June 26, 2012

Fooling Yourself Into Failing Yourself: The Trap of Anxiety and Avoidance

“But I just don’t like to do that.”

That is what she told me — the young woman who said she didn’t want to go to a restaurant alone. “Why should I do that? I’d much rather eat with someone and be able to talk at dinner. Eating alone wouldn’t be any fun.”

True. Most of us would prefer a dinner companion. It probably would be more enjoyable to dine with a friend. But there is an important distinction here. It is between being able to do something that you might prefer not to do, and being unable to do the thing because it is uncomfortable for you; maybe even frightening. And, it is between deluding yourself into thinking that the activity might be boring or stupid when the truth is that you are afraid to do it.

Deluding and denying. We do it all the time. “I don’t like to do that. Why would I want to do that? Why do I have to do that?” And so we persuade ourselves that we can live without certain experiences, side-stepping the things we don’t know about or haven’t done — the small and large challenges of life.

But what are we really doing here?

For the young woman in question, her repeated need to be accompanied to places — her fear to act alone — caused her to be dependent upon people, especially boyfriends. As a result, she found it difficult to be without a male companion for very long and, when she did find one, discovered that she wanted (and needed) to be with her lover more than he wanted and needed to be with her. Thus, her insecurity about being alone and her avoidance of doing things alone made her dependent upon others.

Eventually, the “clinging” drove her boyfriends away. Then she really was alone. Finding herself abandoned and rejected, she turned her reliance on family or friends; if she had those friends, that is, because she had spent so much time with her boyfriends that she’d neglected making platonic friends, along with the work required to keep them.

Some people who are avoidant don’t realize how anxious they are — how much fear dominates their lives. After all, if you turn down invitations to parties because of underlying social anxiety, you manage to avoid getting nervous as you think about the party, dress for the party, drive to the party, walk in the door, and then try to fit in.

The fact that you don’t feel anxious doesn’t necessarily mean that you don’t have anxiety problems. In fact, sometimes a better way to determine whether you have a life-compromising form of anxiety is to make a list of the things you will not do unless forced to at gun point.

Things like giving a public speech, raising your hand in class, traveling to the downtown area of a big city, driving on the expressway, making a phone call, going to a party where you know few people, and eating at a fancy restaurant or any place where you are not familiar with the cuisine.

Things like going to a movie, play, lecture, or concert alone; flying, sending a poorly prepared dish back to a restaurant’s kitchen, saying “no,” returning an item at the store, etc.

Things like trying some new activity on your own or voicing a strong opinion that just might be criticized by someone else; and not looking for a new job for fear of the interviewing process.

Please notice that I’m not talking about some of the very commonly experienced fears such as spiders, high places, and confined places: the phobias we call arachnophobia, acrophobia, or claustrophobia and the like. Rather, my focus is on the anxieties that make for daily difficulties — that make a life so narrow that it begins to look a little bit like this:

To the avoidant, anxious person, the narrowly confined life seems safer. It is fraught with fewer frustrations and failures. It demands less. It feels less foreboding.

If you are heavily invested in social media, you can even persuade yourself that your electronic social life of texting, instant messages, blogging, tweeting, role-playing games, and hundreds of Facebook friends is better than the real thing. And what might the real thing be? Dedicated time unmediated and uninterrupted by technology spent with a person who is right in front of you and within the reach of an outstretched hand.

Can you approach social situations without a preliminary drink or joint? Are you certain that the alcohol or marijuana you use to unwind is recreational rather than an effort to self-medicate your anxiety? Yes, we are pretty good at talking ourselves into just about anything rather than seeing ourselves as we really are.

But if we are avoidant, there is a price:

The same things done over and over and that can be done only in the same places and in the same way; and sometimes only in the realm of electronically achieved distance and safety.

The need to rely on others who provide an emotional security blanket, or substance use upon which one is also reliant.

The self-doubt and the worry that accompanies thoughts of leaving our “comfort zone.”

Too much time spent looking at a television or a Smart Phone or a computer screen.

Avoidance offers no growth and no “life,” only the illusion of safety and the temporary relief that we all know from our school days when the teacher was sick and the test was postponed. I suppose that you can try to postpone the “tests” that life offers until the end of your days. Believe me, I’ve seen it happen. I’m talking about a life of challenges unmet, mastery unachieved — the narrow life that Thoreau described when he said:

The mass of men lead lives of quiet desperation. What is called resignation is confirmed desperation.

And, in a companion quote often misattributed to Thoreau:

Alas for those that never sing,
But die with all their music in them.

But he also wrote:

Great God, I ask for no meaner pelf

Than that I may not disappoint myself,

That in my action I may soar as high

As I can now discern with this clear eye.

We live in “The Age of Anxiety” according to W.H. Auden. In any life there is a first time — a clumsy, unsure time — for everyone and every thing. We fear the judgment of others, the embarrassment, and the mortification of taking a chance and stumbling in public. We compare how we feel inside to the apparent (but not always real) serenity, calm, and self-confidence of others as we look at them from the outside. We condemn ourselves for lost time and opportunity, say to ourselves that we are “too late” or “too old” to take on a new challenge, and thereby guarantee that even more time will be lost; perhaps all the time we will ever have.

We tell ourselves that we can’t try a thing until we first feel better, calmer, and more confident; not realizing that “trying” is just what we need to do in order to feel better about the thing; failing to grasp that anxiety is not the biggest part of the problem, but that a failure to act in spite of the anxiety is.

If you are anxious enough or avoidant enough you might well avoid counseling, too. That is a shame, because there are very good treatments available in the realm of Cognitive Behavior Therapy (CBT). For a discussion of therapy for Social Anxiety Disorder, for example, you can look at this: Social Anxiety Disorder and Its Treatment.

Only if you fully realize that your avoidant coping strategies are costing you something of value will you call a therapist. Are you afraid to call? Is it less distressing to email? Did I hear you say, “Maybe tomorrow?” You may not detect the sound, but the clock is ticking.

As Eleanor Roosevelt said, “You must do the thing you think you cannot do.”

Now.

—

The top image is described as Fear of a blank planet, cover by Lasse Hoile Porcupine Tree Band 2005: http://www.porcupinetree.com/ “OTRS Ticket 2006082110002647.” The Illustration of a Shocked or Frightened Woman has been altered by AdamBMorgan from the original that appeared in Wierd Tales (September 1941, Volume 36, Number 1). The next image is One of the narrow streets in the old part of Toledo, Spain by Allessio Damato. Finally, An old style alarm clock captured by Jorge Barrios. All are sourced from Wikimedia Commons.

January 20, 2012

The Pain of Counseling: When Therapy Turns South

Turning points in therapy and in life are usually seen only in retrospect.

Sometimes — many times — therapy leads to a better life. But sometimes therapy creates pain in the process of trying to do its work. The patient can experience it as a necessary part of the process; or, as one more disappointment, frustration, failure, or betrayal in a life already filled with them.

It often depends on the type of discomfort that therapy is causing.

I’d like to describe four different categories of such therapeutic problems. Three of these involve failures of the therapist. But one (Item #3) is a frequent development in therapy that has to do with the nature of treatment and how people deal with emotional pain, rather than some shortcoming of the counselor.

