Who Helps You Grieve?

You lose a boyfriend, a girlfriend, a spouse or a parent. Death, breakup, estrangement – all terrible. If you are wary of a therapist, who helps you grieve? This tends not to be a thought-through decision. You are in pain, if not overwhelmed. I hope to address here some of the complications of your choice or choices – steer you, too, toward who might be best.

  • Complete Self-Reliance. This is the most challenging and dangerous choice. You have lost a dear person and, perhaps, trust in the virtue of attachment. You fear losing the supportive individual, too, through death, relocation, or misunderstanding; maybe driving them away with your desolation. Grieving alone is a self-alienating process. The parts of you press against each other. Your insides ache, but the world goes by as if nothing happened. Tears are not enough unless they are witnessed by someone sympathetic.
  • A Person in the Midst of the Same Grief. Should a child go to a parent who is also bereft if the child’s father (the mother’s spouse) is the one who is gone? The choice is natural, but the mother has nothing to give. Reverse the situation: should the mother go to the adult child seeking solace when the sting from which the daughter suffers is just as intolerable? Each needs her own support. That said, a parent or an adult offspring might feel responsible and obligated to give aid, and guilty if she does not. Both are adrift. Why do we expect one person to be the life-saving lifeguard when both people are drowning? We go to therapists because they are not suffering our loss. They offer the therapeutic distance the bereft cannot. Only with such remove from personal pain can comfort be provided as needed.
  • Friends or Relatives Who are Judgemental. Some people will blame you. What did you do to drive your spouse away? Why aren’t you going to church and relying on God? You mean you’re not over it yet? You need to move on, start dating again, get a life. Some of these “friends” do not want to consider their own vulnerability to tragedy and devastation. Easier to shun you or blame you. Surprisingly, a friend who has “been through it” might be less sympathetic than one who has not.
  • A New or Potential Love Interest Who Offers Support. Pardon me for being cynical here, but one must be careful of opportunists. Even those sincere in their desire to offer a hand to hold may be unaware of the extent to which they hope for a relationship with you. I’ve seen this opportunism in both sexes. By itself, not necessarily a bad thing, unless your vulnerability finds you making a poor selection of a new lover, choosing the distraction of a rebound romance to salve your faltering heart.
  • A Friend Who is Available For Only Part of the Job. She is a good choice if she is also sympathetic. Such a person might limit contact, but be fully present when able to offer herself. These friends can’t do the complete job of helping you grieve, but a part of it.
  • An Array of Supportive Friends. If you know such people, some of whom might be in your religious community, then you can go to two or three who are free and solid enough to take on a bit of your hurt. By distributing the weight of your pain among a few people, burn-out of any one of them is less likely.
  • A Support or Survivors Group. Especially if you add such a group to the friends with whom you talk, this can provide a means to the end you seek.
  • An Individual Therapist. Again, the various choices are not mutually exclusive. With the availability of a few people to witness your pain and a dedicated professional hand, you now have a system of reattachment to the human community. A counselor has treated other bereft souls before you, the training to help you along, and the aforementioned distance from your loss.

Nothing about this process is easy. No perfect solution exists. Time helps. Love helps. People help. Work helps, too.

The sun has set on your life, but, as Ecclesiastes tells us, the sun also rises.

The first photo is of The Kiel Canal, in the German State of Schleswig-Holstein. Finally, The Sun Rising Through the Clouds, by Moise Nicu, sourced from Wikimedia Commons.

Patients Who Haunt the Therapist

It’s almost Halloween. Time to talk of a patient who haunts me.

I put her in the category of Greek tragedy. After you do therapy for a while, you get a sense of a singular place called “Grim Future;” and a person, admirable in many ways, whose tragic flaw will take her there. Usually, you only witness the first few acts of the drama.

But you are certain, even though the data say therapists are flawed predictors.

These are the patients with whom you are powerless. Not a good thing for a peculiar profession, one hoping to prevent disaster, enable happiness.

She was a university student. Her parents actually did the leg-work to find a therapist to “fix” her. I came recommended, though an odd choice for a family steeped in “hellfire and brimstone” faith, the folks who strangle nearby innocents with certainty of the right and wrong of everything. Their rigidity frightened me, people who sat so tightly wound in my office I thought they might vaporize. Hisssssssssssssssss!

