How to Grieve, How to Live

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You might think that grieving is not an uplifting topic. But there are ways in which that is precisely what it is.

We start with the pain of loss, specifically a loss of something of value. If you lose a penny, you won’t much care. But if the loss is of something of great importance to you, you will care greatly. The pain of loss points to the value of the thing that you have lost; and the value you place on a thing points, at least potentially, to the pain to which you are vulnerable.

What are the things we value? A job, a relationship, friends and family, a promotion; our physical-self, which can be defaced or damaged… many things: money, status, a good name, a pet, and power, too. Take your pick. You decide what is important and whatever is inside the basket in which you put your emotional pain or your vulnerability to such pain — that item has value.

Grieving involves opening yourself to the pain. Now, you might think, “It must be only a recent loss that causes the hurt.” But the heart has no clock attached to it, no timer reading off the digits of distance between you and the loss; so, if you had a difficult childhood, you might still be holding the pain inside even though it is decades old.

Not only must you open yourself to the pain, but you must do it with a witness, a listener, someone who cares and who is present, who is “there for you.” This is necessary to reattach you to human contact — to life, to intimacy — rather than closing off and pulling away from people. And in this sharing — this openness, this talk and tears and gnashing of teeth — the pain eventually subsides. It’s a little bit like kneading dough — you continue to work it until it changes. The story of your feelings will be repeated by you, if necessary, dozens of times in different ways, until the emotions are changed and the excruciating intensity of the loss passes.

How long does this process take? Six months to a year would not be unusual, although it can be longer. The first anniversary of the loss is often especially hard; so are birthdays and holidays in the first year and sometimes beyond. But if you do not do the grieving “work,” the process can be extended and a sense of melancholy or a lack of vitality can follow you relentlessly.

To grieve doesn’t mean you will forget what you have lost. And, indeed, if it is a loved one, certainly you will never forget and you will never be untouched by the memory. There is a dignity in this. We honor the loved ones who are lost in this way and perhaps they live, metaphorically speaking, inside of us. As the Danes say, “to live in the hearts that you leave behind is not to die.”

But “how” to do this grieving — that is the problem. If you have lived your life trying to be tough, you will find that the toughness might prevent you from doing the emotional work that will allow the grief to end. If you maintain that “toughness,” you might find yourself living as if you are numb, or displaying a sunny disposition totally at odds with what is felt deep inside, in the place where you have buried your hurt. And if you have deadened yourself enough, you will have a hard time “living,” since you will be closed-off to feelings. Joy, abandon, and spontaneity will be harder to achieve. Instead, the time ahead of you would be better called “existence” than “life.”

But perhaps you are afraid that if you allow all the pain to come out, you will be overwhelmed to the point of being unable to function. And, indeed, this can happen, at least temporarily. Or perhaps you are afraid of what others might think of you if they see you without your typical emotional control, and you are afraid of their negative judgments.

And so, grieving involves having the emotions without the emotions having you; accepting them and not struggling with them; metaphorically speaking, it is like driving a car with the radio on, but not so loudly that you are overcome by it. In other words, you will have the emotions but still be able to drive — still be able to lead your life.

To do this you must open the pain in a place that is safe and in a way that it is neither deadened or perpetually out-of-control. You must hold the hurt not too tightly and not too loosely, but gently, since it is precious; not walling the emotions off or letting them carry you away from active life for days at a time. Part of this is simply allowing yourself to be human, to honor the injury, not judging or trying to change what you feel (the change will happen by itself if you allow it), but permitting yourself to do what our mammal relatives do — to lick your wounds (metaphorically speaking) and accept the support of others, whether they are friends, lovers, relatives, or therapists.

And, in the end, if you have grieved and have the courage, good luck, and time to continue the human project that we all have been given, you are likely to heal enough to venture forth into the world, again putting yourself into the things and people you hold dear, risking injury once more, not hiding from the dangers that life brings, but also experiencing what is good in life — all the things you still value.

You will be alive again, and the grieving process will have led you there.

The above image is The Grieving Parents, Kathe Kollwitz’s 1932 memorial to her son Peter, who died in World War I.

What Do Antidepressants Really Do?

I believe that the oldest reference to an antidepressant medicine comes in Homer’s Odyssey, which “could not have been completed much before the end of the eighth century B.C” according to Richmond Lattimore. The reference occurs when Menelaos (brother of Agamemnon),  Telemachos (son of Odysseus), and others are grieving the loss of friends and relatives in the Trojan War. Helen, the wife of Menelaos, is also present. It was her departure to the walled city of Troy with Paris that triggered the assault on that fortress to retrieve her. Having since returned to her husband, she wishes to salve the emotional pain of the men who are gathered at her home. The passage reads as follows in Lattimore’s translation:

“Into the wine of which they were drinking she cast a medicine of heartease, free of gall, to make one forget all sorrows, and whoever had drunk it down once it had been mixed in the wine bowl, for the day that he drank it would have no tear role down his face, not if his mother died and his father died, not if men murdered a brother or a beloved son in his presence, with the bronze, and he with his own eyes saw it.”

That would be a potent brew indeed. But the idea of it prompts me to say a few words about what an antidepressant can and cannot do, for there is much misunderstanding on this point. And, by the way, the first real antidepressants only became available in the 1950s.

An antidepressant does not make you giddy about your life or impervious to emotional pain; it doesn’t make you forget bad things. In other words, it is not what Helen of Troy administered. If an antidepressant is working well, it helps put a floor under you. That is to say, many people with depression feel as though there is nothing holding them up (metaphorically speaking), no bottom to their suffering.

