What No One Mentions about Health Insurance

I am always amused by questionnaires designed to reveal whether we have enough money to last a lifetime. They are intended to help us plan for retirement. Yes, many of you are too young to worry about this, but humor me. One of the questions is some version of “How long are you going to live.” Another asks, “How much money do you expect to spend each year (for the rest of your life)?” Those questions are often enough to make us stop trying to fill out the form. Why?

Because we don’t know and it’s too scary to think about.

Which brings up the problem of choosing a medical or health insurance policy. I will use the words “medical” and “health” interchangeably to describe this insurance. I intend to target only two aspects of making a choice of health coverage, each of which follows from the questions above.

Simply put:

  1. We can’t predict how much health insurance we will need because we lack a crystal ball about our future health.
  2. Both psychological and intellectual roadblocks make it difficult to choose a policy. Thinking about illness and death, hospitals and doctors, is scary.

Despite all the words spoken about health insurance in the USA, no one discusses these two points and how they complicate the debate over what should be the federal government’s role, if any, in providing medical insurance for citizens.

I am therefore taking on the job. Again, humor me. This is important.

Lots of adults in the USA still get medical insurance from an employer, who might also insure the spouse and children. Most of you in the rest of the Western World receive government sponsored evaluation and treatment. But, historically speaking (if you are not disabled or “low-income”), in my country there are three choices other than a plan for which the employer pays a big chunk:

  1. Decide you don’t need or can’t afford medical insurance.
  2. Buy a policy on your own, one sold by an association (for example, by your college’s alumni program), or one offered in your state-run online marketplace.
  3. If you are a senior, sign up for Medicare, which is the coverage you get if your employer deducted a portion of your salary to make you eligible once you were old enough.

Our politics is dominated by the question of who makes the choice. Are you free not to buy medical insurance? Are you free to choose the kind of policy you want? One that pays for nearly all medical/psychological conditions or only some? Are you free to assume you won’t need certain medical/psychological services?

Some of the voices in this argument imply this is a rational choice, much like deciding whether you want to buy a car or prefer public transportation; and, if you do want a car, what model might you enjoy and how much are you willing to pay.

In fact, however, the decision is more complicated and not fully rational. Philosophers such as Martin Heidegger, a sociologist named Ernest Becker, and psychologists Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski have raised the issue of our discomfort with even the idea of mortality, let alone facing the reality of serious disease. Moreover, those social scientists created a body of research demonstrating our unconscious flight from the terror of our own personal end. No wonder Ernest Becker called his Pulitzer Prize winning book, The Denial of Death. No wonder the three psychologists do research on Terror Management Theory: not about terrorism, but the terror of knowing you will someday die.

Are you still reading or have you thrown a sheet over your computer screen?

If we cannot frankly face death without a secret shiver and a turning away, how then can we make rational choices about what health care we need or will need?

Will you or your child get depressed, need psychotherapy, or psychotropic medication? Become addicted? Have an accident? Face an unplanned pregnancy and need maternity and pediatric care? Be taken to the ER? Require a vaccination? Encounter a chronic, expensive illness?

No crystal ball, eh?

Few people seek out these unwelcome thoughts. We put them out of our minds when our health is good. Indeed, we must surely have inherited the ability to distract ourselves from life’s dystopian downside. Had our ancestors, broadly speaking, not had such an attitude, they wouldn’t have survived and we wouldn’t be here. They needed to attend to all the immediate tasks of living. “What if I get sick?” was not the most helpful question when the crops needed planting and harvesting.

A certain bravery is to be found in this optimism toward life. The attitude must come from half of our species, the fair sex bearing our children; those who (to quote W.E.B. DuBois) risked their lives and bodies “to win a life, and won.”

Illness and mortality are prospects most of us compartmentalize unless we are battling them. We will acknowledge the concerns, but in an abstract, impersonal way. They are “out there,” or “might happen someday,” but not today. We give these inevitabilities their own separate room within our psychic space, building the structure with bricks and mortar, double thick, the more to keep our emotions and thoughts untroubled. We wall-off potential weaknesses of our psyche and flesh, put them in isolation where we cannot be turned to stone by the prospect of serious illness, as if we faced Medusa.

My office manager routinely checked insurance benefits for new patients when I was in practice. Why? Because they usually did not know about their coverage. Some, in fact, were saddened and surprised to discover they had no therapy benefits and their insurance paid only for physical issues; that is, until the law required attention to mental illness.

