Monday, May 28, 2007

Dishonesty Dialogues VI

Pt: (Looks down, then back up) I don't know what's the matter with me. (Long pause) I guess I'm sorta... I don't know. Depressed. I guess.
Ther: But you're not sure?
Pt: Yeah, I'm... I guess... I'm depressed all right.
Ther: Did you know that when you came in, or did you just then figure that out?
Pt: I guess I knew it when I came in. Sorta, anyway.
Ther: But you said you didn't know. I'm puzzled.
Pt: Well, I guess I kinda knew, but.... (long pause). My wife and I had this big argument last night, and...
Ther: (Interrupting) Is this about your depression?
Pt: Yeah! See...
Ther: (Interrupting) We can come back to your argument in a few minutes. I'm feeling unfinished about what we started with.
Pt: (Puzzled) What?
Ther: When you said you didn't know what was the matter with you, but then later you said you did know. I said I was puzzled by that.
Pt: I don't know what you mean. (half smile, looks down and back up)
[Therapist thinks 'I now have to make a choice, to stay with the earlier confusion or to move on to this second instance, because he certainly does know what I mean. The pattern is that he professes to be confused when he really for some reason doesn't want to specifically address the issue. However, the second instance is just another version of the same issue, so...']Ther: Why do you say you 'don't know what I mean' when in fact you do know what I mean? Seems to be almost habitual.
Pt: Gives me time to think, I guess. Yeah, I guess that's it.
[Therapist thinks "He never says things straight out, but always with the 'I guess' or 'sorta'. I wonder if that's part of the same mechanism."]Ther: Does it seem to you that you're under some time pressure to answer me quickly? (Before patient can reply, therapist continues:) Take all the time you want.
Pt: (looks very uncomfortable) Yeah, I guess I...
Ther: (Interrupts again) No, take all the time you want.
Pt: What? Oh. I'm... I guess I... I don't know why I do that.
Ther: I don't agree with you. You do that so consistently, in such an organized way, that I'm convinced there is a specific purpose behind your behavior, even if it's not easy to put into words.
Pt: I guess I've always done that.
[Therapist thinks, "At least a step in the right direction"]

Dishonesty Dialogues V

The following dialogue is with a patient who has always been the family "ugly duckling", stupid, unloveable and in every way unable to compete with her sister, who is considered "perfect".Pt: ... so I.. we went to the fair, and I had some extra money because I got my check. And C mentioned she hadn't gone because she didn't have the money to spend on it. I asked her if she wanted to borrow $10 and could pay me back whenever. I said "It doesn't make any difference to me". And you know what I said? I said "I have all the money I need." Now why did I say that?
Ther: Why do you think?
Pt: I guess to impress her. A stupid thing! I never did that before in my life, and I thought, "Why am I trying to impress her?" I guess.
Ther: You wanted to impress her?
Pt: I guess. I don't know why I said that. I couldn't believe I said that, afterwards. I never, it never dawned on me what I said right then. Ther: Did you want her to be able to take the money and feel okay about it?
Pt: Probably part of it. Because I did want her to take it. I mean, I'm not rich, but I do have enough money to give her $10.
Ther: So why was it "stupid" to try and make her more comfortable? Is there something else you said that I'm missing?
Pt: No, but I shouldn't have said that! I don't have all the money in the world!
Ther: But your lie was intended to do what? Impress her that you're rich?
Pt: No. I knew she already knew I didn't have a lot of money.
Ther: Did you want to impress her with what a giving and nice person you are?
Pt: Not that either.... I hardly know her and I don't even much like her.
Ther: So... the lie was for what purpose, then?
Pt: To make her feel OK about it.
Ther: What's the matter with that? Is that a bad thing to do?
Pt: No, I'm just saying it was a stupid thing to do.
Ther: How, "stupid"?
Pt: Well, maybe "clumsy" would be a better word.
Ther: So it was clumsy, awkward. But it was well meant, it was an attempt to make someone else feel better. You don't like people to feel bad.
Pt: No, I don't want them to feel bad. That hurts.
Ther: So you embarrassed yourself to make someone else feel better. Your intentions were good.
Pt: Intentions. You know you can't go by intentions.
Ther: Not entirely, but they do count too, you know. Maybe you were awkward and you exaggerated in order to me her feel more comfortable. What's the worst part about it?
Pt: That I lied, and I did it so easily.
Ther: So you've found a way to think of something you did that was actually nice, and you change it around so that you can think badly of yourself.
Pt: No!
Ther: Yes! Are you going to try and tell me there was nothing good about what you did?
Pt: (Long pause) No. I guess...
Ther: Why is it so important that you think badly about yourself?
Pt: (Long pause) It's safer that way. If I'm no good, then... it scares me to feel like I'm good. It scares me to think someone might like me. So I have to drive them away.
Ther: Loneliness is better than.... what?
Pt: Being hurt.
Ther: You believe that?
Pt: Absolutely!
Ther: Another half-truth.
Pt: What do you mean?
Ther: Well, let's look at what you said you believe. Your only choices in relationships are what?
Pt: Being safe by myself, and lonely. And on the other hand, caring and getting hurt and rejected.
Ther: That's the downside of both. What's the up side?
Pt: Well, being with someone, being loved, caring about someone, having a friend. And on the other side of that is if you care about them and they leave you, the hurt is unbearable.
Ther: So you balance on one side feeling loved and lovable, companionship, closeness plus the certainty of getting hurt, sooner or later; on the other side is safety, the assurance of NOT being rejected, plus the steady ache of loneliness.
Pt: That's it.
Ther: Just don't lose sight of the pluses as well as the minuses.