An effective medication creates that bottom, relieving them of the sense that they are without any support underneath them. It reduces their suffering too, makes them less prone to crying, less exhausted, and less subject either to over-eating or having no appetite, and usually able to sleep better. In other words, the medicine helps you tolerate life and helps normalize that life.

Some people, including quite a number who shy away from psychiatric medications or medication or any kind, actually are attempting to “doctor” themselves with drugs or alcohol.

There is danger here, naturally.

You probably know some of the dangers, but one I want to mention in particular is the depressant-effect of alcohol. It might make you feel better in the short-run, but in the long-run it is likely to fuel your depression, not to mention create a dependency.

As the old Chinese expression goes, “First the man takes the drink, then the drink takes the man.”

I suspect that you know someone who believes that psychotropic medication (and perhaps psychotherapy too) is a crutch. There is no denying that being treated for emotional problems can produce negative judgments and a stigma. Moreover, historically speaking, insurance companies have paid less well for therapy and psychotropic medication than for “physical” illnesses. That has just changed in 2010, but the stigma won’t be legislatively erased by the US congress, as was achieved by “parity” legislation that now requires equal insurance coverage of both physical and “mental or nervous” conditions.

Yet some categories of depression are certainly just as “physical” as an imperfect gall bladder is, for instance. Specifically, Bipolar Disorder, also called Manic-Depressive Disorder, is one such biologically-based psychiatric category where medical intervention is often enormously helpful, if not essential.

Would you want your severely diabetic loved-one to avoid the “crutch” of necessary medication? If your answer is “no,” then you shouldn’t be put-off by treating a biologically-based depression with a proper medication to stabilize his mood.

Nonetheless, it is true that many depressed individuals do not have any biological flaw or chemical imbalance, but rather are reacting emotionally to difficult life circumstances such as repeated losses (e.g. divorce, job loss), unfinished grief, or abuse of one kind or another. Very often psychotherapy is able  to successfully treat these people without the benefit of medication. Indeed, sometimes patients are too quick to obtain antidepressant prescriptions which take the edge off their feelings enough to reduce their motivation to address difficult life circumstances, including repetitive patterns of behavior that lead to unhappiness.  In that event, they will risk having to stay on antidepressants lest they fall back into depression.

For those patients, on the other hand, who successfully address their issues in psychotherapy, antidepressants may never be needed or, if they are used, might be required only temporarily.

If you are seeing a therapist for depression, talk with him about medicine for your condition, especially if you feel that you need immediate relief or are having suicidal thoughts. Beware equally of therapists who never want their patients to go on medication, as well as those who always do.

I should mention that while many depressed people obtain medication from their family or primary-care physician or general practitioner (GP), this isn’t always the best source of psychotropic mood-altering substances. While some GPs are both comfortable with and experienced in prescribing such medication, some are hesitant or unsure. The latter group may be less adept at identifying the precise antidepressant which is best for you given your particular symptoms; moreover, their hesitation can cause them to give you too low a dose to obtain a therapeutic benefit.

A good psychiatrist, by contrast, is absolutely up-to-date on everything about the medications available to treat you, adept at identifying which of the available antidepressants is the best fit for your particular situation, and knows how to get you to a therapeutic level of the medicine as quickly as possible. Since those in pain so often feel as if there will be no end to their suffering, and since antidepressants often take a several weeks to produce relief, getting the medicine right as quickly as possible is very important.

If you do choose to obtain medication, be sure to educate yourself about your condition and the possible side-effects of the medication being suggested. Not all physicians are good about describing those side-effects before-hand, even including the sexual side-effects produced by some antidepressants. Be your own advocate. Don’t be passive in treatment. It is your body, it is your life.

Last I heard, you only get one of each.

Hope For the New Year: Old Words After a Tough Twelve Months

Its been a tough year, but not the first in human history. These old words from the great nineteenth-century Scottish writer Robert Louis Stevenson seem just right:

“Give us grace and strength to forbear and to persevere. Give us courage and gaiety and the quiet mind. Spare us to our friends and soften us to our enemies. Give us strength to encounter that which is to come, that we may be brave in peril, constant in tribulation, temperate in wrath and in all changes of fortune, and down to the gates of death loyal and loving to one another.”

Are You Too Emotional?

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You’ve heard it before — “You are too emotional!” Surely you heard it as a child, at least once. But, what does it mean? How do you know if it is true? What is the proper place of emotions in any life? And, if you are “too emotional,” what should you do about it?

First let us establish some ground rules. Emotion is necessary. Imagine a life without it. No  love, no families based on that love, no compassion, no empathy, no righteous anger. What would be left? A life of relating to others as objects, like chairs or tables, their only value in utility — the function that they perform; only reason would be left — cold computation of what to do and how to do it. No laughter, no tears, no gratitude, no passion.

If you agree with what I’ve just said, then it is clear that emotion has a place. It binds us to others, plays a part in letting us know when we have been injured, allows for the possibility of good relationships and a joy in living. It also creates an energy that is necessary for self-defense and for the pursuit of causes. Emotion motivates us and permits the creation of communities.

But, when you are called “too emotional,” the accuser usually isn’t referring to love or happiness or even anger. No, usually he means that you are too easily hurt. And, when you are young, especially if you are male, you are encouraged to “be a man” and live by the “athlete’s creed;” if you are hurt, in other words, rub some dirt on the injury and get back into the game. Don’t complain; that is for whiners and wimps and little kids.

Well, if you are an athlete, that is what you have to do. Think too much about the injury and you won’t be able  to perform. Moreover, if you even think too much about your past failure in the game, you won’t have the confidence and focus to be able to succeed in the remainder of the contest. So, under those circumstances, being “emotional” does, indeed, get in the way. Similarly, emotion interferes with necessary behavior in war-time or in other crises that require focus, indifference to pain, and steadfast action.

