personhood. Too often, this natural movement provokes anxiety for a couple:

“Oh no, they’re moving away!” or the opposite “Ugh, I’m feeling smothered.”

When we fearfully resist (or escape) this natural and reflexive dialectical process, anxiety and the resulting impulse to control the other can soon follow. Being able to relax - rising and falling with the swells of Life is freeing for both in the marriage. It is similar to what is taught in meditation – “follow the breath” – inhale… exhale. Would someone argue that it is more RIGHT to inhale than exhale? (Probably, some would.) Together there is Life, when one stops the other does too – it’s called death. 

The idea of WE, as something distinct from HE and SHE, is an idea too often unappreciated by a couple. I have always enjoyed the following poem which expresses this ephemeral idea:

The Third Body

A man and a woman sit near each other, and they do not long
at this moment to be older, or younger, nor born
in any other nation, or time, or place.
They are content to be where they are, talking or not talking.
Their breaths together feed someone whom we do not know.
The man sees the way his fingers move;
he sees her hands close around a book she hands to him.
They obey a third body they have in common.
They have made a promise to love that body.
Age may come, parting may come, death will come.
A man and woman sit near each other;
as they breathe they feed someone we do not know,
someone we know of, whom we have never seen.

Robert Bly

To me, a compelling question is: How does the couple move from the “bilateral pseudo-therapy stage” of relationship with its assorted games and maneuvers to the more mature, enjoyable, less controlling and anxious, “whole-person to whole-person stage”?

In my personal and clinical experience, it seems that, like other forms of evolution, it is a process borne of necessity, not choice. Either we adapt and evolve a more expansive and flexible style of relating (my Analytic friends might call it sublimation) or the relationship will fail like a root-bound plant. The plant’s previously useful pot (older ideas about the relationship) must expand to allow for new growth. For those with green thumbs, the concept is familiar – sometimes the pot needs to be discarded in the interest of the plant’s health – but the important element is the plant, not the pot. Too often, a couple fears discarding their earlier definitions of the relationship because redefining the relationship carries a risk – a risk of change – and who among us welcomes change when we have become accustomed to what is familiar – even if that familiarity is the very thing that is killing the relationship.

I remember with great fondness (before the constraining “pot” of today’s health insurance), my colleague Tomaso and I practiced co-therapy for more than a decade, a sort of professional marriage. We saw hundreds of families, couples and individuals as a professional team. His therapeutic style encouraged me to see things differently, we sometimes openly disagreed in front of our patient(s) but we were not vying to be RIGHT. Musicians, probably, (I’m not a musician so if I’m wrong, my brother or others will correct me) will agree that playing with others is more fun than… (Dare I say it?) playing with yourself. (Another intended pun.)

There is room for solos, but in this brief commentary I have addressed duets.

A commentator from an earlier column chastised me for not being more encouraging and so I end this column with my prayer for couples:

Look for what is different in the other, strive to appreciate the differentness. Resist the impulse to make others more like you. Look and listen for the rhythms created by the WE.

Perhaps this is what musicians would describe as the “unplayed notes” or playing “in the pocket”. 

Thank you to JB, TH and Bill for your help.

Friday, November 5, 2010

An apology...

I know I’ve recently made various allusions to a former teacher, Carl. Here is another of Carl’s stories. (If anyone knows the facts of this to be different, I hope you’ll correct me.) Earlier, in Carl’s career, he was appointed to a much coveted position as the Chairman of Psychiatry at a famous medical school. Almost immediately, he established a policy that all first and second year medical students must participate in regular group therapy. Probably, this was a great idea but it ended up entirely alienating him from the rest of the faculty. So, soon thereafter, he was fired. It was a terrible blow to his career. From that incident, Carl learned that while it’s important to do what is morally and ethically right, one must also consider the repercussions – particularly if one has a family.

I must apologize to those who read my comments here. Earlier this week, I posted information which I believe is important information to consumers of health-care services. It is possible that there would be repercussions which would impact others. Because of that, I have removed those postings.

If you want to view the information, feel free to email me and I’ll try to help you find it yourself.

Thursday, November 4, 2010

How to Quickly (and Easily) Ruin a Relationship.

So much as been written by so many about how to make relationships (with mates – family – coworkers) better; I thought I’d try it the other way – since there are shelves after shelves of books about improving relationships and the reasons for relationship failure continue to grow.

One might think that (logically) it would be reasonably easy to keep a relationship together; just pay attention to what’s happening in the relationships that go bad… and do the opposite!

To get you started with your own list, I’ll start you off with some of the most common blunders I encounter as I work with families and couples.

[11/15/2010  Warning: the following is irony, see the below comments.]