The careful reader might note that the exaggerations made by the patient ("unbearable hurt") are for the sake of justifying a choice she has already made. The whole thrust of the earlier part of the section is to demonstrate that she is "stupid" and can't do anything right. This proves her parents right about her and reinforces her unconscious wish to take the blame so that she can maintain the fantasy of perfect parents who will someday love her if she can just stop being "stupid".

Monday, May 21, 2007

Dishonesty dialogues IV

Pt: I really don't know why I tried to kill myself...in fact, I don't really remember it real well. I had been drinking, which isn't something I usually do... and... I don't know.
Ther: (Looking at BDI score) You score on this depression evaluation is low. It suggests that you are just barely depressed, at least according to your answers. That puzzles me.
Pt: What does?
Ther: That according to you and what you've told me, you aren't depressed clinically. But on the other hand, I have the records of your suicide attempt, and it was a pretty serious one. How am I to make sense of this?
Pt: (laughs) I don't know.
Ther: Another puzzle. You seem to be quite comfortable with what appears to be a very serious problem. How do you know you won't do it again, when you can't make sense out of it happening the first time? And you're laughing! What in the world is funny here?
Pt: I guess it's easier to laugh than to cry.
Ther: Does that mean you felt like crying but you made yourself laugh instead?
Pt: No.... uh...
Ther: Then we have still another puzzle. What happened?
Pt: It just struck me as bizarre that I would try to kill myself and have no idea why I did that. And I'd rather laugh because it's more comfortable.
Ther: (Has lots of questions) You'd rather laugh than what?
Pt: Rather laugh than be scared.
Ther: I'm uncomfortable with you trying to hide your perfectly legitimate anxiety about killing yourself by laughing it off. I don't take near-death lightly, and I don't believe you normally do. So how am I to understand this? (Thinking of Freud's paper on Gallows Humor and TA theory about the same topic). I'm thinking that sometimes people laugh about horrible or unavoidable misery by making a joke about it, like when somebody about to be electrocuted makes a joke about electricity.
Pt: Yeah... I can imagine doing that.
Ther: So it's possible that you could laugh about your suicide attempt the same way?
Pt: Sure.
Ther: Does that mean it's unavoidable and so you might as well try to lighten it up?
Pt: (long pause) Well, the fact is... (long pause) Look, I'm 53 years old. My kids are moved out, my job really sucks now, at least for the last couple of years. I broke up with the guy I was in love with because it was clear to me that he wasn't gonna leave his wife, and I can't tolerate being "the other woman" like I thought I could. My mother has moved away, and she was my best friend. All this happened in the last couple years. So I'm thinking, what's the point in going further with this? I'm really not that depressed.... but I really am unhappy with my life. There's just nothing in it that I care about anymore, and I don't have any religious beliefs that would stop me from dying.
Ther: So it seems likely that sometime in the next weeks or months I'm gonna read in the paper about you dying.
Pt: God damn it, you just want to cut to the bottom line.
