Close Enough: Recent Episodes
Jeremy Wexler
I recently saw this great video about the partial nuclear meltdown of the reactor at Three Mile Island in Pennsylvania that got me thinking about how a nuclear reactor is like a long term relationship.
Each is a highly complex system. They both generate energy. They both have fail-safes, self-regulatory properties built in to ensure that the energy stays within manageable parameters. They work off of feedback loops (such as an atomic chain reaction in the reactor, emotional responsiveness in a couple). Feedback loops by their nature can quickly lead to the release of too much energy (meltdown, meltdown).
A schematic of a long-term relationship
The presenter, Nickolas Means, talks about the stories that people tell about systems failures (he calls himself a “disaster storyteller”). This is where the interest for me as a therapist really kicks into high gear. Based on the work of Sidney Dekker, Means talks about ‘first stories’ and ‘second stories.’ The first story is essentially a assigning blame. Who failed? Who made the critical error? Means is at pains to show that if we look for human error we can find it but that we won’t learn much that is of use for avoiding future failures if we do. The Presidential commission into TMI could have thrown the operators on duty under the bus and been done but that wasn’t what they did and they learned a lot about the system as a result. People generally act in ways that make sense to them with the information they have even though that may lead to bad outcomes.
‘Second stories’ are about figuring out how a system failed given the assumption that people generally act the best they can, given their circumstances and knowledge at the time with the aim of improving the system to avoid a repetition of the failure.
Moving people from ‘first stories’ to ‘second stories’ is a big part of my work, getting people from assigning blame to thinking about what changes they could make so that they avoid a similar systemic failure.
A supervisee recently told me about a couple she had begun seeing. “It's the old story. The man wants more sex and the woman has less desire.”
It is an old story; once a relationship gets to a certain point the man desires sex, and the woman doesn't. How useful a story is it?
Rosemary Basson writes
Women’s sexual motivation is far more complex than simply the presence or absence of sexual desire (defined as thinking or fantasizing about sex and yearning for sex between actual sexual encounters)...
At the beginning of a given sexual experience, a woman may well sense no sexual desire per se. Her motivations to be sexual are complex and include increasing emotional closeness with her partner (emotional intimacy) and often increasing her own well-being and self-image (sense of feeling attractive, feminine, appreciated, loved and/or desired, or to reduce her feelings of anxiety or guilt about sexual infrequency).
1327-1328
Basson, “Women’s sexual dysfunction: revised and expanded definition”
For the systemic therapist there can be no such thing as a free-floating sexual desire per se, a sexual desire that exists outside of a context, independent from all the other systems in which a person operates, the bio-psycho-social stew.
Basson pointed out something important about women's desire; that women's desire is highly mediated by context. But what is latent in this observation is that desire is always contextual. We can see that most readily in women, particularly women when they get a little older and have been in relationships for a while. Men may not experience their desire as embedded in their context, but it is. We only see men as having sexual desire per se until the moment we realize that there is no unalloyed, pure, crotch-generated, hormonal surge of desire, totally separate from intrapsychic and interpersonal, social and cultural context.
“Thinking or fantasizing about sex and yearning for sex between actual sexual encounters,” ie desire – for any gender, any sexuality, for any place in the life-cycle or for any moment in the trajectory of a relationship - arises in a set of contexts that give it its shape.
The intensity of early experiences of desire, whether our own or as shown in the culture, mask more or less effectively its contextual nature, leaving us with an impression of some walled-off, pure desire, Basson's posited desire per se. But a fourteen year old boy's first sexual longings are as complex and as bound up with hopes, expectations, wishes as a fifty-two year old woman's. The difference is that in the case of the fourteen-year old boy, all those multi-variate, complex forces align to erase their own footprints as it were, whereas for the fifty-two year old woman the fact of desire being contextual is less self-effacing.
Everyone's desire is contextual. It is an artifact of certain kinds of desire that they are experienced or appear less circumscribed by context. A painting by Jackson Pollock draws attention to its paintedness. But every painting is painted.
I have been writing and thinking a lot about how people’s sex lives interact with the rest of their relationship over the course of many years. As a culture, coupled sex is almost always played for a gag or a tragedy. (Paul Rudd and Leslie Mann are hysterical, but they are also gorgeous and super sexy). Very rarely do we see long term coupled sex as sexy. It seems to squeak us out like seeing mom and dad. And yet the vast majority of sex that is being sexed is between people who have been together for more than 2 years.
The fear of being disgusting to one's partner is pretty powerful. Like the earth being hit by a comet, an ill-starred event, coming loose from the cosmic order. It is horrible enough to be sexually disgusting to a stranger who one never have to see again, but to risk being disgusting (and not in a sexy “you dirty, dirty boy/girl” way), perverse, shameful to someone we have to raise children with, share a mortgage with, go to see family for holiday dinners with, that is sexually adventurous.
When i ask couples about what they do together they will often talk about watching a show together. Sometimes they really enjoy this and sometimes they find it alienating and lonely. I wrote here about the ways in which couples attend jointly to something. The netflix example is a good one; are we watching jointly or are we watching the same show separately, each having our own experience? The two things can look alike. (Streaming services never show people looking disconnected by their experience but usually emphatically together).
Do you talk about what you are watching, during or afterwards? Do you notice one another’s reactions? When you see things differently in a show, how does that feel, are you hurt that your partner thinks Game of Thrones is great even though you don’t like it or do you talk about what you like and what you don’t so that you are both attending to something shared even though your experience of it is different? Does one person have to concede to the other’s view or are you able to move back and forth? Or perhaps your perspectives are so similar as to be indistinguishable?
My interest in shared attention comes from thinking and reading I have been doing about sex in long-term couples, particularly where people put their attention regarding sex; are they focusing on pleasure and desire or are they focusing on performance, their partner’s failings, the frequency (or infrequency) of sex? How do people in couples come to focus on these things and to what degree do they do this as a couple and to what degree do they do it as individuals? I have come to think that a couple’s sex life is largely an expression of attention. Dr Lori Brotto’s book is part of what has me thinking about this and it is well worth a read
Do you talk about what you are doing, during or afterwards? Do you notice one another’s reactions? When you see things differently in a sexual encounter, how does that feel, are you hurt that your partner thinks Game of Thrones role-play is great even though you don’t like it or do you talk about what you like and what you don’t so that you are both attending to something shared even though your experience of it is different? Does one person have to concede to the other’s view or are you able to move back and forth? Or perhaps your perspectives are so similar as to be indistinguishable?
A new parent watches their child’s gaze, waiting for the moment the child sees them. The infant also learns to watch their parent’s gaze and pretty soon they begin to track one another’s gaze; what do you see? What is that thing? Who came into the room? It is one of the earliest games a parent and infant play. There is a powerful satisfaction in attending together with a loved one. This is a developmental process but one that is developed dyadically, in great intimacy. I have written here about how intense our responses to a loved one’s face and in particular, their eyes, can be. But I have been thinking recently about the degree to which shared attention is a part of the life of a couple.
As well as being a meditation on identity and writing, D.T. Max’s piece, Magic Realism, in this week’s New Yorker is an amazing portrait of a marriage. After the writer H. G Carrillo died in 2020, his husband, Dennis vanEngelsdorp discovered that, except for his birth date and that he had four siblings, everything that his husband had told him about his life growing up was a lie. Carrillo was a fabulist or - less kindly - a compulsive liar.
But in Max’s telling vanEngelsdorp isn’t angry or even very hurt by his late husband’s lies.
He recalled that Carrillo had once told him he’d sold a vase they’d bought together for a big profit, but never produced the money. Shortly afterward, vanEngelsdorp found the vase in a dresser drawer. He described the terror on his husband’s face when he saw him making this discovery: “It was just so clear. There was panic in his eyes.” He decided then that he could tolerate some myths. “If you need me to believe that you sold the vase - I mean, why wouldn’t I give that to you?”
Every relationship involves some degree of selective attention. What is this vase doing here? Why wouldn’t I look away? A successful relationship involves some degree of mutuality in regards to attention; see in me (and in the world) what I want to be seen by you and see it the way I want you to see it, or at least don’t see it in a way that is injurious to me.
Lies particularly create the possibility to be the focus of negative attention, but most people who have been in a long-term relationship, even those who aren’t prone to lying, know the feeling of terror that they are about to be revealed to their partner as ugly, disgusting, contemptible. Many of us know the feeling of relief and gratitude when our partner tastefully looks at something, anything, else. That isn’t so different from the times in early courtship when we show our new love something we delight in and find that they too are interested (or at least willing to play along).
A client wants his female partner to perform oral sex more often. He has asked her many times over the course of their relationship and she has said that she really doesn’t like to do it. She finds it dirty (and not in a good way). It is a big turn off for her. He isn’t willing to leave the relationship over it but it really bothers him. And no, she doesn’t want to go to couples therapy. He asks the therapist, “How often can I ask for a blowjob before I am just being an asshole?”
Quick: What is your answer?
How did you formulate your answer?
How might it be different if the topic wasn’t sex? Or if instead of oral sex he wanted her to kiss him? Or to have anal sex?
How might your answer be different if the genders were different?
Does it make a difference if they have been together for six weeks, six months or six years?
When does advocating for something that is important to us turn into badgering or coercion? This question comes up in lots of parts of the life or a couple but it can be particularly provocative in the context of sex because power, gender and shame are so close to the surface. We also as a culture have a sense that the potential harm to a person and/or a relationship of being coerced about sex is greater than being coerced about other things. As therapists, we often encourage clients to assert their needs and wants, particularly in the context of romantic relationships. And of we think of ourselves as sex-positive therapists, we encourage people to do that in regards to sex. We also encourage people to set limits. The yin to the yang of the first question is “How bad does it have to be before I say, ‘Stop?’”
We can tell clients to ‘tune into their feelings’ but often people have conflicting feelings about another’s sexual requests/demands; I’m scared I’ll feel dirty later, I want to be accommodating of my partner, I want to be sexually adventurous, I resent that they are asking for what they want, I worry that my own hang-ups may be getting in the way of our shared fun etc. If our clients’ feelings were clear they would either say “stop” or “go.”
When clients are unclear about where assertiveness becomes coercion, or where accommodation becomes capitulation, therapists may apply a “I know it when I see it” approach, explicitly or implicitly applying their own standards (if you are tempted to tell a client “What your partner is doing is inappropriate” ask yourself if that might be a way of saying that you don’t like it). Or they may resort to tautologies; ‘well-differentiated people are assertive but poorly differentiated people are coercive.’
I think it is a misapprehension that there is a clear, bright line between these things. We can all agree on cases at one end or another but there is a lot of room for the therapists’s own subjective, value-laden ideas to come in in the middle. I find it one of the areas where I most struggle with how much or how little to bring my own values into therapy, because these questions “Am I just being an asshole?” and “How bad does it have to be?” are values questions.
Sometimes I hear from couples that they bought a sex toy in the hopes of reinvigorating their sex lives. Many of them find that the toys quickly end up in a nest of of tangled charger cables in the night-table drawer. Once upon a time, vibrators and dildos were called “marital aids” then they got restyled as sex toys in an attempt to connect them with play, enjoyment, fun. Play is a great intention to have for sex. Sex 'toys' may help to achieve that and if they do, that is fantastic, but they may not and sometimes they can hinder fun.
Orgasm isn't the goal of good sex
Sex toys such dildos, vibrators, butt plugs, cock rings, prostate massagers work by stimulating whatever part or the body they touch; usually the genitals or nearby, increasing and or changing physical stimulation. This can be good if a person's genitals need more or different stimulation in order to have a good time during sex. But that isn't the big missing ingredient to having more fun in bed for most people I work with. They want their sex lives to be more... more passionate, more dangerous, more sexy, more loving, more playful, more sensual, more rough, more something. Dan Savage once talked about being on a panel with the late Shirley Glass, a researcher and couples therapist. She said that the brain is the biggest and most important sex organ in a human is between the ears. Dan Savage asked, “But how do I put my dick in it?”. This is a deep sexual koan. People want a vibrator that will stimulate their sexual heart/soul/mind/brain. Stimulating the genitals is a very indirect way to “put your dick in it”.
Play
Toys and play have a complex and fleeting relationship. Many parents can attest to buying a toy which is neglected by their kid in favour of the box it came in. Imagination, flexibility in thinking and feeling, presence, a sense of capability and possibility are characteristics of play. That's also a pretty good headspace for a gratifying sexual experience. Stimulating the genitals or anus may cause more arousal or change or even intensify the quality of an orgasm but becoming hyper-focused on genital sensation is not the same thing as having a good time in bed. In fact, sometimes the former is the death of the latter. Intensifying physical sensation can cause a person to lose track of other things. That can be wonderful in the case of being swept away in a sexual experience. It can also be a distraction from other satisfactions that a wider kind of attention can bring. Many couples become like the hiker who is so focused on the map that they are not seeing the terrain, hyper focused on arousal and orgasm and unable to attend to emotional connection or play or desire, the less physiological but equally important parts of sex. This tendency isn't helped by the focus of modern sexological interventions.
Genital response has been the be-all-and-end-all of sex research for a long time. That is because it is relatively easy for researchers to measure erections or vaginal lubrication or ejaculations or orgasms, easier than measuring things like fun, sexy, adventurous, scary-in-a-good-way, dirty-in-a-good-way, whatever it is that two (or more) people are looking for in sex. Arousal and/or orgasm may be a part of that, even a big part but it does not have to be the goal of sex any more than reproduction has to be. The idea that the physical manifestations of arousal and orgasm are essential in sex is very ingrained in us despite a lot of evidence to the contrary. I have worked with plenty of couples where both partners have orgasms and they don't particularly like their sex lives. I have also seen lots of couples where one or both partners have very gratifying sexual experiences without having much vaginal wetness, or an erection or an orgasm.
The couples I see who want to work on their sex lives generally aren't having difficulty with the mechanics of arousal or orgasm. That is why I have never prescribed a vibrator for a couple to improve their sex life, nor do I prescribe particular sexual techniques. If I thought that might be needed I would refer the couple to a sex therapist or pelvic floor physio-therapist.
Prescriptions
People have a lot of 'shoulds' in their minds about sex: “I should lose weight to enjoy sex more”; “I should relax more”; “I should be more assertive”; “I should be less assertive”; “I should have an orgasm/give my partner an orgasm, a bigger orgasm, a better erection, a wetter vagina”. It makes it tough to be playful when you are ticking off boxes. Attending to a partner's pleasure is a good thing overall but it can definitely get in the way of play, like any other 'should'. On top of a lot of sexual obligation, many couples have a lot of other shoulds relating to kids, family, work. I don't want to add to a couples' feeling of sex as a bunch of things on a long list of hard-to-meet expectations and constraints. I use prescriptions cautiously in regards to sex, and always with the hope of creatingmorepsychological and emotional flexibility, more presence, more feeling of capability. Sometimes I prescribe a week or two of no-orgasm sex to see what they can come up with that feels like sex when they aren't oriented to genital stimulation. Sometimes, I get them to reminisce about times they felt sexy together or to actively fantasize about one another and to identify what they find sexy as a way to start to think and talk about what they want out of sex now. Sometimes I prescribe reflecting on how they would act if they viewed their sex lives as super resilient. Sometimes I prescribe a set time for sex, with sex defined very broadly as 'whatever feels sexy.' All of this with the caveat that they treat with curiosity whatever internal or interactional things come up that make it difficult to be sexual.
In short, we focus on fun, not on toys.
We have all learned a lot over COVID about 'asynchronous' learning, pre-recorded lessons as part of training or a class as well as mixed, synchronous/asynchronous learning. In the show Ted Lasso, Roy Kent the crusty newly-retired footballer finds his girlfriend Keeley masturbating to a video on her phone. The audience is primed to see an argument, but Roy takes it in fun and doesn't shame her but he is curious. He is surprised to find that what she is wanking to is the press conference where he announced his retirement from football at which he uncharacteristically sobbed uncontrollably. She finds his emotional vulnerability hot. Later, Roy hands Keeley her phone and headphones, cues up the video and goes down on her while she watches him cry.
Roy accepts that Keeley finds something about him hot that he disdains. He knows it will be hard for him to offer her that synchronously so he gives it to her asynchronously. What's more he joins in the fun synchronously. Keeley for her part doesn't view this as a cop-out. She is grateful and views his act as generous. She jumps into the moment with enthusiasm.
To my knowledge this is the first pop-culture depiction of a positive, monogamous mixed synchronous/asynchronous sexual/emotional encounter.
Ted Lasso takes place in a universe similar to our own in which people default to behaving kindly and generously with one another.
What if we could cue up the moment when our partners found us hottest and deliver it to them in a spirit of generosity? What if we could accept that our partners finds things hot about us that we don't particularly find sexy. What if we viewed that as wonderful rather than feeling unseen?
What if we leveraged asynchrony in relationships for connection rather than let awareness of our differences turn us off from one another?
I have become very interested in how couples therapists can better integrate sexuality into couples therapy. Sex is sometimes viewed by therapists as very separate from other elements of the relationship or else as a by-product of relationship rather than an important and complex sub-system of peoples relationship. I have been looking for professional writing about integrating sexuality and couples therapy and came across the work of the late researcher Harold Lief. That lead me to this gem. It feels both so far away and so familiar. I don’t know whether these folks are actors; they are so extraordinarily real seeming but they hit so many of the familiar points in this situation that it seems scripted. So much has changed since this video was recorded but so much has remained the same both in couples lives and couples therapy.
Clients often talk about finding their partner sexiest when that person is intensely engaged in something that they love; music, art, intense conversation. It makes sense. They are vital in those moments, they have a kind of intensity that is alluring, particularly if they are good at what they are doing. The musician is a great example. Is there anybody sexier than a rock musician?
This presents a problem. Interrupt the flow of the music to try to connect erotically and 1. the thing that made the other person sexy ceases and/or 2. the other person is deeply engaged with something and the interruption may feel very unsexy to them.
Another dimension to this paradox: Can I accept being the object of my partner’s desire? Amanda Luterman talks about Erotic Empathy; the ability to believe I am sexy to my partner. That can be a lot harder than it sounds. Is it easier for me to desire someone else when the focus of that intensity isn’t on me? Does someone else actively focusing on me erotically shut down my eroticism? If I find someone sexy while they are playing guitar but not when they are actively seducing me, how will I ever take yes for an answer?
Freier is a Yiddish word in common use in Israel. It’s hard to translate. Roughly it means “sucker”, but with a particular connotation; you aren’t a sucker because you are dumb or unlucky but because you follow the rules when everyone else knows that the rules are only for freiers. While a person might be proud to be called upstanding, moral, law-abiding nobody wants to be a freier. (For a great discussion of three possible origins for the word see Balashon’s post).
The word captures a complex set of tensions that people struggle with in relationships; familial, work, neighbourhood etc. People generally want to view themselves as good. But they also desperately do not want to be the last person upholding a norm that everyone else gave up on a long time ago. I roll my eyes or huff indignantly if one person cuts in line, but if there is no line, just a bunch of people shoving, then standing and waiting just feels foolish. If I am honest about how much I earn when I file my taxes I may feel good about doing my part, but if I learn that no one else is being honest, then I start to feel contempt for myself.
Philosophers have discussed situations in which collective action will offer a big benefit but individuals may act to pursue lesser gains at a cost to the whole. Two examples are “the Stag Hunt” or “the Prisoner’s Dilemma.” In those scenarios if someone loses, the loss is material and the players have no way of communicating with one another.
But I often see couples facing “the Freier Problem.” They can talk to one another. The material costs of investing in the relationship are relatively low and the material costs of getting their elbows up and fighting more is high. Yet each of them sits there looking at the other person to make changes. Why double down on behaviour that they know hurts the relationship?
When I ask people they say; “It will be so humiliating to be the only one working for this relationship.” And that is what makes Freier problems so tough. The cost of being a freier is psychological more than it is material. A much more important force than material loss is at stake; the fear that I will despise myself or be viewed with contempt by my partner or my community.
We are facing a whole variety of Freier Problems as a society. Public health measures against COVID-19 are a perfect example. Yes, there are real costs in either complying with restrictions or not. But much of what drives people is the fear of being seen as badly behaved or contrariwise, the fear of being a freier, being the last person to wear a mask, to stay home from work, to maintain social distance.
- Compassion for self and others
Sometimes we mistakenly think that the choice is between a bad situation and a better situation if we just kick ass hard/often enough. If you have tried frequent, emphatic asskicking and it hasn't worked, consider that the choice is actually between a bad situation and a bad situation made more unpleasant by a lot of ass-kicking. -> you are hereby forbidden to use any part of this material for self-recrimination. * Improving sleep
Regular bedtime and wake time
Your bed is for sleep, not for work or fretting
If you are awake for more than 20 minutes move to a quiet spot, read a book until you find you are nodding off
No screens in bedroom
No screens 45 minutes prior to bed
Reduce caffeine, alcohol. * Time outdoors, preferably in nature. Plan for winter. * Regular exercise * Reflective practice.What it looks like
regular
attendance to inner states while serving to “unstick” us from inner states
can be; regular exercise, prayer, meditation * Reduce drug use
includes caffeine, pot, alcohol. * Work hygiene
if you have trouble getting started, begin with 20 minutes of work
have work hours and a quitting time
have a dedicated work space
work outside of your home if possible * Social media (if you must)
take frequent breaks, you can always go back to it if you want after 1/2 hour * Managing worry
Compassion for worrying parts of ourselves; they are doing a very important job. They need coaching.
Office hours for worries. “The office is closed. Please come back at 10:45 tomorrow morning.”
Describing; “I am feeling worried”. “I am thinking about my exams.”
Write worries on stickies, place them on a piece of paper divided in half; left side is “In my control.” Right side is “Out of my control.” If there is a worry that you want to put in between, subdivide the worry until you are clear about what is in your control and what is not in your control
Worry as “dealing”. Am I mistaking worrying for doing something useful?
Set times to revisit decisions. Don't rehash at unscheduled times. * Maintain connections. * Don't focus on happiness, focus on doing good for yourself and others.
When I was training to be a couple and family therapist, a beloved teacher of mine, the late Darrel Johnson, said that young therapists often go into a first session with the idea that you need to be super deft and subtle because a family or a couple is such a complicated and delicate system. “But after fifteen minutes, you realize that you could set off an atomic bomb and they would still be having the same arguments they have always had.”
It is funny how much doing therapy during the apocalypse is like doing therapy the rest of the time. The people who were ambivalent about their relationships before are still ambivalent. The people who were stuck or angry because of childhood trauma or neglect are still stuck or angry. Workaholics work too much , they just do it from home. People who nagged, nag. People who shut down, are shutting down. I reflect on this to clients sometimes; “Wow. So much has changed in the world around us, with all of us having to face how contingent our lives are, how little control we have over so many things, and you are still FILL IN THE BLANK. What can you tell me about that?” Which of course, is me doing my therapist things, but harder; “How did you feel when Karl said that he is the one who always has to fight the zombies?”
Two examples from the larger context:
In the midst of a pandemic that has hit the Montreal health care system particularly hard, in the CIUSSS where I work, we got a new form to fill out. I was amazed. In the midst of an all-hands-on-deck sirens-blaring DEFCON 5 emergency, someone said, “What we need is a different form for telehealth interventions.” And someone else made it. And somebody checked the translations. And a committee had an agenda item during a zoom meeting and approved it. This when they cannot get enough people to go and work in old-age homes.
The second example; a week after protests erupted all over the United States because a policeman killed a black man by kneeling on his neck during an arrest, another cop was filmed kneeling on the neck of someone he was arresting in Seattle. People in the crowd shout at him to stop. They shout over and over again, enraged at what the cop is doing but also amazed at the obliviousness, the determination to do the same thing that got us all here. He cannot or will not change. A whole country is on fire because of this and not only does it not prompt him to change, chances are, it probably deepens his commitment to his stereotyped response.
Probably there are people who gained a whole new perspective on their problems because of COVID out trying to live their lives differently and not coming to therapy. One client told me as much. “My stuff with my partner seems like pretty small potatoes now.”
But so much of what I see both in my clients, in myself and in the world is a dogged determination to do the same thing but harder.
A client of mine who is a recovering addict once told me that in 12 step programs they say that the brain that got you into the problem can't get you out. We repeat our patterns even when it becomes ridiculously clear that what we have always done isn't working. The Quebec and Canadian governments have announced spending for mental health programs related to COVID-19.
I am glad when society recognizes the importance of mental health but I am sceptical that the brain that got us into this mess will be able to get us out. If a mental health pandemic is the likely outcome of COVID, governments will no doubt be as well-prepared as they were for the first one.
I have been getting come-ons asking me to work for some big consortium or another as a therapist. They are gearing up to fill government contracts. Private companies such as employee assistance programs will get lucrative government contracts to deliver short-term, manualized therapies, like cognitive behavioural therapy, much of it on-line. Such a program - iCBT- is already being fast-tracked here in Quebec.
Governments use a medicalized approach to mental health because that is what they have always done; they use the brain that got them into so much trouble in the first place to try to get them out. A medicalized approach means dealing with something when it is already a near-disaster and hoping you can shave a few pennies off the enormous cost. Trying to scrounge up PPE, finding ventilators, drafting health-care workers to come back to jobs when they are scared. This is the equivalent of giving somebody triple bypass surgery when they are gravely ill due to preventable coronary disease. This medicalized approach is hugely expensive, so governments and health care funders such as insurance companies cut corners wherever they can, which means bad outcomes on top of poor planning. It is the epitome of penny-wise pound foolish, and about as scary as that other Pennywise.
A public health approach, by contrast, gives people at risk of coronary disease access to gyms, healthy food, smoking cessation programs etc. It means building long-term care facilities that actually deserve to have the word “care” in their name and having a well-trained workforce that can make a good living off of their work so they don't need to work at two or three jobs etc.
We know what promotes mental health: stable, affordable housing; loving relationships with emotionally healthy people; loving, positive communities; a sense of purpose. And when things go wrong, we know what makes for good therapy: a therapist who forms a solid, caring relationship with a client, who works towards the client's goals, and who attends to the relationship. Not rushing clients through a prescribed series of exercises. Not attending to a manual rather than a person.
