Do therapy docs really listen?

In Try Sitting in My Chair the book I've never tried publishing but will one day, okay?-I tell a few anecdotes to make you never want to become a psychotherapist. Anyway.

It's true that we shrinks sometimes feel a little crazy at the end of the day, having listened to so many problems. I'm the type who cranks up the radio really loud after work-- and it doesn't matter what's on, not initially.

Anyway, I say that because so many people have asked me how it is I still do this job, day after day, week after week, month after month, year after year. I'm not so young anymore.

One day, many years ago, I met an elderly psychiatrist in the hallway of the building where I worked. Dr. K and I were locking up, leaving at the same time. He must have been in his eighties, tall, skinny guy with thin white hair. I asked him the same question.

Dr. K.? How do you do it? Day after day, week after week, month after month, how do you sit and listen to so many problems?

He turned to me, smiled and quipped with no hesitation whatsoever,

WHO LISTENS?

Okay. Maybe so.

It can be a cool job, honest, Me and ol' Dr. K. sitting in comfy chairs, interesting people on the opposite sofa, getting to know them from the inside out; everyone of the people we see unique and mystifying, deep as the ocean; them barely knowing if we like chicken or fish.

Yeah, Dr. K is telling the truth, the partial truth. We don't hear every word, (and he was probably hard of hearing, altogether). But we try.

We go for the broad strokes, the template. Cracking the code's not so hard after awhile; teaching you guys still can be.

But I think we're getting somewhere.

Copyright 2006, TherapyDoc

Evil Step-Mother-First Installment

EVIL STEP-MOTHER

Here's where we take off the gloves. I'm going to try to be fair, but as always am biased by what I've heard people talk about in treatment. In this case it's the hundreds of stories (100s?!) from people who have cried about the terrible pain and abuse they've suffered from the evil machinations of STEP-PARENTS.

I've talked to men and woman who remember violent beatings, emotional torture, and sexual indiscretions. More horrible stories about STEP-FATHERS, frankly, than about STEP-MOTHERS, but I'm willing to acknowledge that my sample isn't representative. (Hey, the PhD was worth something).

Anyway, it's safe to generalize that health professionals get to hear every conceivable combination of horrendous parenting behaviors known to man. (And you envied us our in-roads to the human psyche, all that talk, all that gossip. Maybe my friends were right about switching to real estate.) Being a therapist can be freaking traumatizing at times. But you get used to it.

Let's focus, instead, on the irrational spleen of young people and the displaced anger that they thrash upon clueless NICE step-parents who naively walk into a second (or whatever iteration) marriages. Their new young'uns, being young, do perceive evil and danger and are on the defense. They DID watch Cinderella. Which is what they say.

Here's a common scene.

Eddie is 8. His mom died in a car crash when he was 6. He lives in a very loving community and has a very loving dad, and two older sisters, 10, and 12. His mom, well, she was his world. After the crash he cried, had tantrums, his behavior in school was horrible.

His grandmother, Dad's mom, moved in and took over most of the cooking and cleaning so that Dad could go to work every day. Gram gave in to Eddie's tantrums and excused his anger. Everyone, for the most part, felt pretty sorry for him and tried to comfort him. After awhile he quieted down, but occasionally he would act out, steal something, break something. He was a little boy, at the end of the day, and he had a lot of energy.

Fast forward, Eddie's 14. Dad's finally dating a nice woman he really loves. Miranda is a nurse who works her tail off and has never been married, never had kids. She's ready to take them all on, make them hers. She knows she only has time for one biological baby at best. She's already forty. She and Eddie's dad get married. At this point Eddie hasn't looked at her for the four months prior to the wedding. Now that the two are married, he refuses to listen to Miranda, won't cooperate with her ever, never makes eye-contact.

MIRANDA: Eddie, the car pool will be here in ten minutes! You better get dressed.

EDDIE: Go to hell.

MIRANDA: Seriously, Eddie. You'll miss your ride and your dad will be upset. Why not just get going?

Eddie ignores her.

MIRANDA: Eddie! GET GOING!

EDDIE'S SISTER #1: Miranda, don't yell at him, Jeez.

EDDIE'S SISTER #2: You're so mean, Miranda, honest.

It's always like this. Eddie is the spokesperson for all of them, but the message is clear. Miranda's good intentions are definitely not appreciated. And these are not SUCH bratty kids. But things go from bad to worse and three years later Miranda feels very, very cheated and she is sorry that she married their father, who still feels guilty and misses his first wife.


Now, for you, Dear Readers, to understand how family therapy docs approach this problem, I need to introduce you to some family therapy lingo, stuff I'll build on in future blogs (promises, promises). Let's start with:

Pseudo-intimacy and triangles

Everyone knows what a triangle is. Start with 2 people who get married. That's a nifty dyad. When we draw family trees a square is for males, a circle is for females, and a line connects two commited partners. This is your primary DYAD.

Add a child, and bingo—we have a TRIANGLE. On the diagram, a verticle line descends from the one connecting the partners to the child. Forgive my primitive picture, folks. I'm no artist.


The children are below the parents, because, hey, might makes right! Or would you prefer, because children should be listening to those who are older and wiser?
Symbolically, parents SHOULD be higher up on a hierarchy for all the right reasons.

They are THE MAIN DYAD of a family because optimally they should conspire, make decisions, and share intimately in the five areas of intimacy that I have touched upon in the archives.

Y'all should have a look when you have a little reading time.

Lest we forget, the five intimacies that committed partners really need to make a relationship fly, are Recreational, Work, Problem Solving, Emotional, and Sexual (according to Therapy Doc). We could and really should, add Spiritual Intimacy since so many couples seem to have trouble negotiating each other's belief systems—but ordinarily I'd put that under problem solving. But it can be a real plus, feeling that the other partner is into the same future beyond this world as we know it.

Ah, but I digress. Back to the EVIL STEP-MOTHER.

So IF the marital dyad is the tightest, and the kids are loved but not primary in the decision making process, then whatever shall we do with HER? . by the way, if one of the marital partners is severely disable this changes how healthy families work. You can't have a violent person as the head of the family—or shouldn't. .

HER is the EVIL STEP-MOTHER.

Enough for tonight. Tomorrow I'll write and explain what I mean by pseudo-intimacy, triangles, and how families can begin to solve the STEP-PARENT CONUNDRUM.

Copyright 2006, TherapyDoc

POT

Dear Readers,

Here's a partial transcript (BY PERMISSION, for crying out loud! Whad' ya' think?). It's from a session I had with a new patient a few weeks ago. This is less about self-medicating with marijuana (one of Therapy Doc's big issues) than it is about how complicated emotional stuff can be. One day it's depression, the next day anxiety, one day we're manic, the next day obsessive-compulsive. We humans are complicated folk.

Anyway, this is printed with “Sandra” (not her real name)‘s permission.

JUNE 7, 2006

SANDRA: I don’t know, doc. I’m feeling pretty down, pretty sad. And summer’s my happy season. This is going on for too long. I lost my job. Life sucks.

THERAPY DOC: (At the risk of sounding trite, stroking chin. How long would you say you've been feeling like this?

SANDRA: I don't know. Maybe three months. Maybe more.

THERAPY DOC: Sad.

SANDRA: Yeah. I'm depressed. Everyone's noticed, too.

THERAPY DOC: Excuse me. But I thought that on the phone you said you wanted help with an anxiety disorder. You don’t look or sound very anxious at all.

SANDRA: Well, I've had anxiety my whole life. Panic attacks, obsessive thoughts. I'm a high strung person. If I get depressed it's because of something bad happening, something situational. Like I know I'll be fine when I get a job. Getting laid off really hurt my pride. Talking in therapy like this has helped me before, but the truth is that nothing's ever really stopped the anxiety thing, so that was why I said I had an anxiety disorder when I called.

THERAPY DOC: (thinking,Oh, she has TWO Axis I disorders, for the benefit of those of you who like diagnosing things). So what do you want to work on?

SANDRA: I’d say the depression right now.

THERAPY DOC: And you say you’re not taking any prescription meds?

SANDRA: Right.

THERAPY DOC: Are you drinking alcohol or taking any street drugs?

SANDRA: Oh, I smoke pot every day and drink a little, not much.

THERAPY DOC: All right, so at the risk of you never coming back here again I'm going to recommend that you stop the pot completely for a couple of months at least. The pot’s depressing your brain. And the alcohol does the same thing,by the way.

SANDRA: No way. If I stop smoking pot then I’ll get my anxiety back.

THERAPY DOC: So we’ll work on it with some behavioral therapy, some self-relaxation exercises. If you want, we can start you on decent legal psychotropic medication for anxiety, too. We have better drugs for this kind of thing. It’s likely that the marijuana and alcohol are working against you, not for you. Take a holiday from it. It's garbage.

SANDRA: Okay, I can try, but I’m going to be a nervous wreck. I've been smoking for a long time.

THERAPY DOC: But it's killing you.

SANDRA: Not really. It calms me down.

THERAPY DOC: Before you go, just so you'll have something to depend on other than sucking down poison, I’ll teach you a quick muscle-relaxation exercise. (Yeah, T.D. has a bias against pot, and alcohol, too, you're right. She's not saying it's easy to stop, just that it helps. Heck, you feeling lousy from substances keeps T.D. busy.)

JUNE 28, 2006

SANDRA: I have to say. It was a lot easier than I thought, not smoking pot.

THERAPY DOC: And the depression?

SANDRA: Gone, no joke. MUCH BETTER! I feel like my brain is actually working again. Like it’s unlocked.

THERAPY DOC: When you’re depressed, the endorphins, neurotransmitters in your brain that should zip around freely, get locked into the walls of your nerve cells. Pot effectively froze your brain, slowed down the transmission of the feel good neurotransmitters. You needed your zip back, basically. Serotonin's nature's feel good vitamin, so to speak.

SANDRA: I still don't have a job, but I don't care as much. I know I'll get one.

THERAPY DOC: Cool. I'm sure you will. Did you use the exercises I taught you?

SANDRA: Haven't needed them yet. But I will, I'm sure. First job interview and I'll be a mess. Oh. . . and another thing.

THERAPY DOC: Yes?

SANDRA: I lost 5 pounds in 2 weeks.

THERAPY DOC: Of course you did.

See, sometimes just one or two of these visits can make a difference, assuming YOU feel like working in your own best interest. Years on the couch are truly passé, unless you’ve got the time and the money, in which case, why not, right? (Another time for Why You Should Bolt Therapy While the Going's Good)

Copyright 2006, Therapy Doc

Deception

Dear Therapy Doc,

My eight year old seems to be a chronic liar. It doesn't matter what I ask him, he either makes no sense or is clearly not telling the truth.

He looks me right in the eye and lies!

Is he a pathological liar? How do I break this habit? In answer to your question, we don't hit him when we punish him, we give him a time out. I was giving him a time out every time he lied, but he didn't seem to mind, so now I just shake my head and say, "I know you're lying" and walk away. But he's still lying. And now it's getting to be a sort of a power thing. He'll dig in his heels and say, "NO I'm not," and smile.

Telling the truth is a big thing for me so I am

Feeling Like a Failure

Dear Feeling Like a Failure,

Some family docs would say that there's someone ELSE in the family who is lying, too (like a spouse or other sibling) but I'm going to assume that it is not that and give everyone in your family the benefit of the doubt.

Sometimes lying is about coping, feeling unable to get anywhere, unable to present your side of the story and still be respected for it. Kids aren't as verbally skilled as their parents who can run circles around them. And they're rightfully afraid of getting into trouble for breaking rules, so they'll lie to stay out of trouble. They're not stupid!

You're right to want to break this habit. But he's little and he's clearly playing with you, knowing this is your trigger. I say that because he's still in the stage of life where understanding and liking reality is a conscious challenge. We adults don't like our realities but we have a harder time denying them.

(More on adult denial another time, but know that people with great denial skills are not always great adults, they procrastinate a lot. Yet, sometimes, denial is our best friend. But let's get back to little one.)

I'm thinking that he's smart enough to want to create his own reality and is inviting you into it. No, he's not psychotic (truly detached from reality). He just wants reality to lay off a little and perhaps even wants you you to come down to his level and join in on the process. Think of it as play. I would, at this point, start to join in the fun and embellish the lie yourself. For example, if he broke into the cookie jar you could say,

So, you say you didn't eat the cookies. I'll bet it was Alex, the mailman. He likes cookies

For sure your son will laugh and go, "YES, YES, Alex ate them!" And then you go,

What I should do then is just give him the whole next batch, right? That's the nice thing to do.

See, two people can play this game. Good Luck!

Therapy Doc

Co-dependent, never say no, and he needs me

I used to try to find songs that represented co-dependency. My favorite was from the musical, Oliver. Remember this one?

As long as he needs me
I know where I must be
I'll hold on steadfastly
As long as heeee neeeeeds meeeeee.

As long as life is long
I'll love him right or wrong
And somehow I'll be strong
As long as heeeeee neeeeds meeee.

When you are lonely, then you must know
If someone needs you,
you love them soooooooo

I won't betray his trust.
Though people say I must
I've got to stay through JUST
As Long As HEEEEEEE NEEEEDS MEEEEE!\

Okay, people. If you've been reading me thus far you probably get that this sort of thinking gets me thinking. It's not so good. Living life because someone needs you isn't a life. You actually have one that is far greater than care-taking someone else's, although it is noble to help others. You're worth something even though someone needs you. Identity is threaded with one's job, values, position in your family, community, all that others associate with when they think of-- you. You are a separate entity. You are not all about your dependent.

Or are you?

Emotions and happiness are very much attached to a significant other.

I'll post more on this in the next few weeks.

Gotta' run, T.D.


Copyright Therapy Doc, 2006

Blood is thicker than water.

Sometimes people ask me whether or not they should marry a certain someone. All I can do is predict what will happen in a marriage, based upon what a patient tells me, and help determine whether or not it's worth the risk.

There are certain obvious traps, however, and depending upon how many balls we are juggling and whether or not dropping a few will make a difference, the traps can be insurmountable.

Here's one. Susan is an American girl, brought up by working class Protestants, British descent, and Lawrence is an Iraqi from a wealthy family.

It doesn't matter. She could just as easily be a Latina, a Jew, or a Christian. And he could be Caucasian or Puerto Rican. They could both be Mexican; she could be Swedish and he could be Muslim from Turkey.

What matters in this case is that Susan's fiance could not put her before his son, Moudi. She had moved in with them and was doing most of the domestic chores. Moudi, 24, belittled her and messed the house after she cleaned. If she sat down to watch television he took the remote out of her hands and changed the channel. He told her repeatedly, when she complained, that she didn't deserve his father and that she was a tramp for sleeping with him . Moudi's girlfriend, by the way, spent many nights in his bedroom with him. She wasn't nice to Susan, either.

Lawrence wouldn't talk to his son about Susan's complaints. He dismissed her concerns and acted as if she was interrupting more important things by bringing them to his attention.

Susan thought,

"Fine mate for life this is, and future father of my children!"

She didn't want a kid ordering her around, criticizing her. She grew up in a home with two parents who respected one another and never uttered a harsh word. Lawrence had fooled her by presenting himself as a gentleman, a man who would protect and take care of her. It turned out that he couldn't even protect her from his own family. He said more than once:

"Moudi is my son. This is Moudi's house, not yours. It won't be yours until we marry. Even then the house will still be his. He is and always will be my child and my first priority. Blood is thicker than water."

Children first. Okay. But 24-year old children?

"Come on, Lawrence. Who're you coming home to, Moudi or me?" asked Susan.

She broke off the engagement. She had invested everything emotionally in this man and lost it all. What happened?

Was Lawrence such a bad guy? He treated her well and promised to take care of her, to be her partner for life, eventually father a child.

Susan was stuck in what we family therapists call a perverted triangle. In healthy families the mom and pop are the head of the household. They sleep together, huddle together, think together, conspire together. They dialogue and make decisions regarding the children and the rest of the family, including how they will deal with their own parents and siblings.

If there is a primary dyad in a household it should be mom and pop. Not pop and pop's son. If pop and pop's son are at the two decision makers, then mom symbolically occupies a place beneath them, one less important. The men are the ones in alliance.

Lawrence and Moudi are the two intimates in this case, Susan is alone.

Therapists and counselors see this often in families with marital intimacy problems. If the two parents are fighting and one confides about it to one of the kids, it is putting the other partner beneath that child in the family hierarchy. By confiding the deficits and/or escapades of the other spouse (the drinking, cheating, spending, whatever), the parent who allies with the child not only empowers the child, who may or may not be comfortable with the information, but also relegates the errant spouse to the child position in the family.

If this situation continues, and if the child is really uncomfortable (as they usually are, hearing bad things about one of the parents), we consider it emotional incest.

So. Whether it's a cultural thing that the woman is less important to the man than his son or perhaps other members of his family, or whether it's a machismo chauvinistic thing, that the woman must respect the man but not vice versa, or whether it's an emotional need to ally with a child in the family because of distress and/or anger at a partner, perverted triangles have to change for the family to function happily.

Preferably BEFORE the wedding.

Copyright Therapy Doc, 2006

Gone Postal

Just so you don't think that being a therapydoc is all about manipulation, glamour, and a little heart to heart, I'm going to tell you a story.

This one's about a guy, a new patient who had walked into my office a few years ago and SCARED THE LIVING (sic)DEATH out of me. All of the details have been changed to protect his identity, but I think you'll get the idea.

He wasn't tall, but he was brawny and tattooed, sweaty (it was summer) and unshaven. He wore torn cut-offs and a wife-beater tee-shirt. He had a piece of gauze taped over his wrist, and I knew what that meant. He sat for a few minutes with his head in his hands, staring at his shoes. His head was large and his hair greasy. I chilled.

After what felt like forever he looked up at me and said, "My wife's leaving me so I want to die. Just this morning I tried to kill myself., Want to see?" Uh, no, that's okay, I'm thinking, but I don't answer.

Then he proceeds to unwrap the gauze (thanks) and show me a wound so deep and ugly and, yes, fresh, that I got sick (not literally and I didn't show it, but still feel the nausea when I think about it).

I go, "Uh, there's a hospital down the street. You need to have that stitched up." He tells me he's not seeing any more medical doctors. He's already tried the anti-depressants and he's been in hospitals and he's finished with all that crap. He's just plain finished.

Now you have to understand. This is a guy who had a referral to see me from either an insurance company or a doctor, so he had some program running that worked. And he'd filled out all of his patient information before sitting down in the modest digs I call an office. So how sick was he?

Turned out his wife was angry at him for losing his job (or whatever, remember, I'm changing all the details, he could be a woman, a transvestite, anything).

I got the impression this patient showed some poor anger management at work and was worried his spouse didn't love him anymore, or some such thing, because of a suspension. What matters is that he/she threatened to go postal, to go back to work and shoot them all up.

This wasn't my first patient who had talked about going postal, in detail, describing the who, what, when, how, and why. I don't exactly give homicidal maniacs, or suicidal patients, much room to do it. Not on my watch, says I.

All right, am I making this up, you wonder? I've changed a lot, but the anecdote is pretty much as it happened. Parables, fables, Bible stories—all nice, but stories that smack of reality pack more punch.

At the time, even as I was working like mad to figure out how to get the police to my office while he was sitting there looking very scary, I thought, Who needs this crap? It's why cops are always drinking on television after work, literally hurrying off to the bar.

You want to know what happened? Sure you do.

Somehow I convinced him to let the police come and take him to a hospital. He really did fit a bi-polar disorder profile, which is why the anti-depressants he'd been on hadn't worked for him.

I arranged an admission at a psych hospital using his insurance. He said, "Give me a couple of hours. I'll go home, shower, change, kiss my wife and kids, and then the cops can come and get me. Give me two hours."

I said, "As soon as you leave my office, I'm calling the police. I'll tell them to give you time. They will, I know they will." (I was sure they wouldn't.)

He was fine with that. I called the police, then called his wife, but no one answered. Oh expletive, I thought. He's changed his mind, gone postal. (what would you think). I talked to the police a few more times. They were out looking for him. I even got paranoid, afraid he'd be looking for me.

After work, as soon as I got home (this was before cell phones) I tried calling his home again. A non-English speaking female answered. I asked for him. She said no, not home. Great.

How do you sleep after that? Not easy. Lucky I'm pretty tired by one.

Anyway, next day I called that hospital and sure enough, he was there. I consulted with the docs and told them his history—Give him lithium, dudes, please don't futz around.

Finally a nurse on the floor got the patient on the phone. He said he'd gone to his cousin's house after he left me. They had some dinner, he changed clothes. His cousin drove him to the hospital. He'd been afraid to go home. She kicked him out, after all. He wasn't going to disrespect her.

He said he'd give me a call when he got out of the hospital.

But he never did.

Copyright Therapy Doc, 2006

Confidence game

Confidence. As in, I CAN. Why do some people have it and others don't? There are plenty of terrified artists and violin players-- an occasional Tony winning actor or actress has a drink before going on stage. Concert pianists have been known to take beta-blockers to control their anxiety. Keeps the heart rate in check, I think. People with skills and traits that make them special sometimes have it, but not necessarily.

This post is less about stage fright than it is about social skill. I make a serious leap, an assumption that CONFIDENCE IS ALL ABOUT SOCIAL SKILL, sin qua non, bar none, the single most important element in self-esteem. (Oh NO, what do I do if I haven't got it???) There must be some genetics, after all, you have to put out words, requiring some verbal acumen, and there are disorders that are most likely genetically determined.

But I posit that ENVIRONMENT RULES when it's about confidence, and it's more than having been loved by parents. Parents and care-takers who understand the importance of being assertive, who are socially skilled themselves, have the tools to teach their children, and those kids are just plain lucky.

Behaviorists call engineering traits like confidence "shaping". Shaping social skill can be accomplished by rewarding children, or even manipulating them, perhaps psychologically bullying them, into engaging others socially and/or going after what they need. We reward them or trick them, even hypnotize them (if you're me), to be proactive. Once kids are proactive they realize 1) it's not hard, 2) others like you more, and 3) you really do get what you want.

My favorite example of this is the Uncle Max story. I have this vague recollection being a small child, maybe three, four or five. What I'm about to tell you, by the way, didn't stop at that age, in fact has never stopped, I still get social behaviors pushed on me from my parents— I'm grateful, don't get me wrong.

The Uncle Max story goes like this. As the only girl I had my own bedroom, but I was a little phobic (ghosts, mainly, and home invaders) and very shy. So when Uncle Max and Aunt Goldie visited (or ANYONE else, for that matter, my parents had lots of friends and relatives) my mother would come into my bedroom and say, "Come on out and say hi to your Uncle Max and Aunt Goldie" (or whoever had come to visit).

This wasn't a request, "Would you like to come on out and say hello to Uncle Max and Aunt Goldie." This was a demand. There was no saying, Uh, no, I'm too shy. So then, after I've done this, kissed, too, in the case of aunts and uncles, it was like being on display. Oh, you got tall, or Oh, your hair is so long, or Oh, I hear you have a pretty voice, isn't that nice. I was TERRIFIED.

But never thought twice. There was no exit. There was no saying NO. Just become a social creature, because you have to. This is what people do. They socialize. They reach out, kiss, say hi, or even freaking sing sometimes. And others smile back.

As I got older, it was, "When you see so and so, ask her about herself. She's a painter (social worker, writer). She plays tennis (solitaire, Mah Jong)." "Ask her about her daughter (son, brother, boss)." "Go to so and so and ask for a recommendation." "Ask your teacher why you didn't get a better grade." "Get a job." The social tasks got more complicated.

Enough about me. I had to learn the hard way how to say NO. NO, too, is a most marvelous social skill. Today I saw a client who wanted to know how to help his kid become more confident. It was a little boy who refused to serve mass. My client, the boy's father, has tremendous social skill and confidence and can talk for hours about how his mother made him go to the bank for her when he was nine to make deposits (nine!) and had him navigating the neighborhood at six, grocery shopping at seven, ironing at eight. (these facts, like most anecdotal stuff on my blog are never quite true)

So basically my client already knows what to do with this kid. He has to shape the behaviors, encourage him, reward him, tell him that doing the job is reward enough in itself. He'll tell his kid what his mother told him, YOU CAN, I KNOW YOU CAN. JUST TRY. I'M BEHIND YOU ALL THE WAY.

There's more to shaping. It gets harder the older we are, but we can learn pretty fast as adults, and assertiveness training is a science. But does knowing behavioral engineering help with individuals who have real pathology, mental disorders characterized by severe social withdrawal and sometimes near- psychotic anxiety? People who suffer from schizoid and schizotypal personality disorders, schizophrenia, depression, and social phobia, for example, have tremendous difficulty in social situations. When I discuss these disorders and others in What's this, a Diagnosis? Or Why Some Therapists Hate Labels like Poison I'll focus on differentiating between serious pathology and simply lacking social skill.

Again, one needs a certain amount of genetic substrate to assert and be proactive—there is some verbal skill involved, but much is learned, and can be learned at any age.

That NIKE advertisement has the right idea. It's all about JUST DO IT.

Most of the time, if it's a social thing, You can.
But you might need assertiveness training. A post for another day.

Copyright Therapy Doc, 2006

Religious nut? Or not.

Religious nut or not, that is the question.

There is very little about religion in the DSM IV except that clinicians are supposed to understand a person's world view/culture before assessing pathology.

Ideas of reference (God talks to me) are considered pathological. Mainly, we don't believe that God is talking to people directly via our thoughts or over the telephone lines.

When a patient believes that he or she is in direct communication with a Creator that is telling him to hurt himself or someone else, we worry about psychosis, that indeed, there is potential for danger. If God is telling you to take your own life or that of someone else's, well, who are you to object?

So we worry about ideas of reference as they are sometimes characteristic of some of the more the severe mental disorders.

But for many people, being in touch and having talks with God is not weird, dangerous, or pathological. Some people are simply very spiritual, very sensitive to what they see as evidence of God in the universe, and they maintain a working relationships with Him or Her, or the Higher Power, Cosmos or whatever.

Religious people have an important coping tool at their disposal. They can turn it over, a concept that Alcoholics Anonymous has widely disseminated to alcoholics, but hasn't shared with the rest of us.

Turn it over and Let go, let God, for me, evokes scenes like this, when I have to turn it over:

I've been pulled over for speeding. I want to start lying and tell the policeman that I'm in labor and I'm not even pregnant.

My kid just took the car for the first time. He promised he'd be home at 11:00. It's 11:30 and he's not answering his cell.

My mother's on a flight to Miami and it connects to Charlotte, NC. I hear there's a plane crash in Charlotte, same airline, same time of arrival.

In real time, it might work for a patient with an anxiety disorder, maybe it's mild, like test anxiety.

Joey has a test to take tomorrow. His LSATS. He's barely made it before through SAT's, ACT's GRE's, and other over-valued exercises in futility. But the test has potential to change Joey's future, for better or for worse. He's been worrying for days, studying, obsessing. People are telling him to chill, to quit worrying-- he'll do fine, to get a good night's sleep (ha!). He's still losing it. So much so that he drinks a little too much, when he's not studying, that is.

Lots of the addictions start out this way,alcohol, marijuana, irresponsible sex, computer games-- all help people detach from, avoid negative feelings. They work as coping tactics for awhile, until they don't work and things get a little funky.

If Joey gets dependent upon a dysfunctional coping strategy, it will be hard to lose the habit. Our brains like to go back over the same old pathways. Pleasure is hard to resist, even if there's risk. We're basically like mice sometimes, drawn to the cocaine. You should see the video of the mice choosing coke over cheese. You know people like this.

So Alcoholics Anonymous, essentially a support group with a Judeo-Christian credo, came up with a way to interrupt the compulsion to seek immediate pleasure rather than choose more functional coping strategies. I'm tempted to say like shopping, but there are definitely shopping addictions, too, okay?

So one of the AA interventions is this TURN IT OVER thing, and it is sincerely brilliant and does work.

I'm not going to say it works because a Higher Power actually takes over and helps the plaintiff, however. Sorry guys. You know I love religion. But it works anyway. Maybe He does take over. I honestly don't know. But there are biological reasons it might work.

First look at what you'd need for it to work:

All you need to turning it over is a belief that there might be a Creator or a higher power, one who is paying attention to your thoughts, your life. (If you can't do it, it's okay, we have other interventions for anxiety, seriously). BUT If you can entertain that notion, that there MIGHT be a personal god, an angel on your shoulder, whatever, then you can turn any problem over to that being.

LIFE MAGAZINE, by the way, ran an article a few years ago that polled Americans and found something like 90% pray every day.

So this is a no brainer for religious people. They merely converse with the Higher Power for a couple of minutes, say,

Uh, hello up there. If you're listening, could you do me a big favor. I've done my best and I can't deal with this anymore, would you take care of it for me please? It's your problem, now, not mine. It's in your hands

.

That's it. Divest of future responsibility and hope it works. After all, this is the Creator of the universe we're talking about, should certainly be able to help with the consequences of a test, job interview, illness, in-law interference, partner stress, etc.

Ol' Joey can quit worrying about the LSATS. He turns it over and his test anxiety dissipates. Frankly, I'd teach him some muscle contraction and breathing exercises, too.

But they're right, the AA people. The real reason it works? At some point, when you stop beating yourself up, unconsciously raising your own anxiety, you give the brain a chance to settle down. What goes up neurologically (adrenaline), must come down.

In Joey's case, when he stops studying, he actually gives his brain a better chance of integrating what he's already learned. Pressure about grades, you should know, is the number one cause of suicide in young people.

Recommending the AA intervention (probably their most powerful tool, and they have many) is not to suggest that religion is this wonderful cure for anxiety. But the communists didn't call it the opiate of the masses for nothing. I'll write more about anxiety and what works in another posts.

Meanwhile, for some, turning it over does seem to work. So that's why I'm reluctant to call religious people "religious nuts," . . . usually. There's much to be said for coping.

But the reason psychologists say that turning it over or Let go, let God works is that letting go of the process of having to have control is a tremendous relief. It frees up head space (when you relax there's less brain activity), probably releases seratonin that's locked into the walls of brain cells.

Oh, the thrill of that. MUCH better than any drug.

Copyright, Therapy Doc, 2006

Bi-polar disorder- Not everyone has it, actually

Bipolar I Disorder

The diagnosis of the year.

Never before have so many patients told me they think their partner, brother, sister, mother, in-laws, uncles, first-cousins once removed, just about everyone or anyone they know is for sure bi-polar.

It's good that there's so much awareness of the disorder, perhaps due to the media, especially shows like Oprah. But I feel there has to be more clarification for the general public.

The "bi" in bi-polar refers to teh two poles at the end of a continuum. Symptoms range from manic features like spending WAY, WAY more than you have, to depressive symptoms as in sleeping all day and all night.

I know that Reymundo Sanchez, the Latin King who wrote My Bloody Life and The Unmaking of a Latin King 'fessed up to the disorder at the end of his books (it won't spoil the books knowing this, you had to guess, reading it). Several high profile people have owned having bipolar disorder (BP-1). We use the word "disorder" not "disease," by the way; "disease" has been out of favor for 25 years.

Biographies and public disclosures from famous personalities who suffered from BP-I include, and I'm taking this directly from a website, so take it for what it's worth, I can't vouch for accuracy(Bi-polar Disorder and Public Personalities):

WRITERS Sylvia Plath, Virginia Woolf, Larry Flint

ASTRONAUT Buzz Aldrin, POET Robert Lowell

MUSICIANS DMS and Charlie Pride.

There must be thousands more. I'm always suspicious when a powerful actor gains a lot of weight (like William Shattner) that he's on lithium.

With such distinguished company, who wouldn't want to have it? I know a couple of doctors, one who taught medical school when I was a young person, who admitted to it in his first lecture. So is it romantic and cool?

Not exactly. It isn't a romantic disorder, it's a difficult one that can wreak havoc on a person's life, especially at the extreme poles of depression and mania. One in five suicide.

The good news is that the medications we have now are amazing and have made life not only tolerable, but often pretty darn good for those who want to control their illness. PSYCHO-EDUCATION, which this blog aspires to, enables individual, families and friends to cope when it's known that someone is suffering from Bipolar Disorder.

There are two kinds, and I'll focus on Bipolar I. (Bipolar II is primarily depression with manic episodes few and far between.)

It helps to look at the illness as a very fluid, changing cluster of symptoms that range from one pole to another on a continuum. Pretend there's a baton, that thing that people in marching bans twirl. At one end of the baton is depression, and at the other is mania. I'll describe both ends (and everything inbetween in another post), because the ends are extreme and flag the disorder.

The depressive end of the continuum is so vegetative, so depressed, that a person could sleep 24 hours a day and still not feel good. The manic end of the baton is so awake, so incredibly, alive, that a person feels omnipotent. (This is where some people with mental illness get religious identifications with G-d, but it isn't the only condition that can manifest itself this way).

Manic people (and very depressed ones, too, sometimes) are COMPLETELY OUT OF TOUCH WITH THE FEELINGS OF OTHERS. Manic people at the manic end of the baton need no sleep, I'm not talking like, they get 3-4 hours a night, they get none. They can get very irritable and shoot people without reason, certainly bark at them and abuse them. So, this is not a good disorder, okay? It is not a romantic condition. Lucky for all of us, it is treatable.

Anyway, although symptoms and behaviors at the two poles are extreme, there's a wide continuum of emotional life between them. The baton, by the way, can get pretty long in higher functioning individuals with the disorder.

In our hyper-caffeinated world, I have to say that it is my personal feeling that many people who think they have this illness don't. Cut out your caffeine and alcohol consumption for a month and then look at your symptoms before you look at the rest of this information (in the next post on BP-1) and go, "Hey, that's me!" The catch is, of course, Cut out your caffeine and alcohol consumption. But who wants to do that? Just a thought, something to consider.

There are six separate sets of criteria that differentiate the types of BP-I, and I'm not going to spin them all for you. Diagnosis requires careful assessment and a history, and it won't matter all that much if a person's had a Single Episode, or a Most Recent Episode Unspecified, for example. If you or someone you know has this disorder you should get help and let a professional fine-tune your basic diagnosis.

Suffice it to say that there are six types of BP-I, and there are several variations and diagnoses of Depressive Disorder with no mania, all MOOD DISORDERS.

The Bipolar Disorders and DEPRESSIVE DISORDERS belong to a broader category that the DSM IV, the Diagnostic Statistical Manual of the American Psychiatric Association, the bible of psychiatric diagnosis, refers to as the MOOD DISORDERS.

Anxiety disorders such as social phobia and post-traumatic stress are not mood disorders, they're ANXIETY DISORDERS. A good link to understanding the DSM IV is http://en.wikipedia.org/wiki/DSM-IV.

You do have to look past diagnoses and see the bigger family, the cultural context that aggravates most illnesses. A diagnosis alone tells us very little about how to help yourself or anyone you know who suffer from a "psychiatric" disorders.

You notice I put "psychiatric" in quotes. I'm a big fan of psychiatry and, I'll be honest, work with psychiatrists everyday. But PhD's are sometimes research types and practitioners of individual, marital, family, and relationship therapies (among other things).

In other words, we owe our living to the mental health professional world and tend to love everything "psychiatric." The word is in quotes, however because it really does say that it's all in your head, and frankly, no matter what the condition, no matter what the disorder, it's NOT all in your head.

Stress and illness affects your whole body, your family, your work, school, the way you relate to others, the way you feel about yourself, your thoughts (okay, that's in your head, thinking IS in your head). But illness is not just about genetics. Genetics matter, but they don't help us fix a darn thing.

Labeling someone who really has a disorder such as Bipolar I Disorder is the first step towards medical (medicine, mainly) intervention. But there's so much more we must do, even when an individual is on the right meds, just to keep them from swinging. We do feel that there are variables with potential to "trigger" both manic and depressive episodes, complicating the natural cycling of emotions along the baton, especially anger (EE, Expressed Emotion).

This makes a case, of course, for psychotherapy, family therapy, and behavioral therapy.
Beware if someone you know has a major disorder and is "only taking meds."

Copyright 2006, TherapyDoc

Learn to Listen Silly, Part Two

Parents tend to talk a lot. They have a lot to say, face it, years and years of words building up inside. And kids, well, they’re helpless, captive. What a position of power it is to be so much taller, so much better at words, knowing so much more of life and love, anger and madness, right and wrong.

Those of us without verbal skills may not say anything, may over-look a child’s behavior. That’s sometimes called benign neglect. Or, worse, succumb to bullying or unfair or unreasonable disciplinary tactics (usually poorly executed) that alienate the child. Kids, as they grow and become more confident, can make fools out of us, force us to play a hand that's already been played unsuccessfully many times over. But even when it feels like we’re losing, we’re really ahead. Why?

They need us to love them and approve of them and their choices, as insane as those choices sometimes seem to be. (The best blog, by the way, on parenting and giving kids healthy choices is Of Fish and Family. I'm not saying you have to give in to what kids want, by the way, just entertain their ideas).

If you parent well, your children will come to you when the rest of the world treats them badly. That's the reason for family, really, to provide a supportive place to lift us up when we’re down, support us not only physically, but emotionally, into adulthood. It’s a sign that we’ve been successful if children call us when they need us, especially when they have no where else to turn, and that really does happen. We can always say no if “helping” the child is enabling, making it easier for the child to repeat compulsive, destructive behavior.

It's hard to recognize that the power differential is in our favor when faced with an oppositional toddler or rebellious adolescent (who may not be small but is still dependent and vulnerable, despite the capacity to drive us nuts). But the power differential is there. We have the car keys, so to speak, and the experience, and the professional resources to turn to for support, if necessary.

Parents can run circles around their kids if they want, especially if they strategize with a spouse or a partner. If one of you sides with a child over the other parent, however, forget about it, you’ve lost your power. There's no way to win if you're both not on the executive committee. The executive committee in a family should be the two parents/adult partners who make decisions together about the kids. Ideally, KIDS ARE NOT ON THE EXECUTIVE COMMITTEE. I say ideally because in some families, one or both of the parents may not be psychologically able to make sound decisions, and in some families, THERE IS NO PARTNER! If both parents or adult partners are on the same page, then the power is all theirs.

I’ll talk about single parenting in another post.

This post will focus upon only one strategy, LISTENING. The single most powerful weapon you have is your capacity to listen to a person until that person, in this case a child, is talked out. This can bedazzle, confuse, humble, and ingratiate just about everyone. Respect is amazing like that.

I sometimes tell the story of a therapist I knew who was recently married and had two young children and another on the way. She wasn't working and one day she took a phone call from her husband's partner who asked, had she heard the news? She said No, and was told that her spouse (and the business partner on the phone) had both lost their jobs. The therapist was wild with anxiety and fear, but she decided that this wasn't about her, she'd wait until he got home and see what he had to say. He came home that evening and she greeted him, said Let's talk. They sat down on the sofa. She didn't say another thing for an hour and a half when he finally stopped talking. He had to unload and she gave him the space to do that. He turned to her when he was finished and said, simply, Thank you. It was then that this therapist understood the power of listening, and she tells me it has influenced how she practices, now that she’s back to work.

Thus, the best way to relate to people, to earn their respect and to show respect, is to listen. And children are people, too.

Copyright 2006, TherapyDoc

Listen Silly, Part One

Alternative Universe

Listening to a child, parent or spouse is basically like entering an alternative universe. That's what it's like trying to understand someone else, generally, whether we realize it or not, it's another world. Lucky for us, we’re usually invited in. People want to talk, especially about themselves.

LISTEN SILLY #1 therefore presents a few general principals. Future posts will specify by listening topics— listening to your partner, your kid, your parents, your friends, your boss, your horoscope, (nah, not really the horoscope part). We’ll talk about getting into another person's world in general right now. It isn't easy living in or visiting someone else's universe, but it's cheaper and easier than flying American these days. If you need a hearing aid, by the way, consider the investment. The digitals rock. Let's begin.

On a popular TV show, Star Trek, there was a psychologist. Troi, I think was her name. Ensign or Lieutenant Troi. She was gorgeous, sexy and an EMPATH! She had such an enormous capacity for empathy that she would double over in terrible pain, pass out, nearly die just being in contact with strong negative feelings (I stand corrected if she had to touch a forehead or something, please comment at the end and let me know). Anyway, sometimes the pain of others almost killed her and McCoy or Captain Kirk had to come to the rescue.

What a concept! Being affected to such a degree by other peoples’ feelings that you get sick and almost die! Other peoples’ emotions are contagious, actually, but most of us don’t allow ourselves to connect to the degree that we get sick! We have an unconscious turn-off valve. We don't call depressed people or go out with them if we can avoid it. Why? They depress us! Violent, angry people can hurt us, no question, and we deliberately avoid them. Given the choice, most of us would dodge, either deliberately or unconsciousloy, most of the stuff of life that Troi was unable to filter away.

Therapists have turn-off valves, too, and put limits on how much pain they're willing to listen to or feel in a day. If they didn’t, they’d get sick all of the time. Therapists who feel too much suffering burn out and don't last more than a few years before it's off to selling real estate they go. IT'S TRUE. Ah, but I digress. (I think Troi had GREAT vacation benefits, by the way).

There are really empathetic people, out there, however, who know how to listen and when, who have GREAT listening skills that sincerely convey empathy and caring. My goal in the LISTEN, SILLY series is to make you one of them.

Few people are naturally clairvoyant, and communication therapies make a big deal about mind-reading being a serious No No. So if the person you are trying to listen to doesn't talk, you may have to work at drawing out the words. Trust is not a simple matter. If your significant other or child is uncommunicative, if you want to listen but he or she won't talk, then your job is to indicate clearly that you are accepting and non-judgemental, that you will actually listen hard to that person's thoughts, ideas, and beliefs. It’s harder than it sounds.

Families in which people really listen with feeling, are, indeed, happier. This is why therapists value the quality of empathy, listening to get inside the other's shoes, above all else. If individuals in families aren't able to be speak and be heard, if no one's really listening, then they'll look elsewhere for understanding. Not that that's necessarily bad, but depending upon the age of the individual doing the looking, it can be dangerous.

So how do you get there? How can you become a little more like Troi? The job is to listen so hard and long that if pressed you could literally present the other's point of view convincingly, as if it’s your own. To do that, you have to SHUT UP about your OWN SIDE OF THE STORY, not worry about who is right and who is wrong, and LISTEN TO THE OTHER PERSON'S SIDE, and repeat it back, if you dare.

The alternate universe is the one we don't know; it’s the one we’ve never been to before. It should be more interesting, you would think.

They're shoes are so interesting.

More on empathy another time. Feel free, please, to comment. I'll try to write back.

Copyright 2006, TherapyDoc