1. Countertransference

Therapists can get frustrated or angry with patients, attracted to them or repelled by them, bored by them or fascinated by them. Therapists are human, so they are subject to all the same relationship issues as everyone else.

Of course, we are trained to keep a therapeutic distance and to know ourselves well enough to minimize all of the above. Unfortunately, self-knowledge is always less than complete and training can be an imperfect aid when faced with challenging relationships.

The psychoanalytic concept of countertransference was an early contribution to understanding these sorts of dilemmas within the doctor and patient dyad. It refers to the therapist’s feelings toward the patient, particularly those that may be unconscious and stem from unresolved relationship issues in his own childhood.

For example, does the patient somehow remind him of a mother who was insufficiently loving or too critical? Those are the sorts of feelings that can sneak up on the counselor without him fully realizing what is happening and why.

Therapists who are not aware of the shadow of their own past can be destructive toward the very people they are supposed to help. Similarly, healers who are themselves too needy or too stressed will not be at their best when someone else requires their undivided attention. Simply put, the therapist should be safe and stable — on land if the patient is at sea, so that he will not be sucked into a whirlpool of suffering and make things worse.

In other words, the therapist must be professional. And, if he finds that he is pulling too hard or being too critical, then damage to that person is likely.

How will the counselor react if he discovers that he doesn’t enjoy the patient’s company or thinks that the patient is too demanding or too dependent — too critical or cancels appointments too often — not improving fast enough? Will the therapist lash back, feel hurt, try too hard to win the patient’s approval? Under such circumstances, the patient can be harmed, even if he provoked the relationship complication himself.

Therapists are well-advised to reflect on their own feelings, work on their own unresolved issues, obtain advice or supervision about challenging therapeutic encounters, and sometimes refer the patient elsewhere; not to mention, get their own treatment if their issues are compromising professional responsibilities.

2. Therapists Who Cross Boundaries

There are two categories here. First, those therapists who mean well, but are not aware of their personal vulnerabilities and the necessity of inviolable boundaries between themselves and those they serve. These practitioners therefore fail to set firm limits on responding to the neediness (or attractiveness) of their patients. Second, there are those self-described “healers” who are frankly corrupt.

Let us begin with the first of these two categories. In an effort to help, some therapists simply do too much for the patient. A few examples:

Discounting (or deferring) fees to the extent of feeling resentment.
Agreeing to schedule appointments so early or late (or on weekends or holidays) to the point of wanting to help the patient more than the patient wants to help himself.
Seeing patients outside of therapy in some sort of quasi-friendship.
Giving patients a physical contact that they crave which leads to sexual contact.

I’ve known therapists who took too many calls in the middle of the night for their own good or that of their family, counselors who brought patients who were down-on-their-luck into their own homes, and those who did not (I don’t think) intend for a comforting hug to become sexual, but who found that it did.

In the second category, some counselors — thankfully not a great number (although one would be too many) — take advantage of the power relationship in treatment. An attractive patient can be used for sexual purposes, or for the ego-boost that such encounters can provide, without conscience; or with some sort of rationalization that it is actually therapeutic. It isn’t, no matter how much the patient provokes it, desires it, or the counselor rationalizes it. More on the problem of “dual roles” and boundary violations can be found on a previous blog post about damaged therapists: When Helping Hurts.

3. When the Patient Has Improved Somewhat and Now Has Less Motivation to Continue the Hard Work of Treatment

Naturally, when therapy is working the person who came to treatment starts to feel better. Sometimes, in fact, he feels better even when therapy isn’t doing very much. Many if not most individuals come to therapy in a crisis. Eventually such a crisis will pass or at least begin to be more tolerable, even if the treatment isn’t the reason.

Once the patient is experiencing less pain, he now has less reason to stay in therapy. The pain is what brought him in and the desire to reduce pain was the motivation to do the hard work involved in treatment. Now that there is less motivation, there just might be less cause to suffer the unsettling thoughts and feelings that therapy stirs up, not to mention its financial cost and the amount of time that it takes.

Take a look at the graph below. The red line (AB) is the pain of “life,” the distress that the patient finds outside of the doctor’s office — the upset, unhappiness, and disappointment that brought him to consult the psychologist in the first place.

The blue line (PQ) in the graph is the pain or effort required by the therapy process itself. Therapy is hard work. It is often also intense and wrenching, since it asks people to change, stop avoiding frightening situations, and face the demons that might have been covered over until the therapist worked to address them: those incompletely healed psychic wounds that are still excruciating to touch.

intersecting lines

On the left side of the graph you will note that the red line (AB) is above the blue line (PQ). That is, when the person enters treatment, the pain of the person’s life is greater than the pain caused by therapy’s effort to make life better. But, as I indicated, at some point it is likely that the pain of life is reduced, while the discomfort (effort or difficulty) of therapy remains constant or might even increase. Why increase? Usually because the most tenacious problems are the hardest for the therapist to successfully address and might include taking the patient deeper into traumatic memories that he has tried to look past.

Once the patient has improved sufficiently (where the two lines intersect at point C), he now begins to find that staying in therapy causes more discomfort than getting out of it, as indicated on the graph by the fact that the blue line is higher than the red line (on the right side of the image). When the point of intersection of these lines is passed, the patient often wants to terminate treatment. Only those with sufficient “therapeutic integrity” or courage will stay long enough to resolve the most intractable of the issues that brought them to the doctor’s office in the first place. Or, they will wait until another life crisis brings them back to finish the job.

4. Therapists Who Haven’t Done Their Homework

It has only been in the last couple of decades that research has begun to point clearly to those treatments that are most helpful for some of the conditions therapists treat. Broadly defined, for example, Cognitive Behavior Therapy (CBT) has been demonstrated to be the “treatment of choice” for most people who suffer from Social Anxiety Disorder and Post Traumatic Stress Disorder.

Despite this, many therapists who claim to treat such conditions do not avail themselves of these treatment approaches or don’t familiarize themselves with the research upon which they are based.

Why?

Some weren’t trained in how to evaluate research or in how to engage in this form of therapy. Some stopped reading about progress in working with these conditions or “don’t believe” in the conceptual grounding of CBT. Some are too busy (or think they are too busy) making a living to afford the time and effort required to be up to date. Some trust their intuition to the point of rejecting anything that doesn’t match what they have come to believe is most important about how to deliver service to the people who seek them out.

The difficulty here is that therapeutic models should not be like religious beliefs, based on faith rather than evidence.

While a failure to follow “best practices” for which there is empirical evidence is not as egregious a violation of trust as sexual contact with a patient, counselors must keep learning and growing in their field of alleged expertise, just as much as they encourage their patients to grow personally.

In summary, therapists are not unique in having the capacity to do injury, but their position of authority gives them a vantage point somewhat like that which parents have with their children, making it easier to accomplish quite inadvertently.

The remedy? Obtain recommendations about counselors from those you trust. Read up on the treatment of your condition. Collaborate in your treatment, don’t just count on the therapist to do exactly what you need at every moment. Let him know about any concerns that arise. If necessary, get a second opinion. And keep your eyes open for the things I’ve described.

Not least, have the courage to stay in therapy even when the process touches on important issues that are sensitive.