But how about situations that are less demanding and fraught with danger or competition?

For me at least, emotion has become, for the most part, a friend. I can be moved by the sadness of my patients and those in my life who I love. I do not consider it a weakness. It is simply a part of being the responsive, sensitive person I aspire to be. And I can be moved by music or drama, again to the point of a tear. Life seems richer, warmer, more eventful and worthwhile that way. I don’t feel the need to keep up a brave front, an appearance of having tamed my emotions.

No, I’m not often whipsawed by my feelings, but, in part, that is because I give them their place in things and don’t keep them all bottled-up, looking for a way to burst out of the container that I would otherwise have put them in. And, when it is required, I am prepared to seek solace from a few of those closest to me, just as I give solace to my patients and those I love.

True, being emotionally vulnerable means that you can be injured. But, don’t fool yourself, life will have its way with you whether you are deadened to feelings or not. By killing your emotions, you are probably only succeeding in limiting the fullness of your life while attempting to create an illusion of strength.

Put another way, it is only human to have emotions and best if you are comfortable with that fact almost all the time.

But, beware when the emotions have you!

At the extreme is a condition called Borderline Personality Disorder (BPD).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, states that “the essential feature of BPD is a pervasive pattern of instability of interpersonal relationships, self-image, and affects (emotions), and marked impulsivity that begins by early adulthood and is present in a variety of contexts.” These folks are, unfortunately prone to “frantic efforts to avoid real or imagined abandonment,” instability, recklessness, suicidal behavior, rapid and intense mood changes, emptiness, and anger. They are the flesh-and-blood definition of what it means to be “too emotional.” And, not surprisingly, they are difficult to treat, although Dialectical Behavior Therapy is a treatment specifically designed to do so, and has demonstrated great promise with this patient group.

For those who are not categorized with this diagnostic label, how do you know if you are too emotional? Here are a few questions you might ask yourself:

1. Do people, not only family members, often tell you that you are too emotional?

2. In an over-heated moment do you tend to make impulsive decisions that you later regret?

3. Do you have many arguments and blow up easily?

4. Do friends and relatives have to handle you with kid gloves?

5. Do your emotions suck the life out of you, change easily and quickly, and generally whip you around?

6. Do you weep easily and often in the absence of major set-backs or great losses (I’m not talking about having a tear come to your eye here, but something more gut-wrenching)?

7. If you are in mid-life, are you no less emotional than you were in your teens? (Most of us become less volatile, more in-balance, over time).

If you’ve answered too many of these in the affirmative, you may want to seek counseling.

A last word or two. Life is challenging. We need to permit ourselves feelings and we need to express them, within limits, and to have a sympathetic soul there to bear witness and listen to us. Balance is the key most of the time. It may help to remember a portion of the “serenity prayer:”

God grant me the serenity

to accept things I cannot change;

courage to change the things I can;

and wisdom to know the difference.

If you do not “know the difference,” often enough and go to emotional extremes over the routine ups and downs of life, if even the small things seem too big, then it might be time to seek professional help. Not to kill your feelings, but to make sure that they don’t destroy your ability to have a good life.

You may find the following post of related interest: Vampires and Buried Feelings: The Therapy of Getting Over Your Hurt.

The above scene, Frenchman Weeps 1940, was used in the 1943 US Army propaganda film Divide and Conquer (Why We Fight #3) directed by Frank Capra. The photo shows “French people staring and waving at remaining troops of the French Army leaving metropolitan France at Toulon Harbour, 1940, to reach the French colonies in Africa where they will be organized as Free French Forces fighting on the Allied side, while France is taken over by the Nazis and the Petain regime collaborating with them.”

Wikimedia Source: Records of the Office of War Information, NARA. *Date: June 14, 1940 *L.

Surely, under the circumstances, this man’s emotions were quite appropriate.

Self-Defeating Behavior and the Path to Loneliness

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What price would you be willing to pay to feel that you are special? I will tell you a story of one young woman who has paid that price and then some. She is an example of how we sometimes defend our self-image at the cost of our happiness.

The patient of another psychologist, I knew this woman for about 20 years, filling-in for her therapist when he was on vacation. Gloria (not her real name) had a tragic early life. She was victimized by her parents’ verbal and physical abuse and neglect, and became an easy target for schoolmates. Gloria was unlucky, too, in that she was born with slightly less than average intelligence. Making things even worse, her body was naturally graceless and her facial features were less than attractive. But, Gloria could be sweet and socially engaging, willing and able to approach strangers and make conversation despite a long history of rejection.

Even with all her disadvantages and misfortunes, Gloria, now a middle-aged woman, might still be able to have a good and pleasing social life except for one thing: she believes that she is the world’s unluckiest person, the record-setter for having received the greatest misfortune in the history of the planet. Moreover, she feels compelled to report her tale of woe to those people she begins to get to know, very early in her relationship to them. This has the predictable result — they shy away from her, leaving her feeling rejected once more, and adding to her claim that she has been the most ill-treated human in recorded history.

I am not being facetious here; I once asked her to compare herself to various victims of misfortune including those who had been tortured, suffered in natural disasters, lived in concentration camps, or been plagued with disfiguring and painful illnesses. She assured me that her lot in life was far worse than any of them; and, that it was only fair and reasonable to expect people to be sympathetic to her and give her some of the understanding, sympathy, and support she had always been lacking.

Thus, Gloria pursues with a vengeance the comfort and affection that she believes she has coming to her. Her sense of entitlement to this, her insistence that her fellow-man should and must provide this, drives people away from her in her striving for the love she has never had. Of course, her therapist points out to her the self-defeating nature of this strategy, the need first to establish relationships based on something other than the other person’s willingness to listen to her sadness and anger. Gloria doesn’t accept this, unfortunately. The world and the rest of the human race owe her this hearing (so it seems to her), the sooner the better, and it is only fair and just to expect them to deliver what she wants.