Understand, please, my patients were almost all of average or greater intelligence. Still, most lacked knowledge of potential holes in what they considered to be their healthcare safety net. They trusted they were “well-covered.” Perhaps an insurance salesman told them so or their employer did the same. Or, maybe, after the Affordable Care Act (Obamacare) became law, someone assured them therapy was among the “essential health benefits” in their insurance contract. In the latter case, they did, indeed, have counseling benefits. Again, however, they tended not to know the details.

We live, as humanity always has, in a world requiring a significant amount of faith in other people. What I’m getting at, however, is more than trusting whoever designed your insurance or whoever is offering the product. In order to make thoughtful decisions about medical insurance we must face the issue of illness and mortality squarely, without evasion or distraction; and with a level of experience, intellect, and even specialized knowledge to do the job. We must do this despite our tendency toward mental and emotional evasion of illness and death.

To quote the title of a Tom Stoppard play, what we have here is The Hard Problem.

The top image is a Saddlebred Stallion in Harness by Jean. Balloons in a Car Lot in Normal, Illinois, by ParentingPatch, is followed by Caravaggio’s The Head of Medusa. All are sourced from Wikimedia Commons.

How Vulnerable Can We Be? Emotional Openness in Therapists and Performers

We get to see public people expressing private emotions on TV. Allowing themselves to be vulnerable. Not only on dating shows. Politicians do it on occasion, including George W. Bush, whose voice cracked and eyes moistened more often than any U.S. President I can remember.

Still, most of us try to stay in control. We hesitate to let down our guard for fear someone will reach into our chest and rip out our already wounded heart. In my experience, however, some of the most touching public situations occur when a self-possessed person displays the courage to live so much in the unselfconscious moment that the voice breaks or tears flow a bit. Before I tell you about my own challenge with this, I will relate two other public examples, as well as describing a therapist’s hesitancy to feel too much in session.

Fred Spector, a retired Chicago Symphony Orchestra violinist, told this story in 2001 about an event then three decades old:

We were doing the Verdi Requiem and we knew that the mother of Carlo Maria Giulini, the conductor, died (unexpectedly, while he was in Chicago). He walked on stage (to rehearse with us), starts to conduct the Requiem and stops. He was crying and he said ‘They want me to come home (to Italy). What good is that? My mother is dead. It is more important that I have this experience with you and the Verdi Requiem and think about my mother.’ And now he’s got us all crying, the whole orchestra in tears. ‘That’s more important because then I can experience and think about my mother in this marvelous Requiem. … and those were the greatest performances I’ve ever played of the Verdi Requiem, bar none. … We wanted to get that feeling he wanted for his mother.

Giulini was a private, ever-dignified, old world man (born in 1914) for whom this exposure was uncustomary if not unseemly. Indeed, the orchestra and chorus had been instructed by an administrator not to say anything to him about his loss. Such a direction could only have come from Giulini or his wife.

Of course, it’s one thing to be unguarded in an empty hall and another to “lose it” during performance. Indeed, among the greatest sins of public musical or theatrical presentation is to be so moved by the words you can’t do your job: enable the audience to experience emotion while you remain in control. I am aware of one instance alone when the rule was violated, but the artist succeeded anyway.

A 1947 Edinburgh Festival rendition of Gustav Mahler’s Das Lied von der Erde (The Song of the Earth) was the occasion. This hour-long song-symphony portrays the transient beauties of existence and concludes in a 30-minute Abschied (Farewell) to a friend and to life, based on ancient Chinese poetry.

The work’s last moments are a whisper of exquisite, heart-rending beauty as the singer reflects on the passing away of human life, while the world itself blooms anew every spring, “forever.” The last word — “forever” or “eternally” (“ewig” in German) — recurs several times, ever more muted against the fading, shimmering, ethereal consolation of the orchestra.

According to Neville Cardus, a critic for the Manchester Guardian, Kathleen Ferrier, the contralto soloist, was “unable to enunciate the closing words.” Moved by the music, she broke down.

Ferrier, a 35-year-old woman soon to become an international celebrity, was then new to this composition and in awe of Bruno Walter, the 70-year-old conductor who had been the composer’s disciple and given the work its world première in 1911. Cardus tells the story of his arrival backstage after the curtain calls:

I took courage and forced my way into the artists’ room, where I introduced myself to this beauteous (unselfconsciously beauteous) creature. As though she had known me all her life she said: ‘I have made a fool of myself, breaking down like that.’