  • Believe fervently and insist that your perceptions, judgment and recollections are “RIGHT”. For variety, you can try the reverse – insist that the other person’s recollection of events are distorted or outright lies. Try gently insinuating that the other person is perhaps demented or lacking in integrity. (Just consider how effective this has been for Israel and Palestine.)
  • When you’ve been thinking for days about something the other has done that bothers you – wait until the other party is unprepared and ambush them with your carefully thought-out and rehearsed verbal attack. During WW II this was known as the “Pincer” attack and was successful in defeating the other side.
  • Tell others that you know what they are secretly thinking – this is almost guaranteed to make the other person apoplectic and will damage the relationship.
  • Secretly keep score of who is winning or losing points when there is a disagreement. If you think the other person “won” the last contest, provoke another argument so you have an opportunity to even the score.
  • Make up tests that will determine if the other person REALLY cares about you, is honest, finds you desirable – anything you feel insecure about; design a test (also known as a trap) that will somehow prove that your insecurities are caused by the other person which also means it is THEIR responsibility to behave differently so that you won’t have to deal with your own issues.
  • During a disagreement, be sarcastic and pretend to agree with the other person but paraphrase what they’ve said stating it in the extreme, absurd and hyperbolic manner. For example, if the other says, “I didn’t understand what you were saying.” You could try saying, “Oh, that’s right, I’m the one who doesn’t know how to communicate and you’re the one who never miscommunicates.” (If you can say it in a snide tone it’s even more destructive.) This will often create a no-win situation that will surely damage the relationship.
  • At all costs, avoid stating things in a provisional way. Stating anything provisionally only leads to solving problems. To insure problems, state things in the extreme. (i.e., I never… You always…) Stating things in the extreme will make sure that a disagreement is perpetual. (Isn't this fun?)
  • Whenever possible over-reach your boundaries and encroach on another's boundaries. This should be easy because there are a variety of ways to do it. Here, are but a few you could try tonight. Tell the other person how to drive or where to park. Tell the other they use too much salt. Make social plans without informing others – then “spring it on them” with little or no notice. Tell the other how to dress. When you engage in any of these, reframe the boundary violation as an innocent attempt to be “helpful”. (This way when the other person objects; you can make it sound like you were only trying to help and THEY are unappreciative.) SCORE.
  • Never fall into the trap of accepting personal responsibility for contributing to the misunderstanding. Proclaim your sainthood at even the smallest of opportunities.
  • Only talk about negatives. Never tell the other person about all the nice things they do. This nearly always makes the other person feel like a failure and they’ll quickly stop trying to be helpful giving you another opportunity to criticize them (cool).
  • Remember all the things you used to do early in the relationship that was fun? Don’t do any of them. If you really want to poison the relationship, only do things that are drudgery. Make sure that everything else is more important than your relationship. Work, kids, laundry, softball, lawn-work should all take priority.
  • To spice things up, try blindsiding the other with an ultimatum. Ultimatums will always set you at odds and will surely stimulate resistance from the recipient.
  • Expect others to read your mind so that they would do better than Kreskin (I guess that dates me.) when it comes to reading your body language and silence.  
  • Treat your relationships with others as if they were made of iron and able to tolerate abuse and neglect.
  • Take your relationships for granted. Perhaps this is a little redundant since many of the above are examples of how you can behave as if your relationships are a birthright. Behave as if you are entitled to use awful language. Act like an impudent adolescent and NEVER share in household responsibilities.
These are but a few ideas just to get you started. Remember, improving a relationship takes time and work but tearing one apart can be done easily and quickly without too much effort.

Tuesday, November 2, 2010

Your Beliefs versus a Therapist's Beliefs

As some know, one of my pet peeves is the fact that so many people have unquestioningly accepted the various beliefs and theories put forth by a century of therapists.

James Hillman and Michael Ventura authored a book some years ago – “We’ve Had a Hundred Years of Psychotherapy – and the World’s Getting Worse".

I’m not sure their assertion is accurate but I don’t think the influence on the culture is always benign or helpful. Psychotherapy is in the company of other “healing arts” – they too are not always benign. Who has not heard frightening stories of surgeries gone awry or adverse reactions to medicine; and these are usually the result of well-meaning practitioners using approved treatments. Add to these the quacks using untested methods or phony treatments.

Many, if not most, naively present themselves for treatment, assuming that the treatment provided will help. I am a bit surprised that many of my own patients scheduled preliminary appointments with me without interviewing me first. It is worrisome that some will accept the referral of AN INSURANCE COMPANY employee whom they’ve never met. When I’m on the phone with a potential patient scheduling a first appointment, I’ll usually ask, “Is there anything you’d like to ask me about – my therapeutic approach, how long I’ve practiced, my credentials, what my thoughts are about specific concerns." Some just want to schedule the appointment (I hope if they find me unhelpful they won’t continue seeing me.) A recent patient was candid enough to tell me she just wanted to talk with me for a while to see if I sounded crazy.

Allow me to mention a few of the ideas and practices that I believe are unhelpful. (In previous columns, I’ve discussed what I think IS helpful.)

Talking more is always helpful.

This commonly held belief has prevailed in the Western culture for probably the last 50 years. Rooted in the heyday of anything-goes sensitivity groups (originally, “T-groups”) unedited stream-of consciousness talking was thought to be “healthy”, it theoretically was an expression of an uninhibited mind.

The truth is that more talking is SOMETIMES helpful and it is sometimes unhelpful. Perhaps you’re familiar with the axiom: “You cannot unring the bell.” It is also true that what is said CANNOT be taken back regardless of some people who strongly assert that they take back a comment. Once said, it will exist forever in the mind of the one hearing it.

I have told many patients that when I speak to my boss, I am careful (i.e., full of care). It seems to me that when I speak to someone I care about, my words should reflect my care. If I spoke carelessly to my boss, I imagine I would not have remained employed for more than 20 years. Presumably, I care more about my mate than my boss – I believe my words should reflect that I care. Context is an important (though not sole) determinant of our tone of voice and our words. Some believe that they are not responsible for their words and tone of voice. I assume the most people are (for the most-part) neurologically intact. That leads me to believe that most (99.5%?) do have control of their behavior – despite the insistence by some that they don’t. A gross example would be the battering spouse who would have us believe they were not in control of the hands that strangled their spouse.

A variant of this idea, that we must “say what is on our mind” is an apparent belief that we must express our thoughts and feelings (particularly if they are negative) because if not expressed, we will somehow build-up psychic pressure (as if people are pressure cookers or steam engines) and explode. This belief has no foundation in fact. It does bear striking resemblance to the old but still used ploy told to women (forgive me for the following vulgarity) that unless men can have sexual release with women that the man will develop “blue balls” (an entirely fictional condition). Just as men will not explode without sexual release – people will not explode if they don’t express to ones they care about, complaints or other hurtful comments. (If this principle were true, wouldn't there be a pandemic people - particularly teenage boys, spontaneously exploding?)

It’s OK to say (if it’s true.)
Another falsehood – again I suggest the guiding principle should be “Is this the most caring thing to say and way to say it.” Using the rationalization that “it’s true so it’s OK” is an excuse to be uncaring and hurtful in our communicating.

Most of us have heard the cliché: A woman asks her mate, “Honey, do these jeans make my butt look big?” One can very lamely try to hide behind the rationalization that the jeans are unflattering to say, “Yes, they make your butt look really big.” With just a little thought, one can answer in a more caring way, “Those jeans are OK but I really like the way you look in the other outfit.” The guiding principle is caring.