Gloria is smart enough to understand that people she hardly knows might not have much patience or interest in accepting her premature self-disclosure. And so, you might well ask, why does she continue to do the same thing over and over with the same bad result? Why doesn’t she try something different?

After much consideration of that question, here is the best answer I can provide. First, Gloria is so desperate and needy, so starved for affection, that it is difficult for her to restrain herself from lunging at the thing she desires whenever she first sights it. But, more importantly, I think the one thing that Gloria values above everything in her life is her self-appointed status as The Most Unfortunate Person in World History.

Now, you might say that you wouldn’t want to hold that particular title. But, think about it. I suspect that this designation gives Gloria the only form of distinction she could every expect to achieve in life. Without it, she is simply a sad, angry, lonely, unattractive, unaccomplished, anonymous person; but with it, she is something special, someone who stands out from the crowd, a noteworthy individual, one in six billion, the leader in her class. And the self-nourishment she receives from licking the wounds attendant to this awful position in life almost certainly provides her with some amount of solace.

I’m sure Gloria would deny the psychological explanation I’ve just provided for her self-defeating behavior and I cannot promise you that it is accurate. But I would ask you this. Do you know people who persist in self-defeating behavior despite all the advice, therapy, or wise counsel offered by friends, relatives, and therapists? Have you sometimes wondered why they do so?

Often the answer isn’t “logical” in that it doesn’t “make sense” intellectually. But, it just might make sense emotionally, as I believe it does for Gloria. If, somewhere deep inside, she doesn’t really believe that she can achieve the life she wants, her behavior suggests that she has found a method, however self-defeating it is, to give herself some of the sense of status and recognition that life hasn’t and probably won’t provide to her.

Gloria was dealt a bad hand in life. Her response to that deal of the cards is instructive. She seems to have chosen a sort of fantasy, a story about herself that compensates her for her misfortune, just as it simultaneously fuels her continued loneliness. But be careful should you wish to dismiss her behavior as “crazy” too quickly. We all do self-defeating things in life.

Before you condemn her, check yourself out in the mirror.

The drawing above is called Africa Lonely Kids by Myfacebook. It is sourced from Wikimedia Commons.

Therapy, Responsibility, and the Nuremberg Defense

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Therapy, like life, requires taking responsibility for what becomes of you. But, as the comedy team Cheech & Chong famously noted, “Taking responsibility is a lot of responsibility.” What does that have to do with “the Nuremberg Defense?” Read on.

If you are old enough (or a good student of history) the word Nuremberg has a certain resonance for you. It is a German town that was a center of the Holy Roman Empire and the Renaissance; later becoming the host of Nazi Party rallies between 1927 and 1938, the site of the passage of the Nuremberg Laws stripping German Jews of their citizenship, and equally well-known for the war crimes trials that were held after WWII, in an attempt to hold Nazi villains to account. Such Nazi higher-ups as Hans Frank, Rudolph Hess, Joachim von Ribbentrop, Alfred Rosenberg, Albert Speer, and Julius Streicher were brought to justice there (see above photo); Hermann Goering escaped hanging only by committing suicide.

A common refrain during the testimony of the accused was the statement “I was only following orders.” This line of explanation was used so often that it became known as “the Nuremberg Defense.” It was found insufficient by the judges, who reasoned that the accused had the moral responsibility to refuse orders to commit “crimes against humanity,” even assuming that it could be demonstrated that such orders were given.

Since I don’t treat war criminals, you might be asking yourself how the failure of some of these long-dead Nazis to take responsibility applies to treating people with less dramatic problems of depression or anxiety or relationship disappointment? In the course of talking with my patients, I often discover that they have suffered from some sort of misfortune; be it inadequate, negligent, or abusive parents; accident or injury; or unfair treatment at school, at work, or in love. Sometimes the stories are heartbreaking. It is perfectly proper for patients to blame at least part of their unhappiness on these events and these people. Moreover, it is often essential that they grieve those losses, give voice to their anger and sadness, and rail against the unfairness of life. And it is important for a therapist to help them as they process their grief.

But therapy cannot end there.

The patient, if he is to improve his life, cannot simply assign responsibility to some other person as a release from the need to take charge of what becomes of himself in the future, any more than a Nuremberg defendant might hope that assignment of responsibility to the commanding officer would take him off the hook for the unspeakable acts he committed.

Put more simply, neither the war crimes defendant nor the common therapy patient can point to someone else, say “He is the one who caused this,” and leave things at that. Just as the SS criminals were asked, “And then what did you do?” so must we all, regardless of what misfortune has happened to us, ask ourselves, “Now what? Do I simply accept the injustice, forever blame others, and stay defeated and aggrieved in-perpetuity, or do I grieve my loss, take responsibility for my life, and try to get beyond the injuries I’ve suffered?”

We all know people who, however small or large the disappointment that they have experienced, never get beyond criticizing, blaming, whining, and feeling sorry for themselves. While some of this is often necessary to get past the hurt, a lifetime of it is simply a waste, a personal failure to take control and to admit and accept that if life is to have meaning and value, we all have to do something positive with that life, regardless of bad breaks. Even if fairness demands that others compensate us for our losses, if such compensation cannot be obtained, life still calls us to repair ourselves. As a therapist colleague of mine, at the risk of sacrilege, used to tell those patients who seemed to forever bemoan their fate, “Get off the cross, we need the wood.”

Shakespeare commented on responsibility-taking in Julius Caesar when he gave Cassius the words:

“Men at some time are masters of their fates:

The fault, dear Brutus, is not in our stars,

But in ourselves, that we are underlings.”