As the old saying tells us, “when the going gets tough, the tough get going.”

And, no, I don’t mean “…going out the door.”

—

The above photo is called U-Turn by Zipley is sourced from Wikimedia Commons. Intersecting Lines is sourced from onlinemathlearning.com

July 23, 2011

Too Many Balls in the Air: The Frustrated and Frustrating Life of ADHD

He was dynamic, outgoing, and enormously entertaining.

He was creative, full of ideas, and energetic.

And he was one of the most frustrating people you would ever care to be around.

About whom do I speak? A bright, charming man with Attention Deficit Hyperactivity Disorder.

ADHD is more complicated than you might think. Although there is much written about it, I want to cover a few of the things that can be missed about the condition. But first, let me explain the name and define it.

There are three types of ADHD (Attention Deficit Hyperactivity Disorder):

1. ADHD, Predominantly Inattentive Type. This used to be called ADD, but technically speaking, sufficient inattentiveness is considered a category of ADHD, even though little hyperactivity may be present. These are the folks who seem to be listening, but are lost in space; easily taken away by a tune, a sound, or an idea; the people who miss the details and forget the assignments.

2. ADHD, Predominantly Hyperactive-impulsive Type. This is what most people think of when they hear or read the four letter acronym ADHD. People with this diagnosis are characteristically talkative, active, intrusive; a bundle of unmanaged, impulsive activity.

3. ADHD, Combined Type (meaning it includes the symptoms typical of the first two categories); too many balls in the air, for sure.

What about the man I mentioned at the top; a person who had the “combined type” of ADHD?

He had lots of energy and ideas, so people found him engaging. But it wasn’t a very productive sort of energy. He would begin things, but not complete them. He was disorganized — losing keys and papers, and forgetting appointments. He promised to do things, but couldn’t be relied upon to do them as quickly or as well as expected, if at all.

This man (let’s call him A.T.) went nowhere fast; very fast. A.T. looked liked the “Energizer Bunny,” but mostly traveled in circles.

He tended to over commit himself, taking on more tasks than he could handle effectively, chronically underestimating what he could accomplish in the time available. A.T. was routinely late for appointments, and made decisions quickly, without fully considering the longer term consequences of his actions. Bored easily, distracted more easily, and prone to procrastination, he knew that he wasn’t what others hoped for and expected. Although he was full of promise, his reputation was that of someone who was a thoughtless, irresponsible underachiever — an individual who needed minding.

Employers were disappointed, co-workers were frustrated by A.T., and his spouse was driven just a little crazy, feeling that she couldn’t depend on her partner. She’d married someone who was exciting, only to find that the excitement he produced was more of the “Oh, no!” kind that made her sweat when she discovered he was late to pay a bill or pick up the kids. Not surprisingly, she started to see him as just another one of the kids, as their partnership turned into more of a “disapproving mother/resentful child” relationship than either of them wanted.

Before I tell you about A.T.’s treatment, let me say a few things that might not automatically come to mind about the condition and its consequences:

1. Hyperactive/impulsive ADHD individuals can sometimes look like they are world beaters, but mostly beat themselves; indeed, they are often chronic underachievers. If you are planning on forming a working group or partnership with such a person, don’t be fooled by a positive first impression of excitement and energy. You will almost certainly be disappointed down the road.

2. ADHD, even today, is sometimes not detected in schools. There are several reasons:

The inattentive form of this condition may well produce school failure, but not misbehavior. Inattentive children are often quiet and relatively well-behaved, unlike their hyperactive-impulsive counterparts.
School personnel may incorrectly attribute ADHD-like behavior to laziness or oppositionality. Moreover, school systems, even when they do formal evaluations, are frequently reluctant to identify problems that require additional resources and personnel, which they are hard-pressed to provide given their limited funds.
An ADHD child who is bright can compensate (to some extent) for his attentional problems by relying on his excellent intellectual abilities, at least for a while. Eventually, however, many of these children (as they age and school begins to demand more of them) find out that advanced intelligence is no longer sufficient to permit success.
There is no single standard measure that reliably identifies ADHD. Evaluators commonly use some combination of paper and pencil tests, clinical judgment, and attentional measurements. Intelligence (IQ) and neuropsychological tests can easily miss some of the most clinically obvious cases of this condition.

3. The fact that ADHD children are able to become “hyperfocused” on things like computer games or other tasks that they find especially interesting, does not invalidate the diagnosis of ADHD. Indeed, this sort of selective attention is seen fairly often.

Some researchers believe that those games provide rewarding stimulation in the form of frequently changing images, sounds, and challenges; as well as the success of achieving points or increasing levels of success, thus “capturing” the attention and imagination of the ADHD youngster. By comparison, the real world school room seems boring. Recommendation? Limit your child’s screen time, even in front of regular TV shows.

4. Although many people are hesitant to take medication, ADHD is a diagnostic category that is especially responsive to psychotropic medication. Hundreds of studies support the effectiveness of such treatment for about 85% of children with this condition according to Russell Barkley’s authoritative 2006 book Attention-Deficit Hyperactivity Disorder. In a 2007 paper by Elliot and Kelly — “ADHD medications: an overview” published in the journal Attention — the authors state that “No medicine available to psychiatrists produces a more rapid and dramatic effect more safely than the proper dose of a stimulant to a patient with ADHD.”

5. If medication does work, it will likely be needed on a continuing basis, not as a temporary fix. The irony is that stimulant medication, which will cause internal agitation in those who are not suffering from ADHD, actually permits the person with the condition to focus more and become less prone to the hyperactivity/impulsivity that had been a problem.

6. ADHD is correlated with a greater risk of developing a Conduct Disorder, typically characterized by antisocial misbehavior and defiance of authority. Not surprisingly, such individuals often abuse alcohol or drugs (not only as an act of rebellion, but also as a self-medication designed to calm their hyperactive state). Adolescents and adults who have ADHD are thought to make up at least 25% of the population of prisons according to Barkley.

In all these examples, the impulsive, ill-considered behavior that is typical of ADHD takes a fearful toll. Such individuals are easily bored, requiring intense and novel reinforcement (rewards) to motivate them, and are prone to “sensation-seeking” — looking for extreme excitement that their condition seems to make them crave. Indeed, one patient of mine reported driving at speeds approaching 100 MPH on city streets simply for the feeling it produced in him. Nor did he think he was at much risk (or putting others at much risk) in doing so, thus demonstrating the poor judgment characteristic of those with the hyperactive-impulsive form of ADHD, as well as their tendency to disregard rules and authority figures.

7. While many general medical practitioners (GPs) can prescribe medication for ADHD quite well, some are hesitant to do so, sometimes due to lack of training or inexperience with this particular diagnosis. Cautious GPs will prescribe psychotropic medication, but are prone to giving doses that are too small. It is generally best to see a psychiatrist in such cases; that is, someone who specializes in the prescription of medication for psychiatric disorders.

8. The frustration that ADHD produces in school children can make them give up (and eventually drop out), believing that nothing they can do will make any difference in their performance. Some of them will become avoidant of academic or other work tasks because they believe that they will fail, thus producing a self-fulfilling prophecy. Many will get angry at the teachers, bosses, and parents who so often are reminding them of their inadequacies. Thus, ADHD fuels other behaviors that make a good life difficult.