It is expensive and takes time and creativity to build a society that offers quality low-cost housing in livable neighbourhoods and lively, caring, inclusive communities. It can take time for a person to feel heard and cared for enough by a therapist (or a family doctor or a teacher) to talk about what is hurting. Government will cut mental-health promoting programs and pay big companies that say they can fix a hundred people with anxiety or depression as if they were manufacturing widgets. I know because that is how they have dealt with health for 20 years. That is how we have arrived at such a disastrous situation today in Quebec. If past behaviour is any guide, these companies will deliver off-the-shelf therapies in 12 sessions at the low, low cost of only $2000. That's cheap when you compare it to10 years of subsidized housing for a family with young kids. But the cost of medicalized responses to mental health care add up quickly over a lifetime. They come when the problem is already harder to treat. For the cost of four courses of short term manualized psychotherapy, two psychiatric hospitalizations, two courses of addiction treatment, a year and half of anti-depressant medication and a three-month burnout leave from work you can buy a lot of subsidized housing.
You don't fix problems of human connection by building a less connected, less humane society.
A client recently pointed me in the direction of Diana Fosha and her work on trauma recovery. She comes from a psychoanalytic perspective which is very different than my own training and orientation, and I didn’t know anything about her so I went online and did a little digging. I read a little of her work and I saw that she has her own method called Accelerated Experiential Dynamic Psychotherapy (AEDP).
I really like to hear a therapist talk about their work. It is hard for me to take seriously the insights of a therapist who seems like a jerk, to whom I wouldn’t send a friend or loved one. Hearing the person talk gives me a sense of what it would be like to sit in a room with them as a client. I found this example.
She was warm and personable and very smart and it seemed clear that she spent a lot of time with actual clients and was not solely involved with research. I left the video on while I tidied up in the kitchen. At 7 and a half minutes she said something that made me put down the dishcloth, go over to my computer, and scan back and really listen. And then listen again. She was talking about therapist neutrality and she said: “You can’t do affect with a still face.”
There is a lot in this. Affect is the outward expression of emotion, both what a person says verbally about their mood and all the subtle clues we give off about how we are feeling. So right away she is talking about a therapist who isn’t only focussed on what I say about how I feel but on what I express about how I feel, unmediated by words. One of the limits of talk therapy is talking. It seems pretty evident that some stuff in our minds is harder to get at by talking. Most people have the experience of trying to share an experience with someone else and finding words are insufficient. Therapies that rely only on talk miss important dimensions of human experience. Unfortunately, many manualized therapies are very cognitively oriented, so they often leave out what is harder to articulate or even inarticulable. Psychoanalytic therapy is notoriously ‘talky’ as the client or analysand talks to the quiet, almost silent analyst and slowly, slowly moves to articulate what has been unarticulated, the realm of affect.
The still face is a reference to Ed Tronick’s work on attachment. Briefly, Tronick developed the still face experiment as a way of evoking attachment responses in infants by having the mother show no affect. The video can be hard to watch, so be warned.
Fosha is connecting the affectless parent in Tronick’s experiment to the neutral therapist who refuses to engage on an affective level with a client. This prompted me to think about when I do and don’t connect affectively with clients, when I allow myself to be an engaged, caring part of a two person system, and when and how I hold myself back. It can be hard, now that I am doing therapy remotely, showing concern, caring, warmth to a screen or sending positive regard through a telephone line. Watching this reminded me of how healing the presence of a caring, capable other can feel.
I work on a Mac. I know that when I look at my client’s face, I am not actually looking directly at them and I worry about deepening what can already feel like a gulf. But above my screen are the little round green light and round camera lens. We are so hardwired to find faces that if I squint my eyes, the two odd circles can look like a mismatched pair of eyes, my client’s real eyes, not their virtual eyes. That’s where I look sometimes when I particularly hope to pierce through the ether and isolation and send my client closeness, warmth and regard in the hopes of healing.
I like goals in therapy. I tend to be more directive than other therapists and I have had plenty of clients who have benefitted from 6, 4, or even 1 session of therapy. And I have seen the opposite; people who continued in therapy after they have had as much benefit as they are likely to get.
We are all confronting how much patience we do or do not have and how our just-in-time, efficiency-oriented society has left us collectively and individually under-equipped to meet the medical and psychic challenges of corona virus. This article by Jonathan Shedler and Enrico Gnaulati seems particularly apropos in identifying how penny-wise-pound-foolish thinking in health care, and a general culture of impatience, has pushed psychotherapy away from long-term therapy even when it is indicated.
Academic researchers promoting brief manualized therapies tell us therapy is finished in 8 to 12 sessions. But if we believe the expert therapists—psychologists and psychiatrists of diverse theoretical orientations with an average of 18 years of practice experience—meaningful therapy has barely started.
Sometimes when governments or insurers seek to save money in health care, they end up making an efficient system for achieving poor results.
A few times in my life, at moments of great emotional intensity, I have felt that I could not look at a particular person in the face. It was as if looking at them caused my eyes and mind to burn with a weird emotional fire so that I felt compelled, actually forced as though from outside my own self, to look away. It seemed to me in those moments that I was experiencing both my own and the other person’s emotions and hearing their ideas, not as voices, but as an unshakable certainty about how they saw me. In a milder form, sometimes looking people in the face, particularly making eye contact, can cause me an itchy uncomfortable sensation, or a feeling of intimacy, or both. This isn’t psychosis. In fact, it isn’t even unusual; I see other people react in much the same way all the time. Reading and responding to a face for signals about another’s mental states is a powerful impulse in infants that is probably biological prompted and that we retain into adulthood.
The psychologist Simon Baron-Cohen writes about how most humans, from a very early age and as part of a biologically driven process, develop a complex series of perceptual and psychological tools for “mindreading;” understanding first that we and other people have all sorts of inner states and second, for making good guesses at what those inner states are and finally for understanding that different people will have different inner states. We have a powerful natural drive towards psychology. This is also sometimes called “mentalization.” Baron-Cohen makes the case that much of this is done through paying close attention to another’s facial expressions, particularly, the direction of the other person’s gaze.
He posits that the sub-skills of mindreading are developmental. If you have a watched a 15 month old go up and down stairs over and over and over again, you know the power of development. Human (and other animal) babies at a young age spend a lot of time looking at other’s eyes to assess where they are looking. Later children will point at an object that interests them to encourage another person to share attention, then look back to see that they are looking both of which are ways for children to develop an understanding of what is going on in another person’s mind. They seem to do this without being taught to do so. Early on, we have an innate urge to build mental tools for accessing another’s mind via their face.
In many ways Baron-Cohen’s model of mindreading is similar to John Bowlby and Mary Ainsworth’s model of attachment; the biological drive of infants to form a mutual connection with a caregiver. Both are biological drives of early childhood towards a social and psychological model of the world. It is interesting that Baron-Cohen doesn’t connect ‘mindreading’ with attachment since it seems that one of the early important functions of mindreading is being attuned with one’s caregiver. It would also help explain the intensity of emotional responses people have to facial cues from their partners in conflict; these are attachment responses.
When couples fight, I have observed a curious thing often happens. They often become very preoccupied with their partner’s state of mind. “Look, he’s so angry right now. Do you see how she’s thinking that I don’t do my share around the house?” Sometimes when people are talking about very hurtful experiences from their past, they will assume the voice of the person who hurt them and take on the voice of that person, mimicking it and amplifying its negative tone, its hurtful cadences, pausing to add in what the person was thinking when they said this. They also tend to exaggerate the facial expressions of the person. They particularly echo or exaggerate facial expressions that connote contempt.
Consider the eye roll. Holy smokes, can an eye roll ever escalate a conflict in couple or a family. The couple’s therapist and research psychologist John Gottman talks about the corrosive power of contempt deployed in arguments, usually expressed non-verbally such as an eye-roll, to poison a relationship. I suspect that there is something about the primal nature of face/mindreading and attachment processes that makes negative facial micro-expressions, particularly the eye-roll so dysregulating.
Partners are very good at reading one another’s non-verbal cues, particularly fast, involuntary facial expressions, or “micro-expressions” and most particularly their eyes. We have the idea that when we see these negative micro-expressions we are seeing the truest expression of our partner’s feelings about us. People believe that because these expressions are largely involuntary they have more weight than all the voluntary, willed behaviours of the other person, such as offering support or kindness. In this weird emotion-logic of arguments - ‘what is not willed is more true than what is done deliberately’ - the eye-roll has a special place because it is partially but only partially, involuntary, a silicon semiconductor of micro-expressions. A hurt partner can understand an eye-roll as both a willful act of cruelty and a revelation of a partner’s hidden contempt for them.
I once read a psychologist refer to “hypermentalization” meaning over-interpreting another’s mental states, particularly negative mental states. They went on to joke about “excrementalization;” meaning a shitty ability to read another’s mental states. That’s what we do when we are in a fight with our partner; we excrementalize. We tend to accurately see negative expressions that cross our partner’s face but completely miss or minimize expressions of neutral or positive mental states. If my partner thinks “I’d like to strangle him,” and that causes her to raise her eyebrow in a way which betrays her thought to me I don’t credit her for NOT SAYING a hurtful thing, for refraining from being nasty. If she then sincerely says, “I love you and I want to work things out” both in words and in facial expression, I will probably remain focussed on the eyebrow-raise as a true expression of her emotion and the rest as unimportant or even more destructive, as a lie.
If you understand from your partner’s look that they are pissed off or resentful of you, it may be useful to remember that your understanding of their expression may be very accurate, the product of a well-built and primal system for mindreading and checking on connection to the one you love. But it is almost certainly incomplete. When we are in conflict, with our attachment responses pumping and our mindreading on high alert for negative we see, correctly, that the glass is partially empty, and reject the 93% that is full. In that circumstance, force yourself to look for information that may disprove your idea about your partner.
In the last few weeks I have seen clients struggling with a lot of internal division. These are people who are pretty self-reflective and for whom examining their actions and their motivations is an important part of their identity. These are good qualities but like all good qualities, they can be carried too far. I get to see from outside how they can end up hamstringing people.
We know about the trap of black and white thinking but there is a self-reflection trap that sometimes causes people a lot of grief. I think of it as Progressive’s Pachinko. In the Japanese pinballish game the ball is continually bouncing off one nail or another, unable to pursue a clear course, like Bob Dole/Dan Savage’s phrase “A liberal is someone who can’t take their own side in an argument.” People with a progressive outlook can often get hit with this pretty hard, rehashing in their own minds the ethical implications of every decision. They are often uncomfortable with hierarchical decision making, even in their own minds.
I definitely identify. I had a dificult decision to make recently. It was a decision that had some important implications for me. Every ten minutes, I would ask myself what I should do. I felt like my clients feel; stressed and angry at myself because it felt self-inflicted.
So I used for myself a process that I had stumbled on with clients. First, I asked, “Have you already made a decision that some part of you is having difficulty catching up with?” It turned out I had. I had decided, but I felt apprehensive about my decision. People can spend a lot of time and energy trying to maintain the idea that they haven’t made a decision when they already have.
Second, I asked myself if there was any new information or perspectives on the issue that merited re-examining the decision that it turned out I had already made. The answer was no. So an emergency meeting of the executive committee of Jeremy Wexler Global Enterprises about this decision would not bring a different result but will bring more worry.
Third, I set a date to convene the executive committee to review the decision. It turned out I had made a decision even though I was having a hard time acknowledging that I had. Making a decision can bring some peace, but living in my head it was like trying to work in an office where people were constantly rehashing questions that were settled at the last meeting. “Maybe we should try it this way.” “I still think we should have gone with plan C.” These different voices have important stuff to say. One part is in charge of being scared of anything new. One part is responsible for protecting my sense of independence. One part manages the division of me that dives into any new thing because the grass is always greener. They all bring something to the table. But they tend to be unruly, and will argue their various points all day long. But my wise mind is the boss, a really good boss, a boss who cares about everyone, who takes everybody’s perspective seriously and then makes tough decisions and implements them.
My wise mind had already listened to all the factors. It had already made a choice based on what I knew and what I felt. Re-opening the decision was only adding extra emotional friction. But, it was clear that some members of the executive committee still had serious reservations.
“Okay,” said the wise mind. “We already committed to this course of action for good reasons. I know some of you don’t like it but I expect everyone to give it an earnest try. We will reconvene the executive committee in three months on, January 10, when we will have some new information and we will check in about how this is going. I assure you that I am fully open to the possibility of changing course at that time.”
And that seems to have been enough to appease the dissidents.
A butterfly flaps its wings in Brazil and I worry about tornados in Texas.
One of the consequences of our globalized world and our expanding sense of our interdependence is the globalization of worry. Think globally, act locally is good advice, but is often misconstrued as worry globally and huddle in a corner locally.
What can you do about the rise of the alt-right? Climate change? Plastics in the worlds oceans? Do those questions make you feel empowered to go out and make a change or do they make you want to take a nap? Many of us have a sense of our very personal implication in combating these ills combined with a profound sense of powerlessness. We are told that we must “never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has” and then we are confronted with problems that seem to baffle the will of tens of millions of thoughtful, committed citizens. Perhaps we just need to be more thoughtful.
I have an analysis of why we get this mixed message, how it serves the very wealthy and the very powerful but this is blog about the mind. Suffice it to say that there are things we can impact and things we can’t impact and lots of the everyday, run-of-the-mill grief that I see comes from people mistaking which is which, coupled with common-though-odd, unexamined ideas about how we actually make an impact. (Hint: Clenching your jaw and shoulders while you scroll through social media posts about the approaching enviro-pocalypse does NOT reduce carbon emissions).
I am not a quietist. I believe in change, in action. But worry isn’t action. Awareness doesn’t have an impact. They may be prompts to action but in and of themselves they do nothing. And for many people, at certain doses awareness and worry become a serious hurdle to effective action. So. Think Globally, Act Locally, and Reduce Your Reliance on Worry.
Premier Legault announced that the government is going to review Quebec’s Youth Protection systems. I have never worked for Youth Protection but I have had plenty of chances to see it’s workings as an involved outsider. I hear patients/clients talk about how grateful they are that Youth Protection fulfilled its mandate and made sure they were safe from an abusive or neglectful parent. I see people who are furious that Youth Protection never became involved in their lives or stepped out too quickly and left them in a dangerous, destructive home situation. And I see people who are terribly hurt because Youth Protection intervened in ways that harmed them, exposing them to worse violence and abuse than they experienced at home.
I also see many parents who feel overwhelmed by the demands of parenting. Some of them, many of them, wish they had more support to be the parents they would like to be. The demands of parenting often become more overwhelming when people are faced with poverty and all the grinding daily indignities and difficulties that entails, which is also often tied up with classism and racism. A traumatic childhood of one’s own can make parenting even more challenging and it is my experience that many people who come seeking help to deal with difficult home situations were themselves in painful, destructive homes as kids. Others have mental health issues that they cannot get adequate care for.
Youth Protection is a very blunt instrument for dealing with the problem of families that are struggling to be nourishing and caring enough environments for kids. Any regime risks, on the one hand, pathologizing and further penalizing poverty, lack of skills or abilities and racial or cultural difference, and, on the other hand, leaving kids in terrible danger. We hear about it when kids die in their homes. We hear about it when racialized communities are targeted by the state and kids are taken out of their culture. People who have had helpful experiences of Youth Protection may - for very good reasons - not want to tell their stories, and we may not be as excited or mobilized by them as by the disasters. Most people also don’t hear about the people who grew up in homes where violence or neglect were a daily reality but who didn’t die. But lots of good enough experiences do exist.
We are asking Youth Protection directorates and workers to address a whole host of ills - individual psychopathology, family dysfunction, gaping holes in our care of mental illness, gender inequity, trauma history, addiction, poverty, racial discrimination, particularly the systematic targeting of native people - that are working at a bunch of different levels; individual, family, neighbourhood, community, city, province etc. Like the boy who sees every problem as a nail, we ask Youth Protection to deal with all of these super complex problems by handing them a hammer and then we are horrified when they misidentify a nail.
So Premier Legault, if you happen to read this article, let’s move away from how better to identify a nail and use a hammer. Expand the mandate of the commission to ask “What can we do at every level to help families with children do fabulously well?” Let’s be imaginative, hopeful, honest, kind and generous. You know, like a family.
Normative Masculine Marital Despair is the fancy name I have given a thing that I could probably do a research project on with 12 participants and then call it a thing-conclusively-proven-by-science, then trademark it and write a book and go on a speaking tour, but for now I will content myself with a humble blog post.
Never pick up a cat by the scruff of the neck
Many men, myself included, have moments where we feel that we are incapable of pleasing our female partner. Usually this happens when our female partner is telling us we have screwed up in some way. Sometimes we think, “Okay, fair enough, I blew it.” Sometimes we think “Hm. I don’t think that’s accurate. I think I did pretty well.” Neither of those is NMMD. NMMD is when we say “I will never be able to satisfy her. I will always get it wrong.” Women may have a similar feeling, but in my experience with couples most women may fear being a not being happy or that their partner will not be happy but it seems to me that is slightly different than fearing that you do not have the capacity to ever satisfy your wife or female partner. I have rarely seen a woman react in the ways that many men I have seen.
Margaret Atwood said “At core, men are afraid women will laugh at them, while at core, women are afraid men will kill them." Appearing incapable before one’s female partner is a powerful fear that subjectively holds some of the same terror of helplessness as the female fear of being overpowered and killed by a man. We can view this as silly and dismiss it or as so powerful that men should never have to experience it but I prefer to take it seriously as an element that may drive a lot of conflict in opposite-sex couples, but that does not have to.
This video may be a upsetting but it is a good illustration of the mammalian freeze reflex “freeze”
Lots of men take a deep breath, know that the feeling will pass and get on with their day. Some men get aggressive when they feel this way, some men seek to get away. Some men freeze. I once heard the feeling of hopelessly failing at marriage described as similar to a cat being “scruffed.” Not being a cat owner I had to go check it out and when I saw it I thought it was actually a pretty powerful analogy. Stephen Porges and others have theorized that extreme stress or the memory of extreme stress particularly when there is an element of helplessness or immobility can result in “dorsal vagal shutdown”, that is collapse. This is described as the same reflex that makes the springbok that gets jumped by a lion go limp when it senses that it cannot escape. Many men talk about feeling trapped, stuck or unable to breathe when they talk about this feeling.
When these responses have a lot of secondary gain, for example if a female partner backs off from asserting that something isn’t working for them, NMMD and the response may become more likely to recur. The feeling may also reactivate other, earlier traumatic experiences of being powerless from earlier in a man’s life which can amp up the emotional intensity of the response.
The reactions that can come out of this feeling can fuel a lot of crappy stuff in a relationship, as I think is probably pretty evident, particularly if they happen regularly. But feelings are always legit, worth noticing and breathing through. By calling it Normative I hope people will understand that it is common, both to take the shame out of feeling it and also to help men realize that while lots of other men feel this way, other men have figured out how to manage their responses to it in ways that don’t blow up their relationships.
Recently a lot of people have spoken to me about becoming therapists. Some of these people are just starting in the world of work and some are looking at second or even third careers. It occurred to me that it might be helpful to list some of the things I talk about with people who are considering therapy as a career path.
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Being a therapist can be really rewarding, stimulating and challenging. It isn't for everybody but if you are curious about people's inner workings, if you are reasonably compassionate, if you have a good mix of humility and confidence, it is a great way to spend your work days.
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Find out early what the licensing requirements are for where you are going to practice. I live and work in Quebec and it is highly regulated and the rules for practicing have been overhauled in the last ten years. A surprising number of people still spend several years in school with the idea that, "I'll figure that stuff out when I graduate." A school may be very happy to take your money and hand you a diploma that does not allow you to enter private practice as a therapist. It is on you to be clear about how to enter the profession. It can feel daunting but call the local licensing bodies and find out what EXACTLY is involved.
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Being a good therapist means running a small business. People will sometimes say, "I trained to be a therapist not a business owner," but when you are dealing with people's mental health, you need to respond to calls in a timely way, manage your time and your calendar, bill people appropriately and have a safe and secure way of keeping records. This stuff isn't rocket science, it is part of the job, so start learning how to do it.
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It is important to be able to leave work at work. It takes some time and some practice and for myself I can say that it has been easier at different points in my life than others. Not sleeping at night because your clients are going through something is exactly zero help to them and it is bad for you. Wash your hands at the end of the day, take a walk, say a little prayer when you turn off the lights in your office. Do something that tells your head or your heart that work is over.
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Whether you went to social work school, did a PhD in psychology or got a masters in counselling, you did not learn enough in school to be in private practice on your own. People will come in with serious psychopathology including problems that they will not describe clearly such as psychosis or mania. If you can, spend some time in inpatient psychiatry; it is really worthwhile to know what psychosis, mania, hypomania ad severe depression look like.
By BrocialWork on Etsy "A small reminder to take care of yourself or you won't be able to help everyone else. Remind your favorite social worker, therapist, nurse, emt, or other helping professional of the importance of self care. Be sure to put your mask on before assisting others."
I have begun to assess sleep routinely when I see new clients, particularly those with emotional or attentional problems. Sometimes sleep hygiene is the first area I work with on clients who are depressed or having difficulties with concentration or impulsivity.
It is very nice to look at the possible roots of depression in childhood or how poor attention is impacting a couple but the fact is that if someone is sleeping poorly, it is very difficult to make headway on feeling better in just about any other area of life. Poor sleep makes life hard for individuals and families and emotional and behavioural difficulties often cause poor sleep and then become aggravated by poor sleep.
I have two really good resources to recommend for people who are experiencing problems with sleep that are wound up with other things that might bring them in to therapy.
The first is The Sleep Help Institute's Sleep Help for Those Diagnosed with ASD (Autism Spectrum Disorder). This is geared to parents of kids with autism spectrum disorders and though it gives lots of detailed info about autism spectrum disorders and common sleep problems associated with it including a very readable review of the research on the topic, it also gives really good basic sleep hygiene tips for parents of kids whether they are neurotypical or on the spectrum.
The institute also has a Sleep Help guide for nursing mothers and shift workers, two groups of people who I often see who struggle with mood disorders and sleep problems. They also have areas for specific sleep problems such as sleep apnea. The "About Us" section doesn't give a whole lot of info to understand the Sleep Help Institute's funding stream. They do offer mattress reviews which I haven't checked out and can't evaluate but the sections on sleep problems and good sleep habits are blissfully free of merch placements.
The second resource is Ellen Forney's wonderful graphic-comic self-help manual "Rock Steady: Brilliant Advice from my Bipolar Life." Though Forney is writing from her experience as a person with bipolar disorder, so much of the book is useful for anybody who would like to live a more harmonious life. It is super invitingly laid out and illustrated. She talks about meditation, self-regulation, working with a doctor around medication as well as a whole section on sleep that is great, practical and easy for anyone to implement (I had one small complaint which was that she gives people who wake at night the option of having a small snack, which I always counsel people to avoid). I have this book in my office and have been showing it to many clients who are struggling with managing their emotions; the section on sleep is just one great feature of this great book.
Jokes about clarinets and porcupines. A very grumpy German philosopher. Discussion about a parent and a child who are very different. The very grumpy German philosopher's mother gets her say.
Some couples I see have what I call reality fights. Neither person is psychotic, neither has a brain injury but they can't agree about basic things relating to a fight they had last week. These aren't simply questions of perspective, they are disagreements about things that happened. And they are vexed about it. I want my partner to admit that events happened the way I say they did.
"You came downstairs, I was working at the kitchen table and you opened the fridge and you started complaining about the chicken."
"No, you weren't at the table. You were up in Keith's room."
"Can I finish? And then you started swearing..."
"I never swore."
"You did. You said, it was a 'fucking disgrace.'"
"I absolutely did not. And you weren't there so you don't know what I said, you only came down after I put the tupperware in the sink and then you started yelling about how I never clean up..."
Lather, rinse, repeat.
What is happening here?
Are we Pinky? The Brain? Or do we exist in the liminal space between?
In a recent previous post I wrote about research on how humans, from a very young age, seek shared mental states. According to the researchers we have a drive, evident even at 1 year old, to synchronize our minds with people around us.
We can't ever directly experience what happens in another person's head but we learn through a high-stakes, biologically driven life-long course of study to map others' inner states based on all sorts of outward signals, mostly without the use of language. What's more, these researchers contend that we don't just seek to know what others know, or to plan with others.
Importantly, joint attention is not just two people experiencing the same thing at the same time, but rather it is two people experiencing the same thing at the same time and knowing together that they are doing this (authors' emphasis)
We believe we know what is going on in the other person's head and we experience that not as a belief, but knowledge. 'Knowing together,' in the authors' evocative, mysterious phrase phrase, is a magic fairy dust that we sprinkle over our very detailed ideas, assumptions and guesses about other people's mental states is that we share them, that they are mutually held even when we haven't put them into words. This is particularly true with our romantic partners, we think we understand them before they even open their mouths, we assume that they know all information that we know and that they feel the way we feel, that they remember as we remember. We know together.
The Dalai Lama once asked a group of neuroscientists, "Where is mind?" It is a question that has a lot to it. You could try to answer in many different ways, but one dimension to that question is "How much of our mind is shared or shareable? What elements of our 'inner' state is social?"
What is most significant to me about reality fights is not that the couple remembers the incident very differently but how disturbing these differences are to them, how focussed they become on the details of where each person was, and what words were said, if the chicken was in the tupperware or already on the late. The couple having a reality fight is manifesting dissatisfaction at lack of attunement in their mental states. Different memories of the incident aren't unusual, but they are significant to the people involved, painfully significant, because they show that the two people feel that their mental state was not aligned and may still not be aligned. I seek to force you to see things as I saw them because, if you agree that the chicken wasn't in the tupperware when you came down the stairs, then we will be back in a shared mental state. Even couples that don't like each other very much do this. The only thing harder than being married to someone you know very well and don't like very much is being married to someone you don't like very much and who you don't know very well.
This is most remarkable where there has been an affair. The spouse who is betrayed is confronted in a profound way with the fact that what they thought was the couple's shared reality was partly illusory. While I thought we were a loving couple who were faithful to one another and sexual monogamous, you were sleeping with this other person. When I thought you were at work, you were in bed with them. The revelation that what I believed was a shared mental state was, in fact, not shared can be deeply destabilizing for people because the possibility of 'knowing together' seems not only to be gone, but to have become threatening.
To what degree are our feelings products of our social environment and interaction and to what degree are they uniquely inner states?
Sometimes when I am talking with a couple, I ask "How did you feel when that happened?" The person's response is "Disrespected." Disrespected is the most obvious example to me of words that both describe an emotion but also put it in the context of an interaction, something that happened to me, rather than purely an inner state. Think of frightened, disgusted, enraged, excited. They all have this quality of being both a feeling and a piece of an interaction.