Ther: Well, you're not psychotic, so I can't hospitalize you. Clearly you have a right to make the decision to die, and as long as it's not be reason of mental illness I don't have a legal right to stop you. I understand now what you are talking about.
Pt: My life has just gotten emptier and emptier, and it doesn't look better down the road, what with ill health and old age and all the rest of what's coming. So, I think, why should I hang around until I get old, drooly, helpless, incontinent.... all that stuff.
Ther: What bothers me about what you're saying is that while all that "stuff" is true, it's only half true, so I think there's something more here.
Pt: Why do you say "half true"?
Ther: Well, you paint a very bleak picture. How come your life is so bleak? Or do you think all of us oldsters should just pack it in before the going gets any rougher?
Pt: A lot of shit has happened to me...
Ther: Oh, I see. Just you, then.
Pt: I guess you could say that.
Ther: And your belief that life is bleak and then bleaker is predicated on your belief that nothing can change and make it better, is that right? You're making a joke about electrical services?
Pt: (laughs) Yeah, I guess so.
Ther: I have a thought experiment I'd like to suggest, if you're interested.
Pt: Sure.
Ther: You're capable of keeping a decision you make, aren't you? I mean by that, if you really meant it, you'd keep your word?
Pt: Yes. I would never break my word.
Ther: Once I had a patient who was locked into a miserable marriage of many years duration. She told me "the only thing that keeps me going is knowing I can always kill myself". I guess that seemed a better or more acceptable decision than moving awy and changing her name to "Smith". Anyway, I suggested she consider making a permanent, life-long, no-suicide decision, which she did eventually. A couple years later she filed for divorce. She told me "I could stand anything if I thought I could always check out any time. But when you look at your spouse and think 'I'm gonna be around maybe another 30 or 40 years, and you think, Not like this!' So I had to get a divorce."
Pt: (Is silent for a while, looks thoughtful)
Ther: Making a decision like that is really a major undertaking. It has the power to force you to change your life. So I certainly wouldn't suggest you rush into anything like that. The homework assignment, should you choose to accept it, is to imagine you had made such a permanent decision. And for the next week to consider what you'd have to change if you were stuck in being alive for another 40 years.

There are a number of places in this conversation where the evasions and dishonesties could have been usefully focused. For instance, early in the exchange the patient laughs and responds "I don't know" to the question as to why she might be suicidal, yet it's clear that she does in fact know quite well and has thought about it a great deal. In another exchange about her laughing inappropriately she first gave as a reason that she was laughing "instead of crying", but 2 sentences later she said she would "rather laugh than be scared". Clearly she wants to think of herself as naive (in the first instance) and in the second instance as sad instead of frightened. Many other issues are worth attention, such as her underlying passivity and expectation that life will somehow reward her for being good, and clearly it hasn't; her suppressed resentment is a feature that later in her therapy became an important issue.

Dishonesty Dialogue II.