What happened to our friend A.T?

You’d think it was simply a matter of telling him of the benefits of medication, wouldn’t you?

Not so fast.

He was one of those folks who was uncomfortable with the “idea” of having to be reliant on medicine. He told me that he didn’t “believe” in medication, as if it was a matter of religious faith.

A.T. was also quite narcissistic; in denial concerning his own responsibility for the things that went wrong in his life. Similarly, he had no trouble blaming others including bosses and wives. Not to mention that he drank too much and didn’t acknowledge that it was a problem. Indeed, he had only come into treatment at his spouse’s insistence.

One of the challenges of psychotherapy is the fact that few people fit “pure” diagnostic types. Instead, one must be aware of all the complicating factors that can make effective therapy difficult. This man’s narcissism, denial, and alcohol abuse certainly created just such complications.

Had A.T. been more motivated and self-aware, less prone to denying the misery he was creating around him, a cognitive-behavioral (CBT) approach to his ADHD could well have helped, even if he chose not to take medication.

CBT programs include formal guidance in planning and organizational skills, assistance in problem solving and decision-making, help in reducing the number of distractions in the environment, practice in new thinking skills, training in ways to reduce procrastination, and advice to help you cope with failure. Homework is required between sessions.

The program described by Steven Safren and his associates in the work book Mastering Your Adult ADHD, developed by psychologists at Massachusetts General Hospital and Harvard University, was able to produce significant improvement in about 50% of those patients who continued to have clear problems even after being treated with medication.

So, if you have ADHD, medication and CBT provide reasons for optimism that things can get better.

Just don’t drop the ball!

—

The top image is the Carbon Cycle created by the U.S. Government Department of the Interior. The one that follows is the Tux Crystal Linus Award by Nevit Dilmen. The next photo was created by Thomas Pusch and is called Scolded By Mama. The fourth picture is of Two Men Playing a Computer Game by Love Krittaya. Finally, a picture of a Geode by Whitsoft Development. All are sourced from Wikimedia Commons.

June 13, 2011

Father’s Day (via Dr. Gerald Stein – Blogging About Psychotherapy from Chicago)

This is a revised and expanded version of a post I wrote two years ago about my father.

Father’s Day can be complicated. Like any day of honor, some tributes are deserved more than others, or not at all. Some obligations are carried out with joy, while others are a matter of dutiful routine. And sometimes there is pain, where once there was (or should have been) pleasure. But, for myself, Father’s Day is pretty simple. While I miss my dad (who died 11 years ago), the sense of loss is no longer great. He was 88 when he stroked-out in … Read More

via Dr. Gerald Stein – Blogging About Psychotherapy from Chicago

May 20, 2011

Why Therapists Want to Talk about Your Childhood

Why do we have to talk about my childhood? Shouldn’t I be over that? What difference does that make now?

Sometimes, it makes all the difference.

Not everyone requires an in-depth therapeutic look at their childhood. Many people can benefit from short-term treatment to get over a crisis, a recent loss, or current relationship issues.

Others will profit from a cognitive-behavioral approach (CBT) that works to change present day action, thought, and emotion.

But there are times when the past is a dead-weight on one’s life, preventing any kind of lift-off into a more productive, joyous, lofty, airborne, less anxious and guilty way of being; one that is not grounded by a gravity — an invisible force — that seems to pull one back to a repetitive cycle of sadness, regret, and chronic avoidance of challenges.

An example:

Take an intelligent young woman in her 20s — movie-star beautiful — with a quirky sense of humor, and more than average intelligence. Her parents praised only her beauty, but derided everything else about her. From an early time their constant criticism made her worried about displeasing friends; and later on, lovers.

She learned that she could make a dazzling first impression while hiding her anticipation that others would find out what she offered was only skin deep.

This woman’s super-model exterior and surface gaiety belied her belief that there was nothing inside of her that was really valuable. She hid the thoughts and feelings that her parents had always put down, so as to prevent people from discovering her vulnerabilities.

But even when she was successful at “fooling them into thinking” that she was better than she really was, the praise and approval she received only persuaded her that she was a good actress — that beneath the stage makeup she was nothing — just nothing but an empty, worthless shell.

Her anxiety about being “exposed” for the fraud she felt herself to be was combined with a depression that grew out of her failure to win her parents’ love. And, in order to achieve that love, she continued to try to extend herself and prove herself to them, only to be rejected or neglected or taken advantage of once again, thus confirming her sense of worthlessness.

Unfortunately, she was also drawn to potential boyfriends and platonic companions who resembled her parents in their mistreatment of her — as if the only love worth having was one that would allow her to triumph over rejection and win the affection of someone who resembled her parents in their lack of affection for her.

Our heroine succeeded in graduating from college and getting a good job. But none of this filled her up more than temporarily, just as a new purchase of an attractive dress might make her feel good for a few hours or days until she sank back into her default state of sadness and misgiving.

Now imagine that you are her therapist. What would you do?

Tell her that she is beautiful, talented, and accomplished (as evidenced by her academic and vocational success)?

She has already tried to tell herself this, she has already heard this from others, and she still feels bad.

Work with her to improve her social skills?

She is already skilled socially; “a good actress,” as she would characterize it. She is able to be assertive professionally and put-up a good front; until, of course, it involves a personal relationship about which she feels strongly.

Send her to a psychiatrist for anti-depressant or anti-anxiety medication.

Perhaps, but this does not guarantee that she won’t continue to have the same self-doubts and make the same bad relationship choices of people who treat her poorly.

Use Cognitive Behavioral Therapy (CBT) to help her “talk back” to her negative self-attributions (put-downs of herself) and help her to evaluate herself more objectively.

This is not likely to be sufficiently helpful by itself if she continues to favor people who reject her, caught in some version of the old Groucho Marx joke: “I wouldn’t want to be a member of any club that would have me as a member.”

Use CBT to help her gradually stand-up to the people who are treating her badly.

Again, this might be somewhat useful, but will be countered by her belief that there is something wrong with her, and that she deserves the mistreatment she receives. Moreover, it will be hard to be assertive because of her terror that she will lose these same people if she pushes back against them.

What then is left?

In my opinion, this lovely young woman will have to begin to see (really see) and feel what has happened in her life, going back as far as necessary to the mistreatment she received at the hands of her parents: their failure to give more than lip-service to loving her, their cruelty, their inattention when she did something that should have been praised, their criticism, and their tendency to make her feel deficient and guilty.

If she does not see them for who they are, she is likely to continue to believe that it was largely her own inadequacy that caused her to fail in her quest for their love. And, if she continues to place them even on a relatively low pedestal, she will also keep reaching out for love from all the wrong people — the people who remind her of those parents; those who possess the only kind of love she wants because it is unconsciously associated with her parents.

It is not enough that this patient becomes intellectually aware of all that I’ve described.

For therapy of this kind to be successful, she will have to feel it, not just know it.

Feel it intensely.

Why?

Early life is a “hot” moment in virtually any life. Emotions are highly charged in children. We have not yet learned how to regulate those feelings, and so we are very, very vulnerable to injury. Nor do we have any of the defenses or the intellectual understanding of things and of people that will help us later to navigate the choppy waters of life.