This is not always literally true. But there is no better way to live than to try to make our circumstances the best we can, however unlucky our lot. A good therapist will help you get there.

How to Choose a Therapist

Most of us are not at our best under pressure. Similarly, when depressed, anxious, or otherwise stressed and in crisis, the patience and clarity of thinking needed choose a therapist might well be in short supply. So here are a few pointers, things to consider, when you decide to consult someone for psychological assistance:

1. Ask a friend if he or she is able to recommend a therapist with enthusiasm. Also be sure to request that your acquaintance explains “how” the therapist was helpful. Not all counselors are equally adept at treating every problem, so your friend’s recommendation should be carefully considered in light of whether your issues are different from your friend’s. You might also ask your physician for a recommendation. A good way to phrase the question is, “If you needed to get a therapist for someone you loved, who would you choose?”

2. Internet searches of various kinds can help find a good person. Various organizations list therapists who perform a certain type of therapy or work with certain types of problems. An example would be the Association For Behavioral and Cognitive Therapies: www. abct.org/ The National Register of Health Care Providers in Psychology is another such group: http://www.nationalregister.org

3. Some information about the therapist is usually available on web sites such as those mentioned above. If the therapist has a web site of his own, you will usually find out a good deal more.

4. What kind of therapist are you looking for? There are many choices. Clinical Psychologists are doctoral-level professionals (Ph.D. or Psy.D) who typically have completed four years of training beyond their college Bachelors degree and had additional instruction and supervision in the form of a year-long internship, often within hospitals or clinics. In most states psychologists cannot prescribe medication, but have received more graduate training in psychological evaluation (testing) and therapy than is typical of any of the other disciplines who perform therapy.  Psychiatrists are physicians trained in medicine, who also receive specialized training during a psychiatric residency. They can and do prescribe medication and a number of them also do therapy. Clinical Social Workers generally have a Masters Degree obtained in the course of two years of post-college study, in addition to practical experience and a history of supervision. Marriage and Family Therapists usually also have a Masters Degree and may have a similar amount of training as do the social workers, although their education is not identical to that group. All of these disciplines encourage and sometimes require therapists to continue their study via post graduate course work, supervision, and reading.

4. What kind of therapy do you want? In part, that might depend on what kind of problem or problems you have. Psychodynamic psychotherapists will tend to pay much attention to early life issues including unresolved feelings toward one’s parents, and the potential impact of additional events that occur during the growing-up years in an attempt to free you from repetitive patterns of behavior that might have started at that time. Cognitive behavioral therapists use CBT to focus more on present day concerns, attempting to help you take steps to alter the automatic and self-defeating thoughts that influence your mood and fuel your depression and anxiety, as well as assisting you in changing your behavior. They spend much less time on early life events as a rule, and do not usually consider “insight” into the causes of your troubles to be crucial to assuaging your emotional pain. Marriage and family therapy aims to treat couples and family systems, usually meeting with the marital pair or family group rather than with one person at a time.

5. Try to determine how much experience your potential therapist has with a given kind of problem. Some therapists specialize, for example, in treating alcohol and drug abuse and are certified in this field (CADC or certified alcohol and drug counselor). If you have anxiety issues, on the other hand, ask your therapist how many people he has treated with this condition. Similar questions might be asked of someone who you wish to consult for the treatment of depression or schizophrenia. Don’t be afraid to ask. Any reasonable professional in the health care field will welcome your making an informed decision.

6. Other factors might be considered. How active do you want the therapist to be? Some tend to direct the therapy, while others are more comfortable listening to you and responding to just those issues that you believe are important. Some people choose therapists based on gender, believing that they will feel more comfortable with one or the other sex. Age of the therapist is important, since it tends to be correlated both with professional experience and life experience. If you believe that not everything in life is learned in a classroom, you will probably want to see someone who has a few gray hairs and who has been married with children.

7. Financial considerations often enter into the choice of a therapist. MDs are usually the most expensive people to see and Masters level professionals are the most economical. Ask your therapist about what he charges for his services and what portion, if any, of his fee is covered by insurance. Some communities have public mental health agencies that offer therapy at a heavily discounted price, although they often have long waiting-lists. A portion of therapists will discount their fees if you can make a good case for such a discount.

If you go through your insurance company, it is likely that they will steer you toward a practitioner who has a contract with them and has agreed to discount his fee to you. Understand, however, that the discount also typically benefits the insurance company, since they will have to pay less money in benefits if you choose a provider who is in their network. Therefore, their recommendation comes with a degree of self-interest.

Be aware that (as the old saying goes), sometimes “you get what you pay for.”

8. Some people choose not to use their medical insurance to pay for counseling. They make this decision because they have concerns about the impact of a mental health diagnosis on their future ability to get life or disability insurance, and the possibility that having a “pre-existing (mental health) condition” will complicate their medical coverage should they ever change jobs or go for a period without insurance and then attempt to obtain it again.

9. Remember that the most important element in obtaining a therapist is getting a person who is accomplished, talented, experienced, and a good fit for your therapeutic needs. You should also have a sense that he really cares and wants to help. While some of the other considerations mentioned previously might be important, if the therapist can’t help you, nothing else really matters. When you meet the therapist (see my blog post “What to Expect in Your First Therapy Session“) he should be able to convey expertise, compassion, and competence, as well as giving you a sense of hope. Don’t settle for less.

Infidelity and Its Treatment

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The names don’t really matter. Today they are Tiger Woods; Mark Sanford, Governor of South Carolina; and John Ensign, U.S. Senator from Nevada. Tomorrow they will be someone else. Every day, there are other names, little known, but causing no less pain.