B. Suicide attempt
The patient was seen as an inpatient following a serious suicidal attempt.
Pt: I just want to die… (sobs)
Ther: So why aren’t you dead? (thinking, “I hope this gets her attention”)
Pt: What? (stops crying and looks at the therapist for the first time)
Ther: You heard me. If you just wanted to be dead, you’d be dead. (Thinking, “she uses the word ‘what?’ to buy time”)
Pt: I just don’t have the nerve.
Ther: What do you mean by that?
Pt: I mean I’m afraid of the pain, and of the… of dying.
Ther: OK, now I understand you better. You want to die, but not all that much… at least, the pain and the dying seem worse than living at the moment, but not by very much, huh?
Pt: That’s right. (some relief in the voice)
Ther: Why did you only tell me part of it?
Pt: Well, that’s the part I wanted you to know about. I mean, about how bad I feel.
Ther: You wanted me to take your unhappiness seriously… not think it isn’t as bad as it really is?
Pt: That’s it.
Ther: I guess you must expect that people won’t take your unhappiness seriously.
Pt: Nobody does, I think. They just tell me that things will get better, and shit like that.
Ther: So if you had trusted me to listen better, what might you have said?
Pt: I guess…. I coulda said that I’m so unhappy that I want to die, but I’m still too afraid of death and pain, and that… I’m afraid you won’t believe how bad I feel, because… nobody else does.
Ther: Now do you think I would believe you?
Pt: (pause, some surprise in voice) Yeah, matter of fact, I think I do.

Dishonesty Dialogues III

Pt: Dr. B, you look like you lost some weight.
Ther: (Pleased) I've been working out a little.
Pt: Good.... I was worried that something might be wrong.... your health.
Ther: Yeah?
Pt: I don't want you to get sick and die... I worry about your health at your age.
Ther: Somehow, when you say it like that, I don't feel that there's any personal concern. (grins)
Pt: Sure there is!
Ther: What concern?
Pt: (long pause) Well, all the work we've done together... I don't... (pause)
Ther: Out with it.
Pt: I don't know if I could start over again with another therapist. So don't die. (laughs)
Ther: I understand now. I'll do my best to stay alive... not on your account, of course. (laughs)
Pt: (laughs with relief)

Sunday, May 20, 2007

Dishonesty dialogues I

I have provided these slightly edited dialogues is for the purpose of illustrating how people constantly provide partial truths, outright lies, and simple or complex distortions in order to present themselves as they want to be seen. The lies of commission and omission stabilize a partial or distorted self-concept, even though it is understood that the focus of therapy is about making changes in oneself. For the most part, the lies are so habitual and practiced that the patient has limited awareness of his/her behavior. The rules of polite, social conversation usually preclude probing questions, because such questions make us uncomfortable and move us too close to unpredictability in casual relationships. The social lies are the “grease” that make polite conversation as shallow and deceptive as we need it to be, and even in the therapy situation people rarely understand that the rules of discourse are different.
So here you will see the usual lies we all tell, and hopefully we can see what the patient is trying to “sell”. Usually what the patient is trying to present is the person s/he wants to be, not the person s/he fears s/he is. It seems to me, however, that changing our self starts with who we are, not who we ought to be or want to be. This follows from the previous discussion of the effects of lying or truth-telling on outcomes in relationships.
There are many ways of handling dishonesty. Every competent therapist, consciously and deliberately or not, has learned how to detect and deal with such lies. It’s my belief that this approach, that of confronting dishonesty, lies at the heart of every effective therapy. I would like to direct your attention to the patient’s style of dishonesty, rather than the therapist’s style of confrontation, which is probably not as important and is certainly idiosyncratic.
Much of the following material was originally presented at the International Society for the Study of Personality Disorders, in Vienna, 1995.
A. Smoking
Pt: I really want to stop smoking (looking directly and sincerely at the therapist).
Ther: (After a pause) And?
Pt: What? What do you want me to say?
Ther: I’m not understanding. There must be more to it than that.
Pt: What do you mean?
Ther: If wanting to stop smoking were all there is to it, you’d have already stopped.
Pt: (long pause) OK, I really want to stop smoking, but I guess I want to keep on smoking more.
Ther: You “guess”?
Pt: (irritated) All right, all right! I want to smoke more than I want to quit.
Ther: I understand you now. So when we started this conversation, what did you have in mind when you told me only part of the truth?
Pt: Well, I guess that’s what I should say… I mean, it’s what I ought to do.
Ther: You didn’t want to say the part about wanting to keep on smoking?
Pt: No.
Ther: Because…
Pt: Well, that makes it look like I don’t want to stop.. or that I don’t want to try to stop, and I do.
Ther: So… if you were going to say the whole thing in one sentence, how would you say it?
Pt: I’d come in and say… “I want you to know I really want to stop smoking, and I don’t want to say that I really also want to keep on smoking, because I think you wouldn’t like that… that’s not the sort of person I want…. Ought to be.
Ther: OK, that makes sense.
Pt: So. Now what?
Ther: I’m sorry. What are you asking?
Pt: How is that supposed to help me?
Ther: I’m not sure. But I do know that dishonesty hasn’t and can’t help you, and if you intend to change something it’s going to start with where you are and who you are, not where or who you ought to be.
I hope the dialogue begins to clarify the patient’s struggle to have a more positive if less honest self presentation. I might add the patient was unusually cooperative and intelligent.