When Walter came into the room she went to him, apologizing. He took her hands, saying: ‘My child, if we had all been artists like you, we should every one of us have broken down.’

For Cardus, it was one of the greatest, most life-changing performances he heard in a long career as a music critic.

Where does a therapist fit in our discussion? He is not a public performer, but must empathize with his patient. Unmoved by the human suffering he witnesses, he is of no value. But what if he is moved to the extreme? Were he to experience the same level of emotion as his client, he himself would become the patient. The room would be occupied by two people equally anguished, both needing support and relief with no one available to give it.

Someone must possess a therapeutic (but not unfeeling) distance from the suffering. The therapist must.

My own challenge with public vulnerability came in toasting my first child’s marriage. Tears interfere with an adoring parent’s speech at many such events. A guest’s attention is then drawn to the speaker’s unraveling, however sympathetic or touching, not his words about the newly married couple. I wanted the assembly to know what I had to say about my daughter and son-in-law, the better to appreciate them. The language, properly spoken, would externalize the internal, convey emotion, and move the audience.

The problem was, in practicing I could not get through the speech. Time after time I tried, time after time I failed, overwhelmed. Were I to tell you the number of rehearsals I attempted, starting months in advance, I suspect you would not believe me.

The day came — the moment came — and I still had not a single run-through without the internal tidal wave overwhelming my words. Once on stage, however, — finally, finally — the elusive control arrived and the toast went well. I was not as emotionally “present” as I could have been, but the cost of unconsciously distancing myself from my sentiments was the price for moving the audience by words and delivery, not becoming overwrought and a bit incoherent.

Why am I reminded of all this? I just completed a course at the University of Chicago’s Graham School in which our instructor, near the class’s end, discovered her voice cracking with emotion. Sometimes this happens in intimate conversation, frequently in counseling, but not so often at the U of C, and not from this confident and expert guide to literature. She said (to someone else) after the session, she “didn’t know where that came from.”

But, you know what? It capped a great class discussion of a moving novel with a flourish. Sometimes one needs to go with the flow, even if the flow is both figurative and literal.

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The painting at the top of the page is called Tightrope Walker by Jean-Louis Forain(1885). The next image is Australian Artistic Gymnast, Lauren Mitchell at the 41st World Artistic Gymnastics Championship in London, UK, October 14, 2009. The photo was taken by Steven Rasmussen, Explorerdk. The following picture is Gymnast Feet on Beam, January 19, 2008, by Raphael Goetter. All are sourced from Wikimedia Commons. Finally comes Tightrope Walker by August Macke (1914), sourced from WikiArt.org/

Where Therapy Starts: Witnessing Another’s Suffering

I was reminded of a basic human need — a therapeutic need — in the middle of a boulevard. Recognizing another’s pain happens routinely in therapy, but this unfolded outside, in public, on a windy winter afternoon.

Imagine a wheelchair-bound, middle-aged black man. His clothing dark, his appearance unremarkable but for the machine he sat in. I hardly noticed him and he was not aware I was standing a few feet behind and to his right. We shared only the patience of waiting for the electronic sign to brighten and whiten — for the Michigan Avenue traffic to stop in Chicago’s downtown.

The walk signal came on and the red light turned green, permitting cars and pedestrians westward travel on Lake Street. Perhaps another second passed before a northbound SUV ran the red light in front of the chairbound man, within a few inches of the chairbound man. He’d just started to maneuver off the sidewalk. Had he owned a motorized device, a quick start would have put him in the SUV’s path. There was no hit and run, thank goodness.

Even from behind his upset was evident. The driver of the tall car must not have seen the artificially short man, diminished by his seated position. The near-victim of the near miss shouted something indistinct in a voice lacking force. He raised a left fist, impotent because it lacked a goal. The hand held only frustration and great sorrow. The vehicle was past him, the driver oblivious. People stepped into the street. No one recognized the close call, the tragedy averted, the remaining distress.

Not quite. My wife did and so did I.

I caught up to him in mid-Michigan Avenue, said I saw what happened. He described the event, needed to tell his story even though I gave my own report. The man related the brief tale twice. I mentioned I was glad he was safe and put my left hand on his right shoulder. He thanked me. The sitting soul needed to talk, needed someone to mark his words. All this in a few seconds, in the time required to cross the boulevard. The stranger wished me a pleasant weekend and again repeated thanks and his hope I’d have good fortune ahead. His speech carried some urgency and offered more gratitude than I expected.

