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.

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.

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.

Are You the Perfect Therapy Patient?

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The blogosphere is full of worried therapy clients. They believe they are “not enough:” not interesting enough, not clever enough, not progressing fast enough. What then are therapists looking for? Are worried patients right to be worried?

Research is limited. An over 50-year-old model based on a survey of 377 counselors by William Schofield revealed what was believed to be the perfect client — the so-called YAVIS prototype: one who is young, attractive, verbal, intelligent, and successful. Schofield saw this as a bias toward patients who exhibited these traits, not careful science identifying those who actually were best suited to treatment. Psychotherapy was then a male-dominated profession, perhaps also contributing to a preference for female clients.

Psychologist Paul Meehl, among others, critiqued this model. He feared practitioners would make “hidden” or biased decisions toward YAVIS therapy candidates and against those who were not YAVIS. A counselor might, for example, work harder with YAVIS individuals because he thought them more likely to benefit from treatment. A self-fulfilling prophecy in other words. By the same token, the mental health professional would perhaps instinctively recommend medication for someone who, according to the YAVIS model, was not typical of those who profit from “talk therapy.” The YAVIS syndrome raises the possibility of other biases, not all of them conscious, including the possible refusal to take on patients of certain racial, ethnic, or socio-economic groups.

We don’t know who today’s mental health professionals would pick for their ideal client. Nor do we understand what attitudinal differences toward patients exist among practitioners depending on their own personal characteristics. Do older clinicians, for example, prefer different kinds of clients than younger ones? Do male counselors hold the same patient preferences as female therapists?

I’ll offer a few thoughts on the broad subject of “ideal” patients. No gospel is here offered, just one person’s ideas. I’ll start by considering the YAVIS profile:

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YOUNG: Let’s set age 40 as our arbitrary limit on “youth.” Let’s also stipulate that you can be “old” before your time. Meaning what? Too set in your ways, rigid in attitude and behavior, closed to new ideas and risk-taking. By this standard, youth holds the advantage of openness to change. Moreover, those clients who are “too old” have an increased likelihood of experiencing regret that cannot be erased by future action: the inevitable foreclosure of some opportunities in life when we pass the “use by” date on our early, fleeting talents. I’m speaking not only of career possibilities (athletics is an obvious example), but regret over having been a poor parent to offspring who are now adults. The absence of children would be another loss for women of a certain age who desired off-spring of their own flesh.

We can come to terms with some of our past errors, but we don’t always get a “do over.” Youth, therefore, owns the advantage not only of its openness to change, but a plethora of doors not shut to entry. Yes, there are other avenues to pursue for most of us who are past our physical prime, yet they are now different and fewer in number.

ATTRACTIVE: Although one might discuss this characteristic in several ways, I will opt for the obvious: a patient who is sexually appealing. I would be lying if I said I never noticed a beautiful new client in the waiting room. A colleague described the “energy” within the office when treating such a person, at least on early visits. The energy he spoke of was his own.

While feminine beauty has a potential downside (read Beautiful and Smart but Unlucky in Love), a male therapist can unconsciously work hard at his profession to achieve an appealing woman’s approval.  The man might seek a beguiling female’s admiration unaware of what is driving him: captured by his senses but not his sense. The counselor, however, should give his best for every patient. His first steps toward reducing bias are to recognize the danger, look at his reaction to a beautiful new client, and be certain he gives equal effort to all. Indeed, this was possible even though some women made obvious attempts to draw my attention or offered themselves to me as sexual companions.

Experience and conscientiousness, not to mention adherence to professional ethics, reduce a client’s distracting physical desirability. Moreover, I discovered — as I suspect you have — that my perception of another’s external qualities changed as I got to know them. Some become more attractive, others less. A few days ago on a New York subway I noticed myself looking at a rather plain (to me) young woman sitting opposite me. Lost in her thoughts, she had the most touchingly pensive expression concentrated in the unconscious, tender positioning of her mouth. Put differently, a good therapist can find almost all his patients attractive. Indeed, we look for the best in people on every level.