Friday, May 18, 2007

Anger as a form of dishonesty

I don't mean all anger. Some anger is purely and simply the result of frustration. The world, the traffic, our boss... something isn't done as it should be. Something gets in our way, and we lash out at it.

But some anger derives from fear, which it conceals. A friend gets angry at me and I respond by getting angry back. What really happened was that his anger made me anxious, frightened me with the thought of losing a friend or simply of being disliked/rejected. So I covered it with anger, which is a more comfortable part of my self-image than that of being afraid. Sometimes I get angry because I'm afraid that if I let it go on or show fear, the other person will "bully" me. Sometimes I get angry because I don't want people to think of me as afraid. Maybe I simply don't want to think of myself as fearful. Maybe it's easier to think "I'm a little anxious" than "I'm a little afraid".

Angry behavior stabilizes and verifies my self-image as "I'm ready to stand up for myself". It also locks me into behavior that is frequently unhelpful and generally ineffective. If I want to change that behavior, I have to tell myself and others the truth so that I can begin to move on.

Saturday, May 12, 2007

Honesty and dishonesty

In an earlier post I discussed the pros and cons of lying and truth-telling. Briefly, lies serve the purpose of momentarily stabilizing interpersonal relationships as well as our image of ourselves. Lies create more controllable and predictable outcomes; the truth leads to unpredictability and the potential for more change.

The task of psychotherapy is to promote change. Consequently it is important to tell the truth in order for change to occur. Why does it seem so difficult to tell the truth, even to a therapist? My experience is that people grow accustomed to comfortable self-deceptions and outright lies because they are better able to pretend to be the person they want to be. We “put our best foot forward”. We “clean up our act”. We “try to make a good impression”, not realizing that all these dishonesties keep us trapped in our distorted view of ourselves. While we may not know what the “truth” about us actually is, we usually know when we are not telling it.
It seems to me much easier to define “lies” than to define “truth”. What are lies? Lies can be in two forms, lies of commission and lies of omission. The former is fairly easy to define: to lie is to make a statement of fact that you know to be untrue. Examples are abundant. The lie of omission is a little more difficult to define, as any attorney can tell you. Leaving out all or part of the truth is harder to define. When our former President said "I did not have sex with that woman" he was. at the least, telling a lie of omission. But even if you allow him the liberty of defining words any way he wants, his intent was clear: it was that of lying to conceal the truth. Leaving out a part of the truth that would materially affect the person(s) with whom we are communicating is an important lie.