Sometimes I think that this is a way of avoiding facing the reality of one's own inner experiences as well as the reality of another's behaviour. Saying "I felt disrespected" assumes another's motivations. It can also be a way of smooshing together a feeling, an interaction and an assertion about a standard of behaviour. We often do this when we have a hard time taking our own feelings seriously. Replace "I felt disrespected" with "I don't like how he treated me." Now the person who doesn't like how she was treated has to take seriously that her bad feeling may have importance not because it was disrespectful but because it felt bad to her. In case you haven't noticed, there is an important gender piece here; women are often the ones who talk to me about feeling disrespected. I suspect that saying disrespected rather than "I don't like it" has to do with women being told that their feelings don't matter. The message seems to be that it is okay to object to being disrespected, but it is not okay to object when you feel bad. I would say that for some people, it is important to relearn the lesson that feelings are important. It is important information that you don't like something regardless of whether it is disrespectful.
A similar recent phenomenon has been clients telling me they feel 'gaslight-ed'. While actually gaslighting is unusual, a lot of people, women in particular, feel that their partners don't take their experience seriously enough. But it is hard for these people to feel confident in the worth of their own subjective experience. It is not coincidental that gaslighting comes from a movie in which a man makes a woman appear insane; 'crazy' is one label that is often thrown at women who assert the value of their own subjectivity.
None of this means that our feelings don't have a social dimension to them. There is interesting research that shows that very young children have a drive to seek shared mental states with others. Attachment theory is one well-studied manifestation of the social dimension of human emotions.
All of this has implications for how couples succeed or fail; should people grow stronger boundaries between themselves, containing emotions, taking responsibility for their own feelings and managing them, or should we seek shared emotional states, emotional and psychological connectedness, interdependence?
Is disrespected a feeling?
An article about "How We End Up Marrying the Wrong People" in the Philosopher's Mail is wonderfully thought provoking, full of great insights and very wrong. I probably should agree with it since it recommends that people undergo lots of self-reflection and guided psychological processes before they get married. In fact, the last line is a call for "psychological marriages." Sounds like it would be good for business.
The good. The article -- which, oddly, is unsigned -- has many fantastic observations about relationships.
“We ‘project’ a range of perfections into the beloved on the basis of only a little evidence. In elaborating a whole personality from a few small – but hugely evocative – details, we are doing for the inner character of a person what our eyes naturally do with the sketch of a face.
We don’t see this as a picture of someone who has no nostrils, eight strands of hair and no eyelashes. Without even noticing that we are doing it, we fill in the missing parts. Our brains are primed to take tiny visual hints and construct entire figures from them – and we do the same when it comes to the character of our prospective spouse. We are – much more than we give ourselves credit for, and to our great cost – inveterate artists of elaboration.”
This is a lovely way of showing us how much we project onto our partners. I spend a lot of time with couples trying to get people to disentangle what they want or fear or expect from their partners, from what their partners are actually saying or doing or feeling.
“Prior to marriage, we’re rarely involved in dynamics that properly hold up a mirror to our disturbances. Whenever more casual relationships threaten to reveal the ‘difficult’ side of our natures, we tend to blame the partner – and call it a day. As for our friends, they predictably don’t care enough about us to have any motive to probe our real selves. They only want a nice evening out. Therefore, we end up blind to the awkward sides of our natures.”
In my experience, both personal and professional this is true. Couplehood can make us to examine our faults because there is a lot at stake. But is knowing oneself a prerequisite for a good marriage? Of course a publication called the Philosopher's Mail thinks so. Me, not so much.
The MistakeWhat follows from this smart, though pessimistic, view of human nature and relationships -- that a battery of psychological testing prior to marriage will enhance self-knowledge and knowledge of the other person and thereby fix what ails marriages -- is a mistake. A whopper of a mistake. A mistake on the order of picking a life-partner with eight strands of hair and no nostrils.
The mistake is that it both underestimates and overestimates what psychology is.
I recently saw a couple who had been married for 25 years in which the man was completely resistant to all my psychological blandishments, he wasn't hostile or 'in denial' or 'defended'; he just was completely uninterested in his own motivations. As he saw it, over the course of a long marriage, he had forgotten to treat his wife well and now he wanted a chance to do what she was asking for; more attention, more romance, more sex. I wanted to know 'why' but after three sessions he had changed and she was happy. The surgery was a disaster but the patient not only survived but felt much better. The lesson: Who cares 'why' if a relationship works? There are plenty of couples who are happy enough, for enough of the time that they don't need to spend a lot of time reflecting on it. (This is one of the great discoveries of John Gottman's research). It is easy to extrapolate from unhappy couples in a therapist's office to assume that all couples are unhappy. The dubious statistic (Philosopher's Mail, thankfully does not) about 50% failed marriages can re-enforce this idea (for why the statistic needs to be taken with a grain of salt see here). Even if we grant it for a moment that 50% of marriages will last sixty years, it is worth noting that the vast majority do so without without anybody ever stepping into a shrink's office. As I have remarked before, marriages, like people, are resilient. A realistically optimistic focus on individual and couple resiliency is honest and healthy.
The most serious problems people encounter in couples are not magnifications of the same problems they encounter in friendships or the work place. The reason for that is that a couple relationship isn't the same as other relationships. I see a lot of young couples, couples who have recently moved in together after a year or two of dating. They fight, they hurt. They come in bewildered because what they are experiencing is so different from what happens in the rest of their lives and what happened for the first year of their relationship.
From what I have seen, after a year or two in a relationship, if and when we feel safe with our partners people sometimes do something different than they do in other relationships such as friendships. My metaphor for this is: we come to our partner timidly, expectantly, filled with hope and reach out to them and offer them a beautiful silver platter filled with our shit. When we feel safe and loved and secure enough we bring out things that we haven't paid attention to or thought about or reflected on for years, things that we are ashamed of, afraid of, mistrustful of, don't have any idea how to handle. It is a paradox that the tribute of love is our own least loved parts. These are things that psychological testing won't discover. And our partner's reaction to us offering up our damaged bits can't be easily predicted.
Couples can and should talk about their expectations: money, career, housework, children, sex. People need to be honest with themselves about what is important in a partner but also need to know that will change over time.
I don't believe in compatibility so much as I believe in kindness, flexibility and positivity. Those qualities will see couples over a lot of hard stuff including a lot of incompatibility.
Nobody knows why therapy helps. We have theories but no solid understanding of the mechanisms involved and we probably won't for a long time. Therapy isn't alone in this. Nobody knows, for example, why SSRIs, a commonly prescribed class of anti-depressant works either.
André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."
We do know that for certain categories of psychological problems -- some couple and family distress, mild to moderate depression or anxiety, certain personality disorders, and some psychotic disorders -- psychotherapy helps a significant portion of people and has minimal down sides (there are possible negative consequences to therapy some of which I discussed here).
These two points -- that therapy works and that we don't know why it works -- are important to emphasize because government and private insurance are increasingly involved in the practice of psychotherapy. An example; this week the Order of Psychologists of Quebec announced that it is proceeding against two people for practicing psychotherapy without a license. Here, in Quebec, since 2012 you must have a license from the Order to offer psychotherapy, which is defined as follows...
“A psychological treatment for a mental disorder, behavioural disturbance or other problem resulting in psychological suffering or distress, and has as its purpose to foster significant changes in the client’s cognitive, emotional or behavioural functioning, interpersonal relations, personality or health. Such treatment goes beyond help aimed at dealing with everyday difficulties and beyond a support or counselling role.”
Clearly, the provincial government is taking psychotherapy more seriously. Also it is clear that it is hard for lawyers to write a good definition of a process that we don't understand very well. How far in can the government wade? So far it has been restrictive legislation. André Picard of the Globe and Mail, who writes as well as anybody in Canada about psychiatry, mental health and mental illness, has written a very good piece aimed at beginning (again) a discussion around the funding of psychotherapy through public health insurance. Currently, no provincial government funds non-MD-provided psychotherapy in the same way that it funds medical procedures. Here in Quebec, non-MDs -- psychologists, social workers, creative arts therapists sexologists etc. -- who work as psychotherapists in the public sector get paid a salary through their institution, they don't charge per procedure. They are also increasingly rare. The vast majority of out-patient psychotherapy is provided by private practitioners for whom clients pay out-of-pocket and either get reimbursed by their private insurance or not. This means that people who might greatly benefit from psychotherapy but can't afford it are unable to access it. The more seriously mentally ill a person is the more likely it is that he or she is poor, and the less likely it is that he or she has private insurance so this way of delivering non-emergency mental health care is seriously off.
I like the idea of people being able to access psychotherapy regardless of income. But I have some serious reservations about the idea of public health care funding for psychotherapy.
- Psychotherapy is one thing that can help with mental illness. There are lots of other non-medical treatments that can help the mentally ill: stable, supportive housing is a big one; case management is another. If we want to spend billions helping the mentally ill do better in the hopes that we will benefit as a society, we need to take these two as seriously as psychotherapy and medication.
- It can be a bonanza for some and create rich, entrenched interests that distort psychotherapy. Research into psychotherapy can make for very dispiriting reading. It often looks like this; I have developed Wexler's Wonder Therapy (TM). I test WWT (TM) on people with depression by giving them 8 sessions. I exclude from my study anybody who has a drinking problem, couples problems, a history of childhood trauma, depression that has been treatment resistant or anyone with a cat because these other factors would confuse the research. I begin with 15 people who meet these criteria. Six drop out. Of the remaining nine, six experience greater relief than they would if they were on a waiting list. Wexler's Wonder Therapy (TM) is 67% effective! It works on non-drinking, non-childhood trauma, non-treatment resistant, non-cat owning depressed people in only 8 sessions so it is incredibly cost effective. It becomes the treatment standard for psychotherapy for depression. I will train clinicians in WWT (TM) for a mere 1200$. With that money I prove that WWT (TM) is also effective for anxiety and couples difficulties. And so on. This is not to say that psychotherapy isn't effective. It is. But for many conditions there does not seem to be much daylight between different therapies. And people are a lot more complex in clinical settings than in research trials, which means that claims to deliver highly-effective, short-term psychotherapies are often over-hyped.
- Psychotherapy isn't medicine. These difficulties come of trying to shoehorn psychotherapy, and psychological care generally, into a medical model. Psychotherapy is connected to medicine because of its origins and because there is real overlap, but it isn't the same thing and trying to use our health-care system to pay for it means putting a square peg in a round hole.
- It seems very unlikely to happen. Quebec is in the midst of cutting hundreds of millions of dollars from its health care system and psychiatric outpatient care is being hit hard. Proposals to take on additional expenses seem likely to be DOA here and elsewhere.
I want to ensure that people who need non-emergency psychological care can get it regardless of income and at the same time maintain a practice of psychotherapy that is flexible and not overly bureaucratized. Here is a suggestion: borrow from the Americans, specifically Obamacare. Rather than expand Medicare to include non-hospital psychological treatment, require private insurance companies (which are making billions of dollars a year) to offer all Canadians 25$/year mental health insurance plans. No cherry-picking, no pre-existing condition exclusions. All plans must cover the cost of non-hospital services like psychotherapy, case management and emergency supportive housing. Require all Canadians to have a mental health insurance plan. Plans that do a good job of keeping policy holders out of hospital for a year get a portion of the cost of saved hospital psychiatric care. Incentivize non-hospital based psychological care and let groups of clinicians experiment with what gives the best results. This is probably more likely to happen than provincial governments finding a few 100-million$ a year in spare change at the back of the couch and might preserve some creativity and flexibility in psychotherapy as well as ensuring non-psychotherapeutic treatments are on the table when necessary.
Prof. Heather Macintosh spoke last week at McGill on Childhood Trauma and Emotional Regulation in Psychotherapy. She was talking about shame and jokingly differentiated between "felt shame" and "dinosaur shame," primordial shame at a level largely inaccessible to language or cognition. She talked about the difference between feeling shame and shame as an identity.
Shameosaurus (a.k.a. "Afrovenator abakensis dinosaur" by Mariana Ruiz Villarreal LadyofHats - Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Afrovenator_abakensis_dinosaur.png#/medi /File:Afrovenator_abakensis_dinosaur.png)
I am curious about how emotion, intense emotion, our own, or another's can overtake our sense of self. Virginia Goldner, who I have mentioned before, talks about how anger, for violent spouses, can often feel dissociative. Emotion can displace a sense of self for a while; the person becomes lost to him/herself through emotion. This reminds me of the line in the final scene of the (exploitative, yucky, though gripping) film "Seven," where the killer, John Doe, played by Kevin Spacey, urges the hero to "become Vengeance, become Wrath." The conceit of the film was the Catholic doctrine of the seven deadly sins being incarnated in different people, but that line, and the experience it encapsulates of a self- and world-eclipsing embodiment of wrath reminds me more of Robert Oppenheimer quoting the Bhagavad Gita "Now I am become Death, destroyer of worlds" when reflecting on the detonation of the atomic bomb.
Oppenheimer had studied the Bhagavad Gita and knew that the context was Krishna's injunction to Arjuna to destroy men in a cataclysmic battle, both friends and enemies with selflessness, for the sake of the Divine who had per-ordained their deaths. It is a wonderful encapsulation of the sense of the self vanishing in the face of forces that feel transcendent and wildly violent. As far as we know, no dinosaur ever experienced shame, either as an emotion or as an identity. I love the way "dinosaur shame" evokes how primordial shame and other intense emotions can be, prior to and remote from language, as well as the feeling of destructiveness they come with. But given that shame is a human legacy, -- "man hands on misery to man" -- perhaps a more accurate description would be from the other end of the time line; "atomic shame".
Science made tremendous strides in treating mental illness in the years between 1800 and the 1930. As Edward Shorter points out in his "A History of Psychiatry" perhaps the greatest challenge of 19th century psychiatry was neuro-syphilis. Nobody treats neuro-syphilis today with talk therapy or anti-psychotic medications because we know what causes it. In the developed world syphilis is treated with anti-biotics before it ever destroys a person's nerves and brain. But the days of simple cures for debilitating mental illnesses are over for the foreseeable future, though, for obvious reasons, people wish it weren't so.
Marvin Ross wrote a piece about evidence-based medicine versus alternative medicine in mental health care titled "The Only Thing That Will Improve Mental Illness Treatment is Science." Like Mr. Ross, I am opposed to using public money for treatments that not only lack a base of evidence showing their efficacy but have been shown to have no benefit. But I am also opposed to huge investment in research when known, effective treatments go begging hat in hand. There are plenty of things that we know help people who are mentally ill to live healthier, safer, happier lives. These are treatments that have been demonstrated to be effective in study after study; stable supported housing, case management, regular follow-up, early intervention for psychosis, psycho-education and, in some cases, talk therapy. As a society we don't do them. In fact, in most places in North America government is pulling away from offering these services at taxpayer expense.
If there is a limited pie of government money to be spent on the mentally ill, why do we persist in spending it to look for a magic bullet that will cure schizophrenia or autism or Alzheimer's when for the same money we could treat these diseases mitigating a lot of the worst effects of the illness? In the last forty years with all the billions of dollars in tax breaks and subsidies that has been spent on brain research there has been no significant clinical advance on the treatment of these diseases -- despite hundreds of breathless reports that a cure is just over the horizon. If you want to look for magical, non-evidence-based practices, spending public dollars on neuroscience in the hopes of an imminent cure for serious mental illness is akin to using Reiki to treat a broken leg.
I think there are several reasons we persist in this way of doing things. One relates directly to the rise of alternative medicine. Both Reiki and neuroscience journalism about fantastic breakthroughs in neurotransmitters appeal to a similar human impulse; the desire for a comprehensive and elegant solution to complex problems. But the low-hanging fruit of scientific discovery has been plucked already. Science has become so arcane that Clarke's rule that 'any sufficiently advanced technology is indistinguishable from magic' is true of most science today for most people. We may believe that we understand how our cellphones work but I am guessing that most non-scientists would have a hard time being able to say clearly where the limits of science (eg. the dubious theory that imbalances of neurotransmitters cause mental illness) leave off and where the limits of magic (homeopathy's dubious claims that microscopic amounts of certain natural occurring substances can treat imbalances in your body's chemistry) take up. Add to this the hiddenness of science which is increasingly conducted behind paywalls and the result is that most people have as strong a sense as ever that "scientific" means whatever a person in a white lab coat says and the only choice is whether to swallow it whole or reject it.
The other factor that is stopping us from treating mental illness as it should be treated is the fact that people don't get fabulously wealthy by giving home follow-up and nursing and psychotherapy and regular injections to the mentally ill. If reimbursed properly, a lot of people might live good lives working in these areas. Nurses and social workers, clinical psychologists and psychiatrists put more of the money they make back into the economy than executives and board members of pharmaceutical and medical tech companies. I am not convinced that we need to choose between good research in neuroscience and effective high quality treatment of the mentally ill. But spending on treating mental illness in the ways that we know work well is a much better investment as a society than chasing the unicorn of a single molecule to cure schizophrenia and incidentally make a few people fabulously rich.
Science can't fix our culture's obsession with quick fixes or our bent ideas about money and mental health. It is our collective responsibility to demand that public dollars be used where they will most benefit the mentally ill. That isn't Reiki but it also isn't putting college students into MRIs and asking them to read Jane Austen and saying you're looking for a cure to autism.
"There is a story of a certain pious man who forgot a sheaf of grain in his field [thereby allowing him to fulfill the commandment of leaving the forgotten sheaf in the field for the poor Deuteronomy 24:19]. He said to his son, 'Go and make an offering...' His son said, 'Father, what makes you so happy about doing this commandment more than any other commandment?' The pious man answered, 'The All Present One gave us all the other commandments in the Law to do on purpose, but this one [which involves forgetting] cannot be done on purpose.'" Tosefta Peah 3:8
I was re-reading John Gottman's The Science of Trust today in between various tasks of preparation for Passover, the holiday of interrupted memory.
“In 1922, a petite 21 year-old newlywed Jewish woman named Bluma Zeigarnik sat in a cafe in Vienna and watched as professional waiters listened carefully to huge orders from large gatherings without writing anything down. Then she watched as the waiters flawlessly filled their orders. Always the astute observer, Zeigarnik later interviewed these waiters. As they moved rapidly from table to kitchen to table, she found they remembered everything the customers asked for. However, when she interviewed the waiters after they had filled the orders, they had forgotten everything... This later was coined the ‘Ziegarnik effect’. It is defined as follows. We have better recall for events that we have not completely processed. Zeigarnik found that on average, there is 90% better recall for ‘unfinished events’ than for events we have somehow completed. ”
Paul Klee's Angelus Novus. Walter Benjamin said of this painting "His eyes are staring, his mouth is open, his wings are spread. This is how one pictures the angel of history. His face is turned toward the past. Where we perceive a chain of events, he sees one single catastrophe which keeps piling wreckage upon wreckage and hurls it in front of his feet. The angel would like to stay, awaken the dead, and make whole what has been smashed. But a storm is blowing from Paradise; it has got caught in his wings with such violence that the angel can no longer close them. The storm irresistibly propels him into the future to which his back is turned, while the pile of debris before him grows skyward. This storm is what we call progress."
Zheyna Bluma Gerstein was born in 1901 in Lithuania, in the town of Prenai. In one sense, that sentence tells you everything need to know of Bluma Zeigarnik nee Gerstein. To be born in that place, at that time, with the name Gerstein, was to be on a collision course with one of humankind's most ambitious projects in the obliteration of memory. Her work's title "Remembering Completed and Uncompleted Tasks" could be an understated, Proustian premonitory description of Europe and its Jews over the next 50 years. Bluma Zeigarnik was writing a fortune cookie oracle to herself.
She marred Albert Zeigarnik when she was eighteen. They moved to Berlin and she studied psychology with Kurt Lewin. "Remembering Completed and Uncompleted Tasks" was published in 1927 and she received a doctorate from the University of Berlin. Albert became a communist in the face of mounting Fascism. In 1931, the couple moved to Soviet Moscow. No more Viennese waiters with flawless memories. There she could not claim the title of Doctor since a PhD was considered bourgeois and ideologically suspect. She studied post-traumatic dementia and published little. She worked with two greats of Russian psychology, Lev Vygotsky and Aleksander Luria, both of whom eventually ran afoul of Soviet repression of unorthodox scholarship, Lysenkoism and anti-Semitism. Luria is famous among non-specialists for his case study, "the Mind of a Mnemonist," the story of S., also a Jew, a synesthete with a very nearly boundless memory who performed great feats of memorization in public, quickly looking at huge tables of numbers which he reproduced flawlessly. S. eventually encountered the difficulty of being unable to forget the tables of numbers. He was afraid that he would confuse the tables because he could see them all before his eyes long after they had been erased. He resorted to various devices, technologies for forgetting.
“[H]e began to throw away and then to burn the papers on which was written the material he needed to forget...
However the “magic of burning” did not help and one time, throwing the paper with the written numbers into a burning oven, he saw that on the remaining burned paper the traces still remained and he was in despair: it means that even fire cannot erase the traces of that which was supposed to be destroyed!
The problem of forgetting, which did not allow any naïve methods of burning papers, became one of the most tormenting problems with S. ”
— Ivan Samokish's translation http://fusionwriter.com/wp-content/uploads/2014/10/A-Small-Book-About-A-Big-Memory.pdf
In 1940, Albert Zeigarnik was arrested and sent to a prison camp for ten years. Bluma's time in Berlin and cafes in Vienna, her important work on memory which was now being celebrated and elaborated outside of Soviet Europe, all this was a liability. Central European psychology of the 20's with its bourgeois (not to mention, Jewish) flavour could not have been more at odds with Stalinist-Marxist materialism. She did not speak of it. She had two small children. To recall her past was to risk making her children orphans. When Albert was arrested, family papers were seized, the relics of her past disappeared.
She was sent away from Moscow to the Urals. Her grandson, A.V Zeigarnik, wrote a long and loving biographical sketch of his grandmother. In his telling, her life story in the post-war period becomes a series of ellipses and repressions of memory.
"After World War II, Bluma began to prepare a dissertation based on the medical studies she had begun in that period. But just as the dissertation was nearing completion, it disappeared. To put it bluntly, while visiting Bluma at her home, one of her coworkers at the psychiatric institute had stolen it. Bluma then promptly destroyed all the drafts. She was afraid that it might be published, and she would then be accused of plagiarism. Today, such a turn of events may seem implausible, even absurd, but fear is sometimes more compelling than clear thinking.
Other aspects of her research were simply not publishable. For example, among the experimental methods used in attempts at restoring a patient’s motor activity, the following was actually tested: A stand-in, dressed in a military uniform, announces to the sick person that he is a commissar. The commissar gives orders to the patient, the fulfillment of which could lead to the restoration (possibly partial) of lost motor functions. Today, no documentary evidence about such experiments has been preserved; nor is there any data about their reproducibility. But one thing is completely clear: In those years, one could find oneself in prison for conducting such experiments, whereas now it is no longer possible to repeat them, at least not in Russia, since there are no longer patients with such a reverent attitude toward commissars or other political figures.
In 1943, when Bluma returned to Moscow with her sons, she found her apartment had been robbed. While they had been living in Kisegach, the authorities had housed in their Moscow apartment an unknown and unpleasant person. For some reason, this person considered everything his own property, with the result that he had used the home library and much of the furniture as firewood for the stove. It is possible that part of the family archive vanished during this time. During this resident’s struggle for warmth, he tossed into the fire, in addition to the writings of scholars who were unfamiliar to him, all the publications of Marx and Engels to be found in the home. (Does there not seem to be something mystical in this unabashed materialism?) The writings by Lenin, however, remained. Bluma had to endure numerous humiliations, but, after the intervention of a military prosecutor, the apartment was returned, and she was then finally able to resume her normal daily life."
In a final triumph of materialist erasure, Bluma's one reflection that has been translated into English about the Berlin period is hidden behind Wiley's paywall. In 1984 she wrote a memorial for her old teacher Kurt Lewin on the occasion of his death. For 32$ you can read and print the reminiscences of a pioneer of the study of the human mind, fugitive from fascism and prisoner of Stalin about her old beloved teacher and mentor on the occasion of his death. She died four years later, to all appearances a loyal daughter of Soviet communism.
I imagine a ghost, the memory of an unfinished task persisting even after the body that contained it has gone; a waiter at a Viennese cafe, unable to forget, because she left before he could deliver her order, her odd meal, which he seeks to deliver year after year and which she can never receive; four cups of wine, three pieces of flat bread, like the poor people eat, a roasted egg, some bitter herbs, a shank bone, a bowl of salty water.
Roz Chast's Big Egg Lady. To see more of Chasts's eggs click on the image
"Do you think that you might be crazy?" It is one of those impolite questions that I get to ask that makes being a therapist fun and rewarding. When people come in to see me they are sometimes half-convinced that they are crazy. Sometimes people confuse the intervention with the malady. Smart people can have the unexamined belief that "If I take the pill, if I see the therapist that means that I am crazy." Recently, I've started asking more. A lot of people who come to see me are. Worried, that is. I guess whether they are crazy or not depends on what you mean.
People who have a personal or family history of mental illness are often very worried about being crazy, sometimes terrified. They may have a very particular idea of what mental illness looks like and be terrified that that's what's in store for them. Other people come in with a fear that is augmented -- with lots of good intentions and some greed -- by attempts to broaden people's picture of who can experience mental illness. On the one hand, attempts to destigmatize people with mental illness are laudable. On the other hand, hyper-sensitizing people to mental illness, encouraging them to view themselves and everyone around them as psychological orchids who need specialized interventions simply to survive in the world, is IMHO, plainly nonsensical, inimical to good mental health and partly motivated by the desire to sell us stuff (medicines or other therapies) that we don't really need.
I recently saw a woman who is a new immigrant to Canada. She is having difficulty learning French and is a new mother. She felt stressed, scared, overwhelmed, sad and very lonely. She had been prescribed anti-depressants and an anti-psychotic for sleep (the practice of GPs prescribing anti-psychotics off label without the simplest discussion of sleep hygiene is troubling to me). On top of everything that was going on in her life she was terrified that she was crazy. The persistency and intensity of the feelings, a family history of mental illness, her sense that she should be able to get over them and probably the fact that she had been prescribed medication all fed into her sense that she was going crazy. This is not to say that the anti-depressant was not appropriate. But it had a powerful meaning for her. When I asked if she was worried she was going crazy, she began to sob. She is scared to pick up her French classes again or try to find a job because she views herself as too anxious to take on anything new. She is becoming more isolated. I asked her if seeing me was going to make her think she was crazy because I did not think she was and I did not want to do anything that would give her that idea. If coming to see me would make her think she was crazy I would refuse to see her. Why? Because viewing herself as crazy was making her crazy(-er).