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VERBAL/INTELLIGENT: In talk therapy — a treatment involving many words — an inarticulate client is a challenge. I recall a bright man who lacked verbal fluency and had a limited education. He progressed well, but the demands on me to understand ideas and emotions he could not express with ease made treatment challenging. I was able to overcome the obstacles, in part, because of his patience and my persistence. Just so, those whose intelligence is below average may have trouble understanding concepts like transference. On the other side, one also deals with individuals lost in their own intellectual/verbal juggling act — preoccupied with the word play in their heads. A different form of challenge, then. Still, a therapist prefers a patient with a decent command of language.

Understand please, I’m not referring to those who are afraid to be open with their feelings and thoughts, but rather men and women with difficulty expressing themselves while trying hard to do so. Fear of self-disclosure is a different story. Counselors find female patients are generally more comfortable revealing their emotions, no small point when the individual comes to treatment because of mood issues. Thus, the therapist faces some clients frightened to say what they feel, others who don’t have the words to make themselves clear, and a few who struggle with both. The clinician does his best regardless.

SUCCESSFUL: A lack of “success” can prevent the patient from affording treatment, adding an additional hurdle to the therapeutic project. Many clients, however, came to my office thinking themselves unsuccessful. Some were correct from an objective, financial standpoint. An absence of success as defined in the materialistic USA is no automatic impediment to a good psychotherapeutic result. Success did, however, sometimes signal I was in the presence of a person who had surmounted past life challenges, and therefore predicted a capacity to take on those emerging in therapy. To me, high accomplishment by itself never meant the course of treatment would be easy. Indeed, some of the wealthiest clients I met were poor patients, often because of ballooning egos and a narcissistic inability to look into the mirror and witness an accurate reflection.

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What else made a client into a promising therapeutic prospect in my mind?

  1. MOTIVATION: In the best case these folks led the therapy, doing everything they could to make their lives better. More often it was enough if they were responsive to homework assignments, thought about the sessions rather than forgetting them after they were over, brought in issues for discussion, and recognized treatment needed to be a joint effort, with two people pulling the same sledge to a better place.
  2. OPENNESS AND A LACK OF RESISTANCE: Some clients fight the therapist, summarily discounting any ideas or interpretations suggested by him; reflexively saying “I’ve already tried that.” They were like giant tin cans in human form, well-versed in how to resist the can opener, aka the doctor. The best clients are emotionally available or learn to trust the clinician enough to permit a gradual revelation of difficult issues and feelings. They don’t make the “fifty-minute-hour” into a battle.
  3. CONSISTENT ATTENDANCE AND PAYMENT: Regularly missing sessions makes it impossible to get anywhere. Woody Allen denies saying “Ninety percent of life is showing up,” but (whoever said it) there is truth in the expression, even if one might disagree with the exact percentage. With respect to payment, a counselor doesn’t want money to be an issue between himself and his client. Many accept either pro-bono or sliding-scale patients who pay nothing at all or something less than the customary fee. Others will let clients in difficult circumstances run up large tabs. Usually you get paid at some future time, sometimes you get stuck. Such is life, but again, if a therapist has a choice, he’d prefer to deal with what makes sense, not cents.
  4. THE ABILITY TO TOLERATE DISCOMFORT: Change is rarely easy. The more damaged the patient, the more courage required. As a mental health professional you bring people along slowly not to overwhelm them. Nonetheless, therapy is a challenge and at least a bit of heroism is necessary.

What is left to say? It’s all very good to minister to a “perfect” client, but most therapists don’t waste time dreaming of that impossibility. By definition we receive those who are struggling. The entry to my office didn’t resemble an amusement park ride with a height requirement and a linear measure to make certain you were tall enough.

Sublimely well-functioning creatures, if there are any, don’t seek mental health professionals, nor do counselors have a waiting room runway for beauty pageant contestants. If patients were motivated, hard-working, communicative, showed up without urging, and were open to the challenge and pain of the process; then, in general, I had all I needed to do my best work. A sense of humor was a bonus. Most counselors are patient and don’t believe in miracle cures. Nor do we need to be entertained.

