A surprising outcome

 I am 90 years old and have been a psychotherapist for over 60 years. For most of that time I have treated   people who have come to a Community Mental Health Center for treatment. They are financially poor and struggling to survive in a  world that has little use or place for them. While I don't share their financial problems, I am now struggling to find a value and meaning for me in what I do.

In recent years, more and more I find that new patients are not interested in psychotherapy. They want, even demand medication and emotional support. They want the world they are in to change and make it more possible for them to have a comfortable life. They have little or no interest in therapies that would help them feel better about themselves or that would show them how to continue growing up. 

When  prospective patients are admitted, they want something easy and short. When they are referred for psychotherapy, they come for a few sessions, rarely more than 4 or 5, and then they stop coming other than to get medication and apply for whatever financial assistance might be availabled.

Let me be perfectly clear about this. There is nothing wrong with what they want. The world they live in has little in common with the world I came from. But the world they come from is totally unlike my world. There is an increasing disconnect between the middle- and upper classes and the poor.  There seems to be no easy way for people to change their worlds from poverty to middle/upper class.

I and other psychotherapists are part of that disconnect. The bottom socioeconomic classes have little or no understanding of mental health or illness. They come into my office with absolutely no idea as to what could happen. They are not accustomed to talking about personal issues with others face-to-face, even their parents.  They rely on smart-phone contacts, video games, social websites. They are accustomed to quick and effortless results, and TV ads have lead them to expect medications to solve their problems.

Their values are different from those of other generations, which is to be expected.  They don't know what is possible or even desirable. The idea of being in psychotherapy just to help them develop longer range values, such as growth and emotional maturity, does not occur. They understand wanting "to feel better".  They may not understand the value of greater honesty and kindness in relationships because they have not seen that demonstrated in their families, which of course is not their fault.

Most of them think that individual "counseling" is simply understanding and comforting. Two or three individual sessions and they are "done", they "feel better". Most of them need help with basic life problems, such as jobs, transportation, even a bed to sleep on. This socioeconomic class of people have few survival skills beyond the most basic. Even safe shelter and regular meals are hard for them to manage, and social workers (at least where I work) are far more helpful and useful to them than the therapists. 

From a more personal standpoint I have watched my hard-earned skills lose their importance or relevance. I have less and less value for the most poor. When they do make an appointment with me, they almost never return for more than 2 or 3 sessions.

Of course, initially I did what I was taught to do in these circumstances.  I looked at the "common factor" in these cases, which, of course, was me. I sought consultation, learned some "brief therapies", discussed it in staff meetings, only to find out that all the other therapists were having the same problem.  The difference was that other staff had not often (or even "ever") had patients who wanted intensive individual therapy. For them, the drop out rate had been the same "bad rate" from the beginnings of their practice.  The administration seemed to be pleased by the rapid "cure" (or drop-out rate). As far as they were concerned, rapid early termination of therapy was a desirable outcome.

So eventually it occurred to me that my goals and values were hopelessly out of date. Why did I not like the dropouts? That seems to be considered a success, not a failure, as I was taught. In fact, it seemed to me a big disappointment and a failure. I again did as I had been trained to do. I asked myself what were my needs and why was I paddling a canoe when most other therapists had speedboats?

I enjoy (perhaps too much) the attempt to make better and more honest connections with my patients. I value the effort to get past the cliches they trot out and enjoy the moments when we make genuine and honest contact. For a brief time the patient and I share the same world, before we drop back into the cliches and lies we rely on in "social settings". 

A few patients return. For them, therapy is a place in which honesty and kindness is valued, and they see themselves growing as human beings. The same applies to me.  Honesty and kindness are important growth factors for the therapist as well as for the client. I believe I have grown with my patients over the years, and I don't resent the time that has been spent attempting to help them. It has helped me as well.

 

What's the matter with "Guilt"?