So the intent to deceive is part of the definition of lying. Clinton lied because he wanted to control and stabilize the outcome of the interpersonal transaction with the public. He expected (rightly) that the truth would result in unpredictable outcomes. You will note that this definition is not a "moral" one, but simply a functional description of how deceitful or honest communications work. A moral description would include our judgment of Clinton as a person; a functional description would simply note the intended outcome and effect and judge its efficacy. A lie can be judged to be effective to the degree it works to stabilize any relationship.

The rightness or wrongness of lying is a moral issue. The effectiveness of a lie has to be judged within its context. Stabilization of a relationship is not a bad or wicked thing to do. However, lying minimizes the likelihood of change at that time, which can be either a good or bad thing, depending on what the relationship is judged to need. Change is not always a good thing or a practical thing at a given time; its value depends on the situation and context.

Helmuth Kaiser, in his book Effective Psychotherapy, concluded that therapy occurs when one of two (or more) people in a room is saying what he/she means and meaning what he/she says. In my opinion, this is the most profound and powerful statement about human relationships ever made. I have been thinking about this idea for more than 40 years, and its value has been proven to me time and time again.

"Saying what you mean and meaning what you say" is a good definition of telling the truth and avoiding even lies of omission. When truth-telling occurs in a relationship of ANY kind, change can happen. The situation/relationship becomes inherently unpredictable because it is open to change at that time. In a marriage change is growth, which itself may be either useful or harmful to the stability of the relationship at that time. Marriages and friendships can grow and improve or grow and end when the whole truth is told.

In a psychotherapeutic relationship this kind of truth-telling, ‘saying what you mean and meaning what you say’ promotes change. However, the contract between therapist and client precludes (or hopes to preclude) abandonment of the relationship when such change occurs. So both parties agree to remain in a truthful relationship with one another and to deal with change and instability that results in some kind of positive way. This procedure makes change inevitable in a therapeutic relationship.

When the topic of conversation is about facts, the definitions of truth and lies given above is fairly clear-cut. I can say where I have been and what I have been doing. I can say where the money was spent and what I had for lunch. I can even talk about what I thought about last night or whether I like your new shirt. When the topic of conversation is about the relationship itself, the definitions are more difficult. What is the "truth" about a relationship? How would one go about telling a lie, either of omission or commission, in a relationship? While I don’t have a general answer to this latter question, I can suggest some specific ones: I can lie about how I feel or how I react to something that happens. I can lie about what I meant when I said something. I can lie by not telling you what I really thought or felt at a given time.

As we talk in a therapeutic relationship, sometimes the topic of the conversation may be about ourselves, our values, or our history. There is something different about this sort of talk. I have noticed many times that when I try to think about my values and beliefs by myself, I have no way of determining whether I'm telling the truth or lying. There is no one to listen, and that makes all the difference.

These same statements made in the presence of another person sound differently; telling lies makes me uncomfortable when someone is listening in a way lying does not when I'm alone. Suppose, for example, I'm trying to explain to myself some behavior that seems to express a different value than I might want. I recall as a child taking a toy from the counter of a store. I knew that this was a bad thing, but I told myself that the store had a lot of toys and they wouldn't miss one. Within a few minutes I had myself convinced this explanation was the "truth". However, later my father asked me where I had gotten the toy, and the explanation I had prepared was unconvincing and clearly false, and I knew that it was false the moment I began the explanation. It wasn't whether my father could tell I was lying. At that moment I could tell that I was lying, and that was a surprise.

I don't know how to account for this peculiar quality of perception, the fact that we hear things with different ears when someone is listening. However, this factor is one of the things that helps a close relationship (therapeutic or not) grow and change. When you're talking about important issues for you, you can tell whether you are lying. Forcing yourself to be ever more truthful opens the possibility of destabilizing an unhealthy adaptation and beginning the change process.