What had I done? Nothing remarkable, but something necessary.

A man in a wheelchair is an easy target. Imagine his life. People are always passing by, speeding up, trying to get away. You have no stature. In a measuring world you are deficient. Your presence sets others to flight, instigates multiple small rejections. You are identified not by your human qualities but a machine; as an encumbrance, an obstacle to be negotiated, a thing. Does such a one feel helpless? This person appeared to. I could not climb down into his head, but I wondered later if the incident made him feel less of a man.

I deserve no special credit here. This is not about me. This is about humanity, our needs. On big city streets we are invisible or objectified, even the handsome and beautiful. But we are people, not furniture, not newspaper kiosks, not light poles. We suffer, we laugh. We create, we love. We live and die. All this is personal, treated as impersonal. In between the two sides of Michigan Avenue a man was witnessed. An anonymous individual became a person. Dignity returned to him in some small measure. At least that is what I imagine.

In giving the stranger my focus, perhaps I provided a bit of repair to someone who was otherwise not even an afterthought. Therapists do this in session. We validate and acknowledge; we listen, note the hurt and give it weight, meaning; extend a metaphorical helping hand, a meeting of the eyes, an affirmation.

Recovery often sounds complicated and often is. But remember too, life is full of simple things; simple but valuable things a therapist offers: everyday gestures that do not always happen every day.

We humans do not ask so very much.

The top photo is of Franklin Delano Roosevelt in a wheelchair. It is the work of jimbowen0306 and sourced from Wikimedia Commons.

Being the Odd Man Out in Your Family

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Every home is a theater. Every family has its roles to cast. Even with no outside director, positions must be filled, characters assigned. We are all auditioning in each moment of early life. Someone must “wear the pants” in the family, whether he or she wears a dress, a suit, or shorts. The ensemble requires a caretaker, not necessarily the adult variety. In dysfunctional homes one role is the most challenging: the person who recognizes the dysfunction for what it is.

You don’t get paid for taking this part, except in tears; nor will your fellow cast members applaud. Indeed, you become the clan’s scapegoat, the one who takes on most of the blame for the whirling, muddy mess of life at home. The part can kill you or liberate you, or both. One thing for sure: you will need strength and endurance.

The job of portraying “the bad one” doesn’t always demand that you do any major wrong. A fine student and a good citizen can fit the slot so long as he is not what a parent was hoping for. Were you supposed to be a boy, but turned out a girl? Are you artistic when an athlete was expected? Were you required to be forever devoted, but began having ideas of your own, a life of your own? Do you bear a resemblance to someone a parent disliked? Perhaps the elder is jealous of your beauty, intelligence, or his spouse’s affection for you. Maybe the issue comes down to knowing too much for the comfort of others.

Your character’s script gives voice to pained pleadings for the guardian’s approval, but allows only inconsistent success, at best. The parental judge is not impartial. Brothers and sisters, better treated than you, won’t acknowledge the truth in your complaints. Perhaps the other parent instructs you not to upset his spouse, as if you own more power than you do, as if the trouble is your fault and not his.

The odd man out attempts to find a regular ally. No takers, I’m afraid. This job would not only put him in the crosshairs, but worse. He’d have to know the family for what it is, share the psychic pain of realizing its truth is false; its court unjust, with no hope of appeal.

Sides must be picked, teams chosen. You might have a single ally only on occasion, but not anyone with the courage and insight to make common cause with you and speak truth to power.

A kind of brainwashing occurred in your home. The family “drank the Kool-Aid” or breathed in the air of the household delusion. They are blinded to the truth, as you are not.

The one who is immune to the family’s warped vision is dangerous. What might happen if everyone recognizes the reality of the home dysfunction? No, this can’t be permitted. The play would fail, the audience depart. The odd man out must be crushed.

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Such a person is likely to become the “identified patient (IP)” of the family, the one who is “wrong,” the one with the problem. He may be depressed, angry, rebellious or all of these.  The IP can lose years, decades to the stamp of imperfection emblazoned on his personality. A lifetime is not long enough for such a one to find approval on this morally bankrupt stage. If, however, he enters treatment he might grieve the undeserved contempt that is his lot. Now, finally, he escapes from home psychologically, perhaps physically.

