One of my mentors was a psychiatrist of immense intellect and a laser’s capacity to cut to a psychiatric diagnosis. His brilliance as a diagnostician, however, did not extend to gently bringing his well-defended patients down the therapeutic path. He was a surgeon of the mind. Surgeons leave scars.
You might think of psychotherapy’s beginning as a kind of dance, with the patient in motion like Salome, wearing seven veils. The veils and shifting movement are for protection, not seduction. The client suffers “too much” and the covering — any covering — guards against invasion. If you, as doctor, rip the gauzy garments away, you do an injury. Without a shield, the client is exposed, terrified, and likely to flee treatment.
Too much too soon. A good mental health professional doesn’t drain a protective moat until the patient develops the courage to take on the scary world outside the castle (or inside his head). The counselor must avoid retraumatizing the patient, in effect flooding him with emotions he is unprepared for. The irony of hurting when you mean to help could not be more poignant or more terrible.
Young therapists can miss this. So do managed care companies when they want you to push treatment as fast as possible (to cut its cost) or medicate the insured party for the same reason. My mentor was guilty of ignoring the same therapeutic speed bump.
The challenge of focusing on life’s dark side was understood by the mathematician and big thinker, Blaise Pascal, who died just short of age 40 in 1662. He recognized the need to divert oneself from contemplation of the human condition. Students of clinical psychology might benefit from his words. For example:
Being unable to cure death, wretchedness, and ignorance, men have decided, in order to be happy, not to think about such things.
I have often said that the sole cause of man’s unhappiness is that he does not know how to stay quietly in his room.
In short, the world can overwhelm such small creatures as we are. Those in most need of distraction are often the least inclined to make use of this necessary method in the pursuit of equanimity.
However sad a man may be, if you can persuade him to take up some diversion he will be happy while it lasts, and however happy a man may be, if he lacks diversion and has no absorbing passion or entertainment to keep boredom away, he will soon be depressed and unhappy. Without diversion there is no joy; with diversion there is no sadness.
I’d say Pascal goes too far, but his point is a worthy one. I can name many people who seem relatively happy (at least for the moment) because they don’t think about the shadow following them down the street. A memorable patient of mine found escape in diversion and denial: she ate enough carbohydrates to push her well into obesity and diabetes. Yet, while eating, she felt good. Indeed, during stressful moments, she believed she deserved a treat as compensation for her upset.
The therapist’s job is to find a balance between allowing people to use their long-standing psychological defenses while gradually helping them recognize the longer term damage they are doing to themselves by not facing problems. With the large lady in question, it was quite a tightrope walk.
I find myself on both sides of the balance beam. Socrates was right when he said, “The unexamined life is not worth living.” So, however, was Pascal, by implying the deleterious effects of too much “examination,” rumination, and painful memory. The truth is hard to swallow, as the kid in the top photo is about to find out.
I guess if I had to create my own mantra, I’d look to alter the inscription on the Temple of Apollo, which read:
My less pithy version would be: “Know thyself, but not all in one bite. Remember: your eyes (for truth) are bigger than your stomach.”
While I have great respect for Rogerian (client centered) therapists, and those who are followers of “focusing,” which is partially based on Rogerian principals, I myself spent about 8 years with a well known therapist known for his skills in focusing, Then I spent perhaps two more years with a “pure Rogerian”. After many years, I have come to regret this. I was allowed all the denial I needed, in fact way too much. I determined the “course” of therapy and the therapists practiced active listening and made very few directive interventions.. They didn’t bother with “corrections” if my ideas and thoughts were leading me down some very non-productive paths. Rogerian therapy can take you so far, and then you need someone who can say “Well don’t you think you need to change this,”, instead of being so “accepting” about your own beliefs about yourself. .
When I mentioned to the Rogerian therapist that I was depressed and sleeping 16 hours a day, I remember that his reflection was “so you are sleeping 16 hours a day.” It went on like this, and my depression worsened to the point where I eventually needed hospitalization.
Never once did he say, “you know you really need to get out of bed, and start functioning” or something similar. “Active listening” should be a technique, not the be all and end all of therapy. This may vary from patient to patient, but some patients denial or lack of self-awareness about some issues is very profound and much more active techniques are necessary to break through their defenses.
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Absolutely, Rick. Extremes are always dangerous. You’ve described very well the risk of allowing the “veils” to remain on permanently.
Your last sentence really struck me, and I think it’s certainly true of me at times, in therapy. I can be disappointed in my therapist for not going deep enough, quickly enough, or when she is trying not to intrude or not to move too quickly, or trying to give me the tools to cope, before proceeding further. Thank you for another excellent post….