I’d be seeing the daughter, however, I said to myself. I told them she would be my patient, not they; once I evaluated her and assuming I believed good might be done. I “would not, could not” (as Dr. Seuss says) report back to them; short of imminent risk of self-harm or danger to someone else. They seemed to agree.

She walked in and springtime came with her. A silvery thing, she lit the room, though I cannot explain how. A “presence.” Therapists take in everything or try to.

This young woman was tall, perhaps 5’10” and willowy; black hair against porcelain skin, a pleasant face. Her complexion was so fair I could almost see through her. Someone else had, I suspected, and seen there was no will in her to resist much of anything.

She was not the most expressive person I ever treated, more sadly placid. Not serene, but the kind of calm derived from having the fight drained from you. Almost weary. Her parents had sucked the life out of her. Think vampires. The wind would take her where it chose. Right now she had youth and beauty, but as they say about the short careers in the National Football League (NFL), the three initials really mean “not for long.” Of course, I didn’t understand all this immediately.

Her parents wanted her to follow some “serious,” academic track. She was a dancer. They wanted her earthbound. She wished to leap. Bad combination.

Many of us try to get the love we couldn’t get at home, don’t we, at least for a while? My patient was looking for such affection. Her folks didn’t like her boyfriend: he was not a member of their suburban, uppity class, and worse (to them) freighted with a minority heritage. But before you feel too sympathetic toward him, you must learn more.

I discovered he had introduced her to cocaine, which he also used: a drug, for her, like a key for her internal lock. There she found release, relief, and ecstasy. There, she was no longer anyone’s hostage. But, of course, she’d simply gone from being her parents’ chattel to that of the boyfriend and the drug.

Treatment didn’t go on for long. The job of freeing a person from parental dominance or a lover’s grip must wait if simply getting through the day is difficult.  I explored addiction treatment with her. I don’t recall if she began or not, but her interest was only dutiful. Soon enough her parents discovered her use and blamed me for not telling them. Therapy ended.

The character of Alfieri, in Arthur Miller’s A View From the Bridge, says the following:

There are times when you want to spread an alarm, but nothing has happened. I knew, I knew then and there – I could have finished the whole story that afternoon. It wasn’t as though there was a mystery to unravel, I could see every step coming, step after step, like a dark figure walking down a hall toward a certain door. I knew where (she) was heading for, and I knew where (she) was going to end. And I sat here many afternoons asking myself why, being an intelligent man, I was so powerless to stop it. And I even went to a certain old lady in the neighborhood, a very wise old woman, and I told her, and she only nodded and said, ‘Pray for (her) …’

The cynics say counselors are only interested in money, making a fine living off the pain of others. Well, some few are, but most of us want the best for everyone, not just our patients. We are rewarded by human contact and flourishing.

Yes, we cannot help without a therapeutic distance. The invisible boundary doesn’t inoculate us all the time. People we know, in and out of therapy, get inside. It happens to us as to you. We are not sculpted from stone.

Halloween is an odd day to be thinking of prayer, but apt perhaps. This year, when you tuck your candy-buzzed child into bed, and after all your treats have been gobbled up by greedy little monsters, sit back and rest and be grateful if no ghosts haunt you. Then, if you have a picture of this fragile creature because my story was well-told, pray for the (now, no longer young) woman, if she lives.

And for your counselor. This, from an ex-therapist who doesn’t believe in God.

The top painting is Marie, by Peder Severin Krøyer. The second image is The Ghost, by Tsukioka Yoshitoshi. Both are sourced from Wikimedia Commons.

The Taoist Farmer and a Patient’s Search for Answers

Part of the human dilemma is the trap of unhelpful, but habitual ways of thinking. Cognitive behavior therapists call them thinking errors or cognitive distortions. On occasion you probably have made one or more such wrong-headed mental turns into an emotional sink hole. Catastrophization is an example: predicting the worst possible outcome you can imagine happening to you, sure the expected calamity will finish you off, even when there are many less dire potential futures and most bad results are temporary. But other mental traps wait for us, ones not so commonly found in a therapist’s lexicon. Good/bad, right/wrong, lucky/unlucky are not as clear as we think.

Take the old story of the Taoist farmer.