The family condemns him for betrayal, of course. Disloyalty is added to his list of transgressions and if guilt can be induced he will return to them for more of the same life: more of the same mistreatment. His role in the play resembles Sisyphus, the mythological character who was assigned the punishment of pushing a huge boulder up a hill until it rolled back down; up and down, never reaching the top, for all his days.

The identified patient can be drawn to a mate who also rejects and ridicules him, persuading their children our hero is the problem. Thus, we reach the second act of the performance, where the lead character enacts a new version of the torture, one he has chosen, unconsciously replicating his early misfortune. Perhaps he resembles Tantalus in his futile, unending search for that which is unreachable. Despite knowledge of the familial corruption, he cannot resist the temptation, the desire for proper acknowledgement. The Greek myth tells us Tantalus stood in a pool, forever hungry, forever thirsty. Bending, the water receded, leaving him parched. Reaching for fruit from a branch just above, the nutrition raised itself and could not be grasped. He was “tantalized.”

Do not lose heart. With sufficient courage and time in treatment our protagonist can become the healthiest person in the clan. The rest, you understand, continue bumping into many of life’s obstacles, the parts to which they are blinded. They too play a role assigned in childhood. They do not know themselves well, since this would require seeing the family as it is, not the imagined world of pretend functionality that was the first lie taught at home.

Terrible choices? Yes. Victims all, but in different ways. Yet a scapegoat need not enact the role night-after-night, as if indentured to a long running play. All of the players in the small ensemble can, at last, say “enough.” Ironically, the one who saw the home-grown theater for what it was — the one who suffered the most — has a head start for the sign marked EXIT. The bright letters shine in the darkness and lead to a world of possibilities.

The top painting is Franz von Stuck’s Sisyphus. An illustration by Koloman Moser follows: A Modern Tantalus. Both are sourced from Wikimedia Commons.

Why Therapists Leave

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Any beginning predicts an ending. Permanent relationships can become impermanent with time’s passage. That knowledge unsettles those in long-term treatment. Abandoned before, they wonder not “if,” but “When?”

Why do therapists leave?

An example: the man and woman had been married for six years. In mid-life, however, he was afflicted with a rapid and permanent hearing loss. In the midst of the crisis, his mother-in-law was diagnosed with cancer. She lived 1000 miles away. What was the wife to do? She chose to spend the last six weeks of her mother’s life with mom. She’d have done the same thing if she’d been your therapist.

Granted the departure was temporary, but such disruptions happen and are sometimes more lasting. A lovely psychologist of my acquaintance, a being so calming as to make quiet moments with her almost holy, fought illness off and on for years. Her resilience seemed infinite. In her ninth decade she banged against infinity’s wall and retired abruptly, having met physical problems even she could not shake off.

The choice is usually not so harrowing. My own retirement was the consequence of the increasing depletion I felt from doing my work. The weight of the problems of others pressed heavily, even though my clients were less troubled as a group than they’d been earlier in my career. Then too, books called out to be read, courses of study beckoned, and new wonders of the world awaited.

Therapists are notorious for burning out, though not all do. Unfamiliar places trigger our wanderlust. Everyone seems to believe California or some warm spot would be nicer, at least if you live in the Midwest. Grandchildren need attention while they are small. You cannot place their youth in a safe deposit box for later use any more than you can your own.

Life intervenes in unexpected ways. I do not mean to minimize the pain when a therapist departs before a patient expects the end of the relationship. I helped clients grieve such losses when they came to me afterwards. I also caused unhappiness myself by deciding to leave practice. Unexpected finishes, however, cannot be allowed to finish us off.

When I was about to embark on the capstone or giant-killer to a graduate education, the dissertation, my advisor disappeared, vanished. I found out he was going through a messy divorce. Fair enough, but to another state? Without telling me? I adjusted. I lined up a new dissertation committee chairman and was ready to proceed when my initial advisor returned, as unexpectedly as he departed. Granted, he was not my therapist, but still …

Therapists also, on occasion, change as people. Funny, one wants a transformative counselor, not a transforming one. The patient expects to be the only person to make substantial self-alterations, setting aside any desire for a reduction in boundaries allowing more intimacy with the doctor.

A young therapist/colleague became a carpenter in his ’30s. I met a lawyer with a towering income who opted out of his partnership to opt into a seminary. Charles Krauthammer, a syndicated conservative columnist, was a psychiatrist. Granted, not many established counselors change careers, but an occasional dropout happens.

