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.

 

A therapy problem

At an out-of-state convention I was talking with another therapist who presented an interesting treatment problem.  I had no really adequate answer, and after having been a therapist for 60 years that's at least a little unusual.

His patient told him that many years previously he had committed some terrible crimes.  Without going into detail, the patient stated that he had accepted money to kill several people. More recently he had gotten sober for the first time in many years and had subsequently fallen into a severe depression.  He had become suicidal and been hospitalized.  

His therapist told me that later on in the therapy his patient recognized his nearly unbearable guilt as undoubtedly the driver for his suicidal impulses and depression.  The patient's depressive thoughts were severely self-blaming, and in some ways even appropriate.

Here are the questions the other therapist asked me.  Should he even be assisted in recovering from his depression?  Isn't his guilt an appropriate response to his behaviors?  Is it an appropriate use of psychotherapy to be relieved of the guilt for his crimes?  Is it acceptable to kill people and then expect to be relieved of the psychological cost of committing such awful crimes? Is that even ethical?

I thought a long time before I was able to give the other therapist any answer at all.  After some thought my initial response was that the first and second principle of the psychologist's ethical code is:  Do no harm. Act to help the patient.  There are no exceptions to those principles, and to me there should be none. 

That being said, the other questions are open for your answers.  I'll be glad to hear any comments.

How psychoanalysis lost its way

Freud invented psychoanalysis as a way of exploring the processes of the mind.  The 'analysis' part of the title refers to his hope of finding patterns in apparently random  thoughts, patterns that would reveal a logic governing mental processes.  It was an experimental process.  It was not aimed at 'curing' anything or anyone.

The procedure was very simple.  One simply said everything that came into one's mind, without censorship, editing or correction.  The 'analyst' simply listened and hoped to find a logic that governed the process of human thought.  Freud wanted to explore what had never been explored before.  He had no real idea as to what he would find.

But as with many experimental processes, patterns could be discerned.  More properly, the analyst began finding ways of putting together the processes of thought in ways that sounded logical.  Freud began hypothesizing various 'causes', forces within the person that without his knowledge dictated the order and content of his thoughts.  Having apparently found such patterns, he began to find more and more cognitive events that could be fit within the patterns.  The old process of confirmatory bias began to operate.

When he looked at the mental processes of the depressed or dissatisfied person he found himself looking for 'causes'.  What caused people to be so dissatisfied with themselves?  Were they hiding secrets from themselves?  If so, how could that even happen?  The idea of having a secret hidden from one's own self was almost absurd.  Why would we do that?

Freud began making guesses, some inspired, others not so much.  A person might keep a secret from himself because it contradicted what he wanted to think of himself.  For instance, a person who prided himself on his honesty might prefer to 'forget' an instance in which he was clearly dishonest.  Secrets might be kept to protect the self=image or concept.  Perhaps keeping secrets from oneself contributed to someone's unhappiness.  So telling the truth might be a road leading to greater comfort and self-acceptance.  There's still some validity in this conjecture, but comfort and self-acceptance are not the criteria for curing mental disorders, like depression and anxiety.  Not having depression or inappropriate anxiety are.

At this point Freud and his increasing army of followers left the road of pure investigation and began to consider their methods potentially curative.  Not a science, now.  A treatment.  New theories and hypotheses abounded around a wide variety of symptoms.  The underlying concept was that understanding would lead to freedom and health.  Now psychoanalysis was not only a treatment but a series of methods and concepts that were aimed at a 'cure' of some sort.

There is some truth in this concept, apparently.  For some, it works.  For some, analysis becomes an endless exploration aimed at understanding everything, but changing nothing.  Knowing how and why you are harming yourself is useless without a change in behavior.  But of course there is nothing in psychoanalytic thought that suggests that behavior is important.   Some enthusiasts spent years and thousands of dollars in understanding themselves, with no detectable difference.  A jerk who understands why he is a jerk is still a jerk until he changes how he behaves.

Lies in relationships, an expansion

Honesty destabilizes, for good or for ill.  It creates the possibility of change.  But change can be in many flavors and directions.  For instance, confessing to an extramarital affair will very likely result in substantial change. However, change in itself is by its nature unpredictable.  When we tell the truth, something new can and will happen.  There is no guarantee that the change will be for the better, depending on how you define "better".

Psychotherapists and counselors are change agents.  We are hired by people who are troubled and unhappy to promote change in them and in their situation.  Since they are already unhappy, change is somewhat more likely to be in a positive direction.  So we tell the truth and encourage our patients to tell the truth.  This honesty can destabilize their inner world and ultimately their relationships, including with the therapist.  Therapists are trained in keeping the changes from damaging the relationship with the therapist, although this is not always possible. The relationship frequently becomes uncomfortable and produces anxiety, sometimes in both the patient and the therapist.  Sometimes the discomfort is great enough to cause the relationship to end.

The therapist is also trained to detect dishonesty and to confront it, so that change can take place.  People are frequently dishonest, even with themselves, and being confronted with the truth allows for growth to occur.  A good working assumption is that recognizing the truth in oneself results in positive change.  It is also necessary for the therapist to be honest.  That does not mean the therapist says everything in his or her mind.  The therapist has the additional obligation to consider the kind of changes and discomfort that arise and to avoid those that might be harmful to the therapy.

The therapist is obligated to be kind as well as honest.  While this is a good idea for all human relationships, it is especially true in the therapeutic relationship.  Therapy is not a friendship with equal and mutual obligations.  Therapists are not there to get better, themselves.  The relationship is not balance or equal, which is one of the reasons money changes hands.