And so, in this “hot” and challenging early time in our existence, we begin to formulate solutions to the difficulties of life.

For example, if voicing opinions different from dad’s beliefs results in his condemnation, many kids will learn to keep their mouths shut and internalize their feelings. Meanwhile, they are likely to feel diminished and less good about themselves if there is too little love and too much criticism.

A parent’s opinion counts enormously in the formation of the child’s self-image.

Time passes and the child perhaps has succeeded in reducing, at least a little, the amount of displeasure, anger, and targeted discontent coming from his mom or dad. So the behavior of keeping a low profile and “acting the part” that the parents expect is reinforced, even though depression and self-loathing are below the surface.

Such choices are made by the child unconsciously, but seem to make the best of a bad situation and become a well-ingrained pattern of behavior.

Eventually the child becomes a teen and soon a young adult, away from a good portion of the daily parental disapproval. Now, having established some defenses and skill in handling life, the crackling tension of early childhood is over. Instead of the ever-present hot moments of early life, existence now consists mostly of many more “cool” moments in which the pattern of behavior becomes solidified and habitual.

Think of it this way. A small child is like a piece of metal in a forge or foundry. The searing affective cauldron of early life is like the super-heated nature of a forge, designed to make the metal malleable so that it can be wrought or cast. Unfortunately, in the childhoods I’ve been describing, the little piece of metal that is this tiny life is shaped by the destructive forces of the household into a form that is warped; not fully serviceable.

With the passage of time and the “cooling down” of the emotional intensity of that life, the newly shaped adult — like the forged or cast piece of metal — is no longer malleable. The pattern and outline he or she is now in — the self-opinions and self-defenses that were established in the forge — have taken on a permanent, fixed form. The same ways of living developed while young continue to be used to some extent, even if they are not all that useful; even if conditions have changed.

Obviously, new learning is still possible, but at the deepest level — the level of self concept and self-love, as well as the tendency to be drawn to certain kinds of people when looking for love — alteration of the shape or form or way of living is much harder to achieve.

What then does therapy do to assist with this much-needed alteration?

The therapist and patient work together to re-enter the “forge” of childhood, that time of “hot” moments when personality was fashioned into its current image.

Once back in the foundry, the emotion generated in recollecting that time can make one malleable again: capable of being reshaped and of reshaping oneself into a less self-critical person who believes in his value and no longer seems so drawn to people who are excessively critical.

Therapists who do this kind of “depth” or “psychodynamic” psychotherapy may well encourage the patient to journal — even to write autobiographical essays. They can be assisted in remembering what seem like incidental details of early life such as their school teachers, the friend who sat next to them in third grade, the path they took to walk home, what TV shows they watched, the time of day that mom or dad came home, the summer vacations that were taken, the sounds present in the home, the aroma of cooked foods, and so forth.

Anything that might be useful to jog emotion and memory is fair game, including old photos and report cards, conversations with siblings or childhood friends, and revisiting the neighborhood in which one was raised.

The process can be painfully difficult. Indeed, it must generate significant emotion to reproduce, as far as possible, the forge-like nature of early life — the conditions which permit a realignment of internal interpretations, understanding, and feelings. Grieving over the losses of the past can only come with openness to whatever is felt and discovered in digging up the psychic “can of worms” that sometimes is to be found in one’s past.

And it is the emotion connected to the early trauma that, when finally re-experienced to at least a partial degree, proves cathartic and informative; allows one to realize that “it wasn’t your fault;” at least not to the disqualifying extent that you have come to believe it.

Sometimes there is a “break through” moment, as in the film Good Will Hunting with Matt Damon and Robin Williams. But even without that kind of emotionally generated epiphany, this type of treatment can be transformative.

Of course, not everyone needs to do this. A more cognitive behavioral approach along side this type of exploration may also be helpful in some cases.

But sometimes there is simply no substitute for the hands-in-the-dirt and feet-to-the-fire process that I’ve described.

Take heart.

If your therapist wants to talk to you about your childhood, sometimes it might just be exactly what you need; just exactly the cauterizing instrument that your hurt is waiting for.

Remember — the heat of the forge can be hard to withstand, but upon emerging from it perhaps you will notice that its warmth has healed your lonely heart.

—

The above image is Metallurgist working by the blast furnaces in Třinec Iron and Steel Works courtesy of Třinecké železárny, sourced from Wikimedia Commons.

August 10, 2010

Guilt about Betraying Parents: “They Did the Best They Could”

Young children are not the only ones who believe that their own mom and dad are the best in the world.

You know the sort of thing I mean: “My dad is stronger than your dad” and the like.

Adults do this too. Or, at least, try very hard not to think the worst of them.

Any therapist with experience has heard many heartbreaking stories about children who have been abused, deceived, lied to, cruelly and unfairly criticized, used, mistreated, and neglected. He has heard from the adult children what their parents did do and didn’t do — about folks who perpetrated the abuse directly and others who looked away or simply told the son or daughter to “try not to upset dad” rather than protecting him or her from dad.

The now-adult children will make up lots of excuses about such things: “They did the best they could” or “They didn’t know any better” or “Lots of parents were that way when I was growing up” or “How can you expect anything better when my folks had even worse childhoods themselves” or “They were having so many of their own problems at the time” or “Other people had it worse than I did” or “They’re old people now and I wouldn’t want to hurt them (by bringing this up)” or “It happened a long time ago; what is the point of talking about it now.”

Or simply, “It feels wrong to talk negatively about them.”

Most of the patients about whom I am speaking come to therapy with some sense of personal inadequacy, low self-esteem, and unhappiness, if not depression. Some have these feelings despite a considerable set of personal achievements. They may be captains of industry, millionaires, doctors, lawyers, college professors, and professional athletes. Many of them have a good and loving spouse and adoring children. But, no matter what has been accomplished or how good their current life is in an objective sense, it doesn’t seem to be enough.

Others try to fill themselves up with acquisitions: a new car, a new house, a new spouse, a new watch or appliance or piece of clothing; and, for a brief period — an hour, a day, a month — this might even boost their mood. But then, things return to the steady-state of emptiness as the shopping-therapy fails.

For these people, the ones who seem to “have everything” but remain unhappy, the Marilyn Monroes of the world, the solution usually requires that long-standing internalized negative self-attributions (critical thoughts or beliefs about oneself) be reviewed and challenged. Sometimes cognitive behavior therapy is able to achieve this.

But there are other instances when the negative verdict of a difficult childhood is so indelibly stamped on the soul of the patient, that he must look back at the original painful source of his injury, grieve his losses, and reevaluate who his guardians were and what they did, or didn’t do.

In cases such as this, the set of excuses I mentioned earlier becomes a problem. Words like “They did the best they could” stand between the patient and his ability to look frankly at his early life without feeling that he is betraying his parents in so doing.

Here is what I frequently say to those of my patients in this predicament:

First, you will do no harm to them in talking to a therapist. There is no rule that says they must be told what you are relaying to a counselor. Indeed, if your parents are dead (as is sometimes the case), then they cannot be told and are safe from any injury that you believe you might do to them.