Lying about myself serves a number of purposes. As in all lies, when I lie about myself I stabilize my perceptions about myself. As a young therapist I was required by a supervisor to write verbatim the contents of a therapy session with an individual client, and I was to do so immediately after the session. As you might expect, this was a time-consuming task, usually taking several hours. When the task was completed, the supervisor would sit with me and the transcript, and listen to the tape made of the session. Of course the transcript was neater and more compact, without all the stammering and fragmented thoughts characteristic of a normal conversation. But beyond this "normal" editing, there were major changes, rephrasing of comments, omissions of entire topics, misstatements and alterations. And all of them served the purpose of making the therapy look better, making the therapist look better, and fitting what was said more neatly into the theories I had been taught. Nothing I ever did so convinced me of the nearly infinite capacity for self-deception we all have, and how difficult it is even under the best of conditions to tell the entire truth.

A competent and truthful therapist (or friend or mate) can frequently hear the evasions and discomfort associated with telling a lie, and bringing the lie to the attention of the speaker makes it easier for the speaker to tell the truth. In the next blog I intend to post some dialogues between me and clients in which the dishonesty of the client was fairly easy to spot, but at the least illustrates the point.

Sunday, May 06, 2007

Values clarification

When people are unhappy with their lives they can either live with their unhappiness or do something about it. When they decide to do something about they may thrash about almost randomly, making poorly considered decisions. The "mid-life crisis" and the cliche red sports car are examples. So is the "geographical cure" or the "vocational cure" in which the person hopes that moving or changing jobs will cure the unhappiness. It rarely does, though we have probably all tried it or considered it. Those "cures", like marriage, only change problems; they don't solve them. Desperation doesn't lend itself to making good decisions.

Most psychotherapists spend much of their professional lives dealing with people who are unhappy in this way. Such people are not "mentally ill" but their unhappiness arises from psychological causes. They may be repeating patterns from their past (see the section on Injunctions) or they may simply be suffering from values conflicts which have not even been considered, much less resolved. They think they want a particular thing or to reach a particular goal; they don't realize that this aspiration is incompatible with other goals, either present or in the near future. They may not even want to consider the conflict of present wants and future goals, because they might (or certainly would) get frustrated.

Consider the young married person who desperately wants to succeed at his/her demanding job, but whose marriage is failing because of lack of attention, and child-raising is essentially abandoned to others or hired help. Imagine that same person at age 50, divorced, with family distant or uninterested, with lots of money but nothing special to spend it on but him/herself, wondering what went wrong. Yet that same person, back at the start of the disaster that his/her life has become, could have told you what his/her long-range values were. The person might well have said he wanted a loving marriage, children who grow up healthy and happy, and to have some time for fun. They didn't want to think that what they saw as an "interim period of sacrifice" was actually becoming their life. They didn't recognize that the values they were living by were inconsistent with one another, and that the outcome was in many ways predictable.

The therapist working with such people spends a lot of time getting the client to listen to themselves. The therapist makes the client listen to their inconsistencies, their self-deceptions, the incompatibility of current behaviors with future goals. The therapist makes the client start to pay attention to what the client's actual future goals may be. A very wise therapist once said "The hardest question of all is 'What do you want?'"

I call this sort of therapy "values clarification". It is not based on exploring your past, except insofar as it clarifies present choices. It is based on honesty with self and others. The therapist struggles to say what he means and mean what he says, and he encourages the client to do the same. Dealing with dishonesty of all kinds is at the center of the therapy. Self-deception is easy and ubiquitous. Omitting the truth is considered acceptable, and in public it is acceptable, but it is not in psychotherapy, which is not bound by social rules and "tact", though it is bound by the importance of kindness.

I see my task as a therapist as fairly active and confrontational when I detect inconsistencies and conflicts among people's values. Sometimes the client is uncomfortable enough with their conflicts to conceal them or avoid them; sometimes the client simply has never thought about where their choices are inevitably taking them. In some ways this particular job is a more difficult task for a young therapist than an older one, and in human history this task is most often undertaken by the "elders" of the human tribe. I suspect that in our abandonment of grandparents as advisors we have lost the natural source for this sort of wisdom, and are reduced to having to pay for it.