How does it happen? How does it happen that people who claim to live by well established moral norms, who have taken a public oath to remain faithful to their spouse, violate that promise? There are several reasons:

1. Power and celebrity = opportunity. People in positions of power and celebrity have more opportunity than most to be unfaithful. They are surrounded, sometimes literally, with admiring and attractive younger people. As Oscar Wilde said, “I can resist anything, except temptation!” The famous and powerful have plenty of that.

2. Contiguity. You might think that the separation of sexes in some religious fundamentalist societies is unfortunate or wrong, but it does keep opportunity at a minimum. In modern Western secular civilization, men and women work together, eat together, and travel together on business. Repeated contact with a sympathetic business associate, pulling together with that person as a team on a business project, creates not just the opportunity for sexual contact, but the chance to get to know and like one another. Perfectly moral and decent folk can find themselves stirred by the presence of a person to whom they are not married, even though they weren’t looking for anything outside of the marriage.

3. Disinhibition. Alcohol and drugs. If you are around sexually attractive people in a party atmosphere or when you are “under the influence,” your judgment and hesitation are more likely to be set aside.

4. The “Great Man” rationale. More than once, I’ve heard men justifying the concept of infidelity in the case of those who are accomplished and powerful. Often, the rationale includes reference to the role that “the great man” plays in benefiting society. According to this line of reasoning, the “heroic” figure is thought to have earned the right to live by a different set of rules than the common man, and should be given the chance to be compensated for his contribution to society by being allowed multiple sexual partners.

5. The “It won’t hurt anyone” rationale. The faithless sometimes persuade themselves that there is nothing wrong with their behavior so long as anyone who might be injured (spouse/children) never knows about it. This is akin to the old philosophical question, “If a tree falls in the forest, but no one is present to hear it, does it really make a sound?” What the argument ignores is that the transgressor is changed by his act of betrayal, that he must tell a continuing set of lies in order to maintain the fiction of his character, that he risks his partner’s physical health in the event that he has become a carrier of a sexually transmitted disease, and that it is impossible to guarantee that the secret will never be revealed.

6. Mid-life crisis. Poor humanity. Poor man. We age, we lose our youthful good looks, sometimes our hair, our virility, our energy, our strength, our stamina. The antidote? A youthful or new sexual partner who, for a time, can help us shut out the dreaded and self diminishing passage of time.

7. Solace. The ups and downs of life are inevitable, even in the luckiest of lives. The best marriages are not immune to the daily stress that  takes a toll on a spouse’s ability to be compassionate, encouraging, and supportive. Financial worries, business reverses, family illness, house keeping, and child rearing soon diminish the “date night” and honeymoon atmosphere of the early days of the relationship. A fresh and sympathetic set of ears, all understanding and acceptance, often develops into something more, and something sexual.

8. “It’s not natural.” Some people, mostly men, justify infidelity with the notion that man was not meant to be a monogamous creature and the flowers of the field (i.e. the opposite sex) were meant to be enjoyed.

9. Longevity. At the turn of the last century in America, that is, about 1900, the average life expectancy was about 50 years. By that standard it was usual for marriages to be relatively short, 25 to 35 years at the most, many much shorter. No longer. Many now last 50 years and more. What happens in that time? People get older, their bodies change, and their personalities alter as well. When I do marital therapy, I usually ask couples what initially drew them together. The most frequent answer I get is something like, “He was hot and we had a lot of fun.” Thirty years on, it goes without saying, he isn’t so “hot” and they sure aren’t having fun.

In order for marriages to thrive into mid-life and beyond, the couple has to work very hard at the relationship, to keep the sexual spark alive despite physical changes and familiarity, and to see to it that personality alterations are compatible or synchronous. Too often one partner wants the marriage to be exactly as it was at the beginning and believes that both the personality and physical changes in the other person amount to a breach of contract. Meanwhile, the other might feel held to a contract that is no longer appropriate to the current state of the couple’s life together and to their age, personality, and experience. One or the other very well may see infidelity as tempting under such circumstances.

10. The scoundrel factor. Although an injured spouse sometimes believes that “evil”  is the most likely explanation for her spouse’s betrayal, in most cases it really isn’t. Most people don’t set out to behave badly and many feel guilty when they do. That said, there are certainly more than a few cads among us, and they do with impunity what others only do with hesitation, a troubled conscience, or not at all.

11. Boredom. Boredom doesn’t cause anyone to stray, but it does set the stage for the temptation. Routine can kill even the things that we love. The pattern is well-known: wake up, go to work, come home, play with the kids, do the bills, and collapse from exhaustion. Or, the stay-at-home parent’s version: wake up, make food, shop, make food, take care of the kids, do the housekeeping, make food, clean, and collapse from exhaustion. Either way, the routine is deadening and there is little room for excitement.

12. A lack of sex. Again, this doesn’t cause infidelity, but can set the stage for it. A warning here: cease sexual contact at your own risk and at the risk of your marriage. But, this is not to suggest that you should have sex only because your partner wants to.

13. Cruelty, sarcasm, and a lack of appreciation. If the marriage has turned into a battle ground, with gratitude replaced by indifference or hostility, infidelity is more likely on either side.

When the infidelity is exposed, the result is devastating to the victimized spouse. Rage, sadness, a loss of self-regard, and feelings of inadequacy are common. What did I do? What didn’t I do? Why did he do that? If he felt that way, why didn’t he leave first before he took on another partner? The devastation occurs whether the infidelity is fresh, or the betrayed person discovers it years after it occurred. The emotional clock of devastation only begins to run from the point that one becomes aware of what happened.