People have all sorts of ideas about what being crazy might look like and what it would mean. I saw a young woman the other day who wanted to know if she had Borderline Personality Disorder. First, I told her that I am not a doctor and I can't make a diagnosis. Then I asked her what it would mean if she did have it. She felt like then doctors would have some direction about how to treat her so that all the stuff that wasn't working in her life would get better. "And what if you are sad and lonely because important people in your life have been hurtful towards you for a long time? What would that mean?" "Then I'm just a screw up." Crazy might be better than the alternative; the frightening responsibilities of sanity.
It probably isn't very wise of me to admit this but I use the term crazy in my own head sometimes when I think about clients. Usually what I think is, "What a crazy thing to do." It means something like 'inexplicable and self-defeating'. In other words "Human." One thing I don't mean is "mentally ill." Mental illness to me means something is going on in the person's mind that is far beyond the usual degree of human irrational, self-destructive behaviour. I think what my clients worry about -- or sometimes even long for -- is being far beyond the human pale, unable to return, irreparably psychologically destroyed.
Resilient is the opposite of crazy in that sense. Child birth is messy, it is occasionally very dangerous. But our survival as a species up until the 20th century is incontrovertible proof that it can usually be done outside of a hospital. Similarly, the fact that humans are around at all is proof that we are well-equipped psychologically to deal with hard stuff, to suffer, to hurt, and be hurt even to go crazy and to recover.
I am glad to live in an age of medicine. I believe in therapy. Part of resiliency is having people around who can help you. But therapists also need to remember to 'first, do no harm'. And if the cure is worse than the malady then it's no cure.
Ginger Campbell host of the Brain Science podcast, after a great interview with Norman Doidge about neuro-plasticity, said that doctors often don't prescribe behavioral therapies because they have the experience of patients not following through (1:05:00). "Many patients would rather take pills than follow treatment regimens that require them to do most of the work themselves." I will write about Doidge at some point soon, but I thought a lot about Ginger's statement about homework and follow through.
Recently, I have been finding that the most interesting moments in therapy come when I ask a client to try something that he/she/they won't or don't do and we unpack that resistance. I have said before that on a handful of occasions, I have given people really good advice in therapy. But much more common are people who know more or less what they need to do to make changes in their lives but resist it for reasons they cannot fully understand.
I recently told a client who was feeling ambivalent about his marriage -- he couldn't commit to it and couldn't leave -- that he should try being fully invested in his relationship for 3 months. At the end he could still leave or stay or continue being undecided, but in order to see what the relationship might be, he should try actually working at making it good for a limited amount of time. He physically writhed at the idea. He almost began to twitch. What makes committing to the relationship, even provisionally, so hard?
I told a couple that they should spend ten minutes a day talking about something tough in the day and supporting one another. When I asked them about the exercise he said, "It feels weird because we see each other all day, she knows everything about my day." They began to see how her being available to him for almost all his emotional needs throughout the day was not so great for their relationship.
I told a client to meditate so that he could be a little more present to his partner. "Sitting still for ten minutes is my idea of hell," he said. She began to cry because she wants him to be able to be still for her. It turns out that he has missed some crucial hurt feelings of hers because sitting still with emotions is so painful for him.
People have reasons for not changing. Sometimes it is a cost benefit analysis: "This requires a lot of work and I don't have enough confidence that it will make a difference." I think a lack of confidence that medical science actually knows what is good for us is an important and neglected part of that cost benefit analysis. It is hard to take your doctor's prescription seriously if you don't think s/he understands what is going on with you and what you want. That doesn't come in 15 minutes. Sometimes the road to such confidence comes from taking the time to unpack what else makes change hard.
It is ironic that most doctors probably know that just prescribing behavioral change is unlikely to get people on board, yet they still do it. Another opportunity to ask the question, "What makes it hard to do this?" And perhaps the beginning of real change.
When I get a referral for my private practice I ask people if they have private insurance. If they do, I tell them to check with their insurance to see if they will be covered. As often as not, they won't be covered for my services as a Social Worker - Psychotherapist. Despite years of graduate and post-graduate training, despite the Quebec government's law 21 which requires all professionals practicing psychotherapy to meet the same rigorous standards -- not to mention additional fees -- in order to be licensed by the order of psychologists. The law does not require private insurance companies to respect the title of psychotherapist. It is frustrating as a business person and clinician to hear regularly, "I would like to see you, but my insurance won't cover me."
Let's leave aside for now the question of why psychotherapy is not covered by our public health insurance (I have written some about this here). Insurance companies aren't required to recognize the title psychotherapist even though mental health professionals are. This means additional costs for me, higher fees for consumers and a distortion of the market because clients with private insurance tend to go to psychologists, who often charge more than other psychotherapists.
The insurance industry could fix this. They know the law. They choose not to respect it. (It is impossible to tell which companies and which policies do cover psychotherapists and which don't because insurance companies keep the various policies they offer secret). The Quebec government could correct this. Private insurance is provincially regulated. The government could require insurers to respect the title of psychotherapist and reimburse clients equally whether they see a 'social worker - psychotherapist', 'a creative arts - psychotherapist' or a 'psychologist - psychotherapist'. They haven't. It is, after all, easier to pass legislation that affects hundreds of small, independent clinicians than to pass a law that would affect a few big and very wealthy companies.
If you care about this issue, I would urge you to contact your MNA. (as of writing this, Kathleen Weil hasn't returned my emails or my call. UPDATE: April 17, 2015. Got a form email a few weeks back and on April 8, after tweeting a lot about this, I got a call from a staffer who said 'we take it very seriously' though he didn't really seem to have any idea what I was talking about. He also said Ms. Weil's office would be in touch in a week. Hmmm.). If you hold a private insurance plan, contact the company and ask them if you are covered for psychotherapy by a psychotherapist. I would love to know. Tell your insurer and your employer that you want your insurance to respect Quebec's law 21 regarding the title of psychotherapy.
There is almost always a moment in couple's therapy (often lots of moments) where one or both partners says, "It's not fair." I am not talking about "it's not fair" relating to housework or money or other life tasks. I'm talking here about the cry of "its not fair" about the burdens of the relationship; "It's not fair that I always have to put my feelings on hold to listen to her." "It's not fair that I have to take responsibility for initiating every conversation about making changes." "It's not fair that I am the one always being blamed for not caring about us."
Couples will often stare at each other over an abyss of fairness waiting for the other person to initiate kindness, intimacy, caring or even simple friendliness.
It is easy to get into a fight over one of these statements that goes something like. "That's not true. I did ....... last Thursday." "Only when I told you to." "But I never get to because you are always telling me to before I even have a chance to." Or some other totally derailing fight that ends with them looking to me to adjudicate. Who is right? Who is more aggrieved?
The therapy is now in session...
I tell couples I am not Judge Judy. I tell them I cannot say that if he responds kindly 55% of the time then she must say positive things about his appearance 64% of the time. It is for them to decide what is enough. It is for them to figure out what happens when their partner doesn't deliver.
An obvious point but one worth bearing in mind: in couples therapy people don't generally say "It isn't fair, s/he is always putting my emotional needs first. I never consider her feelings and s/he is always attuned to what I want." This is a small hint that a search for impartial justice is not what drives most people when they say, "It's not fair..."
"Its not fair..." is often a way of saying a couple of things, a pair of contradictory messages and a meta-message. The first message is "I have something I want or need." The second message is "I shouldn't say that I want or need this thing." The meta-message is "These two contradictory impulses make me feel out of control."
People say it isn't fair when what they want is for the situation to be different. "I want my spouse to be more loving, I want my partner to initiate compliments, I want my girlfriend to take my feelings seriously." Why don't they just say that? Why do they appeal to fairness?
Often what they want or need feels primitive, childish. Harville Hendrix says that when people say things like "s/he always does this" they are experiencing time as a child experiences time; what is happening right now is what has always happened and always will happen. "It's not fair" usually has an "I always" or "s/he always" flavour behind it. The unmet, unarticulated desire feels primitive, childish.
There are two things that usually work in tandem to keep such desires from being articulated. One is, we are embarrassed. We don't think it is okay for us to say that we want to be loved more or that we need more appreciation or to be criticized less. It is childish, it is shameful, it is silly, name your poison. The other reason we don't say what we want in those moments is because it doesn't feel safe. If I say "I want more love," my partner may say "tough." Our partner's power to withhold keeps us from saying "This is what I want or need."
At that moment, we are bound between our two desires, unable to have the things we want and unable to get out of the situation. We imagine that some outside power will do what we cannot do; deliver our desire and protect us from the dangers of having to take our desire seriously. I think when people say "It isn't fair" they fantasize that I will say "You are absolutely right and s/he is absolutely wrong," then turn to their partner and compel him/her to want to freely and generously hand over the love/appreciation/caring.
Relationships are inherently unfair. Another person has the power to deliver or withhold things we ardently desire. On a whim. Not because of our actions or our merits or our character but largely because of his/her own wants or needs or impulses. In a relationship we confront our own insufficiency. Hopefully we choose a partner whom we trust enough to be generous enough with the things we desire.
"How about a nice Wensleydale?"
I broke down and did it. Between appointments, I wrote index cards that said, "Your partner's favourite band," "What your partner was wearing when you first met," and "Your partner's secret ambition." These come from a series of exercises developed by John Gottman called "Love Maps". You hand the cards to the client and s/he says what s/he thinks is the right answer or asks his/her partner. Gottman is one of the most prominent and serious researchers of couples ever. There's a whole lot of theory and research behind "Love Maps" but the first time I handed these cards to my clients, I cringed a little (I hope I did a reasonable job of hiding it).
My cringe went a little like this: "I went to graduate school for three years and then did post-graduate training for years afterwards. Now I am doing an exercise that feels like it has been clipped from Elle magazine."
Love Maps has a high 'cheese factor.' That kept me from using it for a long time even though it is an evidence-based practice for helping couples do better.
What is it about cheese? I rely on being able to offer people something they can't get from a popular magazine or an online quiz for my living and my sense of professional attainment. Not only that, coming to someone who they believe knows a thing or two, helps people feel safe, which is a prerequisite of a lot of the work of therapy. I worry that the pungent odor of cheese can destroy that confidence that my clients and I rely on.
Its not just me. My training has been aimed at instilling a sense that therapists have complex, scientific knowledge that allows us to serve as serious professionals with something to offer that goes beyond the self-help section of a book store. I think that is true. But I also remember what Sylvain and Elise told me (names are made up). They came every week to therapy and used it really well. But at one point they said to me, "You're nice and all and you're probably good at what you do but for us the metro ride over is the most therapeutic part of the whole thing. We never have a half an hour where we are just sitting and talking about what's going on with us."
Family doctors are highly trained professionals who spend a big portion of their time telling people stuff that their moms could have told them; "Have some soup and rest." "Stop picking at it." Sometimes you need a professional to tell you (because you won't listen to your mom). In plenty of cases the mechanics of having a loving relationship aren't rocket-science; be kinder to one another, develop affection, show caring, stop bad habits that drive one another away, pay attention to your own and your partner's feelings etc. What is hard is making the commitment to do it; taking the weekly metro ride over to my office may be some or even most of the therapy.
So now I don't cringe (much) when I take out the Love Map cards. Some couples roll their eyes and laugh at how cheesy it is and I laugh with them, but usually they smile at each other they laugh at one another's foibles or shared memories. When they do the Love Maps exercise, couples understand one another a little more. They have a little more feeling of affection after they do it. And despite doing something they could have done online or from a magazine, many of them find it worthwhile to come back.
Not doing things because they feel cheesy is actually a pretty big issue for some clients as well as for their therapist. Some people hate the idea that doing basic, pedestrian things is going to help them. (I wrote little about this here). As the therapist, I sometimes have to model that we can push past our impulse to eye-roll just like we can push past other things that keep us from doing what helps.
I would love to know your experiences of cheese in therapy. The person who sends in the best example will get ... hmmm. a lovely stilton? or perhaps a nice wensleydale? whaddya say Gromit?
Jess says, "I want him to be more understanding of my mental illness." I ask, "What do you want him to understand?" Jess: "How to talk to me when I am upset so that I will calm down." I ask Steve, "What does Jess look like when she is upset?" Steve hesitates. He doesn't know how much it is okay for him to say. "She can't stop moving. She walks all over the house for hours. She's talking, talking, talking." Jess says: "I know I talk a lot but I just want him to tell me its going to be okay. I know I get intense when I am upset but I don't think its that bad. Steve: "She talks super fast for hours at a time, till three in the morning. And I have tried touching her, she doesn't want to be touched. Everything I say is wrong. She's super irritable. She screams at me, sometime she throws things. Hits me." I say: "That doesn't sound like you were upset. That sounds manic. Or maybe a mixed depressed-manic. I don't think a anybody -- the best trained psychiatrist or nurse -- could talk to you in a way that would calm you down when that's going on. I understand that you want him to soothe you, to make it better in those moments but I don't think he can." (This couple is a composite of many couples I have seen).
People with mental illnesses can have problems in their relationships just like other people. (For my thoughts on the fluid and ever-expanding definition of mental illness, see here and here). But serious mental illness impacts on couples work in a few ways that can tell us some interesting things about all of us.
The first time I worked with a couple immediately after one of them was discharged from psychiatry, I spoke to the treating psychiatrist about trying to help the couple re-establish some sense of intimacy. He said something very wise. "Sometimes people who have psychotic disorders can't stand too much intimacy." Intimacy is the bread-and-butter of couples therapists, whatever our orientation. Help people feel a little safer, a little better heard and they will feel closer and more connected to their partners. For people who have had the integrity of their sense of self fall apart, being connected with another person can be an existential threat. It may be a human drive to connect with others, but it can also be something that threatens our psychological wholeness, not a small consideration if you believe your psychological wholeness is fragile.
Like just about everyone, the mentally ill want their partner to complete or heal the parts of themselves that are broken. Jess, in the composite above, wants her partner to keep her from being sick. A lot of people with mental illness who I have seen, want this from their partner, whether they articulate it or not. They long for their partner to save them from this serious and frightening condition. Cognitively they may know that it isn't realistic but they want it so strongly that it can be very hard for the relationship. Sometimes it can turn to blaming the not-mentally-ill partner for things way outside his/her control. This is tricky: stresses in relationships, hurts and frustrations, neglect and emotional abandonment, not to mention outright abuse can be very psychologically destructive. For someone with a mental illness, a cruel partner can make things worse. But I am clear with both partners that a loving supportive partner can't heal a mental illness, and a garden-variety jerk can't cause it. Mentally ill people need to take responsibility for getting appropriate care (for how difficult this has become see here).
I once saw a woman in psychiatry who was recovering from an episode of psychosis that had been induced by a side-effect of a medication. She was afraid about how she would remember the episode. She was worried that she would be humiliated, frightened and ashamed by how she had acted. I told her that in my experience many people don't remember episodes of psychosis very well. Like a bad dream, psychotic episodes are vivid and intense at the time and often evanescent afterwards (in particular if they are ego-dystonic, that is if they experienced it as troubling and contrary to their usually sense of self). I have seen this with mania as well. People are often amazed and doubtful about the descriptions of their friends and relatives about how they acted after the fact. I think this is a tremendous mercy that our minds show us in regards to these unusual mental states, that they can be forgotten or minimized. It can be very adaptive. However, it can be very painful and destructive for a relationship. A client says, "We can't talk about what he is doing when he is acting really crazy because there's no talking at that moment, and we can't talk afterwards because he doesn't think it was that big a deal and its mean to rub his nose in it."
There's a really neat blog post by Rebecca Jorgenson summarizing a study about attachment style, memory and conflict.
“The results were clear. Clients with Avoidant Attachment Styles, those who when feeling threatened manage distress through emotional distance and acting independently from their partners, and who withdraw under threat, were far more likely to remember the distressing conversations in a way that matched their autonomous reactivity. The avoidant partner remembered being far more clear and assertive than they actually were.”
— http://www.rebeccajorgensen.com/what-you-need-to-know-about-memory-and-insecurity-that-will-help-you-with-clients/
People who manage distress through emotional distance from a partner are more likely to cognitively distort their memory of their arguments.
We all have a fragility of the sense of self. We all seek to protect ourselves from the hurt a loved one can cause. We all look back at arguments and paint ourselves as a little calmer and a little more patient than we were because recognizing that we were irrational is so painful. These are human ways of being in a couple that can be magnified when mental-illness is part of the picture. People with mental illnesses deserve couples therapy that takes them seriously as people, and part of that is taking seriously the impact their illness has on them and their partners.
"After slaying the giants, perhaps we should have a go at barriers to accessible psychotherapy, Sancho?"
Spring 2014 was a different time. Back before we had a Liberal government that looked like it was going to rule Quebec for the next 10 years, a push was on to publicly fund psychotherapy. The Quebec order of Psychologists was pushing for it. An organization called the Coalition for Access to Psychotherapy was pushing for it. Then two doctors got elected and decided to dismantle the health care system. The idea of the government paying for anything in the health or social service sector that can't be contracted to the rapacious SNC-Lavalin or some equally befouled Quebec engineering firm seems Quixotic.
As readers of the blog know, I used to work in settings where I got to provide psychotherapy for people who really needed it and often could not afford it. Dr. Barrette laid me off (there were some intermediaries involved, too). Now, I provide psychotherapy privately to people who benefit from it and who can afford to pay for it out of pocket or through private insurance. I work on a sliding scale but my overhead, much of which is government mandated licensing fees, means I can't see the clients I used to and still make some money at the end of the day. I feel useful, but I doubt I have kept anyone out of the hospital doing this. Even for a person with serious mental illness who everyone agrees would benefit from psychotherapy, it is nearly impossible to get it in the public system anymore.
Minister Barrette (centre) tours the new Super Hospital with SNC Lavalin's Robert Card (right). $172 million could buy a lot of psychotherapy. Gazette photo.
By contrast, for the cost of one night's stay in a psychiatric hospital bed, I could offer one year's psychotherapy once a week at the low end of my sliding scale to someone recovering from a severe depression. I could give a year's family therapy to a family supporting someone with schizoaffective disorder. I could offer a twice a week dialectical behavioral therapy group for people with borderline personality disorder.
Nevertheless, I have serious reservations about government funding psychotherapy. Government will insist on putting psychotherapy through a meat-grinder; make it highly routinized, outcome driven (as opposed to outcome-minded) metric-oriented etc. In other words they will use all the bureaucratic tools that have protected us from corruption in the construction industry. And like with the construction industry, where government money goes, corruption will surely follow. If psychotherapy becomes publicly funded, I predict within two years you will have psycho-therapeutic equivalents of SNC-Lavalin springing up, offering to fix major depression in four sessions using a manualized, patented therapy that has been extensively tested (on seven people who were feeling a little blue) and can be administered via the internet by qualified practitioners in the developing world. Doctors will be the gatekeepers for publicly-funded therapy meaning a huge uptick in psychiatric diagnoses. Think psychiatry and big pharma in the US.
Speaking of the US, maybe it would be worthwhile looking at Obamacare. If we want Quebecers to be able to get psychotherapy regardless of their income, maybe we should be looking at some of the deepest pockets in Canada.
Sun Life Mutual, Manulife and Desjardins make billions of dollars in profits each year and sell plenty of insurance in Quebec. They could be doing more to ensure that access to psychotherapy is equitable (and I am sure they will embrace the chance to show civic-mindedness and gratitude for the billions).
First, they should be required to offer packages that are in line with Quebec law. Manulife among others has plans that only reimburse you for psychotherapy delivered by a psychologist (check with you insurer about the details of your plan). That despite the fact that by Quebec law, psychotherapy can be delivered by a variety of professionals. Quebec insists social workers, creative arts therapists, OTs, nurses etc. meet specific criteria and pay for a psychotherapy permit overseen by the order of psychologists. But the government doesn't require insurance companies to use the title. If all psychotherapists meet the same standards, and are delivering the same service, that service should be reimbursed equally by insurance companies. Require insurance companies doing business in Quebec to respect Quebec's own regulatory regime, offer equal coverage for any psychotherapist, regardless of training. That would increase access for insured people and reduce the costs of private psychotherapy.
Second, insure the uninsured. 25% of Canadians do not have supplemental health insurance (that statistic is from 2004 and I am guessing the number is considerably higher today). The mentally ill are less likely to have private insurance than most people because they are less likely to work. The onset of many mental illnesses is in early adulthood. Young adults are less likely to have private insurance than older adults. Quebec could require insurers to offer low-cost individual health plans that include mental health services (and no prior-condition clauses) that the unemployed, underemployed or independent workers would be required to buy.
Now that would be a public-private partnership that might actually serve the public interest.
When I worked in inpatient psych the stories people would tell me were always a mix of sadness and joy, brokenness and resilience, the ways family can heal and hurt, sometimes simultaneously, back and forth across generations. Drugs, what we call -- for lack of a better term -- mental illness and plain old human hurt wound together so tight the divisions between them become indistinguishable, the things that bring people into hospital are always part of a story of a family, trying, failing and succeeding in various ways to hold a human soul. The CBC radio documentary "Tragedy Builds a New Family" from the Sunday Edition took me back to that.
Burkhard Bilger's piece about kids riding bulls, "The Ride of their Lives" in Oklahoma and Texas in this week's New Yorker provides a fantastic illustration of how kids can grow and thrive in all sorts of lives and how our ideas about what childhood 'should' be are circumscribed by our tribe.
“I thought about a playground near my house in Brooklyn, in Park Slope. A couple of years ago, it was beautifully renovated by the city, with a rock-lined stream meandering through it and an old-fashioned pump that children could crank to set the water flowing. The stream was the delight of the neighborhood for a while, thronged with kids splashing through the shallows and floating sticks down the current. Yet some parents were appalled. The rocks were a menace, they declared. The edges were too sharp, the surfaces too slippery. A child could fall and crack her skull. “I actually kept tapping them to check if they were really rocks,” one commenter wrote on the Park Slope Parents Web site. “It seemed odd to me to have big rocks in a playground.” Within two weeks, a stonemason had been brought in to grind the edges down. The protests continued. One mother called a personal-injury lawyer about forcing the city to remove the rocks. Another suggested that something be done to “soften” them. “I am actually dreading the summer because of those rocks,” still another complained.
The parents at the camp flipped this attitude on its head. They valued courage over caution, grit over sensitivity. They revelled in the raw physicality of boys. The mothers sat in the bleachers taking videos and hollering advice—“Wyatt, just ride the way Daddy taught you!” The fathers straddled the chute, leaning over their sons to cinch the rope and shove the calf into position: “Are you ready?” “Yes, sir!” “You’ve got to take the fight to him.” “Yes, sir!” “You’ve got to want it.” When the gate blew open, they leaped up on the rail and watched their sons with clenched fists and narrowed eyes. They weren’t stage parents, for the most part. They just took following your bliss to its logical extreme. “I’d let my kid do whatever he has a passion for,” one mother told me, “even if he wanted to be a piano player.””
— New Yorker
"Even if he wanted to become a piano player" instantly become a piece of shorthand at my house.
Finally, I have been thinking about that stupid bromide "It takes a village to raise a child," because of the reaction that has been prompted by two similar law-suits filed by people who have left hasidic communities, one just outside of Montreal (Mike Finnerty conducted a really thoughtful interview with Yohanan Lowen, the man formerly of the Tosh community; you can get there if you follow the link to audio). I don't write about it much, but I have spent a lot of time working with ultra-Orthodox Jews in various settings. One thing that the reaction to these two stories illustrates to me is how confused we (by that I mean everyone who isn't an ultra-orthodox Jew or part of some other tight-knit, small traditional community) are about 'community.' We value 'community' in the abstract, we love to say "it takes a village to raise a child" but we have little experience of the travails of living in a village. Someone I know who grew up in Grenada told me that if he did something wrong at school he would get spanked by the teacher and then when he walked home, the neighbour-ladies on his street would see him come by, crying, and each in turn would call him by name up to their front porch and each one would give him yet another spanking because they knew why he was crying "You didn't listen to the teacher?" To me this is a perfect illustration of the mixed-blessings of growing up in a village. Tight-knit communities are tight-knit because people feel responsible for one another and entitled to enforce compliance to community standards, in particular when it comes to kids. They coerce people to act right. They are conservative; they do not value change and are wary of outside ideas and different people. Some communities are more like this, some less but you can't have maximum individualism and still eat the cake of a shared set of values and communal responsibility. There is a reason people are leaving villages all over the world; we live in an age where personal expression and individualism are more important than adhering to norms set by the past and our neighbours.
Three angles on how those around us grow us up into who we are.
Whining can truly make you want to pull your hair out. Here is another in the Fridge Magnet Therapy series of printables all about how to deal with toddler whining, a suggestion from reader and friend of the site Ms. T. I hope it proves helpful. Your feedback is always appreciated.
Click on the image to download the pdf
Illustrations are from project Gutenberg's "A History of Champagne, with notes on the other sparkling wines of France" 1882 by Henry Vizetelly (chevalier of the order of Franz-Josef, no less. No note about whether chevalier Vizetelly illustrated the work himself or not.) I included an additional one (right) that didn't make it into the printable. Is he wondering if a drink might help him be patient with the whining at home?
It's one of those things that is easy to say and hard to do but when your partner is hurt by or angry at you and every fiber in your body is screaming for you to retreat or lash out and protect yourself, that is the moment where you need to reach towards your partner's emotions. To be clear: you should never put yourself in danger of being the target of aggression. There is no excuse for physical or verbal aggression. But the unstated request by one or both partners in arguments is almost always "Soothe me by showing me that you understand my feelings of hurt that you caused." It is a paradox: "You are the problem. You are the solution." If that seems unreasonable and unfair, it absolutely is. Nevertheless, I think everyone who has been in a relationship has done it. We do it in different ways, criticizing, storming out, being sarcastic, shutting down, hauling in past wrongs, all the things we know we shouldn't do, we do them because we have trouble saying, "You hurt my feelings. You scared me. I feel vulnerable in front of you. And I need you to help me feel safe and secure."