 It's not uncommon for people to seek help from a therapist to alleviate the guilt that results from something(s) they have done which they do not approve. They see therapy as resembling confession to the priest and expect to be given a punishment commensurate with their "crime",  Somehow they have come to the belief that causing themselves pain (or allowing others to cause it) wipes out their slate and they will be guilt-free.

The notion that you can reduce your guilt through suffering is clearly absurd.  Whatever harm you have done to yourself or others "proves" that you deserve suffering. More suffering is better than less, and the history of religions is witness to that belief. The focus is on the reduction of the feeling itself, not on attempting to repair the damage done to self or others.

Somehow the guilty person believes that suffering and self-blame is enough to undo the bad behavior.  Is the world a better place as a result of your pain?  Exactly how does this take place?  If you take the time and trouble to consider this belief, its absurdity becomes obvious. The bad behavior is ignored. Only the relief from guilt matters. 

Guilt is the recognition that you have done something damaging to your world, combined with the belief that if you can manage to feel badly enough, your guilt will go away.This belief is clearly self-serving. You have done damage. How exactly does your personal pain take that damage away?

Following this line of thought results in the recognition that your interest is not in making the world a better place, but in a magical belief that there is somewhere a cosmic accountant who keeps track of the good and the bad that we do, and that we can bribe him/her/it with a gift of additional misery to clean our record.  Seeking help in therapy to get rid of therapy is exactly the same reasoning: a magical cleansing.

What the guilty person has not done is recognize and take responsibility for what he has done, and try his best to do enough good that the bad is countered. If you break something, fix it.  If you can't fix it, do enough good that you have more than made up for it.

If you follow this rule, you will leave the world better than you found it. Punishing yourself does not typically result in benefiting you. And it certainly does not help the people affected by your behavior. 

 And shame and guilt are not illnesses.  They are both learned and built in, and they serve a useful and valuable purpose:  to encourage people to adhere to the rules of their tribe. Don't expect your insurance company to reimburse you for feeling guilty or ashamed of bad behaviors.

What's the matter with 'Shame'?

Lately I've seen some advertisements for workshops purporting to be in the service of banishing shame from people's lives.  The reasoning seems to be something like "If it feels bad, it must be bad".  I think this is a gross simplification, perhaps to help people or perhaps to provide a salable product. I propose to take a deeper look at shame and how it functions.  

Firstly, shame is a phenomenon that only exists in group settings.  If you were hopelessly alone on an island in the middle of an ocean, would shame be relevant to your experience?  Would you blush if you were nude in the open?  Would remembering some social gaffe you perpetrated earlier in your life embarrass you?  Probably not.  If you were giving a lecture to a hundred people and discovered that your fly was unzipped (assuming only for the moment that you are male) or loudly farted, would you be humiliated?

Shame appears when the unacceptable behavior is known to other people in your group.  To feel shame you would have to have done something others in your group would find unacceptable.  When you are a young adolescent, for instance, wearing the "wrong thing" can be catastophically shameful.  If nobody notices you would not be embarrassed.

Shame is experienced when we deviate too far from the norms of our group.  Partially it includes fear, fear of rejection in the form of being laughed at or jeered.  It is an emotion that operates to push our behavior back within the range of acceptance of our group.  It encourages conformity to our particular group norms.  Deviating from the norms of a group to which we do not belong is not shaming.  Something in us tells us that being excluded from our group is awful-bad-dangerous.  We are urged to change our behavior to fit in.  Think of The Scarlet Letter, for instance.

What happens in a world in which there is no shame?  There is nothing to encourage conformity.  There are few prohibited behaviors, and we can do pretty much what we want.  But do we want to live in a shameless society?  We would be confronted with behavior that is now strictly prohibited.  We would live in a world in which little is forbidden other than those things we prohibit by law.  Our behaviors would be wildly divergent. Breaking the law would still have consequences, but shame would not be among them.

It would be a lot like it is now, only more so, wouldn't it?  I leave you to decide if this is a good thing.