Thursday, May 28, 2015

CBT and Song: I'll See You in My Dreams

It is no secret that when a therapist goes to a conference and learns something new, or merely signs up for a continuing education course online and actually applies herself, learns the material before taking the test, she'll probably talk about the new intervention or theory for at least a week or two. All patients are unknowing guinea pigs. Beware.

But sometimes we come upon something on our own, a random strategy that helps us with our depression or anxiety, and having successfully applied it, we know that it works for at least one case study. If it lifts our dopamine or serotonin, changes the way we feel, why wouldn't it help at least a few others?

Not to tell all, but I had a bad day, and I felt really badly, and I couldn't shake it, obsessed about what had happened far too long. This can happen to anyone and probably does, but knowing that time heals (most of the time) didn't help at all. Neither did any of my tried and true CBT interventions.

Talking to FD and my friends, which usually helps SO much, only helped a little. No emotional energy left to write (not wanting to revisit the material, that's for sure), I was frustrated and out of steam. Then, out of nowhere, I remembered something.

Maybe the writers of Blythe Danner's I'll See You in My Dreams remembered it, too.
I'll See You in My Dreams

The movie is all about Ms. Danner, and if you've been missing her, you won't in this film, she is all of it. This is about aging and loss, and that's as far as we'll go with the spoilers, except to say that at some point she is discussing her first career as a singer with the pool guy.

Yes, there's a pool guy, and yes, very handsome (Martin Star).

He asks her, "When did you stop singing?"

She doesn't know.

That's all you'll get about this film for today.

So here's the thing about singing. It does change the way you feel, as does listening, but it is active, not passive,like listening tends to be. It focuses the mind with several senses, not only one, especially if you try to sing well, by ordering the lips to work in a certain way, the chest to breathe deeply, to hold then release the breath, the words, with exactitude.

To say that song is an avenue of expression is redundant, but if it is, why don't we sing more often? We're fearful of being heard, obviously, and being laughed at, as if anyone really cares or would. Like sport, where spectating is the next best thing, we listen to and admire Adelle, Renee, so many others. We sing along and cry, perhaps, transcend our realities, dissociate from what is troubling us. That is what it is, really, when we're engaged like that, dissociating from problems. We all have them, and creating something new, when we do something creative, such as sing or sing along, puts us totally, consciously in charge. Except when we hit a wrong note. But we're not Adelle, not Renee, not even, dare we say it, Barbra. So sure, there will be a wrong note or more.

So there I am, can't remember exactly where, probably in the car where they say most people sing, no, in a parking lot looking for the car, and I'm actively searching for a song to lift me up, and I remember Barbra's Smile, everyone's favorite, and I begin to sing and it lifts my spirits some, but not nearly enough. In fact, the song makes me a little worse, because it is about feeling sad and how smiling makes us feel better (believe it or not this is true). But a person has to really work at smiling when it doesn't feel natural, when the feeling isn't there.

This is a do it thing, however, and if you do force your face into a smile and hold it, this, too, can produce a little change in the brain, enough of one that many depressed people who go to work and have to smile because they won't sell something if they don't, or people will ask too many questions if they don't, will report that their days, while faking it, can feel pretty good.

So smiling is an excellent cognitive behavioral exercise, and Barbra's song is spot-on.

But it's sad!

I switched to happy songs, literally peppy tunes, which helped enormously. Zippity Do Dah and High Hopes--Oops There Goes Another Rubber Tree Plant, and a few slow ones (Where is Love, Oliver) some of my all time favorite songs.

And yes, I have been suggesting to patients that they do this, find happy songs. Although crying feels good, and surely, we can't help it, we have to cry, it is irrepressible; but if it is at all possible, if we can get out of our sadness, pull ourselves out of that dark place, lift our own spirits without waiting for the Lexipro to kick in, then there's no better feeling, no better facial expression, than a smile.

Because at some point, as the queen of Broadway croons, What's the use of crying?


Oh, just a few.


Wednesday, May 20, 2015

Child Sexual Assault: A Different Paradigm

May is Mental Health Awareness Month, and what better way to promote that than to discuss a successful therapy. Thanks to the American Psychological Association's Annual Mental Health Blog Day (today, May 20for keeping us current.
APA Mental Health Day

APA Mental Health Day

Onto the case study.

This is about Ziv Koren, who at the age of six became the sexual obsession and conquest of her uncle, remained an extension of him for ten years. As in the case of many pedofiles, entirely possessive, the abuse blocked Ziv's social and psychological development. Her identity remained in no-man's land as did her sense of self, even after the abuse had stopped.

She had six years of unsuccessful therapy (Ziv suffered addictions and a plethora of disorders), until she met Dr. Rachel Lev-Wiesel, a professor and childhood sexual assault specialist at the University of Haifa, in Israel. Dr. Lev-Wiesel is director of the Graduate School of Creative Arts Therapies. (For another synopsis of their work together, click here).