"Just do that"
Why don't we just offer what our partner needs? Why don't we just say, "I get it. I see how scared and sad and frustrated and angry and hurt you are by what I did?" Most people are able to do this reasonably well with a small child, to say in effect, "I see how see how frustrated and angry what I did makes you." It gets harder with other adults. For one thing, we think we are right about what we are arguing about and we confuse connecting with and acknowledging feelings with giving up what we want. There are people who feed this confusion by manipulating; demanding that we change what we do as proof that we understand how they feel. That makes it tougher to connect emotionally and still feel like you can stand your ground about what you need and want.
Second, connecting with another person's feelings is threatening to our sense of self. The more intense and sustained those feelings are, the more threatened we feel. Some of us have had bad experiences of being intruded on by others which makes it even harder to tolerate another's emotions without feeling our sense of self being swept away, annihilated in the storm of our partner's emotions.
I am finding that more often than not, couples therapy is about trying to help people connect emotionally to their partners well enough, often enough. I think for my clients at first it can feel like being told, "Just do a triple gainer followed by a reverse jackknife. Oh, and the pool is only four feet wide, so don't miss." But I do think it is a skill and a habit people can develop. The other thing is, of there is an alternative way of having a happy relationship over a long time, we don't know what it is yet.
Want to raise honest kids? Don't lie to them or in front of them, more tips here.
When parents lie to their kids it is often for good reasons; a topic is scary for the parent and/or for the kid or a parent foresees that a little bit of information will raise a lot of difficult questions (see this blog post for a hilarious example of the latter). But lying to kids is a losing proposition. First of all, it is a pretty good way to ensure that they will lie to you and to others. Being honest with and around your kids is the single most effective tool you have to teach them honesty. But there are other, related reasons not to lie to kids even when it is hard. By about five years of age kids will begin to keep track of how reliable you are in giving them truthful information about the world. They will weigh your past record of truthfulness when deciding whether to believe what you say or not. That includes when you tell them; "Smoking is bad for you," or "There aren't any monsters in your closet" or "I love you and I will always be there for you."
Parents are the most important instrument kids have for making sense of their world. Having a parent you can't trust is like trying to find your way in the woods with a compass that only works half the time. Kids need to feel safe with their parents and part of safety is consistently helping to make sense of the world. The English psychiatrist and family therapist John Byng-Hall wrote a wonderful article about secure attachment in families in which he talks about the correlation between parents' ability to tell the story of their lives and the feeling of safe attachment in the family.
“What is most interesting is that the coherence of the narrative can predict whether or not the parent has a securely attached child. A coherent account ...[gives]... a clear and convincing picture of what it [the parent’s childhood] was like. It is truthful, succinct, yet complete, relevant, and presented in a clear and orderly way.”
— John Byng Hall
There are two caveats to the rule of honesty with kids. One is, honesty should serve the child and not the adult. Adults shouldn't use kids as confidants simply to unburden themselves. This requires adults to have some capacity for self-reflection and some parent-child boundaries. And two, the information we give kids needs to be age appropriate. "Age appropriate" is a funny term. It's easy at the ends of the spectrum: a five year old can know that animals die, no five year old should see videos of beheadings. But it gets tougher to find two "experts" who will agree on what is age appropriate when you get to more complicated questions. This takes me back to what I said at the beginning; parents often lie to their kids for good reasons, because they don't want to impose their hurt and fear on their kids or because they don't have any idea about what how to deal with something hard in an age appropriate way. But secrets have a way of coming out. Here are some tough calls about honesty with kids.
- A ten year-old asks her/his parent about a family member who died before he was born, not knowing that person was murdered by another family member.
- What should a parent say to an anxious 8 year-old who hears about an abducted child on the news?
- What should a parent say when his/her ex reveals to their 12 year old that the marriage ended because of an affair?
If the child has younger siblings these questions become even more complicated because a parent should not impose secrecy on the elder sibling and cannot expect a kid to finesse "age appropriate" when it is near-impossible for an adult to swing.
So what do I do with clients in similar circumstances? First, I try to remember that I don't have to live with the consequences of the decision to be honest and that my clients do, so the client has to feel reasonably okay with his/her call. Second, I advise erring on the side of honesty because it's better for your child to have a reliable guide through an uncertain world than a paper-thin veneer tacked over life's hardest questions and a guide who they aren't sure they can trust. "Deborah was killed by Andre. He was very sick at the time." "It is very rare but sometimes adults do want to hurt kids, that's why your dad and I take good care of you." "Yes. I had an affair. I made a really stupid mistake." (This final one is the trickiest. A child in this circumstance will inevitably want to insert him/herself between the parents. The parents need to give the child the message that adults take care of adult problems, but I think that a short clear statement taking responsibility for infidelity in that circumstance is better than leaving it to a kid's imagination and doesn't invite the kid to step into the role of co-parent).
After these truthful, succinct, yet complete, relevant, and clearly presented explanations, the parent needs to say, "And if you want to talk about it more now or later we can. There may be some things I may not be able to tell you but you can ask anything you want to." Then shut up and listen like you have never listened before.
I recently heard the wonderful Ginger Campbell interview Allen Frances on the Brain Science podcast. Almost before my headphones were off I had run out to buy Frances' book "Saving Normal, an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life." Frances clearly and humanely outlines his case that "The cruelest paradox of psychiatric treatment is that those who need it often don't get it, while those who do get it often don't need it."
I had some concern, even after the very thoughtful interview on BSP, that this would be a soft-headed screed against psychiatry. I know a lot of people who have benefited from mental health treatment including psychiatric medication, and I think it is very wrong to frighten people away from psychiatry who really can use it. I needn't have worried. Frances is a psychiatrist with a great love for the profession and confidence in the good it can do. He is absolutely committed to the idea that psychiatry can be beneficial to seriously mentally ill people and at pains to illustrate that.
But he is also clear-sighted about the failings of psychiatry and medicine generally (he is very much talking about the US situation. I will reflect a little on the Quebec context below). The big failing Frances takes on is 'diagnostic inflation.' He means the tendency to expand the criteria that are used to diagnose mental illness, either by loosening criteria for exiting illnesses or by 'discovering' new illnesses. What prompted this call was the American Psychiatric Association's process to issue a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM. Frances thinks the authors are too quick to expand definitions which will inevitably lead drug companies to step in and push for meds for people who could do without them. Frances is in a good position to comment because he was in charge of the DSM-4. He is very up front about his own failings in having lead that installment and apologizes for his mistakes. It is extraordinarily refreshing to hear someone with such a level of authority offer a public apology.
One of the diagnostic overreaches that he addresses is 'psychosis risk syndrome'. We are close to being able to identify people who are at high risk of developing psychotic disorders like schizophrenia. We know many of the risk factors including certain genetic markers, we think that delaying onset of schizophrenia means being less sick and we know that being very sick with schizophrenia is very hard. Why not target teens who are at elevated risk and are exhibiting "prodrome" symptoms; self-isolation, quirky or aggressive behaviour in the hopes of forestalling or even preventing the onset? Frances gives a very good answer to that. First of all, target them with what? The answer will probably be anti-psychotic medication. We have no indication that taking anti-psychotics before developing psychosis will help stave off or mitigate the effects of schizophrenia and the side effects can be very serious, including obesity and diabetes and everything that comes with that. And, he points out, we can identify teens who are at risk, but that would probably involve identifying a lot of kids who will never develop the disease and potentially subjecting them to this very serious intervention. It begins to look a lot like the aggressive screening and treatment of prostate cancer, too many people, too invasive for limited benefit. Frances doesn't mention the possibility that teens who are identified might benefit from interventions that have less potential downside like counseling about delaying use of street drugs including marijuana and psycho-education about reality testing. Given the way Quebec is headed, it seems unlikely that we will see a targeted public health campaign that relies on disease prevention using labour-intensive methods like psychoeducation.
Frances also alludes to something I have mentioned elsewhere in this blog; namely that not all conditions of the human soul are diseases in any recognizable sense and yet increasingly the DSM includes them. The idea that mild to moderate depression, or attention deficit disorder, or anxiety is a neurochemical imbalance fits very nicely with a drug company's bottom line. The emphasis of the last twenty years on neuroscience has tilted us towards a chemical fix for ailments of the mind. Yet not one significant advance in diagnosis or treatment of mental illness has come out of all the important research on neuroscience so far. Diagnosis remains entirely symptom-based. The mechanisms for the function of treatments is poorly understood, if at all.
“All of this may seem very much like “inside baseball” for people who don’t spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don’t need...”
All of this may seem very much like "inside baseball" for people who don't spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don't need, medicines with serious side-effects that may not have been adequately tested on the populations for whom they are being prescribed. He reports that the sale of anti-psychotic drugs at $18 billion (US) now delivers more cash to the pharmaceutical industry than anti-depressants. Anyone who has any experience with them knows anti-psychotics are powerful medications with very serious potential side-effects. They are helpful to people with psychosis. But now they are being marketed for use with children and the elderly. 20% of people treated by primary care physicians for anxiety now receive an anti-psychotic as well, according to Frances. The trend towards GPs prescribing psycho-active medication is troubling for Frances as well. That GPs give out anti-depressants and anti-anxiety medications routinely should surprise no one, but I was amazed to learn that 50% of anti-psychotics are prescribed by GPs. (I am not sure if that accounts for GPs taking over the prescription of anti-psychotics after an initial prescription by a psychiatrist.) Frances goes through the familiar litany of the dangers and over-promises regarding SSRIs for treating the 'worried-well' market. These are problems we see here in Quebec, though certainly not to the degree they are experienced in the US.
Whose fault is all of this? For Frances the answer is pretty clear. Big Pharma and the big money it is willing to throw around to advertise direct to consumers (only in the US and -- apparently -- New Zealand as well), to co-opt the better judgement of doctors and researchers as well as to fight legal battles and pay fines when they get caught behaving badly (as with the off-label marketing of anti-psychotics for kids). He gives policy recommendations for taming the excesses of big pharma. Naturally, dear to my heart are all the plugs that he makes for psychotherapy as an alternative or adjunct to pharmacology.
“There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs.”
— Saving Normal
Here in Quebec, we are retrenching from any kind of public outpatient psychotherapy, at great cost to our well-being, I believe. It is nearly impossible in Montreal to get psychotherapy at a CLSC (public health and social service clinic). This despite the fact that we know that psychotherapy can sometimes head off episodes of serious mental illness later for certain people and keep them from needing much more expensive hospital care. Follow-up care after a psychiatric hospitalization is spotty and seems unlikely to get better with more cuts coming.
“The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. ”
While I am a believer in psychotherapy, if I have a quibble with Frances, it is over this. My experience is that many psychiatrists and other psychotherapists have been and continue to be high-handed, overly jargonistic, faddish, opaque and sometimes deeply anti-scientific. Frances himself mentions the terribly misguided satanic ritual abuse accusations of the 1990s and the role played by therapists who "developed and instant expertise on day care sex." Many people mistrust us because they view psychotherapy as elitist mumbo-jumbo that changes tack every ten years. All those primary care doctors who are prescribing medications rather than sending their patients to therapists don't trust talk therapy. Why should patients? Hell, I have met quite a few psychiatrists who don't have faith in psychotherapy. The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help.
I read a wonderful reflection on mysticism the other day and started to think about what makes it hard to put some things into words.
“Mysticism is a seemingly positive term that denotes a negative, as the word darkness, which seems a positive term, denotes only an absence — the absence of light... A nonmystic is someone who believes that when truth is explained to him in words, he should understand that truth. The mystic is some one who knows that real truth, meaningful truth, can never be fully expressed in words. ”
— Joseph Dan, The Heart and the Fountain, p 2-3
Sometimes I see clients in therapy who are mystics in the sense that Dan describes. They may not identify as spiritually inclined but they mistrust language to adequately convey truth. Dan goes on to says that for the mystic, "Only the trivial, or the false can be communicated and understood." It is hard to administer a talking cure when a person views language as untruthful.
Sometimes mysticism looks like a defense. I will say something like: "Did that make you sad?" The mystic replies "Not exactly sad." I say, "So how would you describe the feeling?" The mystic: "I can't describe it." Talking about feelings is like dancing about architecture. But in this scenario the mystic also can't dance about dance. The mystic ineffability of inner experience can be a way not to experience feelings. For many people, saying "I am sad" with intention is akin to God saying "Let there be light." It is the baldest, most powerful truth of all, in that it creates the reality to which it refers. (An odd variant on this theme: saying to another person, "I feel lonely" with intention can be a powerfully connecting thing).
Because being a mystic means having access to a truth which cannot be adequately conveyed, it holds a special status, for good or ill. "I am sad," is a profoundly human statement, and it makes me like 99% of my fellow humans who have experienced sadness. Saying "The word 'sad' is inadequate to describe what I am experiencing," means I stand alone. Being an unremarkable human with unremarkable human feelings can feel good a.k.a. 'normalized,' or bad (as in 'unimportant'). To connect with another risks making my experience banal.
Mysticism and depression are two degrees of separation apart. Nihilism is the missing link. The mystic denies the possibility of being able to bridge the gap between one's self and the universe beyond through language. The nihilist denies the possibility of bridging the gap between self and other entirely. Depression is the affective prison in which a person is convinced of the impossibility of connection with others, the world of sensation, God, even elements of the self.
Some therapies have taken the mystical contention about language to heart. Sue Johnson, the founder of Emotionally Focused Therapy views purely cognitive therapies as flawed because they don't address affective truth, a felt, experienced truth that is prior to and largely inaccessible through language or at least through cognitive language alone. (I find it ironic that Sue Johnson has spent tremendous effort to empirically demonstrate EFT's claims that reasoning is insufficient for addressing matters of the heart.)
Rabbi Shais Taub talks about addiction as an expression of the urge to transcendence that is part of mysticism. "Crippling self-consciousness is the root of addiction. When they (the addict) take this poison it simulates the effect of spirituality in that there's this release from ego, rather than being self-transcendent release from ego... it is a self destructive release from ego. ...(T)elling the addict... 'Don't you see you're destroying yourself?' is the most ridiculous thing you can say because if they could articulate what their soul they would say 'Yes, I am trying to destroy Self.'" (You can listen to the whole episode of Tapestry here. The interview with Rabbi Taub is at about 19 minutes).
I feel both the mystic's tendency to view some of the most important things as ineffable, the desire to connect outside of language and to transcend the crippling 'self'. But I also feel a hard-headed commitment to the 'communicability' of many of our most complex and difficult truths.
"It is not in heaven so that one could say, 'Who will go up to heaven for us, to get it for us and make us listen to it, to do it?' "Nor is it beyond the sea so that one could say, 'Who will cross the sea for us, to get it for us and make us listen to it, to do it?'" For the thing is very close to you, in your mouth, and in your heart, to do it."
Some basics for dealing with kids and teens when they lie. Parents often find this very difficult because they worry that a child or teen who lies will grow up to be a liar. The fact is every kid lies at some point (as does every parent) and few people are chronic liars. I hope these will help you if you feel like you are at the end of your rope. One thing I didn't have space to point out in the printable: I mention various punishments or consequences in the printables. These are examples and not recommendations per se. It is important for you to set consequences you feel okay with (within the limits of not physically harming or humiliating a child or making a child afraid for his/her safety). I may make a printable about consequences at some point so be sure to check back.
This is the second in the Fridge Magnet Therapy printables series. I love feedback so please let me know if/how these are helpful.
You can click on the image which will take you to a pdf or on this link. Lying
Illustrations are by Alice Carsey (Pinocchio 1916) and Charles Copeland (Pinocchio in Africa, 1911)
5 things to do if your kid tests limits
I am starting a series of 8" x 10" posters that you can print with basic tips for parents and couples dealing with common issues I see in therapy. You can download them, print and share them with attribution and a link.
The first is "5 things to do when a kid tests limits."
Thanks for the really cool old-timey clip art from the graphics fairy.
I'd love your feedback.
I get requests for therapy from a lot of young couples. This surprised me at the beginning. When I was first learning about working with couples I read that couples often don't seek help until their patterns of negative interaction have been set for six years or more. I expected to see a lot of couples in their late thirties or forties with kids. Instead, many of the couples I see have been together for two to five years and are without children. At first it was hard for me to get my head around the idea of people in their twenties seeking couple's therapy three years into a relationship. The conflicts they bring to therapy are not the long-standing, cumulative resentments of a couple who have been together for fifteen or twenty years. And without kids in the mix the collateral damage of choosing to end a relationship rather than work on changing difficult patterns is definitely less. But when I speak with them, most of these young couples describe real challenges. The value they place on their relationships is usually high. And as one client told me, "We want to get this right, now, to set a strong foundation."
Perhaps some couples therapy is in order.
There are probably a couple of reasons why I see more young couples than I expected, more than perhaps I would have seen if I was practicing twenty years ago. One, I work on a sliding scale, so young couples with less disposable income who are looking come my way. Two, stigma around couple's therapy may have decreased. The third factor, I think, is generational. Unlike previous generations, people in their twenties and early thirties have been living with the sense that lifelong couple-hood is unlikely to succeed. They have grown up with the idea that as many committed long-term relationships fail as succeed (the much bandied 50% divorce rate number for the US has never been that meaningful. The odds of a particular relationship staying together for life are probably higher. A 2005 article in the NYT article gives a good run down of the difficulties with the 50% number). They have seen long-time married couples at close range that were full of anger and hurt, either their parents or friends of their parents. It is my sense that many of the young couples I see, feel that they are doing something very nearly counter-cultural and difficult by trying to stay together and stay loving for the long haul. Viewing staying together in a loving relationship as hard may make some couples more likely to seek help earlier that they otherwise might.
I have been working in an inpatient psychiatric ward in a hospital for almost a year. It has been sad and joyful and sometimes boring or infuriating and full of discovery and very occasionally frightening. Before February, the last time I had been in an inpatient psychiatric facility was twenty years ago when I was a social work student at Columbia and I went on a visit to Ward's Island in New York. In between, I viewed inpatient psychiatry as the place where people who were 'truly mentally ill' were treated. By contrast, the people I worked with, people who were not in hospital beds, didn't seem ill in the same way that someone who is diabetic or has cancer is ill. Of course, I would speak of mental illness when I talked about moderate depression or anxiety or Asperger's syndrome. There are good reasons for this. I have always believed that a person's biology is intertwined with how his or her mind works. The things for which people seek the help of a therapist or a social worker are impacted by their brain chemistry, their genes, in short the organism in which the mind arises. And almost everyone finds having a mental illness -- a biological condition -- less shameful and frightening than being labeled crazy.
But I was never fully convinced that these conditions were illnesses like physical illnesses, either. I am not a doctor and perhaps my layperson's lingering idea of illness -- a microbe from without setting to work to destroy tissues -- is part of the reason I have resisted the description of these conditions as mental illness (most types of cancers and diabetes do not meet this definition of illness). Still, I imagined that behind the doors of a psychiatric ward there were examples of mental illness that clearly demonstrated a causal connection, while yet poorly understood, between disorders of the mind and the physical organism.
I feel like my ideas about mental illness have been made more confused not more clear by working with people whose minds are so disordered they need to be in hospital. I sat in the hospital hallway with a man who positively knew that someone was breaking into his brother's home hundreds of miles away. When I asked him how he knew, he could not give any answer except that he knew. The fact that his idea made no sense to others or to himself did not diminish its intensity. But it saddened him deeply; he understood -- at least in part -- that this thought was nonsensical, yet it was absolutely real for him. It seemed to me, at that moment, that something biological was clearly going on, as if this man had suffered a brain injury and it was only a matter of time before medical science could discover where exactly it was located and how he might be helped. I imagine that almost everyone who has worked with people with schizophrenia must have had this experience and yet the causes of schizophrenia remain unknown after a century of research, and treatment is focused on symptom management. This man has lived much of his adult life absolutely bubbling with paranoid ideas and the accompanying sadness and frustration of not understanding where these ideas come from.
There are people who come into hospital deformed by love. There are the suicide attempts and the severe depressive episodes brought about by failed or elusive love. Occasionally people with no previous history of mental illness come to emergency manic and delusional because love has gone wrong. On the one hand this is the most easy form of disturbance to extrapolate from for most people; everyone has experienced heartbreak or rejection and can imagine him or herself driven to extremes by love. But it is precisely this universality that makes those who end up in psychiatry unusual. After all, what makes one person see his love everywhere, believe she is sending him messages through strangers, chase her barefoot all over the city and fight with police and security guards, when nine hundred and ninety-nine other rejected suitors cry, listen to sad music and then move on? Is that the difference between health and illness? Or is it something else?
In the hospital psychiatry ward you can find people who just about everyone would agree are ill. Even though no one can explain exactly the mechanism, it seems that their biology is making their minds work very differently from the minds of most people and often in ways that feel awful to them and put them in danger. But mental illness of this unmistakable type is a I-know-it-when-I-see-it kind of phenomenon because for every clear-cut case there are people who are odd or sad or exuberant who fall in a grey zone.
None of the disorders treated by psychiatry today have a blood test or pathology lab test for diagnosis. They are all diagnosed by symptoms and reading symptoms remains quite subjective.
How we think about disorders of the mind has a real impact. One of the most powerful impacts is the use of drugs to treat mental disorders to the exclusion of talk therapy. Thankfully we have left behind the era of psychoanalysis to treat schizophrenics (as well as cruel theories about how schizophrenia was caused by bad mothering). But now we have moved to a situation where -- in Quebec, anyway -- talk therapy is almost never viewed as a way to treat mental illness despite its proven effectiveness for many -- though not all -- disorders. People discharged from hospital for surgery can get physio and occupational therapy to help with recovery as part of the services covered under their provincial health insurance. Psychotherapy is almost impossible to get in the public system either in hospital or out. I think that this is partly a function of not viewing talk therapy as a way to address a medical illness. How can an illness be treated by talking? As much as disorders of the mind may not look like illnesses, talk therapy doesn't look like medicine. Not to patients and not to doctors and certainly not to ministers of health.
Here is a story that illustrates the constraints of operating solely with a illness/health model of the mind. A man in his late forties was brought into hospital for running around in traffic. He was a chronic schizophrenic. How did we know? Because that was his diagnosis for many years. It was also possible that he had a mild intellectual handicap. Doctors over the years had examined him and observed symptoms that pointed to these conclusions. The psychiatrist I was working with spent a long time talking to him and his family. What we learned was that the man had experienced a terrible set of traumas when he was young and had used a lot of street drugs. He was very reticent but eventually he talked about the toll that the pain he had experienced had taken and his guilt over what he had done to others. For years he had been a patient of various psychiatrists who saw a painfully inarticulate, inwardly focused man who had gone spectacularly off the rails at eighteen and came to the conclusion that he was schizophrenic. But with time it became clear that he was a confused, deeply hurt person (absolutely no intellectual handicap) with very little if any of the psychotic features that are integral to schizophrenia. The voices that he had reported hearing telling him he was bad were much closer to the 'voice' I hear in my head telling me that I better get my work done than the voice a psychotic person hears which causes him or her to look for someone speaking. He had never, in the course of twenty plus years of psychiatric treatment, been given enough space to talk. When we asked him why he was running around in traffic pulling on car doors, he said "I guess I wanted to get away."
This is not just a story about misdiagnosis, "House goes to the psychiatric floor." It is a story about using the tools of medicine to examine something adjacent to -- but not the same as -- medicine. Not every affliction of the human heart calls for a cardiologist.
“The physician, who through his studies has learned so much that is hidden from the laity, can realize in his thought the causes and alterations of the brain disorders in patients suffering from apoplexy or dementia, a representation which must be right up to a certain point, for by it he is enabled to understand the nature of each symptom. But before the details of hysterical symptoms, all his knowledge, his anatomical-physiological and pathological education, desert him. He cannot understand hysteria. He is in the same position before it as the layman. And that is not agreeable to anyone who is in the habit of setting such a high valuation upon his knowledge. Hystericals, accordingly, tend to lose his sympathy; he considers them persons who overstep the laws of his science, as the orthodox regard heretics; he ascribes to them all possible evils, blames them for exaggeration and intentional deceit, “simulation,” and he punishes them by withdrawing his interest.”
— Freud, five lectures on psychoanalysis
At the beginning of this week's This American Life there's a piece in which the writer David Hill, who has dabbled in playing the strategy game Diplomacy, takes Dennis Ross, Bill Clinton's old Middle East envoy, to the world championship of the game.
It is based on Hill's article in Grantland. A couple of things were percolating in my head when I heard this. The most prominent was that Dennis Ross seems like a jerk. As much of a jerk as the people who get angry and overturn the board and yell at the Diplomacy tournaments. Maybe more. Not because he is evilly-intentioned or malicious. Quite the opposite.
Dennis Ross is sometimes referred to as the architect of the Oslo Peace accord. For those who don't remember, the Oslo accord in 1993 brought together then Israeli prime-minister Yitshak Rabin and PLO chairman Yasser Arafat to agree on movement towards a two-state solution to the long-standing fight between Israeli Jews and Palestinian Arabs. There are people who spend a lifetime studying the ins and outs of these things and they can't agree what went wrong, but one thing is clear in the summer of 2014 as a war rages in Gaza and the south of Israel; the Oslo peace process did not lead to anything that anyone could call a solution. Meanwhile Dennis Ross is a prof at Georgetown in the school of foreign service and a Distinguished Fellow at a fancy institute and Diplomacy coach for hire.
I am not going to go on about Gaza and Israel. My interest here is in the dangers of bringing in expert-consultants and why some people chronically behave badly in interpersonal situations and what they have to do with each other.
Dennis Ross could have told David Hill, "If you want to win, don't take me to the game. You will be painting a huge bulls-eye on your back. And since I am busy at Georgetown I won't be able to stay and clean up the mess you will make for yourself." Instead Ross comes in, gives advice based on his gut and his experience, then leaves Hill in an awful situation, possibly a worse situation than if he had just said "No." Experts generally give bad advice. There are a lot of reasons for this.
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Experience itself is at best an indifferent teacher. People need clear, unambiguous, immediate feedback in order to learn. In complex areas like adult human interactions its very hard to build in such feedback. When Ross claimed there was a resemblance in the body-language between a Diplomacy player and a Soviet diplomat he dealt with I groaned. I imagined hearing a cop say "Evidence?! I don't need evidence. I've seen lots of guilty people and I can tell when someone is guilty." Which leads to number 2...
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People who believe they are great at reading people are usually no better than average and sometimes worse.
