How Therapy Fosters Courage

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You came to the therapy session. Courage was required. You admitted things were too messy, desperate, painful. A brave step was needed. Despite hesitation you took the road less traveled.

The therapist was not a monster. He invited you into his office. Your courage was reinforced.

Now you find he hears your words, watches without blinking. The attention is encouraging. Few ever took you seriously, showed patience, gave you their time — listened with quiet intensity.

You discover the contact has value — the relationship is worth something. Again, the effort didn’t meet with the disaster you expect as a matter of routine. The reinforcement makes future risks more likely. You begin to wonder if perhaps you previously fulfilled some of your own dire prophecies.

The counselor is reliable. At first you think he is a unique example of dependability in an undependable world. What luck! Later you recognize the truth: others as good, or close to it, might exist if only you raise your eyes to look. An intrepid search begins for those who are also decent and caring.

Issues too deep for words are exposed in session. You surprise yourself with your openness. Your vow never to make yourself vulnerable again is set aside. Courage grows.

Perhaps you begin to recognize grit is not always a matter of physical bravery. Indeed, you identify its presence when you look in the mirror. Especially if you face your short comings in the reflection. Change takes more bravery than what is demonstrated on the football field. Your moral muscle increases in size. Your heart becomes toned. You develop something called “therapeutic integrity:” to stick with treatment despite the punishment it inflicts. Your head is held higher. Avoidance is less often your first choice.

Yes, the rose of life is full of thorns, but the scent and beauty are worth an occasional prick. Your bravery makes this revelation possible. You learn to survive such pricks and avoid them when you can. Especially the human kind.

You voice strong opinions to your counselor and the world does not end. He applauds the growth to which he is witness. You begin to internalize his approval and the strength in you he identifies. More and more you come to lead the process — more evidence of therapeutic integrity.

The things you never thought possible — the behaviors others could enact but you didn’t — are done. You explain this not by some sort of therapeutic magic, but by the virtuous qualities inside you of which you had no awareness.

More chances are taken. You learn to say no, to travel alone, speak your mind, grieve, enjoy a restaurant dinner solo, date again (or perhaps, for the first time), recognize the toxic takers, act in spite of fear, dust yourself off when you’re down and come back for more. Your pulse quickens not with fear, but a lust for life.

Your intrepidity manifests itself in “baby steps” at first. Later they are well-placed strides. Eventually you run with joy, recognizing life is in the running, not always the winning of the race. You have discovered you can “take a licking and keep on ticking.” The scars you were ashamed of become badges of honor. The lines in your face are earned. They enhance your beauty to those who recognize the richness in you, not just your sausage casing.

Lord Byron wrote in Prometheus Unbound:

To suffer woes which Hope thinks infinite;
To forgive wrongs darker than death or night;
To defy Power, which seems omnipotent;
To love, and bear; to hope till Hope creates
From its own wreck the thing it contemplates;
Neither to change nor falter nor repent;
This, like thy glory, Titan, is to be
Good, great and joyous, beautiful and free;
This is alone Life, Joy, Empire and Victory.

“Good, great and joyous, beautiful and free …”

Blame and lament are past. Fear is no longer a constant companion.

You are your own self, the maker of your life in so far as we are ever able. Take up your chisel and approach the marble — create the art that is your life.

You’ve learned the sculptor’s hand is never finished with you; and that fate is but one sculptor.

You are the other.

Courage made it possible.

Three Words Therapists Do Not Speak: Strength of Will

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Imagine a game in which you alone determine when play begins and ends. Although not an easy contest, you get to set the goals and mark the finish line. You can interrupt the match whenever you want and restart later if you wish. The game may last a long time or a short time, but you are assisted by another player who will help your cause.

Now guess the name of the game.

Psychotherapy.

As I’ve described it — and I hope you agree — there is no opponent other than the one you face daily in the mirror. Then why is “the talking cure” so hard?

Lack of willpower is one of the reasons. And, ironically, strength of will (or rather, its absence) is the one least discussed with patients.

Counselors don’t talk to clients about will because doing so sounds critical and blaming, as well as being unhelpful. Examples? “You need courage. You must push through.” Or, worse yet, “man up.” In practice, that means tolerating the emotional pain of facing yourself and uncovering difficult truths about yourself; spade in hand, excavating excruciating memories you’ve dismissed or buried. It presents one of the greatest challenges any of us ever face: change.