You should use communication the way I do.
For me, it’s annoying when people seem to believe that others should communicate in a way that essentially is similar to their own. Previously, I reported a saying from my old mentor: “The fact that we both speak English only augments the delusion that we are speaking the same language.” Clearly each of us uses language differently, some more effectively - others… not so much.

Problems develop proportionally to how much we expect others to believe and communicate as we do. I can personally attest to this. Not everyone appreciates my sense of humor. In the not-too-distant past, I was careless about my sense of humor. In recent years, I have become more careful. I used to believe that everyone could, with only brief notice, express how they think and feel (copiously) about almost anything. I’ve learned that others are not like me – some people prefer to be more deliberate (i.e., think before they speak). I’m unaware of any word that has a unitary definition and if there were, we would still moderate the word by the tone and inflection we use. Others will not (ever) communicate the same way we do. You might wonder, “How then do we ever communicate?” The answer is the same as the punch-line to the old joke: “How do two porcupines mate?” The answer is, “Very CAREfully.” Effective communication acknowledges that we are all different and so we communicate most effectively when we try as much as we can to avoid assumptions that the other has understood what we intended with our comments – we intermittently confirm that we have communicated effectively - when we detect miscommunication, we correct it.

I was perfectly clear in my statement – YOU misinterpreted.
An axiom of communication theory states: “The meaning of a communication is its effect.” (not its intent) This is a very difficult notion to understand. I too have trouble accepting it, particularly if I’m the one that feels that I was totally clear about what I’ve said. If I am trying to communicate a thought or idea to another, it is my responsibility to express it in a manner in which it is most likely to be understood by the other party. If their reaction to my communication suggests they may have misunderstood, it is my responsibility to restate the communication more effectively. It is not the receiving party’s responsibility to understand me (particularly if I am using expressions that are not commonly understood). Believing that “I communicated clearly” is very similar to the delusion “I am right and you are wrong.” (see my earlier post.) Anyone who does public speaking will appreciate that choosing the right words and tone is their obligation. Again, in homage to my teacher, Carl, “If during a play of a comedy, the audience doesn’t laugh, it’s not the fault of the audience.”

Feelings reign supreme.
Psychotherapy has encouraged the idea that feelings and emotions are more important that thoughts and behavior. Truthfully, all are important but the relative importance of each merits greater reflection because they each are differing categories of experience.
Feelings are emotional facts like the doctrine of The Trinity is a religious fact. It is a disservice to try to justify these as concrete facts – this doesn’t however diminish their importance. Feelings can be very ephemeral; I may experience an emotion for a moment and then it fades. An emotion is not bound by appropriateness or consistency. I’ve often heard a patient say of their mate, “I love him but at times I could just strangle him.” Emotions don’t have to be reasoned, they just are. Emotions can shift from one moment to the next. Thinking is more deliberative; we have considered a variety of factors and have come to a tentative position.

Think of behavior as sign-language. I remember that for years, I expected my father to express himself the way I do. For years, I believed that because he didn’t communicate and believe as I do, he was in “denial”. When I became a bit more open-minded, I saw that his behavior communicated what he couldn’t verbally express. Too often, behavior is under-appreciated. When a man changes the oil in his wife’s car, it is an act of caring. When a wife makes dinner (please excuse my sexism), it is an act of caring.
At least twice monthly a patient tells me, “I love my mate, but I’m not “in love” with him/her.” To me, this reflects that my patient is expecting the exhilarating feeling of infatuation that is often experienced in the first stage of a relationship. Some of my patients have told me love is a verb. Love is what you do or what another does for you. Being “in love” is an experience – the experience is not a constant; it is a variable phenomena that ebbs and flows. Reflect on other feelings such as fear, joy, anger or suspense. These are not constant, they come and go depending on context.

Feelings are not more important – they are feelings, nothing more and nothing less.

My last comments before ending this rant; please consider carefully anything a therapist says. Remember, unlike physicians who have x-rays and lab tests all we have is beliefs. A therapist's job is to help you be more clear about what you think and feel – not to indoctrinate you into what they think and feel.

Sunday, October 31, 2010

Family Mythology (instead of individual pathology)

Earlier today, I had a “first appointment” with a patient. Her concerns were in many respects similar to many patients but her family history is the stuff of epic stories.

I think our family histories (and herstories) are largely neglected in the way we view ourselves. In this present day, most view themselves as discrete phenomenological packages that emerged the day we were born and conclude when we die.  We have somehow become blind or conditioned to dismiss the generations that eventuated our existence. We fail to view ourselves as an extension of a lineage of lives and stories. We have been severed from our family tree or what many call their family-mythology.

Our family heritage/mythology influences us in ways that are sometimes very obvious and at times in very subtle ways. Even if the “facts” of our heritage is not clear, the stories (true or not) leave an indelible impression. Patients have told me they know nothing about their family-of-origin history but the non-verbal attitudes of their parents is as strong or stronger than known historical facts. I often have seen this when my patient is Latino. Perhaps their parents were born in the US and they believe they are thoroughly Americanized/modernized – but their parents were raised in homes that had strong traditional values – those values are powerfully transmitted from generation to generation. I have sometimes said to my Latino patients, “Your consciousness may be very American but you blood and bones (the unconscious) are still nurtured by the Soul of Mexico.”

My patient today has a family mythology going back many generations. A grandfather was a famed captain of industry; she said he was a “king” and his spouse, a “queen. The king and queen begat princes and princesses, one of which begat my patient.

When I asked my patient about their spouse’s pedigree s/he was a bit clueless. The spouse’s lineage was unclear due to a father that was mostly absent due to military duty and a mother, enchanted by wanderlust. Imagine the relational dynamics when someone descended from a long aristocracy partners with a mutt. One has well established expectations of high achievement the other has no established familial patterns for a template of personal values and behavior.

Because the contemporary culture has suggested (and most are too willing to suckle from any breast of information) that we are monads, devoid of generational influence, when conflict arises we naturally assume that the problem stems from the so called “individual pathology” of the two parties. It would be very unusual but very reasonable to suspect that the misunderstanding stems from transgenerational differences. If an Irish-Catholic partnered with North African-Muslim, I think most of us would understand that the couple would have predictable misunderstandings. In graduate-school, there are classes in cross-cultural psychology. It would be good to pay more attention to differing family mythologies.