Honesty in relationships also promotes anxiety, in that the changes that occur are not predictable, and it is easy for most of us to predict bad outcomes.  Constant growth and the anxiety that accompanies it would be increasingly uncomfortable.  Sometimes we need stability rather than constant change.  Yet if a relationship becomes too stable and "comfortable", it can stagnate and become monotonous, even boring.   We seek a balance between comfort and the excitement and intimacy of growth.

So how do we arrange stability in an intimate relationship?  We tell lies of omission.  In other words, we choose our honesty with care.  We have to respect the right and need of the others in our relationships for some stability and comfort.  Choosing which things to talk about and when requires considerable skill and sensitivity.  All the parties in a relationship are not equally available for change all the time.  And some topics require absolute (and kind) honesty if the relationship is to survive.

There is no simple formula for this balancing act.  In psychotherapy it's relatively easy, because the client is there for change, not comfort.  But in intimate relationships like marriage the comfort of both parties must be considered.

Letting Go

Some ideas that seem useless when you are young get more relevant as you age.  An idea of that sort  is  "letting go".

We hold on to our "stuff", things we have accumulated over our lives.  At the time we get these things we think they are important and necessary.  As time  passes, however, we find taking care of all our stuff gets  more and more difficult and tedious.  At the same time we begin to recognize how little of it we actually use or need. 

Some times we see this even in the short run, such as after birthdays or Christmas.  Even the new car that seemed the epitome of our dreams becomes a thing to get rid of and a pain to take care of.  We see it more clearly when we move from one house to another.  Getting rid of stuff...  what a nightmare!

Our relatives (even the ones we love) die and we must let  them  go. Our friends for a lifetime die as well.  As we age, and if we live long enough, we will lose all the  long-term friends.  Letting them go becomes a frequent and painful job, but we have to learn to do it.

When someone dies with whom we have a difficult or conflictful relationship, letting go is more problematic.  We feel there is "unfinished business".  We experience the burden of the things left unsaid and the questions left unanswered.  Learning to let this go as well is much more difficult and sometimes we simply don't know how to do that.  (This is one of the things psychotherapists spend a lot of time doing).

Finally we have to let go of negative feelings on a daily basis.  We carry anger and resentment far too long,  hurting ourselves but not the person who is the target of our anger.  We carry anxiety about unlikely catastrophes to the point we can't manage the crises of everyday life.  We carry sadness in our hearts for relationships that are long over.  We hate saying "goodbye".

Old age seems to be the time for me and others of my age to focus on the skill of "letting go",  I have to do a lot of it, it seems.  In fact, I would say that the most important skill for the aged is the skill of letting things go, of accepting your losses, and also accepting the peculiar freedom that results.

Bearing Witness

As I look backward over a long life-time, I can see what seem to me  important changes that have lowered the quality of life.  I want to discuss one of these with you with the hope that you might have the ideas that could lead to change or perhaps just to help me understand this issue better.

One of the changes that I  notice, probably because I'm a  psychotherapist, is that with the increased splintering of family structures and the increasing distance in relationships, we are each more alone than in the past.  Many people in my age bracket (antique) grew up in families where at least one parent did not work but remained in the  home.  Children had more supervision and attention and also had more opportunities to learn.  In addition, they had someone to whom they could turn when they were troubled.  Now they turn to each other, with frequently disastrous results, especially if they learn to medicate their pain with drugs.

I think that we seem to be losing the sense of having someone in our lives who understands us and our problems, who is kind and sympathetic but who does not direct or chastise.  I think of my grandmother, for example.  She did not offer to solve my problems, but she knew many of the things that troubled me and understood them.  It seemed to me important that this occurred, and even now, so many years later, it still seems important.  What she did is what I call "bearing witness".

I recall while away from home going through an especially troubling conflict which left me anxious and grieving.  I was sitting in the lobby of a hotel, trying to gather my thoughts.  A good friend who was staying in the same hotel was passing by, stopped and looked at me closely, and said "You look troubled."  I agreed that this was the case.  He sat down and said "I don't know what troubles you, but I think I will just sit here for awhile with you."  And he did so.  I experienced this as both very kind and also helpful in ways that are hard to quantify or explain. Yet the experience remains vividly with me over 40 years later.

The experience is similar to "sitting with" someone who is grieving.  They don't need problem-solving skills or "reassuring" comments.  What they (and we) need is someone who is willing to bear witness to our pain and to treat it with respect and tolerance.  I believe this is a very important thing that humans can do for one another.

It is this "bearing witness" that I believe we are losing.  More and  more often I find myself as a therapist simply bearing witness to the pain of another.  The issues are not "therapeutic".  They are simply the need for someone in pain to have that pain recognized and respected.  Since they are unable to find a grandmother or good friend, they hire me to be their witness.  The most important thing I can do for them is to be quiet and wait with them, not to attempt to comfort or problem-solve in a vain attempt to minimize our own discomfort with their pain.  Distancing ourselves from those in such pain is not helpful.

What a shame that we are reduced to hiring friendship or a quasi-uncle to provide for such a simple and basic need!  We shouldn't have to hire a psychotherapist just for simple human contact.  Nor should we think all our sorrows should be managed by changing our attitude or taking a pill.  Unhappiness is not an illness or a neurosis. It's just part of the human condition.

The "Taffy" Personality

It's really amazing how totally flexible our values are.  There's lots of evidence for that statement.  Think of the kidnappings in which the victim becomes attached to the kidnapper and doesn't run away, even when given the opportunity.  Consider the Stockholm Syndrome.  Leon Festinger demonstrated this with Korean War captives.

As we change our behaviors to better conform to the circumstances we are in, so do our values and ultimately the "inner self" that we usually regard as who we are as a person.  "Temporary" changes also in turn change us, and our values and preferences gradually shift to conform to the "temporary" changes we made.  Eventually we are different people.