If a couple comes to therapy in the wake of such news, several factors go into the therapist’s evaluation of the situation. First, is the infidelity over or is it still going on? If the marriage is to have any chance, the “other” relationship has to end. Moreover, it has to end because the spouse having the affair wants it to end and believes that the marriage is worth saving, not because his marital partner is threatening to leave or because of the fear of financial devastation in the course of a divorce.

The therapist will try to gauge what still binds the marital couple together, if anything. Do they still have positive memories of their courtship? Do they have children and are they concerned about the effects of a divorce on their offspring? Are they still in love? If there is no love on the part of even one partner, therapy is almost certain to fail to recreate it.

If the both parties want to save the marriage, have positive memories of the start of their relationship, and if loving feelings still exist between them, treatment often can help to repair things. One of the first items in need of attention will be allowing the injured spouse to grieve. This will require both tears and anger, but will need to be time limited. That is, however great the injury, the victimized spouse must understand that he cannot forever bring up the infidelity to be used as a weapon when he feels unhappy or aggrieved in the future. As the old farm expression goes, “Don’t burn down the barn to kill the rats.”

Of course, apology by the roving partner will be necessary and it will take time to rebuild trust. Once the immediate crisis is over, the couple needs to look at what contributed to their estrangement and what changes need to be made in their relationship. They have to reaffirm a set of values by which to live and goals for their relationship and for the family. Changes in patterns of communication will likely be necessary, as will time and attention to each other. Serious self-reflection and responsibility-taking will be particularly important for the unfaithful member of the relationship, but the partner too must be willing to look at the possibility that he contributed to his spouse’s feelings of disaffection.

Such situations aren’t easy, but they can come out well. Good will, sincere contrition on the part of the person who strayed, and emotional generosity on the part of the victim are all key. The betrayal is never forgotten, of course. But time does its work on the scar of infidelity, just as bodily scars tend to soften and fade over time, even if they never fully disappear. Happiness and love may yet flourish.

The image above is a cropped screenshot of Lana Turner from the film The Postman Always Rings Twice, sourced from Wikimedia Commons.

What to Expect in Your First Therapy Session

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Going to therapy for the first time takes some courage. You are about to talk about some very personal things to someone who is a complete stranger. What can you expect?

1. First of all, expect to be at least a little bit nervous at the beginning. But even before you get inside the therapist’s office, you will have to fill out some paper work. You will also receive a written description of the therapist’s practice, including such details as whether the therapist accepts your medical insurance and how he handles that. Additionally, he will give you information about how your medical records are safe-guarded and the extent to which those records are confidential.

2. The therapist should greet you, bring you into his consulting room, and sit face-to-face with you. Therapists generally want to convey “openness.” It is therefore rare for a therapist sit behind a desk, with you on the other side.

3. After a few “ice breaking” words, the counselor will ask you why you have sought treatment. If you already told him some of this on the telephone, he will want you to fill in the details.

4. Don’t feel that there is a particular “correct” order in which to tell your story. Simply tell it. Initial sessions should generally allow enough time for you not to be rushed. The therapist has probably scheduled at least 75 to 90 minutes to spend with you.

5. If it makes you feel better, it is entirely appropriate to bring an outline of the topics about which you wish to talk, and to consult this outline or read directly from it whenever you need to.

6. The counselor is likely to have some questions for you. He should want to know about your background, not only about the concerns that exist in your life at the moment. Unless he knows about that background, he won’t be able to fully understand how you came to have the current difficulties and whether they represent a repetitive pattern in your life.

7. Among the topics you might be asked about are such things as a description of your parents and their approach to rearing you, relationships with siblings, the educational and social history of your school years, whether you changed residences with any frequency as a child, past and current health concerns for you and your family, the presence of any traumatic events in your life, your dating experience, the place of friends in your life, work background, alcohol or drug use, current medications, present family relationships (spouse/children), financial concerns, and past or current depression or anxiety issues.

Additionally, expect to be questioned regarding any evidence of mood fluctuations, sleep, digestive problems, headaches, caffeine use, suicidal or homicidal thoughts or actions, attentional problems, hyperactivity, hallucinations, delusions, hobbies, religion, how you feel about yourself, whether you are able to be assertive in your life (say “no” or ask for things), diet and eating/weight problems, obsessive thoughts, compulsive actions, and what you hope to get out of therapy.

Of course, there may not be time to touch on all these areas in the first session.

8. You should not feel that you must talk about topics that are too uncomfortable for you. A sensitive therapist will give you permission to cover only the ground you wish to, and a sense of control over the progress of the session, so that you don’t become overwhelmed.

9. The therapist might well ask you what challenges you’ve had in life and how you have managed to overcome them. This kind of question helps the therapist and you to know what strengths you have and to help you remember that you have surmounted past difficulties and therefore can rely on those strengths to help you surmount the current problems.

10. By the end of the session, the therapist should provide you with some feedback about what you have said. In part, this is to help you and the therapist know if he has heard and understood what you have been saying, and whether his initial impression of you seems appropriate.

11. The counselor, to the extent that he offers interpretations of the material you have presented, ought to let you know that this is a first impression and therefore not necessarily perfectly accurate. Any good therapist needs to hear your concerns about him personally, his ideas, the therapy approach he is recommending, and his effect on you. Such a person will not be offended by your concerns and actually wants to hear from you what feels right and what doesn’t feel right about the therapy process.

12. The counselor will normally allow a good deal of time to answer any questions that you have of him and his approach. It is not essential that you make another appointment at that time, although most people usually do. If you already believe that this therapist is not the right one for you, it is perfectly appropriate to say so and to ask him for a referral to another professional.