Sometimes, though not very successfully, I ask a patient about their “family-religion”. What I am referring to is their family-mythology. In ways, it is similar to a religion. Normally when people think of a religion, they think of beliefs, commandments and creeds. A person has a family-religion. 

Part of my family-religion (imparted by my father/patriarch) were the commandments:
  • Thou shalt never draw attention to yourself.
  • Thou shalt always wear something on your feet, except when in bed.
  • Thou shalt never be late.
  • Thou shalt always behave in a manner reflecting your station in life.
  • Thou shalt always be polite.
  • At all times, be ready to stand and deliver the answers demanded of thee.
  • Never contradict thy father.

Imagine some of the misunderstandings that would develop if I partnered with someone whose family religion encouraged one to be bare-foot and where time commitments were “negotiable”. If both parties are fundamentalists with their family-religion it can lead to real acrimony.

It may be asked, “What is the solution?”

My answer is to develop an attitude of appreciative inquiry; think of yourself as a comparative mythologist.

Vive la différence

Tuesday, October 26, 2010

More of "What is this therapy thing?"

In an earlier post, I deigned to criticize “psychotherapy” because it is not an objective science. Really, psychotherapy is closer to art or theology. Allow me now to say where or how I DO find value in therapy.

I have no argument with religious beliefs. (I have a few of my own.) A religious “fact” does not depend on an objective, concrete, scientific basis. Religious facts and scientific facts are two entirely unique categories of phenomenon. People far brighter than me, who study a branch of philosophy called epistemology could doubtless explain it more clearly. For people of average intelligence (like me) allow me to offer this vernacular explanation: I can resolutely say that I love Janaki, but if asked to prove it (scientifically) I can’t offer anything. A beautiful piece of music is not beautiful due to a scientific fact. These are phenomenon of a different sort, horses of a different color.

This is where “fundamentalists” err. They try to migrate a belief (their faith), to the realm of objectivity, the category of concrete facts.

Psychotherapists can make them same error. Therapists err when they fail to appreciate that their cherished theories and belief systems are mythologems. When a therapist fails to view their belief-system or school-of-thought as just one of many possible descriptions of what may be vexing a given patient, they slip into what I view as therapeutic fundamentalism. These therapeutic fundamentalists, overtly or sometimes with greater finesse, try to make their patients life circumstances fit the parameters of their beliefs. For those unfamiliar with the concept of a “Procrustean bed”, allow me to summarize the basics:

In Greek mythology (from which much of contemporary psychology grows) Procrustes was a son of Poseidon. On the way between Athens and Eleusis. he invited every passer-by to spend the night. The traveler would find themselves restrained in a bed made of iron. Procrustes would set to work on them with his smith's hammer, to stretch them to fit. If the guest proved too tall, Procrustes would amputate the excess length; nobody ever fit the bed exactly because secretly Procrustes had two beds.

This story became the basis for the common idea of trying to make a square peg fit a round hole – or vice-versa.

Therapists make a grave error when they try to cram a patient’s situation into the therapist’s theory.

Instead of this method, therapists better serve their patient by letting the patient explain, in their own unique way, what has happened and is happening.  I prefer an appreciative inquiry approach to working with a patient. I try to understand the unique experiences of the patient as well as the patient’s unique descriptions. I ask questions so that I can better understand the patient’s languaging of the patient’s experiences.

In my experience, as the patient explains and helps me to understand, they simultaneously better appreciate, and understand more fully their experience. Often, the patient will understand something well before me. Quite honestly, it is not necessary that I understand -  but it is in the process my respectful and genuine desire to understand - reciprocated by the patients' languaging of their experiences, that patients find the process helpful. In my work, patients are not helped by me imposing my explanations, but by the patient animating understanding through languaging.

(Note: As I am writing (i.e., languaging) this blog column, I am better understanding the process. It is an in vivo example about which I have been writing.)

Wednesday, September 8, 2010

A Critique of the DSM, by Karl Tomm

This link will take you to a PDF document which, while a bit clinical is brief, concise and REALLY good.I hope you find it interesting.

Tuesday, August 24, 2010

What the heck is this "therapy" thing?

What an excellent, excellent question.

I saw a patient last week who asked me that very question. It’s a question that more patients should ask of their therapists. It’s a question I welcome – but it’s a question that does not have an easy answer and sometimes the answer is not as reassuring as the patient might hope.

I’ll tell you what my rather long-winded and sometimes circuitous answer usually sounds like.

Theories and beliefs
I often say to my patients, “Roman Catholics have their beliefs, Jehovah’s Witnesses have their beliefs, Lutherans have their beliefs and therapists have their beliefs too.” I say this because of my belief that “therapy” has more in common with theology than science. Especially in the Clinic in which I work, I often fall into the “guilt-by association” category. By that, I mean people frequently call me, “doctor”. “Thank you Dr. Bannister.” I correct them the first five or ten times – after that, I let it go.

My colleagues in other departments throughout the clinic have cool lab tests: X-rays, MRIs, pulse oximetry, SPEC scans, CT scans, EEGs. EKGs, colonoscopies, barium swallows, spirometry, ad nauseam.

In my department... we have BUPKISS, NADDA, ZIP, ZILCH! We do have our theories that we love and cling to - and we have beliefs - but we have no truly objective scientific measures. Even the much-touted MMPI-2, perhaps the best researched, oldest and SOMETIMES interesting “test” requires interpretation. It is not definitive and there is much debate within the profession about its appropriateness.

