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

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.)

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.

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:

Pharmalot
Dr. Helen
Crazy Therapies
Daniel Carlat

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"

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.

Coda

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.

Get a Clue Ladies: (I hammered on men last time.)

People sometimes ask where I get ideas for my blog columns. It’s not very difficult. I am blessed with a fairly large number of patient/teachers (my very best teachers are my patients). Frequently, every 45 – 50 minutes, another “teacher” comes to my “classroom” and teaches me something unique about the human experience. Yes, there are recurring themes but each person is unique and has something to teach me – and I thank each one of you. If you weren’t there to help me, I’d only have my schooling.

Recently, I wrote a column which, in large measure, was critical of men. I’ve previously, lamely tried to excuse my bias by explaining that demographically, about 70% of most therapy patients are women. Why is that? (Here, I get to fall back on a cop-out word therapists increasingly use to explain the “WHY” questions.)

The answer is, “It’s MULTIFACTORIAL. (Translation: “We don’t know.” – but, therapists seem to have a delusion that we know everything, so we’ve come up with a word that sounds smart but really it just means that there are so many reasons and we really can’t determine which or which ones explain the WHY.)

In counterpoint to my earlier column in which I expressed the frustrations of many women, let me say UNAMBIGUOUSLY that just because you might be a woman, it does not mean you are a paragon of mental health. The flip side of the coin; if you’re a man, it DOES NOT automatically mean that you’re somehow emotionally vacuous or that all your decisions are regulated by the now infamous “small head”.

Because men see the world through male eyes, it means only one thing – men see the world differently than women. That’s good! Thank God!

My old teacher used to speak of the dialectics of life; the inclination of life to swing pendulum-like. It is true that for centuries the culture was dominated by a male worldview. Psychotherapy has existed since before 1900. While women were “in the mix” from the early 1900's, there has been an increasing presence since that time.

Today, roughly 75% of MFT therapists are female. In most universities, the classes in feminist theology, feminist sociology, feminist education and feminist psychologies are over-enrolled. There’s a clear movement in the culture suggesting that male world-views are anachronistic and that female world-views are more elevated, evolved and valued. As a culture, as individuals and couples, we need to appreciate and value EQUALLY the male and female worldviews. One is not superior to the other. Neither is right or wrong. Both are to be valued. Men can learn much from women and women can learn just as much from men.

Why is it that there are articles littering the media telling men how they can (and should) change in order to be better partners for women, but the articles suggesting that women should change or understand men are viewed as conspiring in some continuing and nefarious subjugation of women and that the ideas suggested are counter to a progressive existence?

Granted, it is women who bear children, but is there some inherent reason there that explains why women have better intuition or knowledge when it comes to parenting? One needn’t be a sociologist to recognize that as the influence of active fathers has faded we have witnessed a near-identical uptick in ill-behaved adolescents and an epidemic of younger male and female criminals?

Men ARE different. Vive la difference! When thinking of the many “suggestions” men are bombarded with daily to be better partners for women, consider that the reciprocal may also be useful suggestions for women. I’ll offer a few examples but I encourage women to consider and perhaps ask what their partners would welcome when it comes to changes in behavior. Before you ask however, let me suggest some preliminary considerations.

If you ask for suggestions, be honest enough with yourself to know whether or not you really care enough about your mate that the answer will be valued. If you ask for information, it is not an invitation to argue about the answer you receive. This doesn’t mean you have to do what your mate suggests – it is information to be heard and to be valued. If your mate asked you what you would like, I’m guessing you’d want them to really hear what you say.

Examples:

• Men and women have very different modes of communication. Don’t expect your mate to communicate the way you do. You do not communicate the “right” way; you communicate “your” way. Your mate’s style is different but not “wrong”.
• More talking does not mean better communication.
• Ask your mate what their preferred communication style is. Tell your mate that you don’t expect an instant answer. The complete answer may take weeks and it may come in segments.
• In a longer-term relationship (more than six months), sexual appetite is seldom synchronized. Because your mate’s desire is different, it doesn’t make it wrong. Different levels of desire are an opportunity for a conversation. Most of us have been heavily influenced by the media. Variation of sexual activity is considerable and very different that what media suggests. In the USA, foreplay will vary between five and fifteen minutes – actual intercourse lasts between two and ten minutes.
• The dynamics that effect sexual desire for women may or may not be similar for men. Again – there no right or wrong – this is opportunity for conversation. The goal is not to win - but to learn what is ideal for you or your mate; to find what is enjoyable based on mutual caring.
• Criticism is a killer of relationships. Don’t nag. If you sense an impulse to criticize, resist it. Reframe nagging or criticism as a goal or as something you're trying to understand.
• You have ideas about what makes for a nice evening, a nice weekend or a nice long weekend; guess what – YOUR MATE DOES TOO! Instead of being dissatisfied that your needs aren't sufficiently valued – think of what your partner would enjoy. Don’t assume that you know – ASK!
• If your mate is loving and caring, your response should be respect and appreciation. There are women by the boatload who contend daily with jerks. If you’re lucky enough to have found a good guy – value him.
• Don’t whine! Take responsibility for doing what you can do to improve situations. In the last few decades many women have developed the idea that the man needs to make all the changes… WRONG-O! Change is a gradual, bilateral process. Before you set out to remodel your mate, make sure you’ve done everything you can to sweep your own side of the street.