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Close to the end of my career I’d hear the question from a patient, “Do you expect to retire soon.” I think I answered, “I have no plans.” Until, of course, I eventually did and then announced my future unprompted.

We (and by “we” I mean you and me) have no crystal ball, no bewitched mirror on the wall. We don’t expect to divorce when we marry, don’t enter careers anticipating they will end soon, don’t fall into friendship with a vision of its erosion or collapse. I can only tell you — only tell myself — the things I know for sure. And sometimes what we think we know we don’t know. Fate’s hand spins the top of our lives in directions never imagined and, when the spinning stops, a new idea forms and informs us.

Therapists leave and it’s not personal, except it is. When you don’t think you are “enough,” a therapist’s departure (at least not one caused by a lightening-strike) says “You’re not enough to cause my staying at the job.” I get it and I also get the absence of an intention to harm.

So yes, your therapist might leave you, but your departure is more probable. The latter is best, for sure, if you’ve gotten what you came for. The good news is we have encouraging career-longevity data on doctoral level psychologists. The American Psychological Association’s Center for Workshop Studies reports that among those already “retired” in 2013, 42% were still working. The median age of retirement was 61, meaning half retired before 61 and half after. The sample included all doctoral level psychologists in the year of the study, not only clinical or counseling psychologists in practice.

Therapists, like most of the rest of us, are living longer and need to make a living. They have multiple incentives to continue. The satisfaction of meaningful work, the intimate contact with good people, and the words of thanks are enriching. The work is interesting and research offers us new tools. It’s an exciting time to be in the field, in the lab, and in the office.

We cannot guarantee our lives, any of us. The retirement or side-lining of a therapist probably won’t happen while you are in treatment. The answer to the “What will I do if it does?” question is that you will do what is required. In the meantime, avoid living the infinite variety of doom-laden scenarios available to imagination: a “thought-error” called catastrophization which can be treated with cognitive-behavior therapy (CBT).

Good advice comes from John Steinbeck’s The Grapes of Wrath and his character “Ma” Joad, the rock of a migrant family almost out of chances. She is the lady responsible for their emotional and physical sustenance, including cooking the salt-pork packed for the clan’s trip to an uncertain life in California. Her 16-year-old son Al asks:

Ain’t you thinkin’ what it’s gonna be like when we get there? Ain’t you scared it won’t be nice like we thought?

No. No I ain’t. You can’t do that. I can’t do that. It’s too much — livin’ too many lives. Up ahead they’s a thousan’ lives we might live, but when it comes, it’ll ony’ be one. If I go ahead on all of ’em it’s too much. … An’ (what I concentrate on is) jus’ how soon (the family) gonna wanta eat some more pork bones. That’s all I can do. I can’t do no more. All the rest’d get upset if I done any more’n that. They all depen’ on me jus’ thinkin’ about that.

The top photo is entitled Goodbye Grenada, Goodbye Karabik by giggle. The cover art for the sheet music for Long Boy (I imagine this means “So Long, Boy”) was drawn by Gar Williams. Both images are sourced from Wikimedia Commons.

“It All Just Amounts to What You Tell Yourself”

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Great literature transports you into the lives of others to inform you about your own. Take The Grapes of Wrath. I’ll offer you a single scene to illustrate how we rationalize our actions. Tom Joad, the story’s hero, reframes cowardice into practicality, moves from fight to flight, and converts hesitation into wisdom; all with the help of a man who has already rationalized his own diminished life. We rationalize because we must — in order to live comfortably with our motives and our choices.

John Steinbeck’s novel is set in the Dust Bowl era of 1930s Oklahoma. Newly available machines allowed rapid and widespread plowing and cultivation of the native grass: an act of misguided surgery. The grass was essential to bind the earth to the land. When drought came, not only were conditions insufferable, but crops died for lack of moisture. The ground became unmoored and simply blew away. In some areas this “worst hard time” persisted for eight years. Dust storms blackened the sky. The fine dark particles invaded farm houses, killed animals, and impaired breathing. Visibility might be reduced to a few feet on a given day. The dust-occluded air produced occasional darkness as far away as New York City.

Tom Joad is a young man just released on parole after four years in McAlester prison. He killed a neighbor who attacked him in a bar fight. Tom and two acquaintances are on the land once occupied by his family. The Joads were evicted in a bank foreclosure. The men notice a police car coming to investigate.

