Friday, August 17, 2012

Emotional Maturity

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

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

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

I suppose that is one definition.

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

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

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

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

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

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

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

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

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

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

Saturday, August 4, 2012

The Disease of Abnormal Integrity

For B&J

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday, April 16, 2012

The Story of You (and Me)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday, January 9, 2012

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

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

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

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

The implications are staggering.

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

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

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

I do not understand the aversion people have to AA. 

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

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

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

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

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

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

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

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

Appendex I I

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

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

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

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

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

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

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

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