Therapists are also hesitant to admit their own lack of all the tools to heal. Yet, we are helpless without your motivation, persistence, and courage. If you dodge self-revelation, keep your barriers high, are unwilling or unable to try new things, don’t show up faithfully to appointments, fail to give negative feedback when necessary, don’t bother to do therapeutic homework between sessions or think carefully about what happened in the meeting — well then, the doc’s job is hard if not impossible.

Sports metaphors come to mind: “the team that wants victory more will win.” Or, “we must give everything we’ve got.” Green Bay Packers coach Vince Lombardi encouraged his players by saying, “Winning isn’t everything. The will to win is the only thing.”*

Even military examples apply. In criticizing a recent failure of the Iraqi forces against the Islāmic State (ISIS or ISIL), US Defense Secretary Ashton Carter said, the Iraqis had “no will to fight” despite vastly outnumbering the enemy.

A psychiatric mentor of mine called the presence of this will, “therapeutic integrity.” With those two words he was referring to people who stop at almost nothing to improve their lives, sometimes leading the treatment by their own self-exploration and risk taking — demonstrating tenacity and quiet determination. This is not a question of fear, but rather of heroic triumph over fear. Indeed, some wonderful models of this characteristic don’t even realize they exhibit anything special.

An example: a middle class, middle-aged woman suffered sexual and physical abuse in childhood, and was much criticized as an adult — to the point of becoming the family scapegoat. Psychiatrically hospitalized, the exposure of painful repressed memories of her abuse contributed to a brief catatonic state in which she was mute. After a long process of treatment she went from terrible guilt and depression to recognizing and grieving what had been done to her by those she loved. Eventually, this person (who had been fearful of noises and male strangers) wound up providing humanitarian aid in Africa in the midst of a civil war.

She had therapeutic integrity. Heaps of it.

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This doesn’t mean the lady didn’t falter or struggle. It doesn’t mean she had no issues with her therapist (me) or an easy time when I went on vacation. It means she “hung in” until she was where she wanted to be. I don’t know whether my client was gifted with resilience due to her genetic makeup. On first encounter her voice was quiet, her body language suggested timidity, her eyes downcast. She was bolstered by a powerful religious faith, but did express temporary doubts about a superior being who would permit what happened to her. Somehow she found strength in herself beyond a therapist’s ability to create.

Not every patient must possess great amounts of intestinal fortitude. Not every person’s durability is stretched to the limit by the arduous road bringing him to treatment and by the therapy itself. Sometimes, however, the presence of “will” is the difference between success and failure of the heroic assault against psychopathological demons.

I don’t blame those who can’t find this quality. Sometimes the therapist is at fault for lacking skill. I think it another one of life’s inequities that resilience is not evenly distributed. I tried to enable everyone in my practice to find this ability.

Many times the resilience seemed to take forever to retrieve. I looked hard for the tiniest of eggs fertilized by a therapeutic spark. No matter how small the egg, with progress the zygote of willpower grew. On other occasions dedication in the face of terrible odds wasn’t anywhere to be found.

In the consulting room, alone with the therapist, you are pitted against yourself. No enemy is fighting you but what is inside, the echoes of past defeats, the injuries still fettering you. I won’t criticize you if the steam roller of the world flattened you and left you unable to get up. I only know I never succeeded in lifting anyone who didn’t (at least in some small part of himself) want to be lifted or who required me to do the heaviest part of the lifting.

Norman Cousins said, “Free will and determinism are like a game of cards. The hand that is dealt you is determinism. The way you play your hand is free will.”

Ralph Waldo Emerson put it this way: ”They can conquer who believe they can. He has not learned the first lesson in life who does not every day surmount a fear.”**

The game is over only when you say so. That is as much control as any of us get.

*Actually, there is some argument whether Lombardi wished to say precisely this or something close: “Winning isn’t everything; it’s the only thing.”

**The italics are mine.

The top photo is of Sultan Rakhmanov in a 1980 weight lifting competition. It is the work of Vitaliy Saveliev. The second photo is called Weight Lifting: Black and White by imagesbywestfall. Both are sourced from Wikimedia Commons.

The Upside of Depression and the Downside of Medication

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Are there advantages to being depressed? Something good about something we think of as so bad? A recent New York Times Magazine article by Jonah Lehrer makes just that case: Depression’s Upside.

The essence of the argument is that some episodes of depression allow for and encourage a kind of analytic rumination that is productive. Put another way, the tendency in depression to focus on a problem, mulling it over to the exclusion of other thoughts, permits the sad person to find a solution to his difficulty and change his life in a positive way.