13. By the end of the session you ought to have a sense of direction and at least an initial treatment plan as articulated by the counselor. The therapist is likely to remind you of the importance of regular attendance and that your dedication to your own healing is essential to obtaining the results you want. Therapy, unlike medical intervention such as brain surgery, requires effort and activity on your part. It is also essential that you have the courage to look at yourself honestly, recognizing that in order for your life to be better you will have to be willing to change some things about yourself.

14. At the end of the first session you might feel exhausted, in part because talking about big emotions is hard work! You are likely to be less anxious than you were when you came into the session. You may feel some amount of relief at having talked about things that you have rarely if ever discussed before. If the therapist has done his job, you should have a sense of hope.

15. In the days following the first psychotherapy encounter, you might well find yourself still processing the material you discussed. This can be unsettling, but it is quite normal. Additionally, a person new to therapy can feel that he has said too much and made himself too vulnerable to the therapist, especially if he (the patient) is a private person. Some people will therefore not return to therapy after the first session. If you have this hesitation, however, remember that it is in your interest to persist despite your discomfort if you sincerely wish to change your life. Good luck!

The above image is the entry to Sigmund Freud’s office at Berggasse 19 in Vienna, Austria. It originally was posted to Flickr by James Grimmelmann and was sourced through Wikimedia Commons.

Last Words: Be Careful What You Say

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We tend to think of last words in terms of famous quotations. On her death-bed, Gertrude Stein (no relation to me) was asked, “What is the answer (to the meaning of life)?” Her matter of fact response was “What is the question?”

John Adams, our second President, alternately rival and friend of Thomas Jefferson, found some relief and gratitude in the belief that “Thomas Jefferson still survives” as he (Adams) lay dying. What he did not know in the pre-electronic year of 1826, was that Jefferson had in fact predeceased him by a few hours. Nor did either of them appear to reflect on the irony that these founding fathers both expired on July 4th.

On a less ironic note, students of American history will recall the story of Nathan Hale, captured and convicted of spying on the British during the Revolutionary War. “I only regret that I have but one life to give my country,” uttered Hale before his execution. More locally, those of us in Chicago might have heard of Giuseppe Zangara, an anarchist, who took aim at President Elect Franklin D. Roosevelt as he and the Mayor of Chicago shook hands in Miami’s Bayfront Park on February 15, 1933. The bullet hit Mayor Anton Cermak, who reportedly said to FDR, “I’m glad it was me instead of you.” Cermak died soon after and is memorialized to this day with a Chicago street that bears his name.

There are other kinds of last words, of course. The father of legendary musician and conductor Carlo Maria Giulini gathered his family around his death-bed to remind them that the word love, “amore,” should guide their thought and conduct throughout their lives. And one can only imagine how many times the word “love,” the words “I love you,” have been on the lips of both the dying and their survivors at the every end of earthly things. The religiously faithful have been heard to add, “See you on the other side.”

Last words of our parents tend to linger in the memory. We are often cautioned to part from loved ones on a high note, not a dissonant one, lest someone be left with the recollection and pain of a final disagreement, or the regret of injuring a loved one in what proves to be their last possible moment.

Two unfortunate examples from my clinical practice come to mind in this regard. One woman, whose mother had died many years before, had difficulty in shaking her mother’s last minute assertion, “You’re an ass, Jenny (not her real name).” It is not the only such example I can recall hearing from one or another of my patients. But the all-time cake-taker, the grand prize winner in an imaginary Hall of Shame of ill-timed and venomously expressed invective, are the words of a rebellious teenager to his severely taxed father.

A long history of mutual destructiveness typified their relationship. It seems that the pater familias was inept and self-interested in raising his son, and the son repaid his parent’s cruelty and clumsiness with as much drug use and petty crime as he could muster. Nor did it help that the family was under financial pressure and that the two adults of the home were a badly matched pair.

The father had only recently sustained a heart attack when the school reported to him and his wife that the son had once again been suspended. The “mother-of-all” shouting matches ensued between the middle-aged man and his first-born disappointment. And then, the last words: “You’re going to kill me.” And the reply, “You deserve to die.”

Not 24 hours later the words were realized. Deserved or not, the father was dead. And despite the fact that one could easily make a convincing rational argument that his death was not produced by his son’s words (or, at least, that the killing heart attack was waiting for whatever the next stressor was and would have happened very soon even without the argument as a trigger), it is easy to imagine that the sense of guilt would be lasting.

That said, I’m not opposed to standing up to people who have injured you, including parents. To say, “I know what you did (even if you deny it or justify it); and I won’t let you do it any more” is sometimes perfectly appropriate. That act of self-assertion can be therapeutic, even though it is usually not essential.

You can recover from childhood mistreatment without confronting the offender. Witness those individuals who do so when their abusive parents are already dead and therefore unavailable for any real-life discussion. What is essential, however, is to make certain that the mistreatment stops. This usually means that you, the now adult child, have to stop it: walk away, say “no,” or hang up the phone — whatever is required.

If, instead, you aim to change the offender, be prepared to be disappointed. Most won’t change or even admit that they did anything wrong. But if you wish to overcome your fear and master the situation, that mastery, at least, is possible.

Better, though, so much better to live as Giulini’s family lived, with love at the center of their being. I’m told that the old Italian expression for this is, “volersi bene” or “voler bene:” an untranslatable sentiment indicating that you cannot be happy without the happiness of the other. Yes, much better this way.

Perhaps its no mistake that in English and German the words for life and love are so close. Change the word “live” by one letter and you have “love.” In German, change the word “leben” (to live) by adding one letter and you have “lieben” (to love). Not just last words or Giulini’s father’s last words, but words to live (and love) by.

The 1935 photo of Gertrude Stein is the work of Carl Van Vechten, from the Library of Congress, Prints and Photographs Division; sourced from Wikimedia Commons.