Hang in there. Do your considerable part. Misguided therapists surely have dumped patients in an unfortunate fashion, but this is rarer than suggested by tragic internet stories. Even if you don’t see over the hill yet, keep going. I never treated a walking, talking, human work of artistic perfection, a painting of Monet or Rembrandt in the form of a mortal being. If you were “ideal” I never got to meet you, in or out of the office.

Mental health professionals are not like the ancient Greek philosopher Diogenes, holding his lantern in a fruitless search for an honest man. We do not make our own nightly, flash-lit quest for a perfect patient.

Since no ideal therapist exists, neither is an ideal client required to achieve the best that therapy can do. Indeed, I learned far more about courage from imperfect patients than they ever learned about it from their imperfect therapist: me.

The first image, Lilium Pink Perfection, is the work of Ulf Eliasson. The second photo displays Claire Parker with Her New MGI Crown, photographed by Ecprpageantnews. A Portrait of Albert Einstein by Hermann Struck follows. All of these were sourced from Wikimedia Commons. The final image is a cartoon figure long associated with the game Monopoly.

 

When Words Fail

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There are times, whether in therapy or in life, when words are inadequate. Listening to a story of heartbreak, sometimes my heart broke a little, too. If my patient watched me carefully (no failure on his part if he didn’t), he saw the tears in my eyes. Words would have intruded on what was happening between us. In a sense, the air, the touching contact of our eyes — the silence — did that which could be done.

This moment in US history cries — and cries out — for a response, but too many words have already been written and spoken. I am reminded of the composer John Cage, a wry and brilliant man. His most famous piece is entitled 4’33.” The composition consists entirely of silence. Quiet is appropriate for mourning, is it not?

Whether in words or in silence, compassion only goes so far. Expressed opinion only goes so far. But the emotional shards need removal, thus grieving comes first for most of us.

The work of therapy begins with the processing of pain. Sadness often robs us of motivation. Fear can paralyze. There are more catastrophes predicted than realized. Unrestrained anger turns you into the thing you hate. Rage is a motivator, but not easily prolonged or healthily maintained. No psychologist would urge you to try.

What then? Prior to counseling’s end you must change yourself if your goal is to change the world, whether one’s small personal globe or the bigger one.

Marcus Aurelius wrote,

The art of life is more like the wrestler’s art than the dancer’s … it should stand ready and firm to meet onsets which are sudden and unexpected.

Like the wrestler we take a breath, search our ingenuity, and get up when we have been thrown to the mat.

A return to the fight is essential whether in therapy or life. Action — exerting control of what you can control — defeats the sense of helplessness.

In therapy and in life we are called to heroism. Courage is required to take on uncomfortable truths, beginning with those about ourselves. Difficult actions must follow. No heroism is needed to pour gasoline on your heart and light a match. Reason is your friend; emotion, not always.

Take responsibility and act responsibly.

Nor does one profit by the simple wish for a result, a passive hope for a change, or a patient wait for others to lift you. Freedom from your demons, in therapy and in life, must be won.

Our demons teach us who we are and what we are made of. Are they perhaps, in this way, our friends? Do we owe a peculiar debt to our challenges? You cannot think otherwise when you watch your 14-month-old child learn to master his universe, but you can when you have been decked. Regardless, whatever we want we must make it so.

Therapy is not an endeavor of a few weeks or months if the goal desired is substantial. Whether in therapy or in life you will succeed only if you persevere. Expect setbacks. Whether in therapy or in life, many make a fast start out of the gate, but fade before the stretch run. The finish line is not achieved and the problems then persist. Lasting dedication of your entire spirit triumphs over both temporary grievances and passing enthusiasms. No distractions are permitted for the true of heart.

Cato said:

When Cicero spoke, people marveled. When Caesar spoke, people marched. … Good judgment without action is worthless.

Whether in therapy or in life the voice is yours, the choice is yours, and the action must be yours.

The painting above is The Silence by Johann Heinrich Füssli. It was sourced from Wikimedia Commons.

Keep Yourself in Check: How Insecurity is Fueled by Over-apology

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In my essay on Signs of Insecurity, I wrote the following, here paraphrased:

The self-doubting person tends to apologize when no apology is necessary. It is as if she expects to be reproached or is afraid to give offense; so, she prophylactically tries to excuse any possible mistake to avoid such a response.