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Experts don't have to live with the consequences of their advice. But their clients do. In therapy, I very rarely give advice. I look at what I see and hear and offer it back to my clients. I ask what it means for them. I try to give them different perspectives on their situation, but I m extremely reluctantly to give advice or make predictions, first because I will likely as not get it wrong and, second because they have to live with the consequences, not me.
I once worked at a social service agency. The bosses brought in a consultant who started the session by saying something like, "I usually consult for business. I don't know anything about mental health and social services but I am sure the principles of managing an organization I will teach you are the same." I felt like I'd been slapped. To me, it is rude to come into a room full of people who have over a hundred years of collective experience in their work and say, "Please do not confuse me with information about what you do." If a consultant or expert is talking more than s/he is listening s/he isn't worth paying attention to.
The second thing that caught my attention in this piece had to do with angry aggression. There is a lot of discussion in the piece about whether a person's anger is real or strategic. Angry aggression like swearing, yelling, threatening and ultimately violence is profoundly paradoxical in that it is a way of gaining control by 'losing control' Virginia Goldner has written wonderfully (here for example) from a feminist, psycho-therapeutic perspective about how abusive men's anger is both a willed act of control and an out of control act. Someone else's aggression often provokes such strong reactions in us, even when we know that there is no threat of violence, because it can makes us feel dominated, like control is being wrested from us.
Because it is so frightening, people who aren't comfortable with strong, aggressive expressions of anger, often treat badly-behaved, angry people like they are weather systems, irrational forces of nature, vaguely predictable, but absolutely uncontrollable. This can be a great way for the angry person to get others to defer or comply. Most angry people have absorbed this; the out-of-control expression of real anger gets them what they want. Angry aggression can be highly adaptive, at least until it becomes a disaster.
Which brings us back to Diplomacy and one of the questions posed in the piece: How can less aggressive people deal with aggression? One of the things that the piece explores is the context of angry aggression. In the game what is strategic, would be unacceptable in real-life. Except those boundaries are kept deliberately vague. People are unsure whether aggression is notional or real. The possibility that anger is real and may become out-of-control is what gives it its power. If there were a card in Diplomacy that you could present to another player that said "I storm off, angrily," it would have no impact. For anger to get people to change their behaviour, it has to be real enough.
One of the most pernicious things Ross does is not to account for what the real-enough aggression of other players will do to Hill. Most people can learn to become more detached from another person's angry aggression, to feel less out-of-control in the face of it. Angry aggressive people can learn they won't regain dominance through an intimidating 'loss of control.' But that takes time and establishing safety, things Ross (and IMHO many other fly-in consultants) view as outside their job description.
Friends sometimes ask how to pick a good therapist. Since I can't just say say "Me!" I have had to give this some thought. So here's what I say...
- It is reasonable to be concerned about price
Therapists want to make money doing what they like to do and -- within reason -- therapists can set their prices based on the market. Therapists who are highly sought after can charge up to 135$/hour. Some professionals (me included) offer a sliding scale based on your income, others don't. Here in Quebec, there can be a difference in price of around 65$ per session depending on who you see. That can add up over ten or twelve or more sessions. Figure out what you can afford to pay and then look around and see if you can match that.
- Membership in a relevant professional order (Boring but important)
There are a lot of different kinds of professionals who can offer therapy in Quebec. The biggest difference for a member of the public is that medical doctors, including psychiatrists, can prescribe medications and nobody else can. Aside from that there isn't a hard and fast rule about whether a social worker or a psychologist or a drama therapist is going to work better with a particular kind of person or problem. Whatever his or her professional training, a therapist should be a member of his or her professional order, the Order of Social Workers and Family and Couple Therapists, the Order of Psychologists, the College of Physicians, the Order of Occupational Therapist etc. There are three reasons; one, a professional body has looked at this person's professional qualifications and said "S/he is able to do the work." The second reason is that the person is bound by a code of behaviour which you can read. If you aren't sure whether the person has the right to ask for payment in a particular way, for example, you can check (For example, I cannot take barter according to my professional order. Sorry, cabbage growers). Finally, if you have some dispute with the person or if you think his or her behaviour is unprofessional, you have an organization that serves the public interest that you can go to.
Here in Quebec we have a new licensing regime which requires everyone practicing psychotherapy to become a licensed psychotherapist with the Order of Psychologists whether or not he or she is a psychologist. So whether someone is a drama therapist or a nurse or a couple and family therapist she or he will eventually need to be licensed for psychotherapy by the order of psychologists. Among other things, this means that the fabulous art and drama therapists of Quebec -- who haven't had a professional order until now -- now have a place to hang their hats.
- Clear goals
A therapist should work with you on setting realizable goals for therapy. If a therapist doesn't ask what you want to achieve and can't say what you are working towards and it is something that you want then you should look for someone else.
- You should feel heard
This will come and go. Sometimes I do a better job listening than other times. But if my clients don't feel heard and understood most of the time then I am not doing my job.
- Non-defensiveness
You should feel like you can talk to your therapist (politely) about the therapy including what isn't working. Recently a client told me that she was really mad about something I had said in a previous session. I was glad because if she had just continued being angry without raising it we wouldn't have gotten very far. I spent a lot of time asking her about what had bothered her so much and when I understood better why it was so hurtful for her, I apologized and we talked about how I could avoid doing something similar again. Most therapists are happy to have this feedback. If you don't feel like you can, then you need to consider whether you can really get what you need out of therapy with this person.
- Professionalism
A therapist should be professional about how s/he conducts business; timely, efficient, knowledgeable, organized, respectful of you.
- Strong
You should feel that your therapist is strong enough, emotionally, to be able to hear things that are painful for you without falling apart. You should not have to worry about taking care of your therapist. Some people have a very hard time with this. Because they are used to caring for others, it can be hard for them to let go and be cared for. But if you don't feel that your therapist can handle your hurt, you need to talk about that with him or her and if you can't resolve it then s/he may not be right for you.
- Recommendations are helpful, but only to a point.
At this point in my shpiel people usually ask for names. I can give names of therapists I like and admire but fit is important. Ultimately it doesn't matter that much what I think. What matters is, do you feel good about this person. If you try therapy with someone that I recommended or your best friend said was amaaaaazing and after two or three sessions it isn't working, take that seriously. Talk about that in therapy. You may find that turns out to be really helpful. It gives the therapist the chance to adjust. But If that doesn't work, try someone else. It doesn't mean therapy isn't right for you and what you want to deal with. It doesn't mean the therapist is no good. It may just mean that the fit between you and the therapist wasn't right.
Good luck and please leave comment about what has helped you find a good therapist or how you would suggest a friend make a choice.
Scientists have measured 'cool' and determined who has it so teens don't have to worry anymore; they can just ask the adult with the pocket-protector and clip-board. In a neat piece of social science researchers looked at how kids made themselves popular at age 13 and followed them through to age 23. Kids who did things to look older at age 13 in order to be more popular, such as engaging in delinquency, hanging out with good-looking peers and engaging in romantic relationships were less socially successful at 23. (It seems to me there may be a tad of wish-fulfillment of grown-ups who were unpopular 13 year olds). This is moderately interesting for people who work with kids and for parents of teens.
Castiglione looking cool
The researchers conflated popularity and 'cool'. Scientists like things that can be measured; popularity among thirteen year-olds is relatively easily measured while cool isn't. The kids I thought were cool when I was thirteen weren't necessarily engaged in 'pseudo-mature' behaviour and weren't necessarily popular. James Dean's character in Rebel Without a Cause which the authors adduce is a loner not a collector of pretty people. Rather the kids who seemed cool to me did whatever they with seeming ease. The Italian's call this sprezzatura. Castiglinone in the Book of the Courtier has one of his characters say:
“What eye so blind as not to see in this the ungracefulness of affectation, — and in many men and women who are here present, the grace of that nonchalant ease (sprezzatura, for in the case of bodily movements many call it thus), showing by word or laugh or gesture that they have no care and are thinking more of everything else than of that, to make the onlooker think they can hardly go amiss?”
Pseudo-maturity doesn't play into this definition of cool. Of course it can be exhausting to be attuned to how one appears to others at all times and probably detrimental to one's cool, as well, but that is a feature not a bug of adolescence I suppose. Now that we have adopted pseudo-youth for adults as an unquestioned value it is probably a feature of middle age as well. One of the features of Castiglione's work is the way in which people of different ages reflect on the blindness of others and in turn betray their own prejudices.
“Thus it seems to me that old people are in like case with those who keep their eyes fixed upon the land as they leave port, and think their ship is standing still and the shore recedes, although it is the other way. For both the port and also time and its pleasures remain the same, and one after another we take flight in the ship of mortality upon that boisterous sea which absorbs and devours everything...”
— https://archive.org/stream/bookofcourtier00castuoft/bookofcourtier00castuoft_djvu.txt
I work part-time in the psychiatric inpatient unit of a hospital. I was talking with a patient there who was sad and frustrated because he really wanted to go home. He couldn’t leave because of a court-order for hospitalization. According to the people who brought him in, he had said things that sounded delusional but it was hard to understand what he meant because he speaks poor English and French and so do the people who brought him in. Even with the help of a translator it was hard to understand what he had said and what he was thinking. Was he expressing anger and frustration or was he expressing delusions, including some thoughts of self-harm? “Why can’t I go. I am okay. You see I am okay. I talk normally. I’m not sick,” he said. I said, “We see two kinds of people in psychiatry who say they are not sick. There are people who aren’t sick and there are people who are sick but can’t understand it because of what the sickness does to them.” I was trying to explain the concept of insight.
Insight has two distinct meanings in psychological parlance; one is understanding something through non-logical means, the “un-huh” experience. The other meaning, which I will use here, is the ability to reflect on one’s own mental processes. This second meaning of insight includes the ability to understand when one’s mind is acting in ways that don’t seem normal. Many people who experience delusions or hallucinations, depression, anxiety or mania understand that those experiences are strange mental states. But insight can be affected by mental illness. I saw a patient who was able to have reasonable conversations shortly after coming into hospital for some pretty strange and dangerous behaviour both for herself and for others. She seemed a little unusual, her speech was a little disjointed, a little pressured but she didn’t seem mentally ill until the psychiatrist who was interviewing her asked about delusions and hallucinations she had expressed. The patient, who was quite smart, was absolutely convinced that these things were real; she talked about them in the same relatively reasonable way that she talked about conditions and the routine in the hospital. After a few weeks in hospital and a lot of psychiatric medication, when I asked her about the thing she had been hearing and thinking, she said they were almost gone. I assumed that she would see her previous psychotic symptoms as strange, perhaps embarrassing, perhaps frightening, maybe amusing, or as a piece of herself she had to contend with. Instead she expressed no surprise that she had experienced these things, no recognition that they were odd and no sense that they were connected with her mental illness. The voices had stopped. They had been real, a feature of her life. It was as if the grocery store down the street had gone out of business. It was there, then it was closed, neither its presence nor its absence was remarkable or connected with her mental state.
I asked a psychiatrist who had seen her about this. He said that years of untreated psychosis had “burned out” the patient’s capacity for insight. There is a “kindling hypothesis” in psychiatric illness. The idea of ‘kindling’ in psychiatry comes from the study of epilepsy and other seizure disorders where it is demonstrated that more frequent and intense seizures cause lower thresholds for future seizures. Seizures cause a change that leaves an organism more prone to future seizures, seizures create the kindling for future seizures. Some psychiatric research think that affective disorders such as bipolar disorder may have work in a similar way, early and intense manic episodes may create ‘kindling’ for future manias. I couldn’t find any compelling evidence that this is the case in psychotic illnesses or a clear explanation of what the mechanism might be.
It is clear that certain kinds of brain trauma can cause severely impaired insight. Anosognosia is the phenomenon of not recognizing that one has an illness and is usually applied to someone has suffered a brain injury. A patient may be paralyzed on one side of the body and find reasons not to perform a particular task that requires both hands. The patient is not deceiving; the brain’s capacity to recognize impairment is, itself, impaired.
In psychiatry, insight into one’s illness may be more complicated than in neurology. Going back to the first patient, cultural and linguistic factors can make it very hard to assess. It is also subject to a lot psychological ‘noise.’ When I talked with this patient it became clear he dreaded the idea that people would think he had a psychiatric illness. There are good reasons why people - whatever the state of their mental health - don’t want to be seen as crazy by others. And recognizing one’s own mental illness is a mixed bag. Schizophrenic patients with better insight are more likely to take their medication regularly but are also more likely to be depressed . Paradoxically, denying that one is mentally ill looks pretty friggin’ adaptive if your idea of mental illness is a life sentence of misery and social ostracization.
For me lack of insight was always deeply, primitively, frightening. First of all, it evokes a trap played by the powerful; say you are unwell to prove you are well. At the same time what was always most frightening about mental illness to me was the primal terror of my own insight failing me, the extinction of something that is at the heart of my ‘self’.
I talked to a former patient this week, who had expressed very strange ideas when she was in hospital and who had little idea at the time that these ideas were strange. She is back in her apartment working hard to keep herself well. She still has paranoid thoughts sometimes but she recognizes that they probably aren’t accurate reflections of reality. She is able to challenge them. She tries not to let them govern what she does. She doesn't find it all that upsetting that some portion of her mind is so cruel. It made me feel happy to hear about her improved insight and I think it bodes well for her.
I find that after working with mentally ill people I am less fearful of losing my own insight. I suspect that like any other mental process, especially those connected with creating a sense of self, insight is nine-tenths smoke and mirrors, an illusion played by our brain on our mind. Insight is a kind of delusion itself, the folly that we can know our own minds.
I recently heard Miya Tokumitsu being interviewed about Steve Jobs' famous “Do what you love” commencement address. She has written eloquently about the late-capitalist wish fulfillment implied in this motto; that unlovable work should not only not happen to 'people like us' but shouldn't be seen or thought about at all.
“In ignoring most work and reclassifying the rest as love, DWYL may be the most elegant anti-worker ideology around. Why should workers assemble and assert their class interests if there’s no such thing as work?”
A further critique of "Do What You Love": As a therapist I work with people in their late twenties who feel that they are somehow psychologically unwell because they have not discovered their life's great passion. They have been told by the culture that they should be fully satisfied and thoroughly successful in their social, romantic and work life, drivers of change at every moment. They believe that life can be an unending climb to success and that if they are 'right' all that climbing will feel GREAT! To be anything less than full of love for life (including work) at every moment is a mark of some fundamental wrongness in them. They are discouraged and bewildered by their lack of passion though they have experienced relatively little of life. They live in terror of being soulless drones in marriage and in work and carry the secret shame of not feeling suitably passionate to escape this fate. (Or not passionate about the right things; the internet is built to be terrifically engaging but our culture doesn't view hours spent intensely focused on porn or playing World of Warcraft as DWYL).
"Class, take chances, get messy, make mistakes."
The fact is that a person's twenties are early to discover lifelong passion. I vastly prefer Ms. Frizzle's advice to Steve Jobs'. (There may need to be a future blog post about the psychological phenomenon of frizzophilia; sexual desire for Ms. Frizzle.)
I tell clients to focus on trying things out, making mistakes, and picking themselves up when it doesn't work out in love and in work. Perhaps they will stumble upon something that grabs them.
But passion is not guaranteed.
Some people are, by temperament, not very passionate. This is another thing that the DWYL approach elides. It seems to me that love is portrayed in the DWYL approach as a near-rapturous state, fully energized, intensely focused that does not mellow with time. This betrays a misunderstanding about love and about the variety of human temperament. A passionate temperament is a mixed blessing; passion can lead people to wonderful accomplishments but can also lead them to reckless self-regard and cruelty. Those who are less passionate can often be steadier companions and kinder partners. Shame about being imperfectly passionate and fear of being locked into a life without total fulfillment keeps these twenty somethings from moving in any direction.
In a happily directionless part of my twenties, I read George Eliot's Middlemarch, which ends with this very un-Jobs-like valedictory for its heroine...
“The effect of her being on those around her was incalculably diffusive; for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been is half owing to the number who lived faithfully a hidden life and rest in unvisited tombs.”
Thoroughly contrary to the spirit of the age. Precisely what we need.
My supervisor and mentor Sylvia always says that "clients come in with an idea about what the story is and our job is to confuse them." I have seen this borne out. Clients have a very firm idea about what the problem is and how they got there but no idea how they can solve it. The therapist drills down and down and down, "slicing it thin" as Sue Johnson says. "I don't think I understood that. How does your mom being too lenient keep you from getting a job?" "Sorry. You said that when she gets angry, you shut down. What does 'shut down' mean?" "I missed that. You were talking about how in 1985 you had a miscarriage and that was connected with not wanting to eat. How does that work?"
How does that work?
I recently read about "The illusion of explanatory depth." The illusion of explanatory depth is what research psychologists Frank Keil and Leon Rosenblitt call the human tendency to be confident that we understand something -- usually how a familiar but complicated piece of machinery works -- until we are asked to explain it. Suddenly we recognize that a toilet or a sewing machine is way less familiar than we thought. The illusion falls apart and we become more humble. We start to know that we do not know.
I was amazed that nobody seems to have written about this in the context of psychotherapy. It used to feel to me like this kind of questioning that psychotherapists were doing about a person's experience was disrespectful. Aren't we supposed to see the client as the expert in his/her/their own story? But there is a difference between being intimately familiar with something and being an expert in it. Asking people to tell a coherent story about themselves and their difficulties can be painful but that doesn't make it disrespectful.
One of the things that can happen in a family in difficulty -- particularly where there is a lot of secret-keeping -- is that the explanatory depth is very thin. These families often have very limited, incoherent stories of themselves yet they are often very convinced that there narrative makes sense. If a therapist asks clarifying questions it can feel very scary because the family may intuit that the illusion of explanatory depth is about to fall away. Like all illusions, the IOED serves a very important function, it gives us a sense of coherence and comprehensibility in the face of things that feel chaotic and scary. But more coherent narratives are therapeutic.
John Byng-Hall citing the work of Mary Main among others wrote about attachment and coherent narratives in families.
“This would suggest that making sense of the events that traumatized the attachments is important. But the most effective way of creating a coherent story line is to help the family to manage their current attachments in a way that takes into account all its members’ attachment needs. This will require them to tune into each other’s pain. The children might then also be able to tell a coherent story to their children.”
One of the interesting elements of the IOED is that if we know that someone knows how something works, we take on that knowledge as if we knew it, too. "Well somebody understands how a toilet works," our brains say, "So I must, too." In a psycho-therapeutic context this can manifest as jargon not connected to real feeling or much detail; "I'm codependent." "He's got a borderline personality disorder." "It's because of early trauma." "He's from Mars and I'm from Venus." This is why a not-knowing approach by the therapist can be so important, even when it is frustrating for the client. Families need to go from being familiar with their own family functioning and stories to being experts in them. That doesn't mean they need to replace one prepackaged expert story with another, as easy as it is for our human brains to do that.
When all goes well, the client or clients are able to construct a more coherent and flexible understanding of themselves, understandings that can better tolerate challenge and reorganization.
A researcher from Ste. Justine here in Montreal, Mara Brendgen did a really interesting piece of research about friendship as correlated with depression in children. You can read the article (if you have academic access) or a nice summary of it at BPS Research Digest by Christian Jarrett. By studying kids who have an identical twin with depression and kids with a fraternal twin with depression Brengdan and her colleagues were able to identify kids who were genetically pre-disposed to depression but not depressed themselves. Then she looked at those kids and looked at the quality and quantity of their friendships.
“Genetic vulnerability to depression in girls was less likely to manifest if they had at least one close friend. Stated differently, the apparent protective effect of having at least one close friend was magnified in girls who were genetically vulnerable to the condition. This means that for girls there was an interplay between genetic risk and the protective effect of friendship. ”
— http://bps-research-digest.blogspot.co.uk/2013/05/stand-by-me-close-friendships.html
There was a beautiful piece on This American Life last week about a girl who had something like Asperger's. Her stereotypical conversation and poor social reciprocity get in the way of friendships. But she still wants friendships. Eventually she becomes angry and aggressive because she is so lonely. Her moms take her to all sorts of specialists (a humbling note for those who work with kids with learning and/or developmental disorders) and none of it really helps until... she makes a friend, a friend who is interested in the same things as her. (It starts at about 41:00 minutes)
A question I have about Brengden's research (or Jarrett's summary, not sure which) is cause and effect. While kids who are genetically pre-disposed towards depression may have fewer friends or friendships they value less, is that a cause or an effect or are they related through some other factor such as personality type or attachment style?
There is a correlation between people with schizophrenia and social isolation which has lead to the recommendation (here, for example) that people at high risk of schizophrenia make a conscious effort not to self-isolate. But we all know that correlation doesn't mean causation or else we would all demand more importation of Mexican lemons until highway deaths were eliminated (link to this and other bizarre correlations).
Nurturing a kid's positive friendships and encouraging him/her to view friendships as worthy of investing some time and energy in seems to me like a good idea whether or not they are at elevated risk of mental illness. Of course, for a kid who is less good at friendship or less interested in it placing a lot of emphasis on making friends can backfire by making him/her feel more incapable. Socially awkward kids often view friendship as an ability akin to drawing or music that relies on a high degree of innate talent (it is interesting that many kids who feel bad about their ability to make friends do so around the age of nine or ten when they also start to notice that other kids are way better than them at some things without having to try hard). It may be true that some combination of genes and very early wiring can make a person better at social situations than others, but I tell kids that friendship is more like riding a bike than playing music; it is something you can learn at just about any age, something you can always get better at by persevering and something you will never be able to learn do by watching others. You need to try it, fall down and try again.
My former supervisor and teacher, Sylvia, used to tell me, "If you are stuck with a client, you need to put that on the table. If you and the client can't get unstuck, stop the therapy." I have been thinking about what great advice that is and how hard it can be to follow. Clients will often say to me, "More therapy can't hurt, right?" I even hear that from medical professionals and sometimes mental health professionals. Generally, people know that insulin can hurt, and they don't take it just 'cause. People don't undertake minor surgery for no reason. Aspirin if taken improperly can put a person in grave danger. If a therapy is capable of affecting someone's well-being for good, then it can also do harm if administered when it isn't indicated or in ways that aren't indicated. Stated another way; If it can't do any harm then it is not worth doing. I am not talking about an abusive or incompetent therapist or an unproven therapy. I am talking about how psychotherapy can hurt when administered properly for the wrong situation or in the wrong dosage.
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Psychotherapy directed towards a fundamentally well person in a bad situation can make the person feel responsible for his or her situation and aggravate worry.This one happens with kids a lot. The parents come into a therapist's office and say, "My kid is anxious/sad/angry all the time. We don't want to discuss our fighting/grief/parenting. Work with the kid." The therapist can treat the kid using behavioral techniques for tackling whatever his/her symptoms might be. I have heard therapists say, "At least I can offer the kid tools for dealing with X that may alleviate one difficulty in a difficult life." I don't agree with this. I think treating that kid in isolation gives the parents license to continue their behaviour and can put the spotlight on the child whose symptom is really the family's. This may exacerbate feelings of responsibility for the family's difficulties.
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Therapy that doesn't change the music.This one happens with couples often. Couples will come into therapy and insist on having the same arguments that they have at home. I often say to them, "It's okay to fight in therapy, but I want you to at least have a different fight than you have at home." Therapy is about making change in patterns and if you are doing the same thing in therapy that you are doing at home, you aren't changing a pattern, you are rehearsing it and you may be reinforcing it. Some couples can't stop this, which is painful for therapists and the clients, but rather than have a bad experience of therapy and a lot of extra practice doing what hurts, it is better to stop therapy. The couple may be able to come back when they are in a different place or work with a different therapist who can get them pointed in a different direction.
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Psychotherapy in place of something else that would give more well-being.People are busy. Therapies can be expensive. People may prioritize psychotherapy over other things, either other therapies or other activities that could improve their well-being. People are often choosing between therapy and a gym membership or a babysitter or a speech therapist or a soccer practice. Those can sometimes be false choices but I actually think that more often than not, they are real. I am all in favour of people prioritizing their mental health and their close relationships but the best expression of wellness is living a full life, not being in therapy. Sometimes people believe, mistakenly, that because they are in therapy, they are taking care of their well-being when, in fact, they are using therapy as a smoke screen. A good question for clients and therapists is "If the client wasn't here, where would s/he/they be? What does missing X mean?"
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Ending too early. The pioneer of systemic, family therapy, Salvador Minuchin pointed out that sometimes people try something new to make a change but stop early when they see no benefit. Some changes yield benefit in a one-to-one ratio -- a straight ascending line -- but sometimes change comes more as an exponential curve or even a "hockey stick" curve in which a person sees little benefit at first but experiences big pay-offs when s/he persists. The down-side of ending early is that it can feel disheartening to work at something and see no result. Depressed people often cognitively distort failures so that is all they see and they see those failures magnified. If a depressed person tries cognitive behavioural techniques in therapy, for example, and doesn't experience change fast enough s/he can view it as yet another failure and feel worse. Going back to the surgery analogy, if we abandon surgery in the middle the results will be not only a return to pre-surgery function but worse functioning.
Avoiding these pitfalls is part of providing good therapy just as providing good medical care involves more than just prescribing medication, but knowing when and where to prescribe and when not to. All this isn't meant to scare people off therapy, but rather to point out that therapy has real effects. If a therapy isn't working, feels like it is hurting more than it is helping or feels stuck, take the time to look at that, client and therapist together.
I have been making my way through FX's "The Americans." (Spoilers ahead!) It is about a seemingly normal couple, the Jennings, who are, in fact, Soviet agents living in a Washington suburb and raising two children. The politics of the show are complicated; the Soviet agents at the centre of the show, Philip and Elizabeth, are very sympathetically portrayed but the very idea that Russian-born Soviet agents were able to successfully pose as native born Americans seems more like post-millennial sci-fi paranoia à la Battlestar Gallactica than cold-war Tinker, Tailor, Soldier, Spy realism. That aside, the appeal of the show is the marriage at its heart. How can two people who are expert deceivers and trained to see deceit everywhere, trust one another? Because they absolutely need to trust one another. They are alone in enemy territory. They are one another's only source of safety.
This is the dilemma at the heart of every relationship; No one can betray me like my lover and my lover is the only one who can heal betrayal. The show manages this with great psychological realism. Its creator is a former CIA agent.