You need not concentrate only on what they did that might have hurt you. It is equally important to look at what they did that might have helped, and at the complications in their own lives that made good parenting a challenge.

But, even if they showed you some consideration and kindness from time to time, if it really wasn’t so bad, why are you careful to raise your child differently than you were brought up?

Realize that good child rearing is not simply the sum total of all the positives and negatives of your parents’ approach to you, such that the former will always balance out the latter. Imagine that your parent gave you a million dollars and put it in your right hand; and then said, “Now in return, you must allow me to disable your left hand.” Would this be an example of good parenting? Would the provision of a million dollars compensate you for the lost use of your left hand? Not to just anyone, but due to the behavior of your parent?

Yes, it is likely true that some others had it worse than you did. But does that mean you are free of injury? Imagine that you are walking down the street. You pass a man in a wheel chair. He is moving the vehicle by use of his two arms and you think to yourself, “Poor man.” But, a few blocks down, you now encounter another wheel chair-bound individual. Unlike the former person, this man’s arms are incapacitated.

If you are to measure the physical state of these two men against one another, you are likely to evaluate the second man as worse off than the first. But, just because the first person is better off, one must admit that he still is unable to walk.

As I said, there is almost always someone worse. But that doesn’t mean that your injury counts for little or nothing.

Finally, the look back is intended not to keep you focused there, but to liberate you so that you can live more fully in the present; it isn’t to be angry with your parents or to harm them (although anger might be involved in the grieving process). Rather it is to free you from the weight of a childhood that you still carry, the sense of your own falling-short that you can’t otherwise shake, to leave you lighter and less burdened by the long reach of your youth.

Wouldn’t loving parents want this — for their child to be happy and free from any hurt they might have caused? What would you want for your child?

You see, the heart has no clock built into it. Even though you may think very little about the time elapsed, the heart still keeps a living record of the damage, as fresh as the day it was inflicted. You’ve tried ignoring it; you may have tried other types of therapy. Perhaps it is time.

You needn’t feel guilty. You needn’t feel disloyal. Your heart waits patiently for its cure. The therapy is not intended to place blame or to harm your parents, but to heal you.

Looking back may be able to help with that.

—

The image above is Parent with Child Statue, Hrobákova street, Petržalka, Bratislava by Kelovy, sourced from Wikimedia Commons.

July 9, 2010

The African Dip: Thoughts on Passive-Aggressiveness, Powerlessness, and Acceptance

My dad occasionally took me to a legendary Chicago amusement park called Riverview when I was a little boy. I was dazzled by the roller coasters, the “Waterbug” ride, and something called the “Rotor.” The latter required you to enter a circular room which spun on a central axis until the velocity and centrifugal force were sufficient to pin you against the wall, just as the floor dropped away.

But, as small as I was, it is a sideshow called The Dip that I remember most vividly. Today I’d like to use this politically incorrect carnival attraction as a spring-board to a few thoughts on the expression of indirect anger that sometimes is called “passive-aggressive,” as well as a therapeutic approach to setting aside the temporary upsets that are a part of any life.

—

Black men in cages. That is what “The Dip” involved.

Unbelievable, perhaps, as we think about it in 2010. Each man sat on a stool inside the cage. In front of the cage, off to the side a bit, stood a small circular metal target that was attached in some fashion to the stool, perhaps electronically, but more likely mechanically.

For less than a dollar, you could purchase three balls to throw at the target, one at a time. If you struck the target solidly, the stool on which the man sat collapsed, and he dropped into a pool of water underneath the cage. You might have seen similar “dunk tanks” at various fund-raising events, often giving students the chance to dunk their teachers.

Harmless fun? Not so in the case of a black man doing the sitting and a white man trying to knock him off his seat.

This sideshow was once reportedly called, “Dunk the N****r,” later “The African Dip,” and finally “The Dip.” It was eventually shut down by a combination of Negro outrage and the increasing disgust of white people to the offensiveness of its implicit racism.

The black men were in a relatively powerless situation — almost literally, “sitting ducks.” But, they did what the situation allowed them to do so as to unsettle, tease, and otherwise disrupt the white pitcher’s aim. The Negroes were careful not to say anything too frankly insulting, lest they stir up the racism (and potential for less veiled violence) that was at the heart of the event.

But they would and could get away with belittling their adversaries athletic skill or throwing ability in a way that was amusing. If their comments distracted the opposition at all — got them to laugh (or the crowd to laugh at them) — or caused a break in the hurler’s concentration, the chance of staying on the seat improved a bit.

According to Chuck Wlodarczyk in his book Riverview: Gone But Not Forgotten, the caged men’s banter could include comments about one’s appearance: “If you were heavy, they’d call you ‘meatball.’ If you were thin, they might have called you ‘toothpick.’ If you were with a girl, they might have said ‘Hey fella, that ain’t the same girl you were with yesterday!'”

You don’t have to be a black man in a cage to have some experience of expressing anger indirectly. We’ve all done it. It takes many forms: talking behind someone’s back and mocking that person, being sarcastic, complaining to a co-worker’s superior rather than to the offender’s face, neglecting tasks you have been assigned unfairly, and procrastinating. These passive-aggressive words or acts are rarely very satisfying. The anger doesn’t dissipate; the grudging discontent usually continues; nothing positive happens.

The sense of powerlessness and lack of control that the passive-aggressive individual experiences can come to dominate that person’s emotional life, rather than allowing him to put effort into changing the power dynamic or to remove himself from a position of weakness.

Unfortunately, for some of those who feel powerless and injured, even a passive-aggressive action seems impossible. Consequently, they take a more uniformly passive role. They defer to others, try to avoid giving offense, act meekly, and position themselves under the radar. All that does, however, is give them second class status, just as it informs bullies that they are easy targets.

Someone in this situation, who repeatedly feels mistreated but isn’t able to take on those who inflict the injuries directly, needs to ask himself a few questions. Why do I put up with it? What am I afraid of? Am I really as powerless as I feel? Am I perhaps overreacting? What would happen if I were more direct? Is there any way to get out of the situation I am in?

Cognitive Behavior Therapy (CBT), which aims to quell and counter irrational thoughts, is often helpful in dealing with a lack of self-assertion and the fear that is usually associated with it. Equally, it gives you practice (sometimes using role-playing within the therapy session) in a gradually ascending hierarchy of challenging situations that require an assertive response.

Some CBT therapists, much like ancient Stoic philosophers, employ an “acceptance-based” psychotherapy and integrate this Zen-like element into their treatment. Why, they might ask you, do you so value the minor indignities of daily life and of opinions and behavior of boorish persons? Is it really a good idea to spend the limited time of your life being upset over rudeness from a tardy repairman or a fender-bender accident you didn’t cause — things that will be of no significance in a week, a month, a year?

Put differently, there will always be injustice, and some of it must simply be accepted as the nature of life and of living. Not every fight is worth fighting about, not every slight is intended. If your skin is so thin that you are regularly being upset by people, perhaps you are valuing the approval and opinions of others too much.

For those who ask “Why me?” those same therapists might say, “Why not you — you are alive, aren’t you, so you are subject to all the same things that can affect any other person.” And, as the Stoic philosophers and Zen practitioners would tell us, if we can accept this vulnerability as part and parcel of living, thereby assigning it less meaning and taking it less personally, our lives will be more satisfying — less fraught with anguish, anger, and hurt.