Equally, answering a question with an upward inflection of the voice betrays uncertainty. The name given to the practice is “upspeak.”

The problem with these behaviors is that they telegraph vulnerability to those who would take advantage of you. Bullies are good at “reading” your actions if you begin waving a white flag. Otherwise they aren’t that smart.

Social interactions can be a kind of test, true enough. Even when not intended, lots of questions about you are being tentatively answered by the ones who care to pay attention, though not everyone does so until we give them reason to.

Among those questions:

  • Is he intelligent?
  • Does she like me?
  • Do we share interests?
  • Am I making a proper impression?
  • Is this individual naïve or street smart — too trusting for his own good?
  • And only sometimes: can I take advantage of him or her?

Note the presence of questions your conversation partner is asking about himself, as well.

The last two of the items listed are the ones offering a narcissist, a bully, or a sociopath the opportunity to bend you to his will. Most of us don’t wish to be thought of as pushovers in any sense. The gaze of someone strong-willed can make the insecure cower — turn the belly to jelly. He is defeated already. Fearing the unproven strength of the other, a fetal position is taken, as if to say, “Please don’t hurt me! I surrender. I won’t resist.” Now he has you. The “kick-me” sign on your bottom is evident, if invisible.

We all set our own price, put a sticker on ourselves that says, “Here is what I am worth.” Everyone is afraid of something, perhaps many things, but advertising the cheapness of your purchase price — in the hope of an unmade promise of safety — is not advisable. Your self-offering as a sacrificial lamb comes without a guarantee except the one you give.

The assumption is that if we apologize in advance — for who we think we are, for less than perfect language, or lack of knowledge — then criticism, being yelled at, or challenged will be avoided. Wrong.

First, you are overestimating the chances of severe reproof. Second, by admitting your flaws unasked, you state, in effect, “Keep on the lookout for my foolishness, ignorance, and weakness.” Without this — trust me — most won’t recognize any such inadequacies, imagined or real.

While we are being evaluated —if we are being evaluated — the judges are looking for big signs, not small ones: the kinds of markers you can’t miss even at a  distance, like the huge letters on Trump Tower in Chicago. Regular people don’t use instant replay. They aren’t equipped with a slow-motion, zoom-in button, at least not yet. The person facing you cannot recognize a bit of perspiration or hear a slight tremulousness. When you identify yourself as insecure, however, he doesn’t need an interpreter with a PhD. in clinical psychology. You have told him straight out. You may as well raise your hand or request a spotlight. You gave away your power for pocket-money. To paraphrase Emerson, instead of saying, “I am,” you are saying, “I am not.”

In the title to this essay I suggested an alternative, a way to avoid quick psychological exposure. It is both simple and difficult. One needn’t possess heroic self-confidence to do what I’m about to advise.

You must be quiet.

Don’t kneel and you won’t need to get off the floor.

Practice (in your head) stuffing the viperous, reflexive, unrequested apology when the serpent tries to escape your throat. The creature can be tamed. The more you do it, the better you get. Before too long people will forget all or much of what you previously revealed to them about your insecurity. Break the routine. Especially among those who don’t know you, more respect will be offered.

Did I hear you say, “I can’t”? Ask yourself whether your strategy of anticipatory self-criticism is working. “Maybe I’d be treated worse if I didn’t apologize.” Ah, but if your method is a good one, you wouldn’t be reading this, would you? The failure of my simple solution might, however, suggest therapy is needed.

Bottom line: don’t invite others to disrespect you by telling them you disrespect yourself.

The photo at the top is a Schademask or Shame Mask. This one comes from Burg Waldburg, Germany. Wearing such masks was a community-instituted punishment once upon a time. The photographer is Andreas Praefeke and the image is sourced from Wikimedia Commons.

The Therapeutic Search for Your Past

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Unless your symptoms can be relieved without an excavation of your ancient history, most counselors will encourage discussion of your past. For some patients this is at their fingertips in fine detail and painful intensity. For others only the emotions are reachable, without being joined to specific memories. A blank slate is found in still another group of clients: they own few recollections, feelings, or interest in bygone days. Yet if the healer believes you were damaged early, he must find a way to assist you in the search for them.