Even behaviors that we regard as "symptomatic" of a mental disorder represent current values of ourselves and our circumstances.  If you are depressed, begin telling yourself you are worthless and begin acting as if you were worthless, your feelings will match your behaviors, but more importantly, your own values of yourself as a person begin to change to match your symptomatic behaviors.

A way of slowly becoming less anxious and less depressed is to act less anxious and depressed.  It may take months but our feelings and sense of self will shift to match our behaviors and new choices that govern those new behaviors.

All such "temporary" changes become more and more permanent.  When we divorce and marry again, eventually we change to become the person that fits our new relationship.  Our values and preference change and we become a different person than we were.  It certainly would be interesting to investigate how a spy "going undercover" may end up becoming the person he/she pretends to be;  are undercover police and spies changed by their experiences in the direction of their pretended selves?  Theory would suggest they would do so.

I have begun to think of the personality as resembling taffy.  Put a little pressure on for a long enough time, and .. squoosh!

Addiction as privilege

Technically, addiction is the result of your body becoming dependent on pleasure-producing substances to the degree that discontinuing the substance causes profound physiological disturbance.  We could stretch the definition beyond usability by attempting to shoe-horn substances like water or food.  What is meant is quite clear, however.

People attempt to widen the definition of addiction to include behaviors, such as gambling or sexual activity.  As a psychotherapist it is useful to ask the purpose of such a re-definition.  The answers seem clear. There is an implication of reduced power to control one's behavior due to some sort of physical dependency.  "Sex addicts", for example, don't simply enjoy sex, they "must" have it or some sort of withdrawal and physiological disturbance must result. Consequently they are not somehow as responsible for controlling their behavior as the rest of us non-addicts.  The same reasoning applies to "gambling addiction" or "food addiction".
Thus defining oneself as an addict of some kind implies a lesser responsibility and blame for the behaviors involved.  If one simply "can't" (not "won't) control their behavior, they can't be blamed.  They want to consider themselves "ill", not morally culpable.  They should get a free pass  for their behavior, no matter how damaging it may be to themselves or others.

Our innate responses to stimuli fall along a normal curve, with the majority in the mid-range, and with extremes at the tail end of the curve.  We respond to sudden noises with a wide range of reaction, from nearly placid disinterest to sudden leaps and shouts.  One has only to watch the reaction of new-born infants behind the viewing glass to flash photographs to observe this range, and it is clearly innate.  But just because our response lies toward one of the extremes does not imply an "illness" or disorder of some kind.  People who have relatively extreme reactions learn to moderate them.  We do not allow people to have a free pass to hurt someone just because they are more easily angry or frightened than others.  The law makes no exceptions, nor should it.

Obesity, depression and recovery

Obese people can be seen as belonging to two separate groups.  "Group 1" is characterized by having a generally satisfactory life, with interests and hobbies (other than food) and reasonably good relationships.  "Group 2" people are usually depressed and/or unhappy, with few or no sources of pleasure other than food. 

Group I people are frequently successful with rigorous diet and exercise programs.  While they may relapse into overeating, they do lose weight at least while they continue the program.  They are able to make a rapid change in their eating and exercise habits, frequently picking a particular date to start and then following through.  Their lives have plenty of good things in them that don't depend on eating.  They frequently have trouble seeing why other obese people have such difficulty losing weight. 

Group 2 people are almost never successful with rapid weight-change programs.  Because they are already depressed or unhappy, they are easily overwhelmed by the amount of change they see as necessary.  They think "I just can't do all that", while envisioning major changes in exercise and food intake.  They have little other sources of pleasure, so that giving up the one and sometimes only pleasure they have, eating, leaves them contemplating a life with nothing rewarding or good in it.  They can't seem to get started.  They don't understand how others can succeed at such a difficult task, which further convinces them of their own inadequacy.

For Group 2 people to succeed, they have to make small behavioral changes, not the large ones they feel overwhelmed by.  They can't deal with losing "a hundred pounds".   They can't accept "no more desserts" or "walking three miles".  They may pick a starting date, but they either don't do it or they give up almost immediately, feeling helpless and intimidated by the task.  Their failures increase their low self-esteem and their depression.

In helping depressed patients overcome their depression, we use what I call the "2-Plate Rule".  This rule applies to all overwhelming tasks, which for depressed people includes almost everything.  The rule states that if washing 2 dishes in the sink is too much to do, change the size of the task by a half. Wash 1 plate.  If that's overwhelming, plan to wash a saucer.  It is crucial that the size of the task be reduced until it can be accomplished, and it doesn't really matter how small the task is as long as it can be done.  My patients are instructed to stop when they have completed the task, and not to treat their success as some kind of trick so they can be urged to do more.  Depressed people need more successes, not more failures.

Group 2 patients need to be assisted in reducing the initial tasks involved in beginning to lose weight until the initial task is something doable.  For instance, the patient may be instructed to pick a task involving exercise or involving diet (not both) and break it down into smaller "chunks".  An exercise "chunk" might involve walking to the end of the driveway and back on the first day, and staying with that chunk for a week (or some specific short length of time).  If they are successful with that task, they might decide that walking to the end of the block is possible.  At the first failure, they are to recognize that they gave themselves too much to accomplish, and that they need to choose a smaller task. 

A diet "chunk" might be to decide to have a smaller dessert, such as a half-piece of cake or pie. Or it might be to decide to not have anything to eat after midnight.  The patient is instructed to stay with their success for at least a week.   Later in their program they can shorten the length of time between changes, as long as they find the task something they can accomplish.  If they have a problem carrying out their task in their time frame, apply the 2-Plate Rule.