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You bet. Glad it made an impact. Retraumatization by the one who is trying to help repair the trauma is a great risk and a terrible irony.
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There is no question, the truth hurts. It is far more palatable in small doses and served with a spoonful of honey. Rumination, self-examination are forms of curiosity that can drive you mad. I am guilty of this, but not sorry for it.
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Also, thank you for explaining that sick feeling in the pit of my stomach the last several months. 😉
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You gave me a smile, since I know of what you speak. 🙂
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Dr. Stein, is that why so many of us have difficulty in accepting the reality of climate change? Is it too terrifying to comprehend and take action?
I am no expert on that subject, Rosaliene, but I’ll offer some thoughts. Perhaps part of it is “diffusion of responsibility.” There was a major research article years ago by Darley and Latane prompted by the murder of Kitty Genovese in Brooklyn. Numerous people heard her scream, but did nothing. The idea of responsibility being diffused among those who thought someone else would take action was raised. Another avenue, closer to what you have already suggested, involves “Terror Management Theory.” That large body of research was prompted by the book “The Denial of Death” by Earnest Becker. The general notion is that our fear of dying (mortality terror) influences how we live and react to threats. Although I support environmental/climate change action, I wonder if the organizations I donate money to spend any of it on research that might suggest the best method of attempting to influence public opinion. Thanks for your provocative question, Rosaliene.
One other thought, Rosaliene. You might find this anecdote about the US Supreme Court Justice, Felix Frankfurter, informative. He was approached by an eye witness to the ongoing Holocaust in 1942. Though himself a Jew, he was so staggered by what he heard that he could not believe the story. You can read the details here: http://www.jewishhistory.org/felix-frankfurter-the-other-jewish-justice/ Perhaps the denial and inaction we witness regarding climate change is akin to this.
Thanks for sharing your insights on the question I raised, Dr. Stein.
“I wonder if the organizations I donate money to spend any of it on research that might suggest the best method of attempting to influence public opinion.”
~ Perhaps you should raise this matter with them. I face this challenge with members of my own family.
Thanks for the Jewish History link. Will check it out now.
Hey, doc – where’s the normal photo credit?
Good catch, Scott. This comes from Jeffreysharrison.com/ I am not sure, however, that he is the photographer. There is no credit listed for the photo there.
“Without diversion there is no joy; with diversion there is no sadness.”
This is so true of PTSD sufferers. WWII combat veterans returned from war and returned to life rebuilding the U.S.’s economy following a decade+ of depression and then five years of war. These men were immersed into life, separating themselves from the trauma of their service. They enrolled into college or went straight to work. For years they provided for their families yet they dealt with terror in the silence of night. They went to work, worked hard, multiple jobs, played hard…they raised their families. When they retired, the led active lives. When the silence of old age commenced and the diversions faded, the war returned and with it the intense nightmares and very real pain. Though the book was not written as a treatise on PTSD, my friend, Author Marcus Brotherton penned the book, “We Who Are Alive and Remain” (http://amzn.to/1FLYJUZ) about several men who served in the famed “Easy Company” of the 506th PIR/101st Airborne Division and their lives after the war. When the veterans became idle, life became difficult.
Yes, I am one of those who deal with combat-related PTSD and the nighttime silence is near-deadly. When I do sleep, the nightmares are horrific. When I was between jobs, I was miserable as the flashbacks, nightmares and memories dominated me. I did find a therapist who was also a psychiatrist and, because of all the issues that you cite with various clinicians and their quick-fix, pill-pushing track-records, I went into that with Fort Knox-like defenses that took months for me to let down. In reading this post, I realize now that he allowed me to take my time to let them down. I never felt pushed or pressured to allow access. I see now that he knew that 20 years of existing and suffering following combat was going to require me to build trust, not only in him, but also in that side of myself. I still lack even the most basic trust for therapist, psychiatrists, counselors, etc. (yes, you included).
Thank you for this very honest post. I appreciate your perspective and am left wondering how many of your ilk would be bothered (angered, even) by what you published.
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Thanks, Will, for taking the time to write this enlightening comment. Thanks, too, for the book recommendation. Your distrust is understandable, ironic because it is also a part of the cost of your honorable service. As to what other therapists might think, I’m not too concerned. Writing anything on the internet puts one in a much diminished line of fire from what you saw at close range. I also know that many counselors would agree with what I’ve written, for whatever it is worth.
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The book is a very enjoyable read. I was a weepy mess when I read through it…especially when I read about what the families of these veterans endured as their soldier struggled.
