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.