This is not to say society should have tolerated the indignity and racism of “The Dip.” There are times when the indirect, but pointed wit of the caged men is the best course of action; and, many occasions when the force of your personality must be brought to bear by confronting injustice. But some combination of directness in taking on unfairness and forbearance in accepting things — in allowing oneself not to sweat the small stuff — tends to produce as good a result as life will allow.

Of course, you have to figure out what the small stuff is and what other things really do matter to you.

Meditation is usually a part of the treatment enabling you to stay in the moment, and let go of your attachment to passing feelings and thoughts, worries and regrets, and anticipations and fears. To be preoccupied with just such temporary upsets causes you not to be able to fully experience what is going on in the present and determine what is really of importance in your life.

By encouraging and training you in meditation, the counselor is attempting to give you a method to achieve a state of psychological enlightenment that (without using words) helps you to distinguish the transitory aggravations, disappointments, worries and anxieties of life from whatever matters the most to you, so you can put your effort into the things of greatest value in your life.

Some final questions:

Do you often find yourself fighting over things others consider to be small?
Do you frequently feel put-upon but are capable only of a passive-aggressive response?
Do you (too easily and too often) assume a fetal position with others (metaphorically speaking), who come to think of you as an easy target and treat you badly (in part) because they know you will not stand up for yourself?

If you have answered any of these questions in the affirmative, you might benefit from asking a couple of other questions:

What does this mode of living cost me?
Am I willing to do the work necessary to change?

If the cost is substantial and you are eager to change, then a therapist can be of assistance. Only then will you be ready to get out of the cage, real or not, in which you find yourself.

—

The image above is the Flying Turns, a toboggan-style ride that was one of the many attractions that made Riverview Park famous.

June 3, 2010

The Limits of Reason: How to Think about Your Date, Your Boss, Your Mom, etc.

As a therapist, I hear a lot of concerns from my patients about parents, bosses, romantic partners, and so forth. The thoughts often take the form of “Why did he do that?” or “What was he thinking?”

Some of this is worth questioning. In life it is useful to take the role of the other person, to look at things from his or her perspective, to try to “understand” that individual’s motivations and reasoning process.

But, there are limits. Here are just a few that make understanding difficult:

1. People don’t always carefully weigh their decisions before making them. We humans frequently think and act impulsively or emotionally. It can be a bit harder to fathom an ill-considered act than one that is carefully reasoned.

2. The person whose mind you wish to enter may not know himself well at all. When you recall what he says are the reasons for his actions, you need to be aware that he may be fooling himself. Alternatively, he might be dishonest with you, giving you less than a full set of data, trying to prevent himself from looking bad in your eyes, or attempting to protect you from being hurt by the truth.

3. We all act in self-serving ways much of the time. The same person who says that he hates it when someone ends a relationship without explaining why — not even making contact or returning phone calls — might well avoid the discomfort of a final farewell or confrontation himself when he decides that a relationship should end, thereby doing the very thing that has been done to him.

4. Most people, in or out of therapy, are often indirect in expressing their unhappiness with you or their disappointments about your behavior. (Marital conflicts and parents talking to children can be noteworthy exceptions to this general rule). But, in the absence of direct communication, it is difficult to be a good mind reader. Indeed, crystal balls are in short supply whenever I go shopping.

5. When trying to understand others, we look for some form of logic. To seek something that is often missing within the person is a pretty big misunderstanding of how people think and act.

6. You may not have enough history and background information to make an accurate analysis of what drives this individual to do what he does.

7. Do you really know the person well “under the skin?” There is often a mismatch between what is happening on the inside and what is occurring on the outside. Put differently, the contradiction between surface appearances and internal truth often affirms the old saying, “Don’t judge a book by its cover.”

Too much time trying to figure out another person is unproductive. For this reason and those cited above, I encourage my patients to set some limits on the amount of time they spend attempting to get into someone else’s head. At bottom, I think, what most of us are looking for is the understanding that will allow us to return to the relationship and put it right, now that we have found the “answer” to what transpired. Or, something that will console us or produce the closure that we are hoping for at the relationship’s end. By attempting to “understand,” we are frequently seeking a sense of intellectual control, partially to acquire information that will prevent future disappointments, but also to compensate us for our loss and to silence the nagging internal voice that asks “What happened?” and “Did I do something wrong?”

It is better, beyond a certain point, to consider several things about oneself:

a. Why did I choose that person to be with? (Obviously this doesn’t apply to your parents; nor does it always apply to bosses or co-workers).

b. How did it happen that I missed the early warning signs of trouble? Oh, I know that you might think that such signs didn’t exist, but it could be that you ignored them, minimized them, or had a blind-spot for them.

c. Why didn’t I set some limits on the relationship in order to prevent the other person from injuring me? And, if I tried, why did my efforts fail?

d. Why didn’t I leave the relationship earlier?

e. What, if anything, did I contribute to the problems that occurred between my friend/partner/lover/boss and myself?

f. Have I grieved the loss or disappointment fully (including attention to both my sadness and my anger)?

g. What do I have to do differently in order to minimize or avoid problems like this in the future?

Instead of addressing the situation in these ways, with these questions, most of us spend no small amount of time ruminating, and then looking for something we can say to the other person to get them to behave as we wish. With some individuals that is possible, but not with everyone.

Jackie Robinson’s breaking of the baseball color-line is instructive in this regard. As you might know, Robinson and his boss, Branch Rickey, agreed that he would not respond to the abuse from fans, players, and coaches that both expected he would receive when he became the first black man in the 20th century to play in the Major Leagues. But, despite two years of taking every racially demeaning insult known to mid-century white males, he succeeded in playing well. Moreover, by this time there were other blacks in the Major Leagues and a great experiment in civil rights had succeeded.

If the story I’ve heard is true, Robinson and Branch Rickey had a conversation at the beginning of Spring Training at the start of Robinson’s third year with the Brooklyn Dodgers. They agreed that Robinson could now be himself, and fight back with words or fists, if necessary. Soon after, the Dodgers played the Philadelphia Phillies, who did not know that Robinson was no longer on a leash. The middle-aged man from the deep south who coached third base therefore once again began the verbal onslaught that he had performed with impunity for the two previous seasons. Robinson called time and walked over to the third base coaching box.

Remember that Robinson had lettered in four sports at UCLA, including football (as a running back). More than most, he radiated intensity, strength, courage, and intelligence. So it was that Robinson moved within inches of the bigot, looked straight into his eyes, and said: “If you ever say anything to me like that again, I’ll kill you.”

Now, I bring this up not to recommend death threats, but rather to point out that Robinson knew exactly who he was dealing with. He knew this man was not going to be persuaded to behave himself by high-flown verbal eloquence; he knew that spending much time thinking about this man’s character was a waste. What Robinson knew for certain was that there was only one thing he needed to understand about his nemesis (his intolerance) and only one approach that would work:

I’m bigger and stronger than you are, so if you don’t stop, I will beat the crap out of you.

Everything changed that day as others quickly realized that Jackie Robinson was not a man who could be insulted any more.