How to be happy

A patient told me a few days ago that he had seen a therapist previously for treatment for his depression.  He quoted the therapist as saying "You have to choose happiness".  He commented that if he knew how to do that he already would have.

I agree with him.  We can't "choose" happiness. Happiness happens while we're busy doing other things.  Happiness is something that has already happened while we weren't thinking about it   But there is something we can do to make it possible.

We can choose to let go unhappiness.  When Buddhists say "suffering is optional", that is exactly what they mean.  It is possible to let go our old resentments, hatreds, grievances and fears.  Dwelling on them and making them part of us is how we make happiness impossible.  We can simply let them go.  We don't have to let them define our lives.  If something in our past seems unfinished, we can choose to finish it and let it go.  We can give up the hope of having a better childhood.

 Happiness can happen by itself when we're not busy being miserable.

Starting psychotherapy

When people come to see a psychologist/psychotherapist, they have relatively little information as to what to expect, other than what they have picked up incidentally from television dramas and the like.  Some therapists like to provide as little information as possible (a tactic dating back to early psychoanalysis) in order to determine what the assumptions and preconceptions the prospective client may have.
What the patient understands and expects may have little in common with what the therapist understands.  Often patients expect that we will fix something that hurts psychologically, just as they would expect a physician to fix something that is wrong physically.  They may take a passive stance, waiting for the therapist to direct or prescribe just as a physician might.  When the therapist doesn't do that, the client has no clear idea as to what should happen next in their treatment.

Currently I am starting new patients off with a short introduction.  Of course, it begins with some questions intended to get an idea as to what might be wrong.  If the problem is a simple reduction in unpleasant symptoms, such as a recent depression or sudden increase in anxiety, I can tell them what techniques I will be using and about how long it will take.  I can tell them what the financial and personal  costs are likely to be.  I can tell them exactly what I expect them to do and the outcomes they can anticipate.  But if the problem is a more complex one, such as when the symptoms arise from conflicting values and/or a dysfunctional life style, I use a different approach.

I tell them something like the following:  I will work with you to show you how to make changes in your life.  I can't make the changes for you.  You will have to decide what kind of person you wish to become over the years. You are in charge of who you will become, and every choice you make will brings your goal closer or moves it further from you.   Sometimes people make changes quickly;  more often they need more time to make them, so I can't tell you how long this might take.  I believe that is up to you.  My job will be to get you started along that path and show you how to continue it on your own. 

 To help you make those changes, I need to know who and what you are now.  I need to know what you believe and how you behave in accordance with what you believe.   Your part in this process is to demand of yourself uncompromising honesty.  Lies or dishonesty, whether of omission or commision, will stop the process of change.  Begin by telling me about yourself, what is important to you and what doesn't work, and we'll see how it goes. 

Since new patients are frequently uncomfortable with the idea of criticising the therapist, I am hoping that you as a reader will be willing to comment as to how you might respond to this beginning to therapy.

Losing weight

Like most psychologists, I see many obese patients.  They inevitably have the same story of how they have tried to lose weight or actually lost it, only to immediately regain the weight they had so laboriously lost. 

I have come to a working conclusion as to what went wrong and what might be tried to fix the problem.  All these patients had something in common beside their overeating:  what little pleasure they had in their lives came from eating.  They had no real fun or pleasure from other sources, except such passive pleasures as watching television, playing around on a computer or reading.  When they set themselves to losing weight, they became increasingly unhappy.  The primary source of joy in their lives was shut off.  Their only positive rewards were in what seemed a distant future.

The solution to the problem may lie in the following suggestion:  We should not give up eating until we have developed another source of pleasure in our lives that is as frequent and rewarding as food.  Food is easily obtained and is always satisfying.  What will we find to replace it?  Exercising is rarely a source of joy even remotely comparable to food, so that's not going to do it.  No one prescription will suffice, because the source of our happiness and joy is peculiar to us as individuals.  We must have access to this source of satisfaction as readily as we do to food.

It's hard to lose weight.  It becomes harder when our lives are joyless.  And we can't count on joy in the future.

Psychotherapy religion vs. psychotherapy science

While the conflict between religion and faith is not a new one, in the field of psychotherapy skepticism is as essential as it is in medicine. Theories of psychotherapy in their infancy or even still in gestation can be presented to the public as if they were already proven true. People depend on the "experts" to have the training to know the proven from the experimental and advise them competently. They have to assume that we are giving them the best available help and advice. Yet perhaps their lives and certainly their well-being depend on what we do to help them.

It's good that new theories and practices arise. Even when the new theories have not yet been tested, or are based on the wildest of suppositions, we have to start somewhere. When we try out new ideas that have promise, the explanations for how they work may lag by years. We can see if they appear to have any validity or if they can be modified so that they are more effective. We can test various aspects of them, keep the valid and dump the others. Then the theories can be changed to support the findings and to suggest new approaches to be tested in their turn.

As long as the people on whom we are testing out new ideas are clearly aware that they are taking part in an experimental treatment AND that they have other alternatives that are not experimental, there is nothing wrong with trying the new ideas out. They should have a right to try an untested or experimental treatment if they are fully informed. Out of experiment and exploration come the ideas that develop into superior modes of treatment.

However, many practitioners of experimental and un-evaluated modes of treatment don't tell their patients. They offer the "latest and best" even though there is not yet any experimental validation. Our patients believe, reasonably enough, that we are providing them the best and most effective treatments, treatments they are not themselves competent to evaluate. Providing them with untested modes of treatment without their informed consent is certainly unethical and in my opinion fraudulent.