There was a farmer whose horse ran away. That evening the neighbors gathered to commiserate with him since this was such bad luck. He said, “Maybe.” The next day the horse returned, but brought with it six wild horses, and the neighbors came exclaiming at his good fortune. He said, “Maybe.” And then, the following day, his son tried to saddle and ride one of the wild horses, was thrown, and broke his leg.

Again the neighbors came to offer their sympathy for the misfortune. He said, “Maybe.” The day after that, conscription officers came to the village to seize young men for the army, but because of the broken leg the farmer’s son was rejected. When the neighbors came in to say how fortunately everything had turned out, he said, “Maybe.”*

As with any parable, multiple interpretations exist. Sometimes apparent bad fortune – like a broken relationship – leads to someone who is a better match. Being fired from a job can be a step toward a better one, even fuel your search and foster your growth. This is not to suggest all tragedies are the yellow brick road to Oz. Yet, we tend to recover, even if recovery can be lengthy, fraught, and incomplete. Then again, luck depends on when you take a measure of your situation. The farmer believed there was still time ahead, and the present moment represented a temporary vantage point: another evaluation down the road might change the assessment of his life.

One alternative way to think about this story is to recognize the problem of “keeping score.” We look around and ask, am I getting ahead or falling behind? In the West, the so-called First World of capitalism, we are trained in ladder-climbing, money counting, and concern with the opinions of others. A bit crazy-making, since someone else always owns “more,” and we are inclined to compare “up” rather than “down.” Put another way, we measure ourselves against those better off rather than those less fortunate. We also tend – after a moment of delight – to take for granted the Christmas toy for which we waited a year. Great honors don’t seem so great after the award ceremony is over.

Is there another way?

A Buddhist (or a Stoic philosopher) might tell you to become less attached to all things in the world: status, property, money; even relationships and health. Put differently, to give up clinging and craving, while practicing loving kindness and steadfast integrity. The more attachment, the more you will lose, so they say. Such an existence – preoccupied with getting and spending and fear of losing (and regret over what is already lost) – is a guarantee of suffering.

Yet another view is this one: maybe life is not a matter of assigning a grade to what we think or do, but to be experienced with little evaluation: passed through, lived. To be in the swim, not outside the pool, watching and afraid of the shock of the cold water if we should jump in. Not asking whether our stroke is beautiful enough, our pace fast enough, the distance traveled far enough.

To this way of thinking, failure and rejection are normal parts of life. They indicate we are still trying; necessary parts, too, because resilience grows from the knowledge you can come back from defeat.

Perhaps winning the game is not as important as playing the game. Perchance the world is to be tasted: different cuisines and flavors, not just chocolate and vanilla. If so, a person would experience many colors, sizes, possibilities. Engage in multiple careers. Know lots of people. Have your heart broken and sewn up and torn again and stitched until the twine itself breaks. And to read and discuss all the worthy books, play all the sublime music, climb walls until your muscles and tendons hurt. No, even past the time they hurt, adapting to the hurt. Not an either/or existence but “all-in.”

Or, is life properly understood to be perplexing and without a “solution”? If so, any belief in your own secret formula is misguided: your solution is, at best, temporary. You are not only fooling yourself, but missing the point. Which is? That the pursuit of happiness is more a journey than an arrival. That when traveling to the airport we should always go to “departures” instead of “arrivals” because we are forever “taking off” for whatever is next and never reach a static endpoint while alive.

Left to you is the creation of a personal meaning, not to be found in a book or a place of worship or from a mentor, whole and flawless; unless, that is, you are among those for whom the answer is unquestioning faith and an ultimate, unworldly reward.

Still another path: one is told the most satisfying existence requires living for bigger things than ourselves, including the future of the planet, our children, and the lives of others. We are warned not to count on or crave a posthumous glory. Unless someone else is doing the scoring, the record book will be lost along with our names, in a fast-fading blue ink on a yellowing parchment. Or, as Arthur Miller suggested, on a block of melting ice.

Is human existence perhaps a multifaceted combination of tragedy, joy, inevitability, necessity, laughter, devotion, confusion, sacrifice, and the way things are until, too soon, they aren’t?

Having written all of the above, I fear my message – the answer without an answer to conceptualizing life – is unsatisfying. I’m not even satisfied. I have given you no certainty, nothing definite. Some of you will reject the inconclusivity. I won’t hold it against you.