Muley, one of the acquaintances, is an older man who experienced the merciless attitude of the bankers, their agents, and the law enforcement officers in evicting most everyone in the area while Tom was in prison. He and Tom talk about the vehicle heading in their direction:

TOM: We ain’t doin’ no harm. We’ll jus’ set here. We ain’t doin, nothin’.

MULEY: We’re doin’ somepin jus’ bein’ here. We’re tresspassin’. We can’t stay. They been tryin’ to catch me for two months. Now you look. If that’s a car comin’ we go out in the cotton an’ lay down.

TOM: What’s come over you, Muley. You was’nt never no run-an’-hide fella. You was mean.

Muley agrees with Tom that he is not the same man he was. Changing conditions changed him. He knows Tom’s nature is to fight, especially on the land Tom grew up on. Muley also reminds Tom of his parole. Any “trouble” and he will be sent back to prison.

TOM: You’re talkin’ sense. Ever’ word you say is sense. But, Jesus, I hate to get pushed around! I lots rather take a sock at Willy.

MULEY: He got a gun. … He’ll use it cause he’s a deputy. Then he either got to kill you or you got to get his gun away an’ kill him. Come on Tommy. You can easy tell yourself you’re foolin’ them lyin’ out (in the cotton) like that. An’ it all just amounts to what you tell yourself.”

Landscape

Indeed. Tom follows Muley’s advice to hide from the police rather than confront anyone.

As with other (mostly unconscious) life strategies, the way we explain our behavior to ourselves can help or harm. Some of us automatically rationalize so many choices we lose touch with who we are and how we hurt ourselves and our fellow man. Others reflexively come to unnecessary and unflattering conclusions about their deeds. They blame themselves and interpret events in a self-deprecating fashion. In effect, each of us has our own internal “make-up” artist. He is the part of us who tries to put a “good face” on the reasons we do what we do, the better to look at ourselves in a friendly mirror: one not too revealing of uncomfortable defects.

Think of a situation in which you fail to achieve your goal. Many explanations are available:

  • I’m a loser. (Here you’ve taken a single disappointment and indicted your entire being and character).
  • It was his fault. He was unfair. (In this example, right or not, someone else is blamed).
  • This is a temporary set-back.
  • Perhaps I need to approach situations like this in a different way. (Possible adaptation and learning enters the picture with this explanation).
  • I did the best I could. (Defeat is acknowledged, but there is also a self-comforting understanding of the event).
  • “Every knock is a boost.” (This was one of my dad’s expressions. He re-interpreted his defeats as exercises in strengthening his character).

Many other examples might be offered. Cognitive-behavior therapists try to help patients reframe their beliefs and assumptions about themselves and the world. They hope to free clients from self-damaging “self-talk.” CBT counselors encourage a reality-based, but adaptive way of approaching the task of thinking about and explaining our behavior to ourselves.

You and I are left with the question implied by Muley in his conversation with Tom: what do we tell ourselves?

I hope you give it some thought.

The top photo is called, Dust Bowl, Oklahoma. It shows a “father and sons walking in the face of a Dust Bowl storm in Cimarron County, OK,” April 1936. The picture was taken by Arthur Rothstein. The second image is Dust Storm Near Beaver, Oklahoma; July, 14, 1935. Both are sourced from Wikimedia Commons. If the Dust Bowl is of interest, you might want to watch The Grapes of Wrath, the 1940 movie adaptation of the Steinbeck novel. Henry Fonda stars as Tom Joad. The film is widely considered one of the 100 greatest American films. The Worst Hard Time: The Untold of Those Who Survived the Great American Dust Bowl is a terrific oral history of the period written by Timothy Egan. Finally, don’t miss Ken Burns’s documentary, The Dust Bowl.

What You Can Do When Trauma Reminders Intrude

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Victims are easy to identify — or so we think. We see them on TV each day. We are inundated with injury. Too many terrified people, mistreated people, and survivors of war zones and privation carrying their children and belongings. The images arrive from displaced persons camps, airports, and highways.

Look in the shadows, however, and you will find even more. Those are the second-hand souls, the past sufferers, the ones reinjured at a distance.

The men and women to whom I refer are recovering from Post Traumatic Stress Disorder. Some of them are rebroken by watching or reading about the latest victims and the menacing public statements of elected officials. They shudder at the unpredictability in the air. According to the conservative columnist David Brooks, we are witnessing  “a rising tide of enmity” in the USA. Indeed, swastikas have appeared in the public library men’s room of my own suburban Chicago community.