Before I end this little rant, rather than repeating myself, I’d encourage you to review my Memo for Women.

PS: One last observation – frequently, when I see couples, it seems like they engage in little verbal "knife-fights". A little poke here, a little slice there… people can die from thousands of little cuts and relationships can die even quicker. Be nice. I’m reminded of an old cartoon ( I’m a guy – so I remember humor that’s a little blue.):

A man is sitting in a dentist’s chair and the dentist has tools in the man’s mouth. The patient, simultaneously has a firm hold on the dentist’s “family jewels”; the caption beneath reads, “We’re not going to hurt each other are we?”

Think of relationships like delicate glassware. Even though guys may be tough in many ways, we are easily injured also – we just do our bleeding internally. Usually when we’re hurt, we don’t say so – and don’t expect us to. As women, you’re pretty smart and if you have the ability to be rigorously honest you’ll be able to know if men are hurt by asking yourself if you’d be hurt if the same was said or done to you.

Primum non nocere

MATURITY: When will males become men?

This column may be biased in favor of the more gracious gender. To be fair, I’ll write another column, soon, extolling the virtues of men and taking ladies to task. Some may think that I should just leave it all alone, but there are things that need be said because mates really can’t say these things to each other; it leads to contempt and resentment. It’s heard as blaming or nagging. If I say it here, there’s the benefit of being a somewhat neutral party – then couples can be blameless with each other and say, “Blame Bannister; I didn’t say it!” (I’m pretty tough – and besides, I get paid to have people be angry with me.)

I saw a younger female patient this week, probably she is in her mid-twenties but she complained about a problem-dynamic that seems ubiquitous and is not age specific. It's a problem I've heard many-many times, hence, this article. When will males become men?

In short, I’ll summarize two of things women often say about their mates. (When I speak of case material anecdotally, I typically refer to men & women as Dick & Jane.)

Example #1 Jane tells me that Dick frequently suggests that Jane may have an affair. This somehow becomes a rationalization for guilt-tripping the women into making promise after promise that she will NEVER stray or even appreciate (as eye candy) some piece of hunky man-flesh.

Explanation: We all have insecurities, but as we mature, HOPEFULLY, we get a handle on our insecurities. We learn there are no monsters in the closet or bogeymen under the bed. To use an expression from a Jerry Seinfeld episode, we become “masters of our own domain”. We learn to take care of ourselves instead of relying on OTHERS to reassure and comfort us. When we were children, perhaps our parents reassured us that we’d be OK; that the sun would rise in the morning – we learned to tolerate our own anxieties and were no longer reliant on others to comfort us. Using psychologese, we develop an “internal locus of control”.

Some people, (men more than women) seem to have a difficult time reaching this developmental milestone. Rather than being responsible for dealing with our own anxieties and being masters of our own domain, men often suggest that our mates are responsible for reducing our anxieties to levels we can tolerate – and these levels are sadly under-developed. [Warning: A crude analogy is quickly approaching!] I asked my patient, “When your mate has a bowel-movement, are you responsible for wiping his bottom?” “Of course not!” she replied. I was relieved to hear that her mate is able to handle his toileting needs himself. Perhaps the analogy is absurd in the extreme, but it illustrates the idea that we all should be expected to handle our most personal concerns without implying or insisting that someone else (usually a female) is responsible.

Example #2 Frequently, after Dick and Jane begin sharing living space, it GRADUALLY becomes Jane’s responsibility to handle finances and other domestic tasks. Somehow, mysteriously, Dick’s only responsibility is to go to work and come home and either drinks beer, watches TV or plays video games or even worse – stays out late drinking with his buddies. I’ve seen this same pattern even if Dick is unemployed and Jane is fully employed. The domestic tasks still fall to Jane even when she’s working full time. And even worse – if there are children – the responsibility for child-care is ALSO Jane’s task.