To my way of thinking, therapy cannot provide “the answer” either. The counselor instead offers a remedy for specifics. He can help reduce or eliminate your anxiety or depression or some other malady in the Diagnostic and Statistical Manual. No text-book or training, however, offers a step-by-step solution to dealing with the human condition. I’m sorry about that, really.

We do what we can.

I offer this consolation to you, nonetheless:

No matter what we look like, no matter how happy or sad we are (or seem to be) for the moment – calm or stressed, wise or foolish – we are all in this porridge together. Sometimes we swim within a tasty bowl – “just right,” as Goldilocks said – though not for every meal and every appetite. Look around you and see all the swimmers. Tiny like us, precious like us. They come in all strengths and varieties, but they will not always be there.

No wonder we search for love.

*Source: Tao: The Watercourse Way, by Alan Watts. The first image below the youtube video is Ilja Richter rehearsing for his play Altweibersommer in Munich. The next photo is the work of SuzannePerry.enoughofit7. Both are sourced from Wikimedia Commons.

Becoming a Traitor to Yourself

All my life I had been looking for something, and everywhere I turned someone tried to tell me what it was. I accepted their answers too, though they were often in contradiction and even self-contradictory. I was naive. I was looking for myself and asking everyone except myself questions which I, and only I, could answer.

So begins Ralph Ellison’s Invisible Man. But these words apply to more of us than the black protagonist of his novel. A careful reader will recognize how many psychotherapy bloggers are quick to condemn themselves. They define themselves as terrible human beings, inconsiderate and selfish. They believe their resentments should neither be felt nor displayed. A “better” person would be kinder, forgiving, more generous. Their unhappiness is taken as a commentary on their value, a failing grade in the class of life.

You will see them marching voluntarily to the world’s slag heap of unnecessary and misshapen things, beyond repair or redemption. They say, in effect, “If you wish to find me you must dig deep in a landfill, where I belong.” I asked one, in light of her self-assignment to the discard pile of life, how then she might describe herself if she were a spouse abuser or terrorist. These are far worse human behaviors than she’d reported and, it seemed to me, her self-condemnation went too far.

Here was a lady who sprinted to the local lumber yard, bought some wood, constructed a cross, and nailed herself to her destiny. To my mind, the bowels of hell (if such exist) are occupied by a group to which she doesn’t belong. They’d laugh if she requested admission.

I might have said, “Get off the cross, we need the wood.”

We can, in just this type of self-punishment, turn traitor to ourselves. I’m not suggesting anyone is perfect. But few of us are so unworthy that we must become our own dartboard. We bleed enough at the hands of fate without offering ourselves as a pin cushion. Some of us have been assigned a shape not our own. Life seems inauthentic. We must reform ourselves, shed the shape assigned, and work to improve it.

First, however, we must buy a new flashlight, stand in a new place, and look with new eyes.

Ellison’s fictional young man sought answers about a path forward. He wished to know who he was. The earnest fellow thought it best to ask others wiser and older. No flashlights for him.

Asked or not, those others give us our first sense of self by what they say and do. Their kindness suggests we are worthy. If they blame us we might think we are not. If they offer false gods, we get a counterfeit sense of what life is or “should” be. We are in the dark.

Ellison’s protagonist tells us he was indoctrinated for 20 years and needed another 20 to achieve self-awareness: to throw-off the self-destructive beliefs he had about himself and the nature of the world. Where can you go to find out whether you are as awful as you think, assuming you don’t like yourself?

Some begin by questioning the most basic assumptions they have. These include whether authority figures are usually right. Which authority figures?

All of them: your parents, government officials, best friends, clergy, and spouse are not exempt. The ones in power and the ones who want it. The pretenders and their defenders. The crowd and the solitary man. The critics and the critics’ critics, the know-nothings and the do-nothings, the show horses and the work horses. Include your therapist, too.

Even your God.

What do I mean? If you have been shamed and demeaned or neglected, especially in your early life, such treatment came from those on this list. If you accept their judgment then you internalize the guilty verdict on your character and talent. You will judge yourself as they have, carrying their voice, now your own, inside you. Indeed, if even a house of God is the source of repeated reminders of the indelible blackness in your heart, a religious book can become a cudgel to beat you with.

Worse still, believing them, you will continue to seek their “wisdom” and approval; desiring a possible reconsideration of your character since their magnetic attraction remains powerful. Or, you may search for others like them, those who claim they are only doing this (injury to you) “for your own good;” in effect, redefining harm as “caring.”