(The questionnaire results in an ever-growing number of scales which are lined up like parallel pickets on a fence, dots are assigned based on the subjects true/false answers to 567 questions. The dots on the scales get connected to produce a Dow-Jones looking graph. Ideally, an experienced trained psychologist INTERPRETS the dots by comparing it to a huge database of other scales – but 97% of the time the interpretation is done by a computer. The result is, “Individuals with similar profiles frequently complain of nervousness, suspiciousness or any number of problems. And then, “The most commonly associated diagnosis is… One might think that the "normative group" (the database of responses against which a patient's responses were compared to) would represent a representative cross-section of the population. Hopefully, there was a demographic adjustment so that if you achieved higher education - your results would be compared to others who had achieved higher education. BUT GUESS WHAT? The original "normative group was
psychiatric inpatients, hospital visitors, college students and medical inpatients. As long as this demographic matched the subjects, a degree of validity might be expected. If it didn't match... SORRY. Is this much better than the old arcade machine that featured “Zoltar”? I think Dr. Zoltar's assessment cost 25¢; the MMPI-2 will cost upwards of $200.)

Have you ever read the package insert for psychiatric medicines? In the explanation of the pharmacologic action (how it works), usually it will say “It is believed…”

REALLY? It is believed? It isn’t known?

I suppose I should mention just for chuckles that the beginnings of psychotherapy come from the very curios mind of Sigmund Freud. (not exactly a paragon of mental health) His ideas about psychoanalysis are ENTIRELY based on ONE CASE and he augmented the case description with more fiction than fact. It’s his theory – it’s his fiction – it his belief system. It was never a fact in the concrete sense, in fact the majority of remnant Freudian psychoanalysis is more of an historic relic than science. Freud was trained and known as a neurologist and a neurological illustrator – his drawings of neuroanatomy are remarkable. He always hoped his theory/belief system/religion would someday be seen as a science… now, its more of an amusing piece of psychohistory.

That’s what you get in psychiatry – and you don’t get much more in psychotherapy.

Who’s right?
Buckle your seat-belt. How many separate approaches/schools of psychotherapy would you guess there are? Let me ask another question, how many different ways are there to fix a broken leg? Five? Ten? Maybe twenty?

There are OVER 500 distinct styles/theories/approaches to psychotherapy! (Corsini, 2008) Over 500! What does that tell you? How many ways are there to fix your brakes? OK, I agree that the human psyche is more nuanced then a braking system in a vehicle, but seriously, over 500? How many religions are there in the world?

The following excerpt comes from Wikipedia:

In 2001, Bruce Wampold of the University of Wisconsin published the book The Great Psychotherapy Debate[31]. In it Wampold, a former statistician who went on to train as a counseling psychologist, reported that

  • psychotherapy is indeed effective,
  • the type of treatment is not a factor,
  • the theoretical bases of the techniques used, and the strictness of adherence to those techniques are both not factors,
  • the therapist's strength of belief in the efficacy of the technique is a factor,
  • the personality of the therapist is a significant factor,
  • the alliance between the patient(s) and the therapist (meaning affectionate and trusting feelings toward the therapist, motivation and collaboration of the client, and empathic response of the therapist) is a key factor.

Wampold therefore concludes that "we do not know why psychotherapy works".

What about Cognitive-Behavioral Therapy? (CBT)
I am often asked about various modes of treatment. Perhaps the most commonly asked about is Cognitive-Behavioral therapy. Cognitive–Behavioral therapy is one of the many beliefs out there in my profession. The basic premise is that our problematic behaviors and feelings are a products of incorrect thinking (cognitive distortions). If the cognitive distortion is corrected, the feelings and behaviors will follow. This may, superficially, sound fairly reasonable, but remember – no particular mode is more effective than the others. So why do we see the frequent pimping of CBT? The answer is because CBT is a form of treatment that naturally lends itself to a research model. Pharmaceutical researchers can easily check boxes, or provide numeric answers to questions like: How many times did the patient self-identify a cognitive distortion? Or: How many lines were written in the patient’s therapy journal between today and the last appointment? Or: How many relaxation activities has the patient identified and roughly how many days did the patient engage in the relaxation activities? This kind of numeric answer is easily crunched by a computer.

It is not so easy to quantify whether a patient feels that a therapist understands them. Empathy cannot be weighed, measure or counted.
So, CBT has become the darling of pharmaceutical companies because it is a natural partner to the rest of their “research” which will coincidentally support the release of their newest break-through drug treatment.

So, what do I do with patients?
I am indebted to a patient who was direct enough to ask this important question. My answer may seem somewhat fuzzy, especially compared to the rationale of the pseudo-scientific CBT postulate. Often, I refer to the appointments I have with patients as “conversations”. That is, after all, what we are doing – but it’s a particular type of conversation. It’s a conversation that often breaks the rules of social convention. In a conversation between you and a friend, one of the more important aspects of the conversation is maintaining the friendship. I have no desire to offend any of my patients but neither am I invested in having them continue seeing me. As much as I genuinely like my patients, I would respect their choice to not see me and I would not be heart-broken. If I think their approach to an issue is ill-advised, I will say so. I believe that the nature of my professional relationship with a patient entitles them to know what I’m thinking about their situation – whether they agree with it or not. I think of my professional conversations as polite debates. A friendly push and pull. Using the concept of dialectics, it is thesis, antithesis and synthesis.

Another concept that informs what I do during my professional conversations came from my days as a younger therapist. (Those were the days when I had hair on my head.)

Occasionally, when a therapist is feeling “stuck” with a particular situation and patient, they will consult with another therapist. This consultation has a name which is a bit of a misnomer it is called “supervision”. To me, supervision implies that my “supervisor” is there in some managerial role or using an employment analogy, they are my superior and that I am their subordinate. Really, supervision in this case is more of a consultation or a second opinion.

In my early days, I thought if I spoke with another therapist to help me get “unstuck” with my work with a patient, the “supervisor” would listen and pick-up on some aspect I’d forgotten to inquire about – or perhaps the supervisor would suggest a technique or approach I hadn’t thought of. Perhaps the supervisor would identify counter-transference that I was blind to.

Routinely, I found the supervisor’s comments to be unhelpful – but – in the process of trying to explain the situation to someone else, it was nearly always helpful. As I struggled to put into words what was happening in the therapy, I would come to a better, clearer understanding the situation. Sometimes, I considered asking my colleague/supervisor to just listen and say nothing – because I knew what I needed was to only try to explain the situation and that that act of explaining would be helpful. If the supervisor didn’t understand – they asked question for their own clarity and understanding – and that also helped me. What helped was NOT their advice or insight; what really helped was me struggling to explain and them genuinely trying to understand. It was the conversation that helped - not their suggestions.