Recently a friend who is trained and legitimately credentialed as a psychotherapist wanted to convince me that the newest treatment she had encountered was truly wonderful. She could not provide me with any experimental evidence or journaled research publications. However, her "personal experience" convinced her that "it worked". The theory behind this therapy has absolutely no construct validity. It relies on unsupported beliefs in "energy flow" and "visualization of personal space". There's no question in my mind that some (or all) of her patients experienced something positive and in some cases believed they were "cured". In her mind this and her own experience is enough to convince her that she has found something true and useful. She therefore belongs to the huge class of people who develop beliefs without corroborating evidence and is therefore a "true believer". There's nothing wrong with being a true believer as long as the belief is not presented as factual truth. Essentially her new kind of psychotherapy is a religion and is supported by faith and belief and her personal skills in using it. For some people, single events are enough to convince; personal experience trumps the accumulation of evidence tested rigorously.

Since she is practicing a psychotherapeutic "religion", logical argument has no weight with her. She thinks I need to "experience it for myself", and she believes that this should be enough to convince me. I find it impossible to explain to her why personal experience is not and can never be enough for validation of a psychotherapeutic approach. Every religion believes in unsupported techniques; whether they are spinal manipulation or rain dances or prayer. No satisfactory evidence has ever been found to support these religious practices, but they do not require support since they don't depend on evidence, but only belief. My chances of convincing my friend are about the same as for any member of any religion being swayed by logic.

Every religion works miracles. Some of the time. Every psychotherapy has successes. Some of the time. Every belief system, no matter how weird or in direct contradiction to physical fact, has adherents who will die to support it. All we skeptics have to rely on is evidence. Since everything works (some of the time) we account for the successes by citing the "placebo" effect. The placebo effect itself is a complex topic and is itself effected by a number of factors. The more convincing the "salesman" of the effect, the greater the placebo effect. I have watched many sick people being "cured" in my younger days by tent revivalists. There has turned out to be no evidence for the long-range outcomes, but I'm sure some people were cured. The ones who died had no public complaints to make.

There's an old joke whose ending involves a man saying to his wife (who has caught him with another woman) "Are you going to believe me or believe your lying eyes?" My psychotherapist friend is convinced by what she has seen. As an amateur magician, I'm glad to have a credulous audience, but I don't want credulous believers in charge of my treatment. I know better than to believe my eyes and my own experience. While personal experience can be convincing, for the helping professions it certainly should not be enough.

Covert and Slow Suicide

Suicide may be a long-term option in dealing with life impasses. Suicide doesn't always have to take the form of a sudden, dramatic event, such as shooting or hanging oneself. It can be a slow and deliberate, barely conscious plan carried out over a period of years. In this latter form it's very hard or even impossible to identify.

Here's a sample scenario: A 40-year-old woman in an impossible and abusive marriage has strong religious beliefs that make the deliberate taking of her own life intolerable. The same beliefs absolutely preclude divorce as an option. She believes she cannot bear the thought of living as she has for the rest of her life. So she begins doing things that will clearly shorten her life span, but will not kill her immediately. She smokes more heavily, eats a lot of fast food and gains weight. Her blood pressure gets fairly high. She is advised to exercise and lose weight, but she doesn't do that. Her physical condition continues to slowly deteriorate. She sleeps and naps a lot, complaining of "being tired". She drinks too much and sometimes (not often, perhaps) drives while slightly intoxicated. Her fights with her husband intensify, and she may be assaulted by him, but never follows through with a complaint. She knows he has a gun, but she does nothing to get rid of it.

She's not directly killing herself, but she knows as a fact that her life expectancy is pretty limited. If her husband doesn't kill her, her health will continue to deteriorate fairly rapidly. The stress of her life style increases the likelihood that she may die of a stroke or heart attack, or even in a car wreck. However, such a death doesn't count as a suicide either in her mind or in the collective mind of the family, her religious community and authorities. Nonetheless, her life is deliberately limited, even though she may never put this intention into words. She has found a way of acceptably solving her problem. If you asked her how long she might live, given her current life style, she would laugh and avoid the question, or answer it in a way that makes it a joke not to be taken seriously (gallows humor) or she may become defensively angry.

Another scenario: A middle-aged man hates his job, doesn't get along with his wife and fights with his grown children. He fantasizes about changing his life, moving away, even getting a divorce, but knows he will never do it. The thought of such major changes provokes a lot of anxiety. He begins to drink more, and his smoking becomes heavy, as much as 2 packs a day. He talks about trying to stop smoking, but nothing seems to work. He spends more and more hours per week at work in a fairly demanding and high-stress job. He gains a lot of weight and signs up for a gym, but never seems to have time to go there. He gets anti-depressant medication from his family doctor but seems to get little benefit from it.

We are all making choices regularly that will impact on our life span. Some choices are simply short-sighted; some choices make our lives better and others may shorten our lives. People carrying out a covert suicide, however, consistently make choices that are known to lead to an early death. They get angry or laugh it off when asked or confronted, because the whole intent is to get away with suicide without being forced to recognize the truth of what they are doing. Much of the time the decision to slowly shorten one's life is not verbalized or even a consciously thought. It's a passive way of dealing with difficult problems and is congruent with people who use passive-aggressive defenses.

While people in the covert suicide category can be treated successfully in therapy, they are not likely to be willing to deal directly with this issue, since a key part of its usefulness lies in its easy concealment/denial. They may ask for help in "getting over being depressed" and will be readily compliant with anti-depressant medication. However, they invariably misidentify their unhappiness as depression, and so anti-depressants don't work very well. What they don't want to do is to be faced with the underlying issue of a miserably unhappy and "trapped" life. The anger and denial they express when confronted is a give-away. They have found a solution for an impossible situation (as they see it) for which they cannot be blamed and which cannot be prevented.