I have a serious quibble with the Jennings children though, Paige and Henry. I am about nine episodes in so this may change but the kids seem ridiculously well-balanced. This isn't meant to be an action-comedy like "Spy Kids" where the parents bring the diaper bag instead of the bomb disposal bag but the show can't shake the very American convention that to be likable, the spies need to be good, loving parents, with essentially lovable, if slightly troubled kids. Paige and Henry hitchhike when the parents don't come to get them (because they have been abducted) and Henry smashes a beer bottle over the creepy driver's head to get away and the sibs pledge to keep it a secret. They get mad and sullen when the parents separate. This is the early 80s and by the standards of the time all this is pretty small potatoes as troubled kids go.
Meanwhile Elizabeth and Philip are patient and present for their kids when they hurt over the separation and sneak into their rooms and give them loving looks at night. These are the same people who stab, blow-up and shoot enemies of the motherland while living a double life as tour agents, people who have given up their pasts and country for an ideology they can never publicly avow.
I haven't worked with someone who lived a double life (any more than we all do). But I have worked with families that have kept big, dark secrets. I have worked with families where one or both parents are violent. There can be protective factors that mitigate the impact of these things but their children are always impacted. Granted, the Jennings kids' don't see what their parents get up to at night. But it is very hard to shut off violence and deceit, to keep it hived off, prevent it from leaking out. And the show recognizes that, plays with it... except when it comes to the kids.
When Elizabeth and Philip tell the kids that they are separating, one of the kids asks, "Will you stop loving us?" It would have been far more interesting (and chilling) to show how profoundly Elizabeth has been marred by years of constant deceit if we were offered the possibility of doubting her sincerity rather than seeing a model of connected parenting. It would be far more interesting if, instead of staring off into space in class, Henry reacted to his parents' separation (and years of hidden violence) by becoming violent himself. How would Philip and Elizabeth see their son -- and each other -- if Henry was beating the crap out of other kids every week?
It is interesting: The show's creator, Joe Weisberg, said in an interview that spy-parents usually have "the talk" with their kids at some point and let them know that they have been living a lie. I suspect that if their parents are doing anything one-tenth as convoluted and violent as what the Jennings get up to, the kids already know. "The talk" probably doesn't involve much listening by the parents or they would have learned that. Like so much that has to do with children, we don't like to face the reality of the impact of lies and violence on them, so much so that a gritty show, all about the subtle, polyvalent impact of deceit and violence on human relationships, can't dare to get it right.
I have been reading John Gottman's latest book "The Science of Trust." It is an interesting read on the subject with some great little tangents into history of science which I really appreciate. Gottman became famous after he was featured in "Blink" by Malcolm Gladwell because Gottman is able to predict with great accuracy if a couple will divorce based on very short interactions.
I love Gottman's approach to relationship questions. He is a social scientist perhaps first and foremost. He has spent years having couples come into his lab and seeing what they do that works and what doesn't. He has discovered that much of what therapists thought was true about relationships wasn't. In some ways, thanks to Gottman, now is the best time in recent history to seek help for your relationship. Gottman has identified what he calls "the four horseman of the apocalypse" for relationships; contempt, criticism, stonewalling and defensiveness. Couples where these are regular features of conflict are likely to set off a cascade of negative feelings that can be very hard to recuperate from.
My biggest dissatisfaction with the book -- and with other things that he has written -- is that it seems to say that people should "Just stop it."
Sometimes I feel like Gottman's prescription is; Read the book, understand the pain you are causing yourself and your partner and don't do it anymore. (John Gottman is a couple and family therapist as well as a researcher and I would love to know what his therapy is like and in what ways, if any, he goes beyond a psycho-educational model).
This approach is useful for couples who are feeling some rockiness and want some tips to help them address it. But I find it limited for the couples who go into a therapist's office or the therapist who treats them. These couples usually say something like 'I know I probably shouldn't ____________ (fill in the blank: criticize, stonewall, put my partner down, insult my partner) but when s/he does ______________ (fill in the blank) I can't help it.'
There is a limit to the power of our intellects to think our way out of emotional entanglements. There are a few times in my career where I have instructed people to stop some really destructive behaviour and they have listened to what I said and then complied. I can count those moments on one hand. Usually, by the time I see people, they know that what they are doing is hurting them and/or the people around them and they continue to do it. So far as I have gotten in the book, Gottman describes these "absorbing" states in which the interactions are "nasty-nasty" very well and documents the destructive consequences of them for a relationship. He says that they are not subject to the same game-theory model he proposes for the other elements of relationships in which people in a couple act rationally by maximizing their payoffs. He determined 'payoff' by having people rate the payoff for the interaction after the fact while watching video of themselves interacting. They rate these very miserable moments as very low on payoff. Why then do they get into these states? Why not "Just stop it?" Gottman's answer, as far as I understand it, seems to be a sort of black box; it is an absorbing state, not subject to rationality. Deal with other states, foster more neutral or positive states when couples are in them and try to keep the couple away from the powerful gravitational pull of these interactions.
Assessing payoff for these highly negative states in the way Gottman describes might be subject to an important methodological flaw that has implications for therapy; the payoff is clear at the time but hard to access afterwards. My experience both personally and professionally is that when someone is very angry and in conflict with another person, especially a loved one, the assessment of 'payoff' changes dramatically. After people really stop being angry, they will often say that they don't understand what happened when they were angry, why they acted the way they did. They may even have trouble recalling the details of what happened. There is a sense of dissonance or discontinuity with the angry state. While a person who is very angry may make decisions that are incomprehensible to him/her later, those decisions make good sense to the angry person who is feeling extremely negatively stimulated; s/he wants to eliminate the negative stimulation. This poses a problem for a person who is angry about the relationship because his or her partner is both the cause and the cure for the negative stimulation. That's why we do things that both hurt our partners and simultaneously try to keep them under our control by either keeping them near or at a safe distance.
Sue Johnson, the founder of Emotionally Focused Therapy, has a different take on this from Gottman that I think makes a good counter-point here. She sees couples in therapy as needing to work on what I think of as the operating system level rather than the software level. Those absorbing negative states need to be addressed precisely because they are not subject to intellectual scrutiny in the cold, hard light of day. When I am calm and able to reflect, I do not have access to my operating system, to all the things that are going on in a primal emotional state. I have to go to that state. My partner comes along with me and if I experience my partner as a supportive figure (a positive attachment figure; Johnson's EFT is very attachment-based), then when I re-enter that state I will turn towards my partner rather than seeking to hurt and control.
I found an old copy of On Becoming a Person at Encore Books a month or two ago. It is by Carl Rogers, the founder of client-centered psychotherapy, and I have been reading it slowly ever since. The first essay "This is Me" is a list of the very humane things Rogers learned over his years working as a therapist and researcher. Perhaps the central piece, the motto of client-centered psychotherapy is "I have found it highly rewarding when I can accept another person." Really accepting another person in his or her otherness is at the heart of Rogers' vision of psychotherapy (and humanness as far as he was concerned). My supervisor and teacher, Sylvia, has been telling me for the last year and a half that the greatest resource a therapist has is the client; I might summarize her teaching to me as, "Be curious. Ask, ask, ask." That is very much in the spirit of Rogers. You may, as a therapist, think you know, but rather than proceed with that assurance, ask. He describes the experience of the research scientist afraid that the evidence might disprove one's hypothesis;
"... It seems to me that I regarded the facts as potential enemies, as possible bearers of disaster. I have perhaps been slow to realize that the facts are always friendly... I still hate to readjust my thinking, still hate to give up on old ways of perceiving and and conceptualizing yet... these painful reorganizations are what is know as learning."
I cannot tell you how many times I have thought that I understood something about a client, some clever idea I had, that when I checked it out in the form of a question turned out to be totally wrong. Sylvia gave me a great example of this that she had from another therapist; a client comes in for a first session and announces that her father has just died. "Oh, how horrible, I am so sorry," says the therapist. The client has the strength to say, "I hated my father. He was cruel to me all my life." I am guessing many clients would not have been so courageous and might have succumbed to the therapist's assumption, really an assertion about how the client ought to feel.
I imagine it must have been very challenging for Rogers to take such a stance in the nineteen-fifties. RD Laing of the famed Tavistock clinic critiqued the idea that he saw current at the time that the psychiatrist is the detective who enforces the law of illness. Even today therapists whether psychiatrists, psychologists, social workers or other allied professions, are encouraged to think of therapeutic work as detection, seeking to unmask through superior knowledge and reasoning psychopathology whether within an individual or a system. Psychiatry and detective novels grew up together. Freud and Holmes both proceed -- by a bizarre logic apparent only to themselves -- to a conclusion that seems inevitable once announced.
Alan Arkin (love him but his accent is Vienna by way of Brooklyn) and Nicol Williamson as Sherlock Holmes in the film version of the Seven Percent Solution.
It is very hard to practice accepting the other when you approach the other as a suspect. I would say that Rogers' and Sylvia's teachings about client centered-ness have been a great life lesson for me.
Rogers also valued pursuing what "feels right." In this regard he is very much a part of the existentialism of the mid twentieth century. He quotes Kiekegaard and Buber, the philosopher of the "I-thou" relationship. This is one piece of Roger's thought that I don't buy.
Therapists and therapy are often informed (misinformed, I believe) by the idea that there are deeper more authentic parts of the self which are obscured by less authentic elements of the self. A good example of this is the idea of primary and secondary emotions (see Greenburg and Safran) which informs many therapies. Primary emotions are viewed by Greenburg and Safran as more authentic and more somatic, secondary emotions are reactions to these first feelings. This can be a useful distinction, it can be helpful for therapists and clients to focus on feelings that are outside of the client's usual repertoire. But I don't know how one can say definitively that one feeling is more authentic than another or distinguish meaningfully between authentic and inauthentic elements of self.
The homunculus fallacy is the name given to the idea that there is the psychological or neurological equivalent of a little man inside each of our heads - a homunculus - who experiences our experiences and commands our responses, an authentic self buried within our bodies and minds. The fallacy is that if there is indeed a self within the self, then why not say that within that there is yet another self and so on. Self becomes a Russian doll and the pursuit of the authentic self a recursive pursuit at great expense of time and money. One of the extraordinary cultural shifts that one can see in Rogers book is in the expectation that therapy be a process that goes on for years. He talks casually of seeing clients for a 48th or 60th session of therapy for what seems to be a therapy of self-knowledge rather than any more focused goal. (I don't know if these were sessions for which clients paid or not). This certainly was before the age of HMOs.
A final piece from Rogers, perhaps his best known quote from the same essay "This is Me," and a truly beautiful bit is the paradox of acceptance and change.
“... [T]he paradoxical aspect of my experience is that the more I am simply willing to be myself, in all this complexity of life and the more I am willing to understand and accept the realities in myself and the other person, the more change seems to be stirred up. It is a very paradoxical thing — the degree to which each one of us is willing to be himself, then he finds not only himself changing; but he finds that other people to whom he relates are changing.”
Carl Rogers
Trauma impacts mental health especially trauma in childhood. In a previous blog post I wrote about how kids who are poor are more likely to be exposed to trauma than wealthy kids. Now there is research that indicates that the effects of trauma can be biologically transmitted across generations. The researchers subjected mice to trauma in the laboratory in the form of electrical shocks. When baby mice were conceived using the sperm of the traumatized mice, the babies had a stress reaction to stimuli that were associated with their parents trauma, in this case a particular smell, and the effects seem to stretch over several generations. The theory put forth by the scientists to explain this is epigenetics, that certain genes are 'turned on' or 'off' by experiences creating heritable traits as a result of what happens in the environment.
If this carries over to humans, it could mean that a kid whose grandmother or grandfather experienced trauma could still carry the impact of that trauma in his or her body. My clinical experience is that trauma does seem to pile up in families. Sometimes the people who come into my office will describe three generations of abuse. It can be hard to get out from under that. Now we have another indicator of why that might be the case. Not only can there be a cultural inheritance of trauma in a family, the genetics of one's descendents can be marked by traumatic experiences.
On a more hopeful note, epigenetics may work to undo some the hurt of previous generations. Researchers here in Montreal, at the Douglas Hospital, have looked at the effect on an epigenetic level of nurturing by a parent on mediating stress (more traumatized rodents).
“Baby rats that are licked often by their mothers—with licking in rats fulfilling the same function as cuddling in humans—are calmer than rats that are not licked enough. Michael Meaney and his team delved further into this idea by tracking the imprint left by maternal care in the brain of young rats. They were able to do this because the action of licking influences the activity of a gene (called NRC31) that protects rats against stress; when activated, this gene produces a protein that helps decrease the concentration of stress hormones in the body. A specific part of this gene must also be activated via an epigenetic switch. ”
— http://www.douglas.qc.ca/info/epigenetics
According to this theory loving cuddling can help kids deal better with stress than they might even if they have an epigenetic inheritance of trauma. So why are you still reading? Go hug your kids.
The ubiquity of pornography has got to be one of the biggest changes in society in my lifetime. An acquaintance asked me what I thought the long-term effects of total access to porn would be for shaping the sexuality of kids growing up today and I really had no idea how to answer. There is much heat and little light on the subject because sexuality in general and kids' sexuality in particular is such a fraught topic.
On the one hand, today's nearly unlimited access to pornography via the internet is part of the demystification of sexuality which has been building steam over the last one hundred years. It is connected -- at least in a six-degrees-of-fornication kind of way -- to changes which I view as absolute social goods, like decriminalizing miscegenation and homosexuality, allowing women (and everybody) a greater degree of control over reproduction and generally removing some of the shame from sexuality for everyone, male, female, gay, straight etc. It is worth remembering that lynchings of non-white men for sex with white women, death by back-alley abortion and 'curbing' of gay people are pieces of North American history that happened within living memory (and are practices some would like us to return to). The impulse to curb sexual freedom, including the freedom to view porn, can be an instrument of sexual repression and shame. A lot of the conversation about pornography and young people -- any sexual topic and young people for that matter -- seems to smack of a old-person's cocktail of wistfulness and resentment ie. "If I can't have lots of crazy sex, then nobody should."
On the other hand, pornography has to own some of the criticisms made of it; it is hugely male-oriented and at least some significant portion is downright anti-women. It seems pretty intuitive that a barrage of woman-degrading porn would do anybody's developing sexuality harm. More generally, porn is, by definition, commercial sexual objectification. Young men and women who grow up viewing sexuality (and we are talking largely about women's sexuality) as an object for purchase or trade, rather than a subjective experience seem more likely to generalize some of those lessons to non-porn sex. These are both arguments that can be made about any type of pornography. There is also a particular techno-bent to some anti-porn writing that makes the argument that a quantitative difference of the internet makes for a qualitative difference.
“What happens when you drop a male rat into a cage with a receptive female rat? First, you see a frenzy of copulation. Then, progressively, the male tires of that particular female. Even if she wants more, he has had enough. However, replace the original female with a fresh one, and the male immediately revives and gallantly struggles to fertilize her.
You can repeat this process with fresh females until he is completely wiped out.
This is called the Coolidge effect—the automatic response to novel mates. It’s what started you down the road to getting hooked on Internet porn.”
— http://yourbrainonporn.com/doing-what-you-evolved-to-do
Digression: Perhaps 2014 should be the year that nobody says "The area of the brain that lights up when..." Regular readers will know that I am sceptical of some of the claims of 'brain science'. The next post on "Your brain on porn" has fMRI images showing how sections of the brain "light up" when exposed to porn which proves that the subjects of the brain scans are addicted much as people get addicted to heroin. ( A primer on fMRI goofiness. ) Here is a picture of a dead fish in a fMRI with its brain lighting up when asked to imagine humans in social situations.
End digression: There is a growing set of men who say that they are addicted to internet porn and/or incapable of erections with actual humans as a result of using porn regularly. This is a tough claim to verify since it is so subjective. Men may experience less frequent erections and attribute that to the use of porn; that doesn't necessarily mean that was the primary cause. That is what is known as the post hoc ergo propter hoc fallacy. It does seem to make intuitive sense that if you don't masturbate for a long time you are more likely to experience an erection in a particular circumstance. It also seems like it would be pretty hard to look at a lot of porn and avoid masturbating, so the two do go hand in glove (as it were). There is a whole online Nofap community where people, mostly men, pledge to stop masturbating and/or viewing porn. They support one another to achieve goals in days. When does this shade over into shaming a normal and healthy sexual behaviour that has already been the target of a lot of shame? I wrote a blog post a while ago about Marty Klein's argument that the term "sex addiction" is a way for people living in a sex negative culture not to address their sexual desires about which they feel incredible shame.
There are a couple of things I am pretty confident about in all of this.
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The whole "erectile dysfunction" piece of the conversation about porn and masturbation needs to get scaled way back. Men are easily goaded into thinking that a rock hard penis is the only legitimate route to sex. That's false and it isn't good for men's sexuality (or for their partners). Start having sex without an erection and you may get one. Keep having sex after an erection goes away, and it may come back. But if you make having and maintaining an erection a prerequisite, that can mean a lot of heart ache. Paradoxically, lots of porn and lots of nofap both seem to perpetuate the myth of no sex without an erection.
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Porn is not sex education. Teens need to know that what they will see in porn is not what happens between most people's sheets. Talking to teens about what porn is and isn't is part of the job description of every parent, and that needs to go beyond telling them it's bad or women-hating. Porn:Human Sex::2Fast2Furious:Driving. A fantasy.
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Teens will try to make their own porn. Not every teen but plenty of them. Maybe not your kid but plenty of kids your kid knows. As Dan Savage has pointed out, smart phones are -- among other things -- mobile porn production and distribution suites. And parents hand them over to kids without thinking about or talking about that. If you must give your teen a smart phone, disable the camera. Tell your kids you will search through the contents of their phones and then follow through. Millions of adult Americans use their phones this way, should we expect teens to act any more maturely?
When did "parenting" become a word? When a publisher realized that there were millions to be made from telling anxious, well-off parentingers about all the things that can go wrong with kids. (And a guy named Stan, in marketing, suggested they move away from the term "child rearing"). Nobody ever sold a book called "If You Can Afford the 30$ to Buy This Book Then Your Kid Is Doing Better Than 99% of the Humans Who Ever Lived." 21st century Canadians live in an age and place where most of us can provide our children with nutritious food, shelter, education, clothing and medical care that most of our ancestors (and many people around the world today) would have been delighted to be able to give to their kids. That and love will go a long way. We live in an age and circumstance of tremendous blessing. So why do we consume parenting advice books and lectures by the SUV-load?
I work with a lot of families in difficult situations and I have seen some pretty bad parenting (by today's standards). I can tell you that very little of what I have seen happens because people didn't read a book on parenting. Occasionally, I will meet parents who honestly did not know better. I tell them to stop and, usually, they do. Twice in my career I have told parents not to threaten to hit their kids with a belt. These parents felt overwhelmed by out-of-control kids and thought that threatening such a beating was better than actually following through. I told them that, for a kid, the fear of such a beating can be almost as devastating as the beating itself. They thought about it and saw that what I was telling them was probably true. We brainstormed some better ways to deal with their kid's behaviours and they never resorted to that kind of threat again.
I see parents who want to stop doing things they know or suspect are bad for their kids but they can't because they have mental health issues or are struggling with the ghosts of their own past or trouble in their present. Just about everybody knows that parents should keep their marital acrimony away from their kids. There are dozens of books that will tell you that. But I have seen a lot of parents who tell me that in their particular circumstance, because their soon-to-be-ex wife/husband is such a poisonous viper, it is absolutely critical for the kids to know everything. Or they make every effort to hold back only to find themselves pouring out all their hatred to a kid who is caught in the middle. A book may help re-inforce a message in such a circumstance but I think that person needs supportive friends, a caring community and probably counselling.
The people who buy books on parenting are often the worried well; parents who lack confidence in their own ability to parent. That is where I have the biggest issue with the parent-advice-industrial complex. By turning something that humans have done pretty successfully for our whole history into a gerundified 'parenting' with classes and manuals and DVDs, it makes parents feel less confident in their own judgement rather than more confident. Ron Taffel wrote a wonderful piece in Psychotherapy Networker a few years back called "The Decline and Fall of Parental Authority... and what therapists can do about it." He wrote about some of the forces undermining parental confidence and what that does to people's lives.
“[A] chronic sense of being held hostage by kids and the culture at large helps explain why parents so often show up in our offices looking and sounding like spineless wimps. With so little time to bond with their children, parents are afraid to take even one step that could drive them farther away, undermine their already shaky school performance, and ruin their chances for social success when little else seems to matter. Not surprisingly, a multibillion-dollar public and private enterprise monetizes these insecurities by selling a raft of social modules and remediation services—including tutors and homework helpers for the well-heeled and supplemental educational materials designed to jack up reading and math scores. The issue isn’t just parental abdication, but what I call the “merchandising of childhood,” based on a deep-rooted fear of failure.”
— http://www.psychotherapynetworker.org/magazine/currentissue/item/1645-the-decline-and-fall-of-parental-authority/1645-the-decline-and-fall-of-parental-authority
Taffel sees economic difficulties as the driving factor in parental lack of confidence. I would go one step further; I think we live in a fear culture. We are encouraged to be fearful rather than generous and open towards people and the world around us and we are especially encouraged to transmit those signals to kids. Engagement in community organizations has plummeted in North America over the last 50 years. People don't join clubs, religious institutions civic organizations. In Robert Putnam's famous phrase, today people are "Bowling Alone." And people are 'parenting' alone as well. Living in a more mobile, deracinated society that is fearful and highly individualistic means people don't have great social networks for parenting. There are fewer norms for parenting and the norms that exist are harder to learn than they once were.
That makes for a lack of what social scientists call self-efficacy among parents; basically the feeling that you know what to do and are able to do it. That is a problem because self-efficacy in parents correlates highly with good outcomes for kids. (Obviously, if you are convinced that the way to deal with a kid is by threatening to hit him/her with a belt or to dis your ex to the kids, that's not good. But it is better to parent with confidence than to parent without confidence, even poorly, and parents who feel confident in their parenting are less likely to parent badly.) Researchers don't know exactly why that is the case, whether confidence comes from success, or if it comes from shared norms and those things generate success in parenting or maybe that kids perceive confidence in their parents and feel a sense of safety because of that. Or a combination of those things. But it is clear that feeling that you can manage being a parent without getting post-doctoral training in child development and arts and crafts is good for families.
This doesn't mean that parenting books can't be helpful for everyday kinds of problems with kids. I have mentioned "How to Talk so Kids will Listen, How to Listen so Kids Will Talk" before which I think is great. But I actively discourage parents from trying to anticipate and preparing a fully developed response to every potential disaster of childhood and adolescence. Now if you'll excuse me I have to go work on the next chapter of my parenting book. The working title is "1001 Things That Will Definitely Go Wrong With Your Kid That Only This Book Can Fix."
Why do most people bounce back from a traumatic experience after a few weeks or months when others struggle for years with anxiety or PTSD? What protects some people from the effects of trauma? What can we do to promote resiliency from trauma? The answer might have to do with 'extinction.'
In psychological parlance 'extinction' can be a good thing. Extinction means 'unlearning' a conditioned response. Remember Pavlov and his dogs? Ring the bell and feed the dogs, eventually the dogs will salivate at the sound of the bell. That is conditioning. Well, after a while if they get their food without the bell, the conditioning wears off and the dogs don't salivate anymore, and that is extinction learning; learning that something that was once associated with an experience may not be connected to that experience.
Maladaptive trauma responses, including disorders like PTSD, probably have something to do with conditioned response. People with PTSD may associate all sorts of things with the original trauma so they are triggered to re-experience the trauma by a smell or sound, or they seek to avoid being in situations which call to mind the trauma, even though objectively those circumstances aren't dangerous. Richard Bryant, a researcher into responses to trauma, has done a really smart prospective study that suggests that a person's pre-trauma capacity for 'extinction learning', his or her ability to 'unlearn' the connection between a negative experience and the circumstances surrounding it, is very predictive of the ability to bounce back from trauma. He describes it at about 31 minutes of this video. The whole video is interesting but this piece is only about four minutes.
Here's the study for those of you interested in checking it out. Bryant doesn't talk about what predisposes people to be better or worse 'extinction learners.' Some of it probably has to do with genetic factors. I would be curious to know to what degree cognitive flexibility, the ability to change one's ideas about the world, correlates with extinction learning. Cognitive flexibility can be enhanced by all sorts of things. If you want to test your cognitive flexibility, some of these tests, like the Stroop test, are good measures. In the interests of full disclosure I did pretty badly on the Stroop test. Not sure what that means for my chance of extinction.
I work with a lot of kids with Autism Spectrum Disorders (ASD) in the context of family therapy. One client of mine will sometimes say something pretty innocuous and then suddenly get worried. He looks at me anxiously, trying to read my expression. He asks me “Are you mad? Did I do something wrong?” He feels like the world is filled with unexpected land-mines. Social situations seem to follow weird rules that everyone but him knows intuitively. People often get angry at him for mysterious reasons, so I might as well. This is pretty common for people with ASDs. They have a tougher time with something called “mentalizing,” which means understanding that other people have different mental states -- knowledge, thoughts and feelings -- than themselves. (I wrote in a previous piece about Theory of Mind, which is very similar to mentalizing. There is a great video demonstrating what this looks like in kids.) People with ASDs can find it really hard to figure out what those other mental states might be, based on cues that most of us read without thinking about it much like tone of voice, facial expression or posture.
Some neuroscientists think that the neurology of people with ASDs is different from other people, that they may have fewer 'mirror neurons,' neurons that are thought to help with connecting to another's experiences on a totally unconscious, physiological basis. Prominent among these is VS Ramachandran, who, in addition to being one of the foremost neuroscientists today, and an interesting philosophical mind, has maybe the coolest accent of anyone I have ever heard speak.
Mirror neurons are pretty spectacular according to Ramachandran, but others dissent. One of the biggest doses of cold rain on the mirror neuron parade is the fact that we lack clear evidence that they exist in humans.
Whatever the reason, people with ASDs do really poorly on a relatively new test for reading social cues called the Movie for the Assessment of Social Cognition or MASC. MASC is a really neat psychology test that lacks the flash of fMRIs but actually quantifies people's understanding of social situations very well. The subject is shown a video of a social situation and asked a series of true or false questions about the mental states of the people in the video. What is really interesting to me is what researchers have found out about people with Borderline Personality Disorder (BPD) when they take the MASC test.
Among other things, BPD is characterized by very conflictual interpersonal relationships. This great animation outlines some of the things that go on for people with BPD and the criteria for diagnosis.