In large measure, that is what I do. I try to understand as my patient tries to explain.

It is true that I give advice (probably too much) but that’s OK because most of my patients don’t do what I suggest – and after nearly 25 years in the profession, it doesn’t surprise or bother me because my “advice” or assessment is just part of the friendly debate. I don’t expect patient’s to agree with anything I’ve said – and I pray they don’t blindly follow my advice. (After all, in the final analysis, all of my patients are ultimately responsible for their choices and behavior. I have no special wisdom and Lord knows, I’ve gotten into more muddles than I care to admit.)

Getting back to the question about what is therapy – it’s a philosophical question. It’s the practice of a conversation, the goal of which is to help the patient.

I have always believed that with any of my patients – if I don’t learn something, then they probably didn’t either and hopefully, they learn more. I practice psychotherapy because I am genuinely interested in people. I’m interested in understanding why they don’t change when their situation is very painful. I’m very interested in understanding why after years of being in a difficult situation, they suddenly change as if someone “flipped a switch”. I’m interested in people. I ask questions because I’m trying to understand the endlessly fascinating and I would go so far as to say sacred mystery that each of us represents in a infinite number of ways.

You might be interested in looking at a few of these links if these ideas catch your interest:

Dr. Helen
Crazy Therapies
Daniel Carlat

Sunday, August 22, 2010

Who Do *YOU* Say You Are?

There’s a portion of the Bible wherein Jesus puts some of his disciples in the hot-seat. He asks them, “Who do you say that I am?” It’s an interesting question. Earlier in Jesus’ life it is reported that he was tempted by the devil:

Then Jesus was led by the Spirit into the desert to be tempted by the devil. After fasting forty days and forty nights, he was hungry. The tempter came to him and said, "If you are the Son of God, tell these stones to become bread." Jesus answered, "It is written: 'Man does not live on bread alone, but on every word that comes from the mouth of God."

Then the devil took him to the holy city and had him stand on the highest point of the temple. "If you are the Son of God," he said, "throw yourself down. For it is written: "'He will command his angels concerning you, and they will lift you up in their hands, so that you will not strike your foot against a stone." Jesus answered him, "It is also written: “Do not put the Lord your God to the test." (Mat 4:1-7 NIV)

These are events in which one’s identity is questioned. What question is more elemental than knowing who we are – yet it is a question that plagues many of us. It’s a question that for most of us is fluid. Some of us would say, “I know who I am.”

Really? Do you really know who you are? Maybe… or maybe not.

Have you ever said or heard someone else say, “I’m so mad at my self.” It almost sounds like three parties are involved. There’s “I” – and then the “self”, which is apparently owned by the “my”. Perhaps you’ve heard someone say, “I don’t know why I did such a foolish thing.” It sounds like two parties are involved.

Murray Bowen, MD discussed the concept of “individuation” (Bowen used the term in a very different manner than did Carl Jung, MD – try not to be confused.). Bowen suggested that individuation refers to one's ability to separate one's own intellectual and emotional functioning from that of the family of origin (including extended family for many generations). Bowen spoke of people functioning on a scale; individuals with "low differentiation" are more likely to become fused with the dominant family emotions they depend on others for approval and acceptance. They either conform themselves to others in order to please them, or they attempt to force others to conform to themselves. They are more vulnerable to stress and they struggle more to adjust to life changes.

Murray believed that to be “individuated” is an ideal that no one realizes perfectly. Usually, we recognize that we need others, but we strive to depend less on others' acceptance and approval. Hopefully, we do not merely adopt the attitude of those around us, but acquire their better traits thoughtfully, winnowing chaff from grain. If we are more individuated, we are less prone to impulsive reactions that were shaped by generations of emotional family traditions. What we decide and say matches what we do. When we act in the best interests of the group, we choose thoughtfully, not because we are caving in to relationship pressures.

As I’ve said in the past, I derive many of my ideas for these columns from my patient/teachers.

Recently, my patients have discussed their concept of self – some believe it is a monolith, for others it is plural. For some it is defined by the culture, their family or their imagined sense of what culture or family would want. The question has been asked, “Am I authentic or am I presenting a sham. This is an unusually difficult question that only the courageous can answer with honesty. My patient told me, “It’s a bitch when you start believing your own PR.” Another patient described it as a “soulless existence.”

20 years ago, I had a small library of perhaps 2000 books. At the time, I told my self (How many parties are in that last statement?) that I was buying these books because I might need them as reference; perhaps as I was writing some imagined ground-breaking book. In retrospect, I was amassing these books for the impression it might make on a visitor to my home. Probably, visitors would have thought, “A smart guy lives here.” I may have read 10% of the books. I told my self (There are those three characters again!) that I’d get around to reading the rest – “some day”. During a moment of unusual honesty with my self, I donated 90% of the library to a worthy cause. It felt like something had died… perhaps, some part of my fake, sham veneer. I was individuating – I felt lighter – I was less fake.

When one predominantly lives the fake life, the inevitable result is diminished self worth – because the real life is not lived – perhaps the real life is even disowned. We can develop a kind of emotional amnesia as we try to be someone other than who we really are.

I still recall the day when I received notice that I passed my State Board license; I ran five blocks to my parents home – without knocking, I burst in and threw the license down on the table in front of my father and exclaimed, “I passed the %$@#” A good, but sad example of an un-individuated person. In this case my father was baffled - it was my imagination of proving something. I was trying to prove something I imagined was important.

One patient described walking into a casino where he was known to be a big roller and bigger tipper. This self was a forgery – his real life is pedestrian. Perhaps Thurber described it in “The Secret Life of Walter Mitty”. Another patient described the thrill of high-risk sex – “It such a relief not to be the boring me.”

How many remember the movie from 2002, “Catch Me If You Can”; it’s the story of Frank Abagnale whose real life was so painful that he embarked on a series of fake identities that helped him feel better. Ultimately his fakery can’t be perpetuated any longer.