Yesterday’s unfortunates are reminded of their imperfect healing by the incivility and xenophobia around them. Their bodies respond by saying “fight or flee.” A sense of being flooded, overwhelmed — even to the point of collapse — sometimes is not escaped for minutes or days.

Retraumatization of this kind can leave the individual disoriented and dissociated. He may undergo flashbacks of his past: a psychic reexperiencing of the event. At the extreme, there is the loss of awareness of where you are, in what circumstances you are, what age you are. You time-travel to a place you escaped, reinstalled into a mental chamber of prior misfortune. Perspiration, nausea, tearfulness, and intense fear are only a few of the possible sensations and emotions.

You are alone, even if others are nearby. The triggered individual is often unable to describe his internal world. He is awash in a fetid river of word-preventing feelings. The proper vocalizations do not come.

What is one to do?

Here is an example of a young man who dealt with a mild version of the problem, but still enough to put him in treatment. He was in his early teens. A bike accident — he was struck by a car — left him with a painful recovery. Even after the physical injuries healed, the newspaper account of the collision — one which blamed him — still felt like an attack. Moreover, the intersection where he had been hurt remained dangerous. He felt both unfairly targeted and helpless to do anything either to vindicate himself or prevent harm to others. He continued to avoid the location, but traffic reports of pedestrian injuries (regardless of where they occurred) darkened his mood and made for painful and repeated revisiting of his experience.

One aspect of his treatment was a turning point. We talked about what he might do to get a sense of control and counter the wrong and wronging newspaper account. This thoughtful adolescent wrote a letter to the reporter who covered the event. Two things followed: 1. His comments were published in the newspaper. 2. The reporter researched the statistics pertaining to accidents at the place of injury and wrote another article detailing the danger. The city council then investigated the matter and made the intersection safer.

Where does that leave you?

You can, of course, hold your hands over your eyes and plug your ears. The avoidance of TV and radio is a close equivalent, as is holding to an agoraphobia-like self-protective self-confinement. Though understandable, these strategies must eventually be set aside lest you continue to remain terror-prone.

Another patient of mine, long after her father died and mother denied (in my presence) that any sexual abuse happened, chose to return to her childhood home. This was the site where years of sexual abuse by dad occurred with mom’s knowledge. She traveled 500 miles to get there. As it happened, the house was being redecorated and the new owner permitted her to look around. My client left the spot with a sense of palpable triumph. She had faced-down the ghost of her demon in the place of his iniquity.

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If you are pained by news accounts in the aftermath of the President’s Executive Order of January 27, other actions commend themselves to your attention. The American Psychological Association offered a concerned Response to this Directive on February 1, 2017. It reads, in part:

‘Refugees, particularly those displaced from war zones, experience stress, trauma and other serious mental health problems,’ said APA President Antonio E. Puente, PhD. ‘Denying them entry to the United States, particularly those who have already been vetted, is inhumane and likely to worsen their suffering. This conclusion is based on extensive research and clinical experience … .’

Such policies can lead to a perception of reduced freedom, safety and social connection for those directly affected, as well as for society at large (my italics) … .

Research has documented serious mental health consequences for immigrant children and/or their parents who have been forced to leave the United States, which may magnify earlier trauma experienced in or upon fleeing their country of origin. Sudden and unexpected family separation is associated with negative outcomes on child well-being that can last well into adulthood.

If you have been retraumatized by the human consequences of your country’s immigration policy, your decision concerning any response may be more personal than most. Others, perhaps less impacted in this way, have marched, attended town hall meetings, written public letters to news organizations; and visited, called, or emailed their elected representatives.

In the end, those without trauma histories would be wise to refrain from judging whatever action you choose or do not choose. The world presents many chances to reinvent ourselves and repair the injuries it inflicted.

Remember, however, that you and your therapist aim to help you distinguish the present from the past, both intellectually and emotionally: to realize you can act today in an effective way not possible before. And to keep the past from recurring in any form by your self-affirming assertive actions.

The top photo is a Syrian Refugee and Her Newborn in Ramtha, Jordan taken by Russell Watkins for the UK Department of International Development. The second image is a World War I propaganda poster called Every Girl Pulling for Victory by Edward Penfield, created in 1917. Both are sourced from Wikimedia Commons.