Some Thoughts About PTSD

Post-Traumatic Stress Disorder (PTSD) is an unique disorder in several ways. It can occur in people who are exposed to a highly stressful event, but may not in all those exposed. It takes two forms: the acute form, which develops quickly after the stressful event, and the chronic form, which develops months or years after the event. In my opinion, acute PTSD is a normal reaction to an extreme event. Chronic PTSD, I believe, is the response of a more "neurotic" character structure to an extreme event, and is not a "normal" reaction.

In some ways PTSD can be seen as a response to a sudden exposure to unpleasant reality. The reality is that we live in a very dangerous world, and we manage our appropriate anxiety through the rather primitive defense of denial. We drive on the highway at 70 mph, with cars going the opposite direction at 70 mph only feet or inches away. We have the illusion of safety, even invulnerability, in our air-conditioned and quiet automobiles. We also know, though we avoid thinking about it, that we are a fraction of a second away from a terrible death. We don't want to know how vulnerable we are; in some ways we really can't afford to know how close we are to disaster.

When something happens to shatter our sense of invulnerability, it may shake us deeply. It breaks the wall of denial and suddenly we are forced to be aware of just how near we are to death at almost every second. We lose our illusions of safety. In a sense, acute PTSD is a mental state closer to reality than our "normal" state of comfortable illusion. We want to retreat to our previous state of blissful ignorance, but find that impossible to do easily. We become angry that we have lost our sense of safety. How we adjust to this sudden onslaught of reality determines whether we come to terms with what has happened and the precarious nature of our lives or whether we become chronically terrified. The more protected our lives have been, the more disturbed we are when we suddenly are exposed to the often terrible reality. The story of how Siddhartha Gautama was suddenly exposed to death and illness (which started him on his search for the philosophy that became Buddhism) is especially enlightening.

The events that result in PTSD are life-changing events. However, instead of seeing our reactions to trauma as necessarily pathological, we should consider that our mental state prior to the incident was one of ignorance or deliberate denial, and that our recognition of the potential awfulness of life, as unpleasant as the experience is, is more healthy and realistic. Our reaction to the necessity of changing our belief about reality may be pathological, but react and change we must. Some people bitterly resent the imposition of change and/or the recognition that they are not as safe as they believe they should be. Some become self-pitying or resentful or victimized or helpless. None of those reactions are healthy, but the reactions are not caused by the traumatic event itself. They are the result of the impact of the traumatic event on the dysfunctional attitude and belief system of the individual to whom they belong.

Guilt and Shame II

Embarrassment, as an emotion, belongs to the "shame" family of feelings and is an interpersonal rather than "solo" feeling. It is related in structure, as is shame, to depression more than anxiety, but certainly has anxious overtones.

Recently, in a therapy group, a member began to cry quietly, and immediately became red-faced and embarrassed. On analysis of her feeling state, she reported thoughts such as "I'm weak, and everyone knows". "People should not cry where others can see." Part of the focus of her embarrassment was her belief in how other members of the group then present would see her. She would almost certainly not be so embarrassed by the same behavior had it been in private.

In her mind she was breaking a group rule whose origins were in her original family. Breaking this rule did not result in exclusion from the group, but did result in group condemnation. The threat of exclusion was real to her as a child, though probably represented less of a threat than she thought. The threat was catastrophic, but came with a prescriptive plan that would avoid the threat being carried out. As a result, the anxiety was limited.

In embarrassment, the focus is a particular behavior which is expected to be changed. It was what she did or might do in the future, not who she was; the negative stroke was for behavior rather than self. As such, it was more limited because it was conditional. She was in effect being warned that exclusion could possibly result if she did not change her behavior. However, the feeling of being "weak" did strike at her sense of worth and self, and became an ever-present threat.

When group members were supportive and even encouraging, she was considerably relieved and less "embarrassed"; it was clear to her and those present that her embarrassment was self-inflicted. Other members of the group were certainly not thinking what she feared. The transferential nature of her feelings and reaction were obvious and could be dealt with as such.

Mid-life crises

While we are young, we lack the imagination to see ourselves at the end of our lives. Our parents and teachers inadvertently teach us a rosy picture of the future: They tell us we are capable of endless achievement and unlimited options. If we work hard and do right, finally we will be rewarded with happiness. The reward at the end of the rainbow is the pot of gold that keeps us striving without too much thought about our day-to-day lives. We are on the tracks leading to a golden sunset, and all we have to do is keep on keeping on, hang on through difficult times, keep our heads down and cope with problems as they come to us.

Many of us, as we reach the latter part of our lives, become increasingly restless. We are more and more aware of the passage of time, and of how little time remains to us. We begin to see the arc of our lives, and instead of going upward forever we see it levelling out, and even glimpse the downward sweep to the end. The promise of limitless possibility no longer exists. We are forced to recognize the limits of our accomplishments. We find ourselves thinking, "Is this all there is?" Where is the pot of gold? Where is happiness and when will it be granted to us?

Even more importantly, we recognize how unimportant our lives are in the "grand scheme of things', and that we, like everyone, must end the same way, facing the dark, knowing that we leave nothing of importance behind. We fear or deny finality, limits, death, loneliness, meaninglessness, while at the same time our recognition of their reality becomes more and more unavoidable.

To avoid this awareness we thrash about, sometimes desperately and frequently unwisely. We want off the tracks down which our personal train is traveling. This is the time of life when people have affairs, not because our sexual drive has increased, but because we desperately long for new possibilites, a different life, a different outcome. We imagine or buy the famous red sports car or something else captivating to the child within us, something to calm our fears and distract our minds. We seek distraction through sex or a religion that seems to offer us an escape from the finality of death. Some chase fame or recognition, hoping to make a mark on the sands, all the while knowing how meaningless and brief such marks are.