People with BPD do very poorly on the MASC test but for almost exactly the opposite reason than people with ASDs. While people with ASDs tend to mentalize poorly -- that is to consider and evaluate correctly the inner experiences of the people in the video -- people with BPD tend to “hypermentalize.” They are very tuned in to the mental states of others, perhaps too tuned in. Some research indicates that people with BPD may actually be better at correctly “reading” other people's emotional states based on limited information than non-BPD people. But like many people with ASD, people with BPD can find the social environment confusing and overwhelming, not because they have too little information to understand what is happening, but too much. I suspect they are also lopsided because their hypermentalizing often tends towards the negative; that is they read negative cues very clearly but positive cues get less focus.
Think about how many quick, frustrated glances or disapproving sighs a person might encounter in the social landscape in a typical afternoon. People who don't have BPD may register them almost unconsciously, as subtle social cues to "hurry up", "hold on a minute" or "give me some space". Those things help most of us adjust our social behaviour. But people with BPD experience each negative micro-expression like an angry, screaming tirade leaving them as bewildered as the young boy with ASD asking, “what did I do wrong?”
Men often fear that therapy is stacked against them. Whether it is couple, family or individual therapy, they think that they are entering a domain where their skills and strengths will be counted as liabilities and they will be asked to do things that aren't just difficult or scary but unbecoming. That isn't a man problem. That's a therapy problem. I was talking recently with another male therapist, Dr. Darrell Johnson, a friend and mentor. I mentioned this campaign to him... (Okay, it isn't Ron Swanson but a Ron Swanson knock-off.)
It is from the Office of Suicide Prevention of the Colorado Department of Public Health and Environment. It's geared at connecting with men, particularly working-age 25-54 men who are twice as likely to commit suicide as any other age group according to the white paper that was used to develop the Mantherapy campaign (US stats). Darrell and I talked about the idea that men are typically more resistant to therapy (part of what accounts for their higher suicide rates than women). I joked that soon it would be possible for therapists to use cookies to give different design templates to their websites so that women and men would be presented with different web sites that are gender specific since too much "feelings" language might be off-putting for men, essentially presenting themselves as Rick Mahogany when men click through. But the Colorado campaign doesn't seem to have been a raging success despite the high production values. The Richard Mahogany video that has the most views on YouTube is at around 8,000. Maybe those are 8,000 saved lives and if so, great, but I don't imagine that therapy's problem with men has been touched much. I think the character seems inauthentic, not just playfully unreal, and for men or women authenticity in therapy is important.
There were a few things in the white paper that I thought were really interesting for therapists to consider about working with men, things that hadn't occurred to me despite having worked with boys and men a lot. One is the value men often place on fixing something themselves and how to make therapy an exercise in 'solving it myself (or ourselves) with help'. One man said to the researchers of the white paper, "Show me how to stitch up my own wound like Rambo." Okay, that's some pretty serious hyper-masculinity but the point is that therapy can benefit from emphasizing the client's efficacy in problem-solving with the therapist as trusted assistant.
The other thing that I thought was really wonderful was the importance some men place on giving back. I was in Hawaii last year. A companion and I went kayaking. We visited a small island and had a great time but when we went to get back in our kayak, we got hit by several waves in succession and my companion got knocked over in the surf and couldn't get up. I watched, barely able to keep myself afloat trapped on the other side of the kayak thinking I might very well see this strong, capable person drown before my eyes in three and half feet of water. But before that could happen two kayakers (much more capable than us) grabbed our kayak and my companion, hoisting him out of the water. I thanked them. They said, "That's what we do." They viewed helping as part and parcel of who they were. I, on the other hand, felt grateful but unsatisfied as they paddled away. I couldn't pay back the debt I owed them. Therapy is a uni-directional process as far as help goes; codes of ethics forbid outside relationships so it is very hard for a client to pay his debt with his skills through labour exchange or barter. I never thought about how important it can be for some clients to be able to show their competency and mastery to a therapist by doing meaningful work or sharing their own products, to give help for help received, and that men might feel that more acutely. The report points out how central the idea of repaying a debt is to AA, for instance. Now I am considering requiring clients in some circumstances to agree to pay part of the cost of therapy by "paying forward" to others using their own strengths and capabilities (see the Milwaukee African Violet Queen). Ron, would like the idea of paying off your therapy by carving duck decoys with kids in an after-school program?
"I'm a a bit fearful that we are verging on what I call 'feelings territory.'"
There was a neat piece on NPR today about gut flora and mental illness which postulated a link between the health of one's inner beasties and one's mind.
But before you run out and buy an industrial tub of yogurt and a tempeh starter kit, know that something as immutable as your birth month also impacts your risk for many diseases including several mental illnesses. From the Atlantic...
“Many contemporary scientists are loath to admit to anything resembling astrology. “It seems absurd that the month you are born/conceived can affect your future life chances,” write neuroscientists Russell G. Foster and Till Roenneberg in a 2008 study. They then go on to then point out no fewer than 24 different health disorders connected to season of birth, and ultimately admit “despite human isolation from season changes in temperature, food, and photoperiod in the industrialized nations, the seasons still appear to have a small, but significant impact upon when individuals are born and many aspects of health.””
— http://www.theatlantic.com/health/archive/2013/11/your-zodiac-sign-your-health/281358/
Marsha Linehan, the psychologist who developed Dialectic Behavioral Therapy, used for treating substance abuse and borderline personality disorder, among other mental illnesses, talks about the importance radical acceptance.
“So what’s Radical Acceptance? What do I mean by the word ‘radical’? Radical means complete and total. It’s when you accept something from the depths of your soul. When you accept it in your mind, in your heart, and even with your body. It’s total and complete. ”
— http://www.dbtselfhelp.com/html/radical_acceptance_part_1.html
Linehan does not mean that we accept our brokenness, our faults, our failings and stay there. As Carl Rogers said in On Becoming a Person, "The curious paradox is that when I accept myself just as I am, then I can change." Linehan, in a very courageous move, recently talked about her own experiences of mental illness, including many attempts at suicide and her recovery from it which was prompted by a religious vision which included a profound feeling of self-acceptance.
“I decided to get supersuicidal people, the very worst cases, because I figured these are the most miserable people in the world — they think they’re evil, that they’re bad, bad, bad — and I understood that they weren’t,” she said. “I understood their suffering because I’d been there, in hell, with no idea how to get out.”
In particular she chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder, a poorly understood condition characterized by neediness, outbursts and self-destructive urges, often leading to cutting or burning. In therapy, borderline patients can be terrors — manipulative, hostile, sometimes ominously mute, and notorious for storming out threatening suicide.
Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense.
NYT http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=3&_r=0
The idea of radical acceptance, even for the purpose of change, seems profoundly lacking in our thinking about health. In North America, at any rate, we are meant to view ourselves as our own greatest work of art, as perfectible.
I am in the change business. If diet can help people with mental illness then I want to know about it. But I also believe that sometimes a hyper-developed sense of agency, which is pretty much the modern condition, oddly, keeps people stuck. Sometimes we have to accept even our darkest feelings, "meet them at the door, laughing, and invite them in" before we can learn what they came to teach us.
The Guest House
This being human is a guest house.
Every morning a new arrival.A joy, a depression, a meanness,
some momentary awareness comes
as an unexpected visitor.Welcome and entertain them all!
Even if they are a crowd of sorrows,
who violently sweep your house
empty of its furniture,
still, treat each guest honorably.
He may be clearing you out
for some new delight.The dark thought, the shame, the malice.
meet them at the door laughing and invite them in.Be grateful for whatever comes.
because each has been sent
as a guide from beyond.-- Jelaluddin Rumi,
translation by Coleman Barks
If you have never done so, watch this video, then meet me down below and we'll talk.
Pretty cool, right. So aside from being a neat little feature of how our minds work what does this have to do with families and couples? This experiment is a great way of demonstrating "priming". We are focused on what we are primed to experience and miss what we aren't primed to see. In the case above we are primed to see basketballs not gorillas. Having our limited attention focused on the basketball means that we have less attention for noticing the bizarre detail of the gorilla.
This has very real implications for human interactions. Confirmation bias is a kind of priming in which we give great weight to cases that confirm an idea we have about the world and discount cases that don't confirm our idea. If I believe that tall people are untrustworthy, I will see examples of tall people behaving in untrustworthy ways and view them as representative, but I will tend to discount examples of tall people behaving altruistically. This explains why more pernicious prejudices like race prejudices become re-enforced and are so hard to break. Here's a great example of racial priming.
These aren't bad people, but both black and white people are primed to see a young, white guy as a parks employee and a young, black guy as a thief. If you want to check out your own priming on race and a variety of other social factors, check out ProjectImplicit and try one of their tests that allows you to assess how your implicit, unexpressed values line up with your expressed values.
Priming happens on a micro level in a couple or family, too. When the relationship in a couple or between a parent and child becomes fraught with bad feelings, a person becomes primed to see the negative qualities or behavior they expect and -- like with the gorilla -- may completely miss unexpected, positive moments for which they are not primed.
In "How to Talk so Kids Will Listen and How to Listen so Kids Will Talk," Elaine Mazlish and Adele Faber talk about "catching" kids being good; noticing and calling out when a kid does the right thing. They present it as a way for kids to feel that they can succeed, which is important. But just as important is what "catching" a kid doing good does for a parent. It re-primes him or her.
If you find yourself counting basketball passes all the time with your spouse or kid -- watching for them to do the expected and annoying thing -- re-prime yourself. Look for good, look for gorillas. They're more common than you think.
I am loving The School (Educating Essex). Nothing I have ever seen captures what schools feel like, for good and bad. This is a perfect rebuttal to most depictions of teens and teachers on TV. You must stick around for "Am I amused?" at 9:30. I am waiting to see a social worker/school counselor.
A great blog post called "5 Stereotypes about poor families and education" in the Washington Post a few days ago quoted extensively from a book by Paul C. Gorski titled Reaching and Teaching Students in Poverty. The excerpt offers a lot of research to dispel some common negative myths about poor people that impact the way schools and educators tend to approach them and how that impacts their experience of school; poor people don't value education, poor people are lazy, poor people are more likely to be substance abusers, poor people are linguistically impoverished and -- the biggy -- poor people are ineffective parents.
This is a tricky subject because some things about poverty can have an impact on kids' school performance as well as physical and mental health. Well-intentioned governments and schools generally want to respond to those negative effects in order to ensure that kids growing up in poverty have the best opportunities they can (or say they do, at any rate). But as Gorski points out fuzzy thinking about how exactly poverty does or doesn't impact kids and families can be deleterious on a classroom or a public policy level.
“Stereotypes can make us unnecessarily afraid or accusatory of our own students, including our most disenfranchised students, not to mention their families. They can misguide us into expressing low expectations for poor youth and their families or to blame them for very the ways in which the barriers they face impede their abilities to engage with schools the way some of us might engage with schools.”
The WP post doesn't discuss the tings we do know about the ways in which poverty (or things that are highly correlated with it) impact kids and families though I am assuming the book will do just that. Paul Tough wrote a great piece a few years ago for the New Yorker called "The Poverty Clinic." The article looked at a medical clinic which used the findings of the Kaiser Permanente Adverse Childhood Experiences study to treat poor families. The upshot of the study and Tough's article is that childhood trauma is a huge risk factor for both physical and psychological illness both in childhood and in later life. Since poor people are much less well insulated against trauma, they are, on average, at greater risk. Trauma both intensity and frequency are a great predictor of difficulty in school and later life, but not poverty per se.
The other piece of really interesting research about differences in family style between poor and middle-class families and how that impacts education that Gorski alludes to in the extract, but that doesn't get a lot of play is Anette Lareau's distinction between middle-class "concerted cultivation" versus poor and working class "accomplishment of natural growth." While not contradicting Gorski, Lareau does portray the poor/working class families in her study as less organized around talk and less at ease with certain kinds of parent involvement (Gorski says that poor families may want to be involved but may feel turned-off by the ways schools invite participation, which tends to be geared towards middle-class parents).
Finally, one of the things that Gorski doesn't address in the blog post is varieties of poverty. Because poverty itself is not the cause of academic failure or ill health or family dysfunction, but certain things that are often associated with poverty are risk factors for all those things, we should look at and think about the way differences between poverties impact those factors; for example, not every poor community increases exposure to trauma for kids. Some poor communities are better at insulating their young against trauma than some wealthier communities.
Talking with kids about sex can be tough for parents even when we think we're ready for it. Julia Sweeney gives the best (or worst) account of having the sex talk with a child ever.
I actually think listening to this is a great way to prepare yourself for talking with kids about sex. Once the topic comes up, kids, especially young kids may ask all sorts of questions that we might never expect, but that are pretty obvious if you take some time to consider it from their perspective. After all, everything about sex seems pretty unlikely to an eight year old.
Also her account is loving and humorous and sort of makes the point that we all make mistakes when we talk about sex with kids, and if we have a loving relationship with our kids, we will get lots of chances to go back and talk more. The importance of having an ongoing dialogue with your kids about sex was demonstrated by a 2008 study done by researchers at Ste. Justine hospital, here in Montreal. That study found that while parents assumed their adolescents looked to friends and celebrities to shape their attitudes towards sex, teens (the study was of teenage girls) report that it is their parents who are their most significant role models, but that despite that they do not feel comfortable talking with them about sexuality. So take heart, your child will look to you more than peers or the popular culture for her ideas about sexuality but you should start laying the groundwork for conversations about sex early.
Dr. Suzanne Koven has just written a great blog post that is required reading for anyone who cares about mental health care in North America, called "Should Mental Health Care be a Primary-Care Doctor's Job?" She points out the degree to which medical mental health care has been downloaded to primary care docs who may or may not feel up to the task.
“I’m comfortable helping people get through life’s more common emotional challenges, like divorce, retirement, disappointing children. If you’re hearing voices, or if you walk into my office and announce that you’ve decided to kill yourself, as someone did not long ago, I know exactly what to do: escort you to a psychiatrist. But what about the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder? Or the businesswoman whose therapist told her to see me about starting an antidepressant? Or the civil servant trying to shake his Oxycontin addiction? They’ve all asked me to treat them because they don’t want or can’t easily access psychiatric care. ”
Here in Quebec, the recent Bill 21, which regulates the act of psychotherapy, gives physicians automatic access to the title of psychotherapist though their training in mental illness and mental health may be limited depending on what their experience in medical school and residency was. While there are many doctors who are great psychotherapists and who have taken the time to get trained, becoming a doctor involves training in diagnosis of mental illness and some psycho-pharmacology and only a cursory understanding of different forms of psychotherapy. (The purpose of Bill 21 is to protect the public by ensuring a minimum of training for psychotherapists. It has serious ramifications for people who use mental health services but remains largely unexamined in French or in English media).
Dr. Koven points out that fewer medical students are going into psychiatry in the US (sorry, I can't give Canadian stats) so both the public and general physicians have less access to doctors who specialize in mental health. I also have seen that there is a feeling among patients that psychiatrists are pill-pushers while a GP may be more accessible and take the time to know a patient better ad this may make people even more likely to rely on generalists. (My experience of psychiatrists has actually been that they are more likely to prescribe talk therapy with or without medication than GPs, but that is very impressionistic.)
Recent changes to the way health care is delivered in Quebec make it harder to access a psychiatrist directly through the public system. In order to see a psychiatrist you must first go to a public health clinic, a CLSC, rather than go to a psychiatrist in the public system directly (except for emergencies). This can be good because people can be seen by a social worker or psychologist at a CLSC which may be what they need, but it re-enforces the model of psychiatry being practiced only with the very seriously mentally ill or the very wealthy. Finding a psychiatrist to really follow someone with obsessive compulsive disorder, for example, to ensure that medication is appropriate and effective and to consult with the therapist, whether s/he is a GP or a social worker, is very hard. It may account for why fewer people want to go into the field, too. After all, who wants to go into a medical specialty where you are supposed to fathom the mysteries of the human heart and human relationships but are unable to form relationships with patients because you see them on an assembly line, and on top of that, you will mostly see people whose illnesses can at best be managed but are without cure?
Dr. Marty Klein makes a really fascinating argument about the term "sex addiction" in an article in "The Humanist"; that that label is a way for people not to have to reckon with the conflict between their desire for what certain kinds of sex gives them and the consequences of acting out their desires.
“New patients tell me all the time how they can’t keep from doing self-destructive sexual things; still, I see no sex addiction. Instead, I see people regretting the sexual choices they make, often denying that these are decisions. I see people wanting to change, but not wanting to give up what makes them feel alive or young or loved or adequate; wanting the advantages of changing, but not wanting to give up what makes them feel they’re better or sexier or naughtier than other people. Most importantly, I see people wanting to stop doing what makes them feel powerful, attractive, or loved, but since they don’t want to stop feeling powerful, attractive or loved, they can’t seem to stop the repetitive sex clumsily designed to create those feelings.”
— http://thehumanist.org/july-august-2012/you%E2%80%99re-addicted-to-what/
He goes on to argue that this condition of wanting certain things sexually and not wanting to take responsibility for the consequences is made more troublesome by a sex-negative culture which punishes people for wanting any kind of sex or relationship that isn't socially sanctioned.
“...the diagnosis of sex addiction is in many ways a diagnosis of discomfort with one’s own sexuality, or of being at odds with cultural definitions of normal sex, and struggling with that contrast...”
The culture today communicates two out-of-sync messages about sex pretty strongly; one, that we should be ecstatically sexually fulfilled all the time and two, that non-socially-sanctioned sex is highly dangerous and scary (gay, non-monogamous, kinky). And there is the meta-message which says that commenting on the discrepancy between these two messages -- "Everybody may not be sexually and romantically fulfilled with one, opposite-sex partner for the rest of their lives" -- is not allowed. A million romcoms have taught us that everyone will end up in a monogamous, same-sex couple and will never feel the desire to masturbate or fantasize about other people or look at pornography because they are so fulfilled. According to Marty Klein, the label "sex addiction" leaves us stuck in that double bind rather than helping us step out of it.
Po Bronson, (co-author with Ashley Merryman of the great book "Nurtureshock") wrote an article a few years ago called "How not to talk to your kids" about the pitfalls for kids of receiving certain kinds of praise. It was based largely on the work of researcher Carol Dweck.
““When we praise children for their intelligence,” Dweck wrote in her study summary, “we tell them that this is the name of the game: Look smart, don’t risk making mistakes.” And that’s what the fifth-graders had done: They’d chosen to look smart and avoid the risk of being embarrassed.”
The article is a great read and the research is an example of interesting social science (that doesn't rely on over-interpreted fMRI images). The upshot is that kids, probably all of us, need to be encouraged to view intelligence as maleable and process-related rather than static and inherent. It is a good way to avoid trapping kids in what Alice Miller called the "drama of the gifted child," the need to protect a false, perfect image of one's self from failure. "You worked hard" encourages us to try new things and, as the incomparable Ms. Frizzle says, "Get messy. Make Mistakes."
The ability to understand that other people have different ideas and information about the world from one's self emerges in most kids by around four years old. This ability that most of us share is really nicely illustrated by this video. According to psychologist (and brother-of-Borat) Simon Baron-Cohen, kids with Autism Spectrum disorder have a much harder time with tasks such as these. A recent study in Frontiers in Psychology found that empathy and the ability to understand irony are correlated in kids.
“Empathy was strongly associated with several aspects of irony comprehension and processing, suggesting that emotional reasoning abilities are important to development of irony comprehension. ”
— http://www.frontiersin.org/Journal/10.3389/fpsyg.2013.00691/full#h5
Makes sense. Irony is a disconnect between what a person says and his or her inner state. By around eight years of age most kids can 'get' that disconnect. The authors point out that these are both areas that are difficult for people with ASDs. Empathy and reading irony both require projecting one's self into another person's inner experience; Theory of Mind. In the case of irony, one has to do that while swimming upstream, as it were, against the current of the literal message. I have noticed in my practice how hard and frustrating it is for kids with ASDs to read and irony.
John Gottman, the most important researcher into how couples function and fail working today, offers three great, research-based insights into what helps or hurts relationships.
We have a choice to turn away or connect with our partner dozens of times a day and that is more important for the health of a relationship than betrayal itself. What turning towards a partner looks like: ATTUNE, an acronym for Awareness of feelings, Turning towards the feeling, Tolerance of two different viewpoints, seeking Understanding of one's partner, responding Non-defensively, Empathy. How CLalt (Comparison Level Alternative or "I can do better") when you are frustrated with a partner can lead to relationship destroying cascades. Great!
I mean aside from gelatin and sugar...
This great video shows a recreation of the Stanford Marshmallow Experiment. It's funny but behind it is a really interesting and somewhat daunting piece of social science. The Stanford psychologist, Walter Mischel, who performed this experiment in the late 60s and early 70s wasn't looking for cute video of kids contorting themselves to exercise some restraint. He wanted to know when children develop the ability to defer gratification, when do they become able to say, "I'll suffer a little now for a payoff later". He wanted to know what variables allow children to hold out and what internal mechanisms they used to defer getting the goodies. It was no surprise to Mischel that older children generally held out more effectively for the doubled treat. What was most surprising was that happened when Mischel followed up with the original test subjects years later. Mischel and others have found that when adjusted for age at the time of the original testing, children who put off eating the marshmallow do better on SATs are more socially competent and self-assured, feel a higher sense of self-worth and are perceived by their parents as more mature. They cope better with stress, are more likely to plan ahead, and more likely to use reason. It turns out that learning how to defer gratification is incredibly important in our society. No doubt some of us are genetically predisposed to be a little bit better at deferring gratification than others, but there definitely learned skills that make up a huge piece of it. Learning to distract one's self and focus on the promised reward are important pieces that can be learned. Another important piece which isn't often mentioned in discussion of the marshmallow experiment is trust. In his original experiments, MIschel had some kids get betrayed by the tester in a small way before being offered the marshmallow. Quite sensibly, they were much more likely to gobble what was in front of them rather than wait for a reward offered by someone untrustworthy. Kids who learn that others generally follow through on their commitments will be more likely to defer gratification and reap the benefits. Kids whose experience shows them that people don't follow through will be prepared for a world of subsistence, grabbing what they can in the moment.
So what's the takeaway. Give your kids practice with deferred gratification. View deferring gratification as a set of skills that can be improved. Those old parental standbys, distraction, focusing on the future benefits need to be repeated and repeated and repeated. And make sure to follow-through with what you said. Deferred gratification on;y makes sense when you think you have a chance of getting the second marshmallow in the end.
Distilled parenting wisdom has it that discipline helps kids and teenagers understand limits, have a sense that caring adults are watching out for them, and that the world has some order. Punishment makes them feel bad about themselves and more out-of-control. Tim Elmore makes the point again in Huffpost and has research findings from the University of Pittsburgh which he says back it up. But discipline and punishment can look very similar. Just calling something a consequence doesn't make it nurturing limit-setting. When you are a parent or teacher, frustrated with a young person who has failed to follow the rules, it can be really hard to know if what you are doing is discipline or punishment (this assumes that the rules are reasonable).
Elmore points out a really good way to distinguish between punishment and discipline if you aren't sure: future-oriented versus past-oriented. If you want to discipline a kid, ask yourself, "Is what I am thinking about doing (grounding, taking away a privilege, ignoring the behaviour, giving a warning) going to help this kid do better in the future?" Punishment tends to be more backward-looking, while discipline is about doing it differently next time. This takes some self-knowledge ("Am I acting out my anger or frustration or fear about what happened?") and some knowledge of the kid ("Is this consequence likely to help her -- in all her wonderful, infuriating uniqueness -- make a change?"). Sometimes just calling the question can help. "I want to figure out what we need to do that is going to help you do it right the next time."
One final note: as with all "parenting" expertise, if, after a fair try, this tool leaves you feeling tied up in knots it should probably be jettisoned. Being confident with your child or students is important and the parento-advice industrial complex can sometimes rob parents and educators of that. Go forth and conquer, gently!
Very no-nonsense, simple piece for enhancing students' classroom listening skills by Rebecca Alber. This kind of teaching will benefit all students but in particular those with attentional difficulties.
http://www.edutopia.org/blog-five-listening-strategies-rebecca-alber
“Ah, listening, the neglected literacy skill. I know when I was a high school English teacher this was not necessarily a primary focus; I was too busy honing the more measurable literacy skills — reading, writing, and speaking. But when we think about career and college readiness, listening skills are just as important. This is evidenced by the listening standards found in the Common Core and also the integral role listening plays in collaboration and communication, two of the four Cs of 21st century learning.
Great piece about the benefits and pitfalls of teaching emotional intelligence. I kept asking myself, "what about the role of parents?" Schools are asked to do an awful lot and parents modelling emotional intelligence for kids is extremely powerful and needs to be supported. Nevertheless a great read by Jennifer Kahn in the NYTM.
“ Depending on our personalities, and how we’re raised, the ability to reframe may or may not come easily. Richard Davidson, a neuroscientist at the University of Wisconsin-Madison, notes that while one child may stay rattled by an event for days or weeks, another child may rebound within hours. (Neurotic people tend to recover more slowly.) In theory, at least, social-emotional training can establish neurological pathways that make a child less vulnerable to anxiety and quicker to recover from unhappy experiences. One study found that preschoolers who had even a single year of a social-emotional learning program continued to perform better two years after they left the program; they weren’t as physically aggressive, and they internalized less anxiety and stress than children who hadn’t participated in the program.
It may also make children smarter. Davidson notes that because social-emotional training develops the prefrontal cortex, it can also enhance academically important skills like impulse control, abstract reasoning, long-term planning and working memory. Though it’s not clear how significant this effect is, a 2011 meta-analysis found that K-12 students who received social-emotional instruction scored an average of 11 percentile points higher on standardized achievement tests. A similar study found a nearly 20 percent decrease in violent or delinquent behavior.
”
— http://www.nytimes.com/2013/09/15/magazine/can-emotional-intelligence-be-taught.html?smid=pl-share
From Reese Rickards Blog
http://www.b93.com/pages/Reeserickards.html?article=11689913
“This was sent to me by a member of the listener family.
— http://www.b93.com/pages/Reeserickards.html?article=11689913
A really nice introduction to Adele Faber, co-author of one of my all time parenting favorites. "You can mess up and you get another chance... you always have another chance to do better..." http://youtu.be/Rv0k1U1NfCA
From the New York Times. Despite the dire title, I find this article hopeful.
“...for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling. ”
http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?src=me&ref=general&_r=0