  • Is your life an unauthorized biography written by someone else?
  • Are you trying to live up to the standards set by your mother or father – grandmother or grandfather?
  • Are you trying to keep up with the Jones’ or your brother?
  • How did your idea of “a fulfilled life” develop?
  • Who is/was the author of that idea?
  • Perhaps it was the reverse – you don’t want to be like your Uncle that was disowned so try to be the opposite.

Perhaps you are one of those very rare and courageous individuals who lives an autobiographical life. Those who live their own life have not chosen the easy way; they are an endangered species and will not commonly truck with those who have taken an easy path. These intrepid ones suffer from what my teacher called, “the disease of abnormal integrity.”

  • Who are you trying to please?
  • Is your life a forgery of what you feel is expected?
  • Have you chosen your own path?
  • Are you a people pleaser?

I will end this small essay with a quote from Martha Graham:

"There is a vitality, a life force, an energy, a quickening that is translated through you into action, and because there is only one of you in all of time, this expression is unique. And if you block it, it will never exist through any other medium and it will be lost. The world will not have it. It is not your business to determine how good it is nor how valuable nor how it compares with other expressions. It is your business to keep it yours clearly and directly, to keep the channel open. You do not even have to believe in yourself or your work. You have to keep yourself open and aware to the urges that motivate you. Keep the channel open. ... No artist is pleased. [There is] no satisfaction whatever at any time. There is only a queer divine dissatisfaction, a blessed unrest that keeps us marching and makes us more alive than the others"

Wednesday, July 28, 2010

Tell me about your anchor.

Disclaimer: Throughout this column, I make repeated reference to Alcoholics Anonymous (AA). I am not a member of AA and therefore, I’m on thin ice when I attempt to explain anything about AA. It is true that for many years, I was Clinical Director of a treatment program for those with addiction problems. Many of my patients and friends are members of AA. I have read much of AA’s official written material – nevertheless, it would be a great mistake for the reader to be left with the impression that I am an expert in AA or that I am in any way speaking for them. I am not.

Do you have an anchor? I don’t know much about boating – actually, I know next to nothing about boating – but I know boats have anchors. I think anchors are really heavy things that in cartoons look like a trident. An anchor is something used to keep your vessel from drifting too far. Without a secure anchor, the tides and currents can take your boat far from where you’d like it to stay.

By the way... here's a picture of an anchor... notice that does not resemble a person very much.


People need a psychological anchor. That anchor takes many many forms. For my father, his anchor was art. It was one thing which no matter what happened in his life, he always had his art. (Maybe, art had him?) Some find religious faith to be a sustaining anchor. What (or who) is your anchor?

Not infrequently, I see a patient who made another person (usually a love interest) their anchor. Generally, people make poor anchors. Even if an anchor-person is REALLY good, nice, thoughtful, caring and loving – it remains true that humans are inherently unreliable. Humans are fallible. If your anchor is a person and your anchor-person says they’ll pick you up at a certain time; there’s a chance they won’t. Maybe they will get a flat tire – maybe there’s bad traffic – maybe their watch stopped – maybe they misjudged time or maybe they totally forgot. (OMG!) If you are DEPENDING on being picked up at a certain time, and your anchor-person is late or (gods forbid) fails completely to show up… well you’re in a bad spot, aren’t you? As I said earlier, humans are inherently unreliable. My old teacher, Carl, used to tell a story that today would be politically incorrect. I’ll clean it up for this blog:

A (fill in the ethnicity) child is at the top of the stairs – his grandfather (same ethnicity) tells him to jump. The child jumps and the grandfather catches him. The grandfather sends the child up the stairs and again tells the child to jump. The child jumps again and again the grandfather catches the child. Again, the grandfather tells the child to jump from the top of the stairs – but this time – the grandfather lets the child hit the floor! The grandfather tells the child, “Let that be a lesson to you; never trust a (same ethnicity).

When I first heard my teacher tell the story, I was shocked to hear him tell a story which I thought was a racist story; I later understood that the grandfather was teaching his grandson that just because another is your grandfather – or of the same ethnicity – the quality of unquestioning trustworthiness does not attach.

More often than not, my patients (mostly females) make an anchor of a person that is far from nice and loving. Now my patient is really in a bad spot. Often, my patient doesn’t understand why their anchor has left them adrift, why their anchor treats them badly, why they are unreliable. My patients want an explanation and they want answers. Frequently they want to know why their anchor disappoints them – and they want help in transforming their wayward anchor into an anchor of stability and reliability. “Why am I in this situation?” “How do I change the situation?”

Neither is an easily answered question and the unsatisfying truth is, therapists only have theories about why and about what to do about it.

I will try to give an idea about the theory as well as ideas for what to do about it, but be forewarned – as I said, the answers are unsatisfying and the offered solution is a tedious one.

A theory in psychology designated “object relations theory” suggests that as infants, our experiences with our primary care-givers (primary part-objects) exert a formative and ongoing influence on our relationships with others (secondary objects). The theory (if you believe in these kinds of stories), goes that if our primary part-objects are adequate, we are said to have a “facilitating environment” and within our psyche, we develop a sense of a “whole”-object instead of a part-object. (i.e., Instead of experiencing only one aspect/part of an individual, we are able to accept the constituent and sometimes conflicting parts – “the whole-object.) Individuals, who see someone either as “good” or “bad”, see only parts or fragments of an object/person. The theory says that if we’ve had adequate parenting we are able to tolerate the ambiguity of people sometimes being good while at other times being bad. People who experience inadequate parenting have horrible anxiety tolerating the ambiguity (sometimes good – sometimes not) of their mate/object.

So that is a story offered by some psychologists. Does it sound a bit like psycho-babble or some creation myth? I’m a therapist so it makes some sense to me. So, we have a theory, but like so much of psychology, theories of etiology offer little as far as what to DO about a situation.

Ideally, the problem has simply been successfully addressed during childhood. Most of us know that we learn far more easily and quickly during childhood. The bad news is as children, we can’t discriminate between having a good facilitating environment and having a very dysfunctional environment; we don’t have the requisite cognitive development yet. As children, we don’t get to pick the situation into which we’re born. If we have adequate, reasonable and predictable care-givers, we will develop an internal psychic anchor (sometimes called a "core" or "self") and become emotionally independent. If we have unpredictable, absent and incompetent parents, we develop into emotionally needy and dependent adults.