Perhaps you’ve had the experience of a particular aroma or flavor evoking a childhood recollection. The most famous literary example comes in Swann’s Way, the first volume in Proust’s In Search of Lost Time. The narrator unknowingly refers to the therapeutic dilemma of retrieving the past when it does not come easily of itself:

It is a waste of effort for us to try to summon it, all the exertions of our intelligence are useless. The past is hidden outside the realm of our intelligence and beyond its reach, in some material object (in the sensation that this material object would give us) which we do not suspect. It depends on chance whether we encounter this object before we die, or do not encounter it.

The narrator tells us how the enormous world of his early memories was opened by the simple act of eating the crumbs of a petite madeleine (a small French sponge cake) mixed with tea, reminding him of this treat offered by his aunt and leading to more and different recollections. Here is the attentive therapist’s key to assisting his patient: a knowledge that the sensory world can help unearth the client’s excavation of his early life. You must dig with your bare hands — get your fingers dirty, literally — if you spent youthful time playing in your backyard in the grass, clay, and soil. There, in the movement, scent, and contact might you find a piece of yourself.

We all recognize our five senses: sight, sound, touch, taste, and smell. Thus, the therapist can suggest his client return to his old neighborhood and walk the path he took to school or the playground, or once again ride the bus along a familiar route. I have even known people who persuaded the new occupant of their old apartment to permit a brief tour. If the patient lives far from this place, an imaginary journey is still possible.

Photos of yesteryear can do some of the work — the heavy lifting of evocation. Songs of the time or those sang by babysitters can spring the release of powerful emotions. Proust’s example leads us to recall what foods we ate when we were small, what sounds were present in our flat and nearby, what games we played and TV or radio programs we watched and listened to, what childhood possessions we treasured. None of this is foolproof, guaranteed to open yesterday’s locked door. Yet such efforts sometimes work like a domino game, one toppled piece striking the next and that piece hitting another in turn, as if each object were a newly triggered memory. Nor should consultation with an old friend or relative be ignored. Their recall may trigger your own.

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A similar occurrence recently happened to me. Since crayons will find their way into my grandson’s hands before long, those coloring sticks became a topic of discussion. In my early school years, Crayola Crayons — the Cadillac brand of coloring hardware — were on the equipment list for the summer’s end march to your new daytime captivity. Mom, ever frugal because of her own impoverished childhood, bought an economy size for me, perhaps only the smallest box of eight or the next step up. To my chagrin, however, all my classmates (or so it seemed to me) had larger boxes, several hugging and lugging the giant 48 (or was the number 64?) cardboard container to Jamieson School. Apart from saving me from a possible hernia, I can now remember a sense of shame and loss of status connected with my small Crayola box. Size, long before I understood anything about sexuality, did matter.

Recollections like these are grist for the treatment mill, capable of revealing the origin of insecurity, depression, anxiety, and more. You can also use them as adjuncts to self-understanding outside of therapy. Distant memories tend to be available for retrieval because of an attached emotional charge, whether joyful or dispiriting. The thrill or disappointment or humiliation of a childhood event seems to bind the occurrence to a place somewhere in our consciousness, even if we must struggle to find it.

As Harvard psychologist Robert Kagan said:

The task of describing most private experiences can be likened to reaching down to a deep well to pick up small, fragile crystal figures while you are wearing thick leather mittens.

Searching your past is not for the faint of heart: you do not know what you might find. Yet among the detritus uncovered in your archeological dig, there may be sharp-edged treasures, perhaps even a key to release you from invisible tethers restricting your enjoyment of life’s fullness.

The old joke tells us that if you find yourself in a hole you should stop digging.

Funny how psychotherapy advice is sometimes just the opposite.

The top picture of the Madeleines de Commercy is the work of Bernard Leprêtre. The photo of the very First Version of the Crayola No. 64 Box comes from Kurt Baty. Both are sourced from Wikimedia Commons.