REALLY? Does this even approach fair? Do you think the couple ever had a conversation wherein Jane said, “I’ll assume responsibility for all the heavy lifting in the relationship and you can be entirely irresponsible.” Uhh… I doubt it. Then how did it get this way?

Explanation: This is an extension of the first explanation. (Hopefully the reader will begin to see a pattern developing.) As toddlers, we have very few responsibilities. With luck, we will be blessed by having parents who gradually require us to be more responsible as it becomes developmentally appropriate. Hopefully, if we are responsible, we will experience positive consequences. If we fail to demonstrate responsibility, our parents will provide effective negative consequences. If we are blessed with wise and effective parents/care-givers we will develop emotional AND intellectual maturity. Conversely (not a tennis shoe reference), If we’ve been raised by care-givers who were over-indulgent or overly punitive, unpredictable, immature and didn’t require us to be responsible in a manner that was reasonable, we will become a dysfunctional hybrid – part physically/sexually mature but intellectually and emotionally immature jerks.

Note: Nature takes care of physical maturity – usually between the ages of 10 and 13 we all navigate the white waters of puberty, but there is more to maturity than the ability to procreate. On average, by the time half of us reach age 17 we will have the intellectual maturity of most adults over 30. But intellectual maturity isn’t the whole enchilada. Most of us will not reach EMOTIONAL maturity, the age at which we should be able to regulate our own emotions, until we are near our thirties! As I’ve said before: If one has lots of money (power), one may never mature.

One may be wondering, “Is there any good news here? What if I’m in a relationship with someone who isn’t “all growed up” but I don’t want to end the relationship – is there hope?” Here’s the answer, “Yes there’s hope.” Just as an illiterate adult can learn to read, an immature adult can mature. (Remember the ol’ joke, “How many therapists does it take to change a light bulb? The answer: One… but the light bulb really has to WANT to change.) The same principle holds true; the immature one must be truly motivated to grow up. If the motivation is largely on the side of the already mature party – it’s not a good predictor.

Sometimes, if the less mature person becomes KEENLY aware that a REAL likelihood exists that the relationship will dissolve if they don’t grow up… there’s a chance things will improve. If the more mature and responsible partner continues to enable the other partner – then I’m not very hopeful. Then you are only replicating the poor boundaries that your partner’s parents exhibited.

Some time ago, a patient helped me understand a definition of maturity.

The ability to discriminate between reality-based thinking and fantasy/wishful thinking…

In this case, the ability to see if someone can REALLY change.

Choosing the reality-based choices/decisions because you recognize that what you wish/want just isn’t based on the reality…

In this case making a choice to stay in the relationship or leave the relationship – but based on realities – not wishful fantasies.

The willingness to tolerate/accept the predictable emotional fallout.

In this case being willing to accept the heart-break if you leave – or accepting the frustration and anger should you decide to remain.

A relational partnership HOPEFULLY involves two people who are (nearly) fully mature. If there’s a significant disparity of maturity – then you’re signing up for a long hitch of frustration, resentment, and threats.

Women (as a generalization), tend to mature more quickly than men; at first it’s biology. Later, if children come along, women quickly learn that the needs of the infant come first. Perhaps, if men became pregnant, men would become more mature, more quickly.

Psychiatry and therapy

A REALLY good interview about psychotherapy and psychiatry - listen if you can! (Click on "listen")

Uhh... can you say NO?

It seems one of the more common buzz-words in the therapy profession is, “BOUNDARIES”.

There are some good books available on the topic – particularly the books authored by Henry Cloud. Mr. Cloud wrote his first book on boundaries and then that book begat about 10 more. (Sort of like the “Chicken Soup” books idea – if one is good maybe I should write a bunch of sequels.) Cloud’s books have a distinct Christian perspective but the ideas about boundaries are quite good.

When one thinks of boundaries a number of examples come to mind, The doors on our homes are a type of boundary; the doors let some people in and when locked they keep others out. The door example is a good one because it also illustrates the idea that usually, boundaries have varying degrees of flexibility – depending on the purpose of the door/boundary. If the door were boarded-up it would be an illustration of a rigid or impermeable boundary. If there was no door or if the door was always open it would illustrate a very loose or permeable boundary.

My patients know my penchant for outrageous and provocative examples so I’ll include a few here. (I’ll start with more subdued examples and ramp up to the more disturbing illustrations.)

Since I’d already mentioned doors, I’ll stay with the theme for the moment. Bathroom doors are a very clear boundary. Usually, one’s bathroom activities are private moments; that’s why there are bathroom-doors. A closed bathroom-door clearly communicates (to most of us) a message; “Stay out. I’m communing with nature.” It’s a boundary. In some homes, some (men more than women), leave the door wide open; the message communicated is, “C’mon in; there’s nothing private going on here”. I don’t know about you, but in my book, the boundaries are way too loose here… but that’s just me. Maybe at your home it’s normal to have communal toileting activity.