What if you didn’t have the good fortune to be born into a nurturing facilitating environment? This is where the answer becomes annoying. It’s similar to the question, “Can an illiterate adult learn to read fluently?” I suppose the answer is a qualified yes. IF the adult is motivated – and IF the adult is diligent and IF the adult is willing to accept that the process will be long and sometimes very frustrating – then the adult has the POTENTIAL to learn to read. If you don’t have an internal anchor as an adult, building one will take time and be arduous. There will be times of great frustration and one will have to manage their anxiety instead of performing a “Vesuvius” gesture. (This would include threatening behaviors to oneself and others or “meltdowns”.)

A movement begun in the early 20th century offers what I believe is a near miraculous answer. In many ways, it offers the essence of what intensive, long-term and very expensive therapy offers and it’s free. The “movement” is Alcoholics Anonymous or its analog, Al-Anon.

When one considers what is accomplished every day in these meeting rooms, it truly is remarkable. It is true that one can easily make many criticisms of AA – so too, one can criticize long-term therapy (Not the least of which is the considerable cost.).

The many elements of AA and Al-Anon are too many to fully describe in this brief blog column, but I will comment on a few of the aspects I consider significant. (Note: Because I leave out many, please don’t infer that I see other aspects as less important – it’s only reflective of the fact that this blog is meant to be brief.) I will try to draw some correlation between the alcoholic who begins working the 12-Steps of AA and the unhappy person who has attempted to moor themselves to an imperfect, unreliable and painfully frustrating anchor/person.

Step 1 of AA states: “We came to believe that we were powerless over alcohol and that our lives had become unmanageable.”

For the unrecovering alcoholic, there have been innumerable attempts to control the effects of their use of alcohol as well as the disastrous secondary effects. (employment trouble, family trouble, DUI, etc.) The more the alcoholic tries to control and moderate (not abstain) the drinking, their situation in life becomes increasingly problem-filled. When the alcoholic takes Step 1, they acknowledge that their attempts to drink in a “controlled” manner were in vain. They have determined they are powerless and to try further (in the same manner) is insanity. This is an ego-deflating admission – that they cannot change their nature.

The individual with an unreliable anchor/person would benefit tremendously if they accepted the fact that their view-point that leads them to believe they can change the nature of their anchor/person is fundamentally flawed. What needs to change is their view that the anchor/person will change. The anchor/person (like all humans) is inherently unreliable. Attempts to “change” the anchor/person meets AA’s definition of insanity. (Doing the same thing but expecting different results.) Repeated attempts to make the anchor/person reliable will be an ongoing frustration and disappointment, eventually leading to despair.

Step 2 of AA states: “ We came to believe that a Power greater than ourselves could restore us to sanity.” When the abstinent and recovering alcoholic assents to this position, they accept that their heretofore typical outlook on life is inadequate. Psychologists may say that one’s ego alone, is not able to surmount the problem; that one must draw on another resource greater – more comprehensive (binocular – allowing one to see with added dimension) than their ego alone (monocular – lacking a depth dimension). Having a broadened world-view, the alcoholic has the ability to view the problem differently and chart a different course to “sanity.”

The individual with an untrustworthy anchor/person is well advised to take a similar step. Hopefully, they will give up their monocular view which invariably leads them to the same perceptions and the same painful despair. If one is able to surrender their monocular, ego-view of their anchor/person, insisting on consistency and unwavering trustworthiness and instead, adopt a broader view of the situation from an elevated stereoscopic perspective, seeing the sometimes-good-and-sometimes-bad anchor/person not as their anchor but as a full person ( sometimes good and sometimes not), they will have a chance to see their situation differently – with different interpretations and hopefully different decisions which lead to better outcomes. (Note: Just as recovery from alcoholism is painstaking and frustrating, so too is the process of “recovering” from having a monocular world-view and accepting a broader view of life that is not solely defined by their ego. A stance that does not depend on far-from-perfect anchor/people for a sense of stability and comfort. Remember, learning to read as an adult is more challenging than if we learned as children – but it is better to learn as an adult than to not learn at all.)

Step 3 of AA states: "Made a decision to turn our will and our lives over to the care of God, as we understood Him.”

(Remember the AA “Big Book” was written in the 1930’s and accordingly modern readers will detect certain anachronisms like characterizing God as male and anthropomorphic. Don’t allow yourself to quibble with petty issues. As I used to say when I was in a pulpit, “Eat the chicken and spit out the bones.” If you’re vegan, use some similar hermeneutic device.)

For recovering alcoholics, it is important that they emphasize the essential action suggested by this step. MADE A DECISION… turning one’s will and life over to the care of a point-of-view that is broader than that perceived by our limited ego-view is a day-by day (sometimes minute-by-minute) learning process. The recovering alcoholic will remind themselves of this idea many times throughout the day.

One recovering from being anchored to a person will also need to remind themselves (initially maybe over one hundred times daily) frequently that their anchor is not the person that they had hoped would be a stable anchor – their anchor must be something greater. They remind themselves that their former insistence that a person be an anchor was unrealistic and based on a worldview that lead them to believe that people are more virtuous than is warranted by the facts.

Remember my teacher’s story – no human is unquestionably trustworthy. If we demand unflagging integrity, we are guaranteed to find disappointment.


I have said many times that if all of my patients – whether they suffer from depression, substance abuse, anxiety, bipolar disorder, marital problems, panic disorder or work stress – probably 75% would be greatly helped by working the steps of AA. I STRONGLY encourage the reader to read a copy of a small book published by AA entitled: “Twelve Steps and Twelve Traditions”.

Also, I’d like to say that I’ve been trying to read the essay by Gregory Bateson entitled: “The Cybernetics of “Self”: a Theory of Alcoholism. Bateson is brilliant beyond my ability to comprehend. When I try reading him for too long – my teeth hurt. If you’re smart, you might try to understand it. If you have sensitive teeth – steer clear.