Saturday, May 05, 2007

Managing Anxiety

Anxiety always results from a specific and consistent pattern of thinking. We become increasingly anxious when we anticipate some calamitous future event. Thoughts and fantasies of the future event trigger the amygdala, the part of the brain largely responsible for the "flight-fight" reaction. Adrenaline and cortisol and other preparatory substances are released into the blood; our blood pressure rises, our muscles tense, our breathing becomes more shallow and quick and our heartbeat becomes more rapid. Our bodies ready themselves for action.


Some sudden stimuli can trigger the amygdala directly without passing through the cognitive parts of the brain. Infants show a "startle response" to a loud noise, for instance. The majority of our anxiety, however, arises through conscious thought processes involving imagining a future event which we expect to be severely unpleasant. We see an object in a stranger's hand; we become anxious only when we identify the object as a "gun" and imagine the uses to which the person might put the gun. The same events taking place on a target practice range would generally produce much less anxiety, because we have assigned a different meaning to the gun and thus different outcomes. We could hardly become anxious at all if we had never seen a gun nor knew what it was. We can learn to recognize and to anticipate danger even in novel forms, which undoubtedly promotes survival.

Once we have imagined the future catastrophe our anxiety rapidly increases. The rate and degree of increase depend partially on the catastrophe we have imagined, and partially on biological and congenital factors that govern how strongly or quickly the amygdala responds. Some infants have more pronounced startle reactions than others, for instance. The same stimulus and fantasy may thus cause very different amounts of arousal in different people.

Our anxiety and arousal have now focused our brains on what may be a survival issue. One can imagine that early humans who did not focus on the future calamity and who went back to sleep or who froze like a deer in the headlights of a truck probably did not become our ancestors. Survival requires that we focus on the calamity and make a plan to deal with it. Once we have done this our anxiety drops at least somewhat and becomes manageable. Our plan lets us know what to do when and if the catastrophe happens.

However, in people who are biologically easily anxious, whose amygdala is perhaps over-responsive, the anxiety may rise to a degree that clear thinking becomes difficult or impossible. Such people may find it difficult to make a plan at all. They may find it difficult to tolerate imagining all the elements of the anticipated catastrophe because the very attempt to do so increases their anxiety beyond tolerance. Having been unable to make a plan, the brain seems to keep the calamity on a "to-do list" with a high priority, which means the catastrophe is re-imagined frequently. Each time it is re-imagined the process is cut short before the person can consider the elements in the catastrophe and develop a plan. The resultant anxiety and arousal thus can’t get resolved; the person attempts to limit the anxiety not by finding a solution or plan but by trying to avoid thinking about the problem altogether. However, lacking closure, the catastrophe is still on the "to-do list" and is brought to conscious attention again and again, resulting in chronic anxiety.

What I observe in chronically anxious people is a pattern of thinking about noxious future events that constitutes a kind of short-hand, a mental image or word that points to the catastrophe without directly invoking it. For example, when a car cut dangerously close to me on the highway at high speed, my reaction was sudden fear; I didn't imagine the potential catastrophe in any detail. The expletive that leapt to my lips in effect "stood for" the imagined disaster. As a result I decided to slow down and keep a little more distance. Even my limited plan was sufficient to reduce my anxiety somewhat.

Chronic anxiety is not a good thing. It's hard on us physically as well as mentally. It actually interferes with problem solving and may reduce our long-term survival raters. It certainly reduces our quality of life. Mark Twain said, "My life has been full of tragedies, most of which never happened". Chronic anxiety can be reduced by medication, but a more long-term solution is to recognize the importance of thinking through the elements of the catastrophe in spite of the discomfort and making a plan to deal with it. Anxiety itself is a normal function of the brain. Stopping anxiety through medication would not help us survive. There are dangerous problems and \dangerous people in our world, and we need to be wary of them. And it's best to have a plan.

Panic is another issue entirely and requires a different approach. Ask me if you want information.