Here is the first bit of “fake news” we receive in life, making us vulnerable to those who offer us — their sheep — a caring hand that will instead shear us of the goods we own and the belief in our own goodness. These “wrong choices” of association with “wrong” people depend on the magnetism they share with those who began our “wrong” indoctrination.

Their magic only disappears when you recognize who they really are; and, who you really are.

Some authority figures deserve to pass the test. Others do not, nor should you return to them. You may be scared to be without their shoddy shelter. The security you believe they offer, however, is an illusion. You can only get out and get away.

All my life I had been looking for something, and everywhere I turned someone tried to tell me what it was. I accepted their answers too, though they were often in contradiction and even self-contradictory. I was naive. I was looking for myself and asking everyone except myself questions which I, and only I, could answer.

The first painting is George Hooker’s The Subway (1950). The second is the work of Tetsya Ishida: The Servitude and Deforming of the Salary Man.

The Music of Catastrophe

If music means something important to us, our contact with a new person finds us trying to discover what musical loves we might share. Thus do friendship and romance begin.

In a world where isolated suffering comes easily, music, like some of the other arts, reveals we have much company in our emotional distress.

Songs add language to instrumental expression, making them more precise in meaning than purely instrumental music. Vocal composition is literally sung to words, but there is just as much of the human experience in the more abstract forms, even if a symphony is not so easily identified with the particular circumstance (say, a broken heart) described in lyrics.

Sound offers solace if a composition reaches the tender, injured place inside. Few pieces, however, deal with cataclysm and collapse. To my ears, one of those is the Symphony #4, the last such work of German composer Johannes Brahms.

Brahms was a life-long bachelor from Hamburg, who died in 1897. He achieved recognition early and much success afterwards. The major unhappiness of his life was his unfulfilled romantic attachment to Clara Schumann, 14 years his senior; the widow of the man who first recognized his genius, the composer Robert Schumann. Some believe their age difference, his virtual adoption by the couple, and the shadow of Brahms’s indebtedness to her late husband made the consummation of his ardor impossible. Brahms’s final symphony reveals he knew much about human calamity, whatever its source.

Lacking a description from the composer about what his symphony “meant” — if anything or nothing — we are left to make our response personal. Perhaps no language exists with which to “understand” Brahms’s Fourth and my use of catastrophe is misplaced, but I am not alone in the opinion.

That disaster, if there is one, occurs in the fourth and last section of the work, the concluding 10-minutes or so. There, too, you will hear a much commented upon “conversational” quality in Brahms, when the wind instruments “speak” to each other. David Hurwitz of Classics Today, finds “active rage and impassive grandeur” in the ending. Jerry Dubins wrote, in Fanfare magazine, of the “final rush to oblivion … on the symphony’s preordained appointment with disaster and annihilation” in “a score of gloom and doom.”

Why might one want to listen given this description?

To me and the many who rank the work one of the most perfect and moving in the entire classical repertoire, much poignant beauty accompanies the ride into the abyss; indeed, because of it. The reasons for listening are no different from those causing us to appreciate a sad song. In Brahms’s 40-minutes we become the composer, inhabit his intellectual and emotional journey, and are seized by towering grandeur; perhaps even  swept away, exhilarated by the suspense and power, and moved to tears. Some would say a great work of art, if masterfully performed, can change us.

Franz Kafka knew the power of all art forms and wrote about the potentially transformational impact of writing:

What we need are books that hit us like a most painful misfortune, like the death of someone we loved more than we love ourselves, that make us feel as though we had been banished to the woods, far from any human presence, like a suicide. A book must be like an ax to break the frozen sea within us.

Will you be changed?

You can find out in 40-minutes time.

The top photo is the work of Ville Miettinen. It is described as, “A crevasse (moulin) in the Langjökull glacier, Iceland. At the time it was perhaps three or four meters long, a meter wide and some 30-40 meters deep.” The second image is the 20-year-old Brahms in 1853. Both are sourced from Wikimedia Commons.

The Therapeutic Journey and Our Problematic Concern with Destinations

We are an impatient race. Tasks don’t get done fast enough, the wait in line is too long, the computer too slow. Our destination looms like a slave-driver of our own creation, craving full speed to the end of our journey and the imagined prize awaiting us there.