Our existential despair is real and is frequently accompanied by anger. We have done all the "right things" without having given much thought to our alternatives. We have lived on automatic with our eyes fixed on the future without much thought. Suddenly the end of the line looms ahead and we feel cheated of our promised rewards. Where is the happiness we sought? How did we miss our opportunities? Were there other roads we could have taken that would not lead here?

There is no cure for the limits of life. Whatever path we take leads to the same terminal. We all grow old, we lose our health and our friends. We realize how little and unimportant our contributions have been, and we die. Much of our anger comes from the realization that whatever joy and happiness we have were on the way, not waiting at the end of the road.

The thoughtlessness, the automatic choices we made all along, make us realize how little power over our lives we have actually exerted. We didn't make conscious choices, and as a result we feel powerless and cheated of our opportunities. Even at this point, we can consciously begin choosing our lives, and recognizing and owning our past choices. We can recover our sense of ownership and power, even though we cannot change the end. We can know that even when we were on automatic pilot, we were making the choices that created our lives, and that we have shaped them all along. Whatever happiness and satisfaction we have, we have ourselves created. We stop being disappointed because we no longer carry the illusions of eventual reward. Our lives are our creation. They belong to us and to no-one else, and that has to be enough.

Boundary exceptions

“Rules” are values which prescribe or prohibit certain behaviors. We grow up with rules, but as adults few of us follow them rigidly. For the most part we follow our rules, but we sometimes allow ourselves to break them under certain conditions and engage in behavior that we might not normally condone. Of course, such exceptions determine the actual boundary of the rules.

Even in the law, rules are never completely rigidly enforced. Instead of mechanically imposing a consequence on a breach of rules, a human being such as a judge can consider the particular circumstances. For instance, we have a rule forbidding murder. Courts have held, however, that under certain conditions the consequences of breaking the rule can be modified or an “exception” made. Such a condition might be that the murderer was experiencing a strong emotion, such as passion, anger or fear. While we may punish a premeditated or "cold-blooded" murder to the fullest extent, a murder based on strong emotion might be assessed a lesser penalty. The rule forbidding murder may be granted an exception under these circumstances.

I chose this particular example because the “strong emotion exemption” to laws is based on a common to many cultures. We tend to excuse to some degree an otherwise illegal act if it was motivated by sufficiently strong emotion. We believe an emotion that is strong enough may justify a temporary exception to our rule. The “strong emotion” exception is of particular importance in understanding human behavior.

It's as if we said to ourselves "I will never do X", and then privately to ourselves, we add "…unless I'm very angry/frightened/depressed/sexually-aroused”. As a result, the test of all our rules is whether there is a hidden or at least unspoken "exception". As a psychotherapist, I want to know the exceptions to someone's rules and boundaries; I want to know under what conditions they are willing to make an exception to a rule they espouse. Often people are unaware of their own exceptions to their rules, or they may take it for granted that “strong-enough” emotion” automatically grants an exception.

We talk about strong "justifying" emotions as if they were something that "comes over us", that overwhelms our judgment, as if they were something outside of our control. There are truly moments like that, such as in catastrophic events or in combat, but these are fortunately rare. Other than in such emergent or catastrophic situations, much of our extreme emotion is self-induced. We increase or sustain an emotion by going over and over a series of thoughts justifying our emotions. We call this tactic “ramping”. With each repetition of these thoughts our emotion grows stronger until we stop it or until we allow it to reach the level of intensity that "justifies" breaking the rule.

A patient of mine, "Fred", who was driving on the highway was "cut off" by another driver, in what Fred felt was a rude and inconsiderate way. He was outraged. He followed the driver almost sixty miles, all the way "steaming" over his mistreatment. He pulled in behind the other driver in a parking lot, went over to the man's car, opened the door and pulled him out, with the intention of "teaching him a lesson". However, the man obviously didn't even know what Fred was talking about, and was frightened. Fred suddenly recognized the inappropriateness of his own behavior, let the man go, went back to his car and drove off. Later, in my office, Fred said "I drove 60 miles, enraged, ready to hit this guy, and he didn't even know he had done anything! That's just crazy! I don't know what's the matter with me. I would never hit another person."

Of course Fred would hit another person. His rule against hitting has an exception in it. He doesn't mention the exception because he doesn't like to think of himself as a person who hits others, but his exception is clear. If Fred feels sufficiently wronged, he goes over and over his “wrong” thereby becoming increasingly “righteously angry”. When angry enough, he allows himself an exception to his "no hitting" rule. A more precise description of what occurred shows that at the time of the “infraction”, Fred decided almost immediately that he was angry enough that he was justified in hitting the other driver. While he was driving, by going over and over his grievances, he was keeping his anger “ramped up” so that his anger could overcome his rule and allow him to strike a blow. It took a lot of energy to keep his anger going for an hour.

In the parking lot Fred realized that the offending driver was totally unaware of his driving infraction.. Another of Fred’s rules which conflicted with hitting someone popped up: "It's not right to hit someone who doesn't even know they've done anything wrong". His anger dissipated as he recognized that he had been wrong in his thinking. He no longer felt “justified” in breaking his rule. As a result, he stopped ramping his “righteous anger” to the exception point.