Of course, we all need to spend some time thinking about others and why they do what they do. But, endless rumination on the subject rarely is enlightening or successful in making us feel better.

Some people are like boulders. They are big, hard, insensate, obdurate, and potentially damaging objects. It is essential to see their potential to injure and realize that when you are downhill from such a human bolder, you are in danger.

If you understand how gravity works and get out-of-the-way, that is all you need to know and do — all you can do.

A shame, but true.

—

The image above is The Thinker by Auguste Rodin.

May 26, 2010

Fear of Change: the Therapeutic Implications of Japanese Holdouts

Things change. The question is, do we change with them? Or, do we instead, continue to operate by the same outdated rules of conduct.

I often said to my patients that they seemed to be behaving as if the conditions of their early life still existed. They had long since fashioned solutions to problems that they faced many years ago, and continued to use the same solutions, even though those methods of living didn’t fit with their current life situation. It is as if one were born in Alaska, learned to wear multiple layers of heavy clothing and then moved to the tropics without a change of attire. The warm clothes were helpful up North, but are a disaster down South.

What does this have to do with the “Japanese Holdouts of World War II? The answer is that these men lived by an outdated set of rules with heartbreaking consequences.

If you recall your history lessons, you will remember that the Japanese soldiers of that period were trained according to the principles of Bushido, a feudal fighting code that derived from the period of Samurai warriors. Above all else, weakness was condemned and surrender was disgraceful. Death by one’s own hand was seen as preferable to permitting oneself to be captured, so as to avoid both personal disgrace and family shame.

The Allied approach to the war against these very soldiers in the Pacific was one that involved “island hopping.” The strategy passed over certain islands, both to save men and ensure that the Allies would be able to capture those islands that were of the greatest strategic value. When the Japanese surrender came in 1945, numerous Japanese troops found themselves stranded on out-of-the-way Pacific islands, cut-off from their command, and without the capacity for communicating back home. These men neither knew the war was over nor could imagine that any honorable soldier, let alone their entire nation, would surrender. Some were in small groups who gradually died from disease or starvation; others were, at least eventually, alone.

While many never surrendered and died still waiting for reinforcements that never came, it was not uncommon in the late 1940s and 1950s to read news accounts of isolated Japanese combatants giving themselves up. The photo at the top of this page is of Second Lieutenant Hiroo Onada, who finally surrendered in 1974, and would not do so until his former commanding officer, by then a bookseller, personally ordered him to lay down his arms. At that point, World War II had been over for nearly 30 years.

Thirty years. Yes, 30 years dedicated to a war that was over and a life of desperation that was no longer required.

But how many years, if any, have you given up to a thread-bare, bankrupt strategy of living that has long since outlived its usefulness?. And, more to the point, how many more will you endure? When will you realize that your “solution” has now become the problem?

In my psychotherapy practice I saw numerous variations on this theme. People who were abused or neglected or criticized as children and who continued to live in terror of disappointing others. Those who found substance abuse the only available way of treating the depression or anxiety they experienced when they were young, and who continued to do so. People who avoided challenges because they were scared of failure, having failed many times in the past. Individuals who wore a chip on their shoulder, forever sensitive to insults and injuries that reminded them of long ago attacks, but now were only injurious in their imagination. And those poor souls who expected rejection because of past rejection. Like the Japanese holdouts, the years pass but the fear doesn’t, and the possibility of satisfying relationships and happiness slips away.

If you still are responding to the present as if it were the past, with solutions that solve little (even if they were once necessary), then it is time to change your life. The barricade of your life’s defenses might be protecting you only from the phantom of an enemy who lives within you, not on the other side of the fortification.

A good therapist is likely to be able to help you develop a new way of living, one more appropriate to the world as it is, not the world as it was; to set aside and heal old wounds.

Is it time?

What is the continuation of your old way of living costing you?

The war, your personal war, might just be over and you don’t know it.

April 7, 2010

Health Care Reform and Unintended Consequences: A Prediction

Health care reform has been necessary for a long time. But having said that, I’d like to give you an example of how the expected changes might lead to some unfortunate results, as well as some that are helpful.

My example will focus on Medicare. Everyone knows that Medicare is expensive for the government and that it will ultimately suck the life out of the national economy if costs are not restrained. One way to restrain costs is to require physicians to accept lower fees for their services, something that Medicare has struggled to do for a while, even before passage of the recent health care legislation. Providers are already getting paid less than they were a few years ago, but even more extensive mandated annual changes have been regularly rescinded by the Congress. If they are actually accomplished in the future, Medicare would pay out still less to those same MDs, Ph.Ds, and other health care professionals.

What will happen when reduced fees become more significant? Some healers will decide that it is financially unwise to see patients who are covered by Medicare. They will drop out of the Medicare panel of providers. The greater the fee reductions, the smaller the number of physicians available to see Medicare patients, while at the same time the number of individuals covered by insurance is increasing, led by the large expected additions to the rolls of the insured because of recently passed health care reform legislation.

Let’s say you are the following person: someone covered by Medicare who doesn’t have the cash to pay for treatment out of your own pocket, who also has a medical problem or concern that cannot wait very long. The good news in this hypothetical example is that your MD still accepts Medicare. But when you call your doctor’s office, you are told that you can’t have an appointment for four months—again, hypothetically speaking. The problem and the pain aren’t getting any better in this period of time, maybe they are even getting worse. So what should you do?

First, you will probably try to find another medic who accepts your insurance and has a nearer-term appointment for you. But given the anticipated shortage of people who do take Medicare patients, it will be unlikely.

Eventually, however, you will do what any sensible person would do once the problem becomes really acute—and what your doctor’s office will probably advise you to do under the circumstances—go to the emergency room of your local hospital.

Since emergency room care is notoriously expensive and since the condition might be harder to treat because you waited, this will only serve to drive up the amount of money spent on health care, something that the intended reduction in doctor fees was expected to reverse. Whether the decrease at one end will outweigh the increase at the other, I do not know.

And, instead of the growing number of people who had no health insurance being the impetus for the increased use of the ER, it will now be people with health insurance who are using it more because they have no other readily available alternatives.

I don’t have a handy solution to this problem. My hunch is that there is some amount by which doctor’s fees can still be cut before they start dropping out of the Medicare system in large numbers. It may be that only trial and error will determine exactly how much cutting is possible before producing the unintended consequences I’ve described. The good news, however, is that where there is a high demand for services, eventually supply does catch up, although in the case of producing more docs it will takes years to do so.

Surely, there will be many more unintended consequences of health reform just around the corner. Some might actually be beneficial, but certainly not all. The system we have is not working well for many of our fellow-citizens, so the status quo is not a good answer. Doubtless, once legislators hear enough complaints about problems such as the one I’ve described, they will attempt to alter the system further. How long it takes before we get something that works well is unknown. It is likely that we will eventually have a two-tiered system: a universal, government-run insurance plan on one side, and some number of pretty rich people simply paying for health services out of their own pockets on the other.

In the short run, all of this reminds me of an old joke Woody Allen told at the end of one of his nightclub routines.

It went something like this:

I’d like to leave you with a positive message.

But I can’t think of one.

Would you take two negative messages?

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