What are we missing?

Many of those in long-term therapy are ambivalent about the inevitable end of the journey. They correctly recognize that accomplishment of one’s therapeutic goals means the terminus of the walk through the mine field of the psyche, the regular sessions, and the severing of the therapeutic relationship.

The mine field traipse is the only one they hope to dispense with. Indeed, most would say removal of unexploded emotional bombs caused their enlistment in treatment in the first place. By contrast, the absence of session-bound, intimate time with the therapist is dreaded, like ejection from a cocoon.

The story is even more complex, however; both for those who fear the loss of their road-trip, therapist-guide/companion and those who believe the journey’s end will bring nirvana, the permanent release from all suffering.

Consider: more than a relationship is forged in treatment. There is a process of struggle, self-reflection, honesty, learning. Perhaps nothing before — nothing the patient has tried or accomplished — has been so hard, but so rewarding. Each step in each session is enriching or intense — alive — even if fraught with portent and overlaid with tears. The furniture in the office stays the same, but the mental furniture gets rearranged, replaced, knocked-over, tested, taken apart, and put together. All this is “process,” not product. All this is overlooked when clients reflect on their ambivalence about the end of counseling and loss of the therapist.

In part, the problem is our instinctive goal-directedness. Often, however, the target — whatever it might be — is not as special as anticipated. Heaven does not exist on earth. We get used to even a transformed life, no matter how worthy. We become accustomed to our new, higher cruising altitude of emotional stability. The background activities — the daily maintenance of clothes, body, and living surroundings — still must be done. As the Zen proverb goes, “After enlightenment, the laundry.”

Therapy becomes a road traveled-well only if we try to notice everything, absorb everything along the way. It is not like pursuing a diploma: trudging through courses in philosophy or calculus that are endured, not enjoyed. The treatment isn’t like having an ice cream cone in its pleasure, but absorbs our entire being as a fount of learning. The engagement is total, the preoccupation remains in mind even after the session ends, the effort is important, the risks great. You are reaching for the next handhold on the mountain. Yes, you are doing so to reach the top, but you will be on summit for just a few minutes, a static place no one can live. You soon must move below. Life is in the movement. What you took away was the experience, the incremental achievement of all the concentration and self-surpassing courage you could muster.

Cervantes’s Don Quixote reminds us, “The road is always better than the inn.”

The post-war circumstances of military veterans add to the discussion. None of them want to relive the horror. Yet, some will say it was the most intense experience of their lives. Moreover, the intensity is missed, if not what created it. Thus, the therapy journey brings not only pain, but something of value in its dedicated, focused, life-on-the-line process. Not a deadened, dull, inert state of being.

Elite athletes, similarly, don’t enjoy every moment of their competition. The combination of actions and emotions includes strain, focus, effort, and fear of failure, as well as elation. We tend to think of goals and the pleasure associated with their achievement without full recognition of the other experiences they live while in motion, in process, and in the moment. Yet this is what any journey worth taking entails.

If you are currently in long-term treatment and agree with my description of the journey’s value, you might say: “Well, then. Now I’m not just fearful of losing my therapist, but the journey, too!”

Fear not.

If the treatment has been successful, a wider world has gradually opened to you outside the counselor’s consulting room. Many journeys beckon, inward and outward, outside your comfort zone, where all journeys live: more and different friendships, travel, new vocations and hobbies, increased openness to art or music, spiritual awakenings, returning to school; and, too, “thoughts that do often lie too deep for tears.”*

You will embrace some of what once frightened you or found you closed off. Not all things, but some things. Even from the defacing hand of age, a man of thieving heart, will you wrest unexpected gifts.

You never become indestructible, but you can move along in life more confident in the ability to manage most of the hurts; accepting that, they too are a part of the human experience, the beautiful/terrible richness of life.

You will not become everything you could be. No one does. But you will be alive to the world.

You cannot ask for more.

* The last words of Wordsworth’s poem, Ode: Intimations of Immortality from Recollections of Early Childhood.

The top photo includes Remains of the Via Appia in Rome, ner Quarto Miglio, by Kleuske. The second image is called Roma, via Appia Antica: Arco di Druso e Porta San Sebastian by Lalupa. Both are sourced from Wikimedia Commons.

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.