We can increase any emotion by ramping up in this way. Whatever the thoughts we have which create or renew our feeling, we can continue cycling through them over and over. Sometimes the rule we are considering breaking simply doesn’t fit our self-image. Someone who is normally proud of “self-control”, for instance, might mentally ramp up sadness in order to justify wallowing in self-pity or simply withdrawing for a while. In a more extreme (but not unusual) instance the self-pity might justify substance abuse or a suicidal gesture. A person who thinks of himself as “brave” might ramp up fearful thoughts in order to justify running away or “backing down”.

We might conceal our unspoken exceptions in order to hide our real intentions or plans. A depressed patient, for instance, might state that he would "never kill himself", but when pushed to state the "exceptions", said "… unless my wife left me... I couldn't stand that". Sometimes the exceptions are so clearly dishonest that the person doesn't admit them even to himself until after the exception has occurred. A married patient admitted to having sex with his wife's best friend, but commented that he "had had too much to drink, and besides, I didn't think my wife would ever find out." He would never have admitted his rationalization PRIOR to the unfaithfulness. It’s interesting to speculate what a marriage service would sound like if the prospective partners had to announce the exceptions to their vows.

The "ramping up" process is a familiar one in cognitive therapies. We use it to whip ourselves up emotionally in order to justify our breaking a rule/boundary. When we do so, we manipulate our own emotions in order to “motivate” our own behavior, rather than making a more rational and cognitive decision. Such apparently impulsive decisions, being dictated by a more primitive and emotional part of ourselves, tend to be of more or less poor quality. We may find ourselves doing things that at a less emotional time we would find unacceptable.

Stopping ourselves from “ramping” is easy to describe: We simply recognize cognitively the cyclic pattern of our "ramping" thinking and choose to break it. By doing so we stop creating more emotion and thereby protect ourselves from arriving at the point where our boundaries have exceptions. Without using strong emotion as a justification for action, we must make behavioral choices based on intellect and logic. Unfortunately, for many if not most of us, intellectual and logical choices do not provide very strong motivation. We may not be so accustomed to making choices coolly by an act of the will. However, by acting on our more mature values we strengthen them and our own emotional maturity. Knowing and admitting our exceptions is an important step in limiting or eliminating them, and every time we are able to do this, we move in the direction of greater emotional maturity.

Self-deception

We can understand why people lie to each other. They lie for some sort of advantage, personal or financial; they lie to avoid disharmony or disagreement, to impress, to mislead. Why do we lie to ourselves?

As a psychotherapist, I spend a lot of time listening to people lie to and about themselves. Generally we lie to ourselves to maintain an image of ourselves more or less false to fact. We reassure ourselves that we are stronger, braver, more able to tolerate pain than we really are. We present to ourselves the image of ourselves we would like to have others see. We deny our age, appearance, weight, sadness, disappointment and grief. As when we lie to others, we lie to maintain a stable and manageable world, one in which we do not have to adapt nor change.

On a deeper level, we always know when we are lying to ourselves. It takes energy not to know what we know. Turning a blind eye to ourselves in spite of all the evidence is effortful.

I think it was Fritz Perls who said that change begins with who we are, not with who we want to be. We have to be willing to let go our fantasies of ourselves before we can recognize what we can or cannot change. So our conversations with others are full of dishonesty and pretense, as we try to present ourselves in accordance with our self-delusion. Others pretend to be deceived because it is easier, more comfortable, and certainly more socially acceptable to be dishonest. Besides, when we accept the dishonesty of another we have a sort of bargain that they, in turn, will accept our dishonesty in return. In this way our social and internal psychological systems remain stable and predictable.

People who promote instability and change in relationships do so by being honest and hopefully kind as well. Psychotherapists make a living by doing this, but loving friends can also serve this purpose. It takes a strong relationship to withstand much honesty, but any relationship that embodies honesty promotes change and growth. Kindness is optional in the encouragement of growth, but as I get older it seems to be a more and more important option.

Dreams in psychotherapy

Many therapists, trained in the psychoanalytic tradition, have regarded dreams as a "royal road" to the unconscious mind. Much time has been spent in the clever and creative analysis of the dreams of patients. Patient dreams are said to be the production of some inner unconscious and highly creative voice, whose stories and creations cannot be understood by the dreamer but which seem to be couched in language understandable by the therapist.

Interestingly enough, the dreams seem to be tailored to the therapy. For instance, the patients of Jungian analyists have dreams full of Jungian symbols; patients of Freudian analysts have Freudian dreams, and so on. It appears that the dream is a communication specifically aimed at and couched in the specific language most meaningful to the receiver/analyst. From whom is the meaning concealed? The patient himself. So the patient has found a way to provide information to the therapist without having to understand it him(her)self.

It's easier to understand a dream as a somewhat dishonest form of communication in which the sender does not have to recognize nor take responsibility for the content. Such deception results in the therapist knowing more about the patient than the patient knows, and the therapist is thus cast in the expert/parental mode in relationship to the therapist.

Transcripts of early sessions of dream-oriented psychotherapy leave little doubt that the therapist can eaily train the patient to speak the therapist's professional language. Patients then become extraordinarily able to express themselves without having to recognize what it is they are expressing, leaving the therapist to translate for them.

How is the patient benefitted by this indirect form of communication? By keeping the dream symbolic and indirect, the patient is in a position to deny responsibility and ownership of the content of the dream. The all-knowing therapist (like the Sibyl of Greek times) can explain the content, unscrew the inscrutable, and have his/her position of authority confirmed.

I think it better to discourage the recounting of dreams in a therapy session. The time is better spent developing a relationship in which patients can become comfortable with their own inner life and with the therapist, enough, at least, to be able to tell their secrets more openly. Honesty and directness are attainable goals, and they bring lasting benefits of increasing self-honesty to the patient. In a good therapeutic relationship, there should be no areas that are too uncomfortable to be discussed.