I hope that what I wrote was truly enlightening for you. The Vietnam vets whom I call friends and brothers are the ones responsible for shining the floodlights on PTSD and how debilitating it is. When they returned home, not only were they rejected by their country, but also by WWII and Korean War vets. They “lost” their war or they were seen as not having fought in a “real war” by their fathers’ generation. Nothing good awaited them which made dealing with the PTS that much more troublesome. The VA rejected them and their combat-related issues for many years. They turned to each other, instead and forged a new pathway to healing that my generation and the current one now benefit from.
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I think what was powerful about what you wrote was the “realness.” I treated some Vietnam vets and dealt with PTSD due to a variety of awful conditions. I remember the politics of the Vietnam War and the shameful way the returning vets were treated. Perhaps you read Studs Terkel’s “The Good War,” about WWII. One of my favorite movies is probably the first effort to portray the complications of returning home: “The Best Years of Our Lives.” I’ve made only one attempt to write anything about war in these posts: https://drgeraldstein.wordpress.com/2010/04/28/two-americas-but-not-the-two-you-think/ You are qualified to write and say things about war and its aftermath that I am not. You lived it.
The Best Years of Our Lives is one of my all-time favorites and considering the denial that Americans lived with in the postwar era, that film pushed the envelope with PTSD awareness and the struggles of reentry following war.
Yes, I read Terkel’s book.
I doubt that my combat experience gives me much in terms of qualifications to write or speak on war. I was but a peon.
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Such a thought provoking post.
My first thought is that working with my therapy dog and linking the healing of the human animal bond with those who want and need it, is my own healing force. It keeps me looking outward.
My second thought was about those seven veils .
I am pretty sure my veil #6 of the 7 veils in my own therapy may not have been totally protective__I am pretty sure it may have been intended as one of those “seduction “ones. Fortunatetly my dancing veil technique was sufficently lacking in mystery, actual dancing, actual veils and generally not so subtle , it turned out to be simply amusing and entertaining (for me at least.) I’m sure my good therapist really filled up his note pad on me that day.
Let keep dancing, Dr S.
Yes, by the time you reach the sixth veil, anything is possible! Another blog for another day. Thanks, Jill.
Forgive my inexperience but are you saying that the therapist walks a fine line between not pushing a client enough and pushing a client too much? How does a savvy client know if he or she is being challenged enough? Seems as if that would be difficult to assess from the client’s perspective. Thanks for the thoughtful piece (if only I had a better grasp of the concept…..)
Yes, JT, I think you understand this as I intended it. It is not only difficult to assess from the client’s perspective, but from the therapist’s. The guiding but imperfect principle is the patient’s reaction to what is happening in treatment and the counselor’s sensitivity to that. You don’t want people in therapy to shut down and flee, you want them to discover they can tolerate difficult memories and challenges. Yours is an insightful question for which there is no “one size fits all” answer.
Therapy seems like an art more than a science then. Scary business. As you say, quite a tightrope walk and there is potential for more damage than healing. Risky business too….
The previous comment re: PTSD made me think of my father. He served as a medic in the South Pacific – a very young man far away from home putting his friends’ body parts into bags to send home. Although he rarely talked about those experiences, it is clear to his children that he suffered from PTSD. We have speculated that some of his PTSD lives on in his children. Doesn’t Jung have something to say about that? Nothing has more importance in the life of a child than the unlived life of the parent? Not that my dad didn’t live his life but that his life was forever affected by those years and so his children carry his pain as well.
Human beings bring such interesting pieces to the puzzle table.
Thanks, again, for the reflective writing.
I’d say therapy is an evolving science, JT. That we have not yet formulated precisely what is the best tempo for treatment and for whom it might be best, doesn’t mean we won’t. There are treatments that have been very thoroughly studied in well-controlled research and have demonstrated their effectiveness for certain diagnoses. Even in medicine one can have the experience of doctors being quite uncertain what is the cause of a serious condition and how best to treat it. (I’ve had this experience myself, now thankfully resolved). Re: PTSD and other traumatic events in our parents’ lives, I’d agree about possible second generation effects. A groundbreaking book on the subject is “Children of the Holocaust” by Helen Epstein, the first effort to look at the common psychology among the kids of Holocaust survivors. You see this too, in the kids of people who had a tough time in the Great Depression.
A look behind the curtain of a Holocaust survivor and her family
Thanks, Harvey. Hope you are well. I remember this from Reich’s Tribune writing. Well worth looking at if one has the stomach for it
[…] Dr Stein recently published a post called ‘The Unsung Value of Denial and Distraction: Where Therapists Can Go Wrong‘. It illustrates just how difficult it is for both therapists and clients to tread the line […]
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