The counter-argument, however, is that the ruminative process is both painful and unproductive — that it often creates a kind of self-flagellating preoccupation with one’s trouble rather than a process that leads to something good; that unhappiness and focusing on pain and its concomitants simply feed on themselves to no helpful end.

In my clinical experience, therapy with people who are depressed over loss or injury often breaks down into two phases. The first of these is a grieving process, where the person expresses and processes (or sometimes purges) the feelings of anger, sadness, emptiness, desolation, and hopelessness that come with the loss of something of value — a love, a job, high social status, a capability, a fortune, etc.

The second phase involves learning from one’s painful experience about how to live differently, make different decisions, associate with different people, become more assertive, overcome fear; value things differently in life such as money, material things, status, accomplishment, friendship, and love.

Naturally, neither of these two phases is absolutely discrete — they blend into each other and overlap each other. As a practical example, someone who has had a series of bad relationships will typically need to grieve the unhappy end of the most recent one and, in the process, learn how he happened to choose a person or persons who made him so miserable; then changing whatever needs to be changed internally and externally so that different and more satisfying choices occur in the future.

People who are like the hypothetical individual just cited usually come into therapy in emotional pain and seek relief of that pain as promptly as possible. This desire is entirely reasonable — who wouldn’t want this? Some of them request medication, which is often the fastest way to “feel better.”

But many are leery of psychotropic drugs and see them as artificial, hoping that therapy will produce a more lasting fix without dependency upon a foreign substance. Indeed, while a good therapist will strongly encourage the use of medication for someone who is seriously depressed, i.e. suicidal, unable to work, sleeping away the day away (or almost unable to sleep); that same therapist will also know that medication sometimes serves to “de-motivate” the patient, giving him or her a relatively quick solution that allows that person to tolerate an intolerable situation. In the New York Times Magazine article mentioned above, Dr. Andy Thomson describes this problem eloquently:

I remember one patient who came in and said she needed to reduce her dosage. I asked her if the antidepressants were working, and she said something I’ll never forget. ‘Yes, they’re working great. I feel so much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.’

Clearly, this woman was aware that she needed to be in some amount of discomfort in her relationship with her husband in order to be motivated to get out of it. The drug made her feel better, but, it also reduced her incentive to change herself and her life. It was, in effect, a kind of band-aid, rather than a real cure. It anesthetized her and, in so doing, robbed her of something that was essential for new learning and behavior change to occur.

Unfortunately, most people who come to therapy are neither as courageous or insightful as the woman just described. Once they feel significantly better, whether due to therapy or medication, it is common for them to be less interested in continuing treatment. They have recovered from the event that precipitated their entry into therapy, but they might not yet have learned enough to avoid making the same mistakes that contributed to the problem in the first place.

Such a person can reason that the cost of therapy (both financially and in terms of time, effort, and the difficulty that comes with changing one self) is now greater than emotional pain from which they might still be suffering. Put another way, at this point, doing therapy “causes” more difficulty and pain than not doing therapy, just the reverse of what seemed true when they started the treatment process.

At this stage, those who continue in therapy have something that an old mentor of mine, Truman Esau, used to call “therapeutic integrity.” What he saw in some of his patients was an almost heroic desire to make themselves better regardless of how much the actual process of doing so was difficult, uncomfortable, or painful.

These patients didn’t shy away from problematic truths about themselves or others. They worked hard to stretch and challenge themselves, knowing that it was crucial to improve. They didn’t simply want a quick fix. Like the woman in Dr. Thomson’s example, they recognized that some pain was essential to being motivated. They knew that there was no such thing as “a free lunch,” and were willing to do whatever it took to repair and better their lives.

If you are in therapy now, it will be important for you to be sensitive to this shift from the often intense distress that brought you into therapy, to the point when the therapy itself might seem distressful. This can mean that the therapist is not skillful or that he is pushing you too much, but it just might also signal that some of the most difficult life changes you need to make are still ahead of you, even if the cost of making those changes seems greater than when you started treatment.

If you leave therapy because it is hard and unpleasant work, the problems you have won’t care. They will simply continue to reside in you, work on you, and trip you up. It is not enough to get over your last disappointment or unhappiness, but to change yourself enough to avoid future problems.

Few things that are worthwhile come to us for free.

The above image titled Depression is the work of Hendrike, sourced from Wikimedia Commons.