Rachel asked Ziv to draw her feelings, her experiences, and this became the vehicle for communication, a process of externalizing pain and telling the story. The doctor and patient published a book together, a near complete transcript of what happens, psychologically, when a perpetrator steals a child's body and mind. It is a picture book. Ziv's art tells the story. When when it is finished, we are treated to the therapist's contribution to mental health, a gift that will change the way many will perceive and approach the treatment of child sexual abuse for years to come, a new paradigm, new ways of seeing this inhumanity. She refines her research in a mere twenty pages.
When Time Stood Still by Rachel Lev-Wiesel and Ziv Koren

Nowhere, not in any of the data bases I've scoured for the latest treatments of sexual assault and pedophilia, have I read the word, "soul". If I did, it was in passing, perhaps soul-less behavior, assault; not a core construct for therapeutic intervention.

But of course this is about stealing a soul.

Rachel Lev-Wiesel, has no issue using the word and discussing the existential experience of assault victims who lose their identity to their perpetrators, and dissociate from their bodies, the bodies that betrayed them. Citing numerous studies on dissociation, she reiterates what most therapists already know. Dissociation is a process that enables sexually abused children to survive abuse. The conscious mind detaches, disconnects from reality, the thoughts, memories, feelings, and acts in the here and now. The onslaught of pain is avoided as reality is put in its place, far away. The soul, or self, or mind, consciousness, whatever you want to call it, is entirely separate from the body, from the event. Identity confusion has to follow, will take years to coalesce, healthy relationships difficult to maintain.

Paradigms about what happens to us during any emotionally upsetting, memorable, traumatic event are referred to traumagenic, and they are not new. At the core of psychological injury, Finkelhor and Brown (1985) categorized four dynamics: traumatic sexualization, betrayal, stigmatization and powerlessness, all associated with victimization, characterizations that have helped those of us in the helping professions to work successfully with survivors. Dr. Lev-Wiesel builds on this theoretical framework, and mental health professionals should be listening.

We need more words, easier words, to work with in treatment.

Those last twenty pages of When Time Stood Still deliver, and the first 147, Ziv's story and art, move us as if we are there, doing the treatment, feeling the pain and the progress. It is an art therapy, and for those of us who haven't ever tried this treatment modality, certainly worthy of considering when words simply don't mean enough. Ziv Koren's drawings are the heart of the book. The pictures aren't pretty, but the art is what art should be, the great communicator. The verbal therapy is via email, a discussion of pictures, and we have the transcription.

Dr. Lev-Wiesel's theoretical framework, however, tells it all. Here is where the concept of a soul's homelessness resides. She explains that most of us see our homes as shelter, safe, predictable places, points of departure and return. The body is similar in that it is the shelter of the soul. The soul is loosely defined, and we might substitute sense of self, other words, but if the body is the soul's private space, and it is invaded, unprotected, that sense of safety is corrupted, ruined.

We all have strong reactions to breaches in personal space. In the case of sexual assault, especially chronic, prolonged sexual assault like incest, the body is no longer safe. It becomes a prison.

What's a soul to do? There are options, Dr. Lev-Wiesel teaches us. (1) Identify with the aggressor (take his identity), (2) split off with dissociation, become oblivious to the body and its needs, and (3) retaliate with punishment for betrayal. This we're all familiar with, self-injurious behavior, substance abuse, eating disorders, promiscuity, addiction to sadomasochism, neglect of hygiene, depression, etc.

No, not new to those of us who work with victims. When the body fails to protect, when it has caved to coercion, an act of self-preservation, it becomes repulsive, contaminated, worthy of self-abuse, self-punishment.

And soul's homelessness is only the first of five exquisitely conceived traumagenic constructs.  Over time we will revisit the others, captured in time, the present and future become reflections of the past; re-enactment of abuse, or time cycling; the betrayal entrapment; and entrapped in a distorted intimacy.

Valuable stuff for not only therapists, but victims and survivors as well. A new appreciation of art, one we won't get in Art History 101.

I'm Blogging for Mental Health 2015.There is much to be positive about this May, Mental Health Month.


More on Ziv Koren's art and her therapy, click here.

Ziv Koren's art

Ziv Koren's art

Monday, May 18, 2015

Mad Men Series Finale

Light spoilers, sorry. But as we like to say around here,
Never lose an opportunity for a teaching moment.
If you haven't seen it, have no intention to see it, assume you'll never see it, reconsider.

To enjoy this last of the Mad Men season, the AMC Mad Men Series Finaleyou really don't need to know very much about what happened previously.

You probably should know that Don Draper (Jon Hamm) is the mind behind several brilliant television ad campaigns in the sixties and seventies, that he does it all effortlessly, usually under the influence of bottle after bottle of Scotch, and yes, he suffered a dysfunctional upbringing and has secrets, other identities.

You might need to know that his ex-wife Betty (January Jones) is a survivor of an era that objectified women and defined the parameters of their success. Not that this era is over, or that she has ever been a warm and fuzzy stereotypic mother. All of the women in this show, for all seven seasