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Wednesday, August 30, 2006

It MUST Be Transgenerational

This is about behaviors and family dynamics that repeat over many generations.

There are some pretty good books on the subject, notably Froma Walsh's work (a text) Genograms.

Here's the kind of thing that will happen in therapy. Like having good china handed down from great-grandparents, people brag that they've had the intangibles passed down, too.

They'll cut themselves slack for all of it, bad tempers, addiction, the right to kill themselves.

The temper thing gets transmitted as follows: ALL THE MEN IN THIS FAMILY HAVE TEMPERS. This is the code men have used on women to excuse themselves from having to control anger.

Nonsense, we now know, in our anger managed world. Having a temper is not like having arthritis. Being easily arouseable (temperament) does not make fury an inevitability.

There is such a thing as playing basketball to let off steam (or any other physical coping strategy, like walking) or thinking of others before venting, good old fashioned empathy:

If I blow up, he/she will feel horrible, so I won't. That's having empathy.

Empathy and exercise are key in anger management.

Some transgenerational patterns can be seen as the family's personal, irresistible madness. I pay attention if a depressed patient tells me there are people up the family tree who have committed suicide.

Similarly, if I know a recovering coke-head or alcoholic is under undue stress, I warn him and his significant other of a potential relapse.

Some things are irresistible, and if they're in the family, there's covert family permission to continue the family mishigahs (yiddish for craziness-- there's just no better word)

It's hard to determine if etiology, the cause, is genetic or environmental. What is at the very heart of the things people do? All of our research explains group tendencies, predicts what most people will do under certain sets of circumstances, not the behavior of any particular individual.

But the individuals are the ones we're talking about. What drives them?

Is it genetics or environment?

Turns out, that as much as empirical science (that predicts group patterns) is favoring genetics, LEARNING still has a more than fighting chance for ascendance in the etiological controversy games.

There’s interaction between the two, no question.

Let's just take a look at an example of how a person can have challenging genetics floating around circa DNA, but can still manage to use learning and experience to beat the family destiny.

I am not making this up.

Call her Sue.

Sue is an alcoholic. Goes to A. A., works a program, hasn’t had a drink in a year, but boy would she like one.

Sue hears her grandfather has died. She has misgivings about going to his funeral in another state because her father is the lone survivor in the family and he’s an alcoholic and a drug addict. Those happen to be her issues, too.

She feels badly, however, for her father who she can picture grieving her grandfather alone. So she goes to the funeral.

The two are alone, approaching the cemetery in a hearse carrying Grandpa. Her dad pulls out a joint. “Wanna’ get high?”

She blew him off.

“So I didn’t,” she told me. “I was mortified, grossed out, disgusted by the idea that he would get high at his father’s funeral. I could have become like that if I hadn’t stopped drinking and smoking. I could have become a person who gets high at funerals.”

All dad was doing was handling his stress, right? His way. Or should we just say it’s his disease and his entire family had it, a predisposition to substance abuse and addiction, some genetic problem.

It doesn’t matter what it was, peops. He couldn’t stay straight for the life of him.

She’s lucky she has other role models and 50% of someone else’s DNA.

I feel the odds are in her favor because she learned not to be addicted. This is no small thing, learning not to be addicted. She did, though, decide at some point, that drinking and smoking wasn't something she had to do. Wow.

Blank destiny and transgenerational patterns, right? Get help and move on.


Copyright 2006, TherapyDoc

Tuesday, August 29, 2006

Assertiveness Training

TherapyDocs with any training or experience prescribe assertiveness to beat social anxiety and depression-- they're related, you know. I've been using the same example to help patients understand what it's all about in simple language for about 25 years.

So here you go.

This is not to say that people can just snap to it and do it, like the Nike people say. It is harder than it looks, and yet, easier than it sounds.

Here's the Therapy Doc primo example. Few of my patients have escaped therapy without hearing it at some point or another.

You're standing in line at the movies. Or at the grocery store.

You're in line, just waiting, wondering when you'll get to the ticket agent, talking to your friend. You notice that someone has just budged.

Budged means, in case you aren't familiar with the vernacular, someone stepped in front of you without permission.

Now there are three choices in this case:

1) you say nothing, the passive choice.
This one is likely to make you feel angry or powerless. Maybe you really don't care, but NOTHING will change in your favor here. If the person who cut in line in front of you gets the last ticket in the theater, you're just plain out of luck.

2) you say something assertive.
ASSERTIVE MEANS JUST THE FACTS. You gently tap that person on the shoulder, point to the back of the line and say, "Excuse me, sir, you must not have noticed, but the back of the line is OVER THERE."

You say this in a calm, rational, factual voice. NO EMOTION. NO EMOTING OR ACTING deserving or snide or angry. NADA SIGN THAT YOU'RE UPSET. This is just the facts, and the facts speak for themselves. Most people move to the back of the line. You have just been pro-active and impressed your date (or yourself) and certainly, me.

3) you can be aggressive.
"Hey, (expletive)," you say. "What the (expletive) do you think you're doing, you (expletive-ing) (expletive)," and shake him by the shoulders.

The preferred choice is choice number 2, the assertive approach.

THERE ARE EXCEPTIONS. If the person who cut in front of you is very tough-looking and seems likely to kill you or beat you, then use your own discretion. Perhaps go the passive route.

The slightest snear from the aggressor and you might consider saying, "Oh, never mind, it's cool." DO NOT GET INTO "discussions" WITH PEOPLE WHO SEEM TO HAVE VIOLENT INCLINATIONS. Again, use your best judgement.

One thing about asserting, if you assert with a more assertive or aggressive person, you'll lose if you're not into conflict. It's okay to lose. Most of the time, however, if you're assertive and not aggressive you'll get what you want. That's winning. I know it's an incredible concept. I know.

Why try it and risk conflict? Like I said, most of the time there won't be any. You have to try this to believe it, but it's true.

Why even bother to try it? It's so scary? I'm sort of shy?

Well, we know that by asking for what we need we are more likely to get it than if we wait around for people to read our minds or Divine Intervention. People who don't ask, who would rather not make waves, are called "passive."

And passivity is associated with depression because if you don't get what you need, you feel unhappy, unfulfilled. Therapists push assertiveness. I practice with clients, script out things like that to help you get better and better at it. Filled is better than unfulfilled any day. Go for filled.

Copyright 2006, (TherapyDoc)

Sunday, August 27, 2006

Marital Therapy-- How to change the pattern

I've mentioned before that people interact in behavioral sequences. . .predictable behavioral patterns. Feedback loops.

That said, Why is it so hard to make each other happy?

Or to put it another way, How hard is it for a couple to break out of a negative pattern if they KNOW the pattern?

The answer is that it is hard for us to look at ourselves objectively. We see the other person's contribution to the problem, but not our own.

Here's the example. Let's make it sexy. Why not.

Joe loves Susan but they've been fighting a long time and he had been holding back a lot of anger about things she said and did early on in the relationship. They're married.

They went to marital therapy and worked through all of that. (YAY)

Now he's ready to be intimate with her, has been for a couple of months. BUT IT'S NOT WORKING. He initiates, she says NO. She initiates, he says NO.

What the heck? What's going on?

Precisely BECAUSE he didn't initiate for so long, she had developed a bit of an attitude. When he talked to her about just about anything, even though they had worked through many issues, she still acted as if she didn't care, as if he didn't matter. Worse, she acted sometimes as if he was an annoyance, a mosquito, a bother. She was acting that way because he didn't initiate sex for so long and she had been rejected MANY times. She was humiliated. His turn.

So when he did try to get amorous, her body language and tone of voice said, Buzz off.

That stopped him from initiating sex. And she had already stopped initiating, for the most part. And when she did, since he was angry at her, he rejected her.

It looked like this initially, before therapy:

She initiated because she loved him→ He rejected her, angry at the things she's said and done → Nothing got resolved → She initiated because she loved him → He rejected her, still angry at the things she'd said and done → Nothing got resolved →She initiated because she loved him → He rejected her, still. . .

See the pattern?

In therapy we resolved the problems. He was ready for a sexual relationship but now SHE acted angry much of the time. Her anger was a defense against getting hurt again. She didn't trust his love. After so much rejection, she wasn't sure. So now it looked like this:

He initiated → She acted like she didn't care→ He withdrew→ Time passed→ He initiated → She acted like she didn't care→ He withdrew→ Time passed→. . .

A simple feedback loop. It doesn't matter where you start in the sequence, it'll start all over again. Once you get it, you can intervene anywhere.

We used two simple interventions to interrupt the feedback loop:

1) When he initiated she was to ask him point blank, "Are you serious? You really want to make love?"

2) He was to say, "With all my heart. I love you."

Then they would hug and take it from there.

So if you can analyze your interactions, who needs therapy, right?

Uh, yeah. Good luck.

Copyright 2006, TherapyDoc

Tuesday, August 22, 2006

Self-Blame

To read this post (which is about how kids see themselves as the reason their parents get divorced) please click on:

When Therapists Blog.

No, it's not funny, but it's interesting and might make you look at your ACODP* friends differently. The post below this one has a nice example of how people LOVE to assign blame. It's a feel good thing, I guess.

*ACODP stands for Adult Children of Divorced Parents. I made it up. You can't google it and get a support group for it, unfortunately.

BLAME

Some people get it right away, the thing about blame. It’s either everyone’s to blame (yuck) or no one’s to blame (yay). If you’re one of those people who really wants to put people on trial, then try to pay attention. We’ll take it slow.

There’s a child rearing universal that children need to learn to take responsibility for what they do, not lie about their behavior. Which makes sense, right? Yet that owning implies blame—if you cause a problem, you’re to blame.

But we’ve been stressing systems thinking on this blog. There’s a homeostasis to behavioral patterns. We take responsibility for our part in a problem, but there are other things happening that triggered our responses.

Since there are so many people involved (past influences from family, friends, work) and so many triggers, family therapists do not like to assign blame. We like to look at what happened and search for a nice solution or ten.

Here’s an example of blame assignment that helps no one:

Barbie calls up her brother Bill to ask him for money. She needs a hundred dollars. Because she’s out of work, she does a lot for their mother.

Bill is used to her asking him for money and would much rather she worked, but he does like that she’s free to take Mom to the doctor. Still, Barbie never pays him back.

Because Nancy, his wife, has been telling him to set a limit, he tells Barbie he doesn’t like “lending” her money because she never pays him back. She gets angry, hangs up on him. Bill calls her back and says “Fine, I’ll lend you the money.”

Barbie is happy. Bill hangs up the phone. Nancy, Bill’s wife, says a little angrily, “I thought you said we were saving money and you weren’t going to do that!”

Bill tells her that he wanted to but he really has trouble saying no to his sister. Barbie has “issues.” He thinks she’ll grow out of them.

Nancy says, “Actually, Barbie will always have issues. We really need to save to buy a house. Call Barbie back and tell her you can’t do it!”

Bill calls Barbie back and tells her he doesn’t have the money right now. She says, “Well, then I don’t have time tomorrow to take Mom to the doctor. YOU take her,” and hangs up.

Now Bill is angry at Nancy. He blames her for what happened.

But is Nancy really to blame? Is Barbie? Is Bill to blame for having enabled Barbie to manipulate him for so long? What should they do?

Nancy tells Bill, “I’m not to blame. This is your problem, buddy.”

Bill says, sarcastically, “Nice to know I can count on you when I have problems.”

Is she right? Is it his problem? Is Nancy wrong for making him fix it on his own?

I’d say that if one partner has a problem, the other one does, too.

So her saying it’s his problem doesn’t exactly fly. And I’d also say that yes, Bill did create the problem with Barbie— to an extent. But Nancy never put her foot down until recently. So she co-created the problem. Then booked.

They need to sit down and strategize together on this one.

AND they need to stop finger pointing. It is very difficult to find the beginning of a relationship problem. They’re usually interactional, no beginning, no end, always one person acting a certain way because the other (or someone else) did something to trigger the response. But that was triggered by something else. And that was triggered by something else. Eventually the pattern will emerge. It takes resolve to find it.

But if you examine these behavioral sequences carefully you may begin to see how there are interactional patterns, feedback loops, that repeat in relationships. When you find the loop you can then begin to insert interventions, CHANGES, to resolve the problem. The pattern suggests that there are really MANY solutions to relationship problems, not just one.

From our example we don’t know what those solutions might be—we haven’t got enough information. All we know is that by assigning blame, we’re not closer to a solution.

There is a post in the archives about “blood being thicker than water.” It is an expression commonly used to mean that the opinions and needs of siblings and parents (the blood) have more sway, more influence on a person (and theoretically should, according to its adherents) than those of a spouse or a partner (the water).

Family therapists profoundly disagree. At the end of the day it is your spouse/partner you need to live with, sleep with, and resolve issues with. The other blood relatives go home to their own partners/spouses or selves. The only exception here is where there’s abuse.

Perhaps it’s time we got to talking about that. THAT’S where I’ll allow blame. No one makes a mature individual hurt another, no matter what the provocation. The responsibility for abuse remains squarely upon the perpetrator. Always.

Another time.

Copyright 2006, TherapyDoc

Kids, divorce, and self-blame

Or we could call it, I Caused the Divorce, I Know I Did

It's so funny how starting to write on one topic MAKES the next one happen sometimes. Yes, I know, it's totally random, but still.

So today's post is for everyone.

A kid came into the office today. We talked about what it was like when her parents got divorced and I remembered the Ultimate Self-Blame Guilt Trip. DIVORCE.

They all think they caused it-- kids, that is. It goes something like this.

Kid is aware that parents are fighting a lot. At some point, usually while looking at the parents, praying no one is going to get hurt, one parent says, Well, YOU should have put away YOUR toys. If YOU had, then Daddy (Mommy) wouldn't be so mad.

Or: Parent TELLS kid a secret, like perhaps that he/she has a boyfriend who is really nice. It doesn't matter if the kid tells the other parent. In kid's heart, when the parents get divorced, it's because one or the other thinks he did. Kid screwed it all up somehow.

Even if there's absolutely no reason to rationally think your kid is self-blaming, you HAVE to check this one out if you're going through a divorce. You HAVE to tell your kids that they did nothing to cause the dissolution of the marriage.

A child thinking that he or she is responsible for the breakup or the marital problems in the family underlies untold, massive, huge numbers of depressive disorders in children and adolescents.

It's one heavy guilt trip that can be prevented with simple clarification. TALK TO YOUR KIDS. FIND OUT WHAT THEY'RE THINKING.

Parents rarely tell their children the real truth behind their divorce, and sometimes that's okay(I have a lot to say on this, usually that it's not). It is NOT okay to allow children to take the responsibility for the breakup. Not ever.

Copyright 2006, Therapy Doc

Sunday, August 20, 2006

Because of You- Part Two

The last time we talked about BLAME it was in reference to Kelly Clarkson’s music video. She blamed her anxiety on her parents’ conflictual marriage.

I used the music video as a good example of how parents who have relationship violence can impair a child’s ability to handle stress, especially conflict.

The brain develops while we’re young, and although we can change it by creating stronger neurological pathways to healthier responses (less anxious responses), the ones we learned as children can last a long time.

But other things can go to hell if your parents had a conflictual marriage besides your emotions. Some people get tougher, not more anxious and will repeat the arguments their parents modeled so well for them.

Kids remember their parents’ arguments and often repeat them, consciously or unconsciously. It just happens.

When people attack each other, they basically lay their own negative feelings onto one another. If that's what they grew up with they see it as normal and acceptable.

There is a difference between arguing to resolve problems constructively, and maintianing a conflictual relationship that functions to dilute intimacy and create distance. Intimacy is actually pretty hard.

I’ve talked about problem solving intimacy in previous posts. We get closer when we solve problems together. It would seem that to do that we have to argue.

Which is fine, but. . . .

Not if it’s going to be hurtful, right? That makes sense. So we wouldn’t say something we know is going to go straight to the jugular in an argument. We wouldn’t say something, as clever as it may sound, as RIGHT as it may be, if it’s going to make our partner cringe.

Cringe is bad.

Making your spouse cringe is bad. It’s harmful. It’s violent. This goes along with my favorite philosophy (and a patient told me there’s a rapper who preaches the same thing!):
WHEN YOU WIN, YOU LOSE.

Why? Because the loser feels bad. You don’t want your partner, the person you love and want to sleep with to feel bad.

Makes sense.

Yes, you deserve to make your point. But no, if making it means revisiting painful territory for the sake of making it, for the sake of winning a point. If it’s going to hurt, then probably don’t make the point.

Sometimes it’s okay. But usually not. The default here, is not.

Eat the point. Stuff it. Hold the thought. Instead, ask a question. Interview your spouse. Get to know your spouse instead.

Here’s an example.

Harry: I’m sorry, honey. I know I told you I’d get home earlier. I had to work late.

Sharry: Oh. Did you meet up with some girlfriend?

Harry: I told you I would never do that again. I was really working.

Sharry: Well, you cheated on me once before.

Harry: There are times I’ll have to work late. I’m sorry. I blew your trust when I had that affair but we’ve talked about it and I promised I wouldn’t do that again. You have to believe me.

Sharry: How can I?

Harry: That’s a lousy attitude.

Sharry: Well, what the hell? How am I supposed to ef’ing trust you if you come home late?

Harry: It’s not that late. You could ef’ing get a life! You’re just lazy.

Sharry: Men are all the same. Such whores.

Obviously, in this case, she’s hurt and still letting him suffer from his past indiscretion. He falls right into the trap. What makes it worse is that her father cheated on her mother so she has history, and her father and her mother had this same argument.

What should she do with her suspiciousness? How’s she supposed to not express her anger? He’s cheated before.

The fact is that even if they’re worked it out and he’s promised not to do it again and meant it, she won’t really trust him for many years.

Does this mean she has to beat him over the head with his previous mistake?

No. She has to talk to him, get to know him better. He’s a good guy. He’s trying. She needs some proof of that.

Let’s revisit the scene, same problem, handled a little differently.

Harry: I’m sorry, honey. I know I told you I’d get home earlier. I had to work late.

Sharry: Oh. Working on anything interesting?

Harry: No, same project from yesterday.

Sharry: Tell me about it.

Harry: It’s not interesting. I don’t want to talk about it. What’s for dinner?

Sharry: I’m going to be honest. When you work late I worry you’re having another affair. I’m kind of traumatized from the last time. I’m sorry. So when you tell me what you’re actually doing at work, it helps me. (WORK INTIMACY—a good thing)

Harry: Oh, sorry, honey. Okay, the proposal had to be rewritten. Then I handed it to my boss who told me that I had forgotten the Smith clause, and I had to call Al Smith and . . . (he goes on about this for a long time).

Sharry: Sounds like a major drag.

Harry: Yup. Glad to be home, seriously.

Sharry: So you don’t want to be with another woman?

Harry: Not at all.

Sharry: My parents used to fight like cats and dogs over this kind of thing.

Harry: Did he cheat on her?

Sharry: Oh, yeah.

Harry: I’m not your father, Sharry.

Copyright 2006, TherapyDoc

Wednesday, August 16, 2006

Kids and Suicide

Adolescents, we're talking about. I have a lot to say on this one but will start you off with an example. You have to click here to see it, okay? When Therapists Blog
Read the post on August 15, 2006.

Tuesday, August 15, 2006

A kid and suicide: Not exactly your Prairie Home Companion

Picture this. He's 14, and big for his age, tall, strong, built like a wrestler. And he is an athlete, actually. A very good one.

But he's had this cloud over his head for as long as he can remember. Like many kids with this particular burden to bear, cloudy outlook on life, he's struggled desperately with academics, barely passing but getting by most years. At this point he can't concentrate at all. He's far behind. No use in trying, really, he says. He's always sad, always has been sad. His thoughts are dark, gothic, and violent.

Of course his body image is TERRIBLE, complicated by the fact that his face suffers the plight of adolescent boys who have a fair amount of testosterone. I can barely believe there's a great looking guy in there but I know there is. His parents say he's seen a dermatologist. I say, push that doc a little, would you? Take it MORE seriously.

Our Boy writes poetry, death poetry. I've seen a lot of kids who write suicidal poetry like this. It's a good release.

If you see the new Garrison Keilor movie, A Prairie Home Companion, you'll get a bit of Lindsey Lohan and her character's suicidal poetry. Lindsey's character is lucky because her mom (played by Meryl Streep) and her aunt (Lili Tomlin), are radio entertainers on the show.

Our Boy hasn't got that advantage. His parents are regular folks and they can't launch him a career in radio/television. But they believe in him as a person who has something to offer to this world. Lo and behold, there's a girl who's been calling him, too.

This poetry thing turns out to be an amazing advantage. He believes in his writing and not only does he believe in his writing, THE WHOLE HIGH SCHOOL BELIEVES IN HIS WRITING! All the kids try to get a glimpse of his notebook. He has to make copies at Kinkos of his entries (this was several years ago).

His parents believe in him, too. They're willing to send him to a poetry contest, in fact, one that I'm pretty sure is a gimmick to benefit the sponsors. But who cares? It's helping Boy's self-esteem.

Boy's parents recognized that their son had an endogenous depression, one that they both suffered as children and still suffer from as adults. We think it's genetic, since it presents so early without any radical environmental triggers. This is a loving family, if not usually happy.

Because of the clear history, his family doc tried him on a very low dose of an antidepressant and we watched him very carefully. Eureka! Worked like a charm.

I write this because there really is concern about overmedicating people and making poor choices vis-a-vis adolescents. Done well, with some good therapy, btw, medication can be a real life saver. Our Boy graduated and is now in college. Heck, by now I imagine he's blogging, not making copies at Kinkos.

I'm going to write the nuts and bolts about suicidal adolescents in my other blog, Everyone Needs Therapy real soon. Bare in mind that "Our boy" in the story above could very well be a girl, and "she" could be great at volleyball or track. But yes, she would be kind of tall and even without the testosterone, she would surely have acne. Our girl or our boy could have written folk songs, played electric guitar, had six holes in one ear or tattoos up and down both arms. I won't tell. I see you all in broad strokes, anyway.

Copyright 2006, TherapyDoc