This brings us to another aspect of boundaries. The permeability/impermeability or looseness/tightness of boundaries is largely influenced by culture. Example: In some homes, dinner-table conversation may characteristically be a free-for-all with multiple simultaneous unrelated conversations. Other family’s dinner conversation may be characterized by one person speaking at a time. Neither is right or wrong, rather it is just what is typical for a given family. Similarly, during dinner, some families think nothing of taking a bit of food from another dinner-partners plate while in other families, taking food from another’s plate may result in a fork being plunged into the interloper’s hand. These are expressions of differing boundaries. One is a non-verbal communication that what is on the plate in front of me is not necessarily mine but is available for anyone. The other behavior is a clear non-verbal message that communicates, “This is mine – encroach at your own risk!”

Another example: The 60’s 70’s and 80’s was a period of much more diffuse boundaries. In the 70’s, two married psychologists, the O’Neils, popularized the notion of “Open Marriage” and published a top-selling book by the same name. They advocated that in marriage, one should be able to have multiple sexual partners. Many people experimented with the concept of loose permeable boundaries in marriage. Suffice it to say, the experiment was a failure, but it was at the time, culturally congruent. In the late 80’s “The Family Bed” was published, it advocated that parents and children should sleep in the same bed. In many parts of the world, co-sleeping is culturally typical. In the American culture, co-sleeping is much less common and reflects the boundary-attitudes of our culture. Based on my own attitudes and beliefs, I am not an advocate of communal-sleeping. I believe it crosses a parental boundary – I believe it commingles family closeness with a couples intimacy (not just sexual intercourse but snuggling and “pillow-talk” that I believe is essential for good marital health). A quick browse of book-store shelves will evidence that many believe the opposite; again neither is right or wrong – it just expresses variations in boundary/attitudes.

A last example: Many property owners know the importance of being clear about the boundaries of their property. If you don’t know or care, it will be only a matter of time before the owner of the lot adjacent to yours begins a building project that encroaches on your property. I am reminded of the sage wisdom of Robert Frost: Good fences make good neighbors.

Now that I’ve demonstrated a therapist’s predilection to suggest there is no right and wrong, I’ll go on to contradict myself (showing the similarity of therapists and politicians).

Are there examples of right and wrong boundaries? In real life, the answer is a unqualified, “YES.”

Obvious examples of unacceptable boundary violations are everywhere. When a man strikes his mate, he has committed not only the crime of battery but he has egregiously violated a personal boundary. Marital affairs are examples of unacceptable violations of marital boundaries. Sexual activity between a mature adult and an adolescent is a crime and a flagrant violation of cultural and developmental boundaries. Stealing is a crime and a violation of personal, cultural and moral boundaries. Sexual harassment in the work-place is a boundary violation that is only recently being understood. These and many others are blatant examples of unacceptable boundary violations.

Now, let’s venture into the liminal range, the area between personal/cultural preference and obvious unquestioned boundary violations. What shall we call this part of a the boundary spectrum. For the moment let’s just call it “Problem-causing” boundary violations – (PCBV for short).

PCBVs require a fair degree of self-awareness. Being able to identify for yourself that your own value-system is being violated is extremely important.

I used to illustrate the concept of PCBVs with my patients (not for the past five years). I would ask, “Is it OK with you if I come and step on your foot to illustrate a point?” Inevitably, patients would give their permission. (Perhaps because they viewed me as an all-knowing beneficent therapist?) I would then proceed to walk to the patient and place my foot on theirs – lightly at first. Over a period of 20 – 30 seconds I would increase the pressure on their foot. (Remember, I weigh about 250 pounds!) Nearly always, the patient would just smile at me. I can only imagine their foot felt some pain. Why didn’t they say something like, “Get your gosh-darn foot off of me!” Clearly, I was violating a personal boundary; I was causing discomfort – and they were smiling at me! My previous posting on codependency discusses how we can be more aware of PCBVs.

I’ve sometimes heard people report that they’ve thought, “What part of NO don’t you understand." Perhaps they’ve thought it – but have they said it? Have they said it CLEARLY? Has their tone of voice and other non-verbal behavior matched the, “NO”?

Why don’t we say no? Is it because we’ve been trained to be placaters? Is it because we fear another’s FEELINGS will be bruised? (God forbid! They might need therapy for years! Are our feelings so delicate that we will never recover? Have we so elevated our emotions that we fear them like some three year-old with god-like wrath?)

If you aren’t aware of where your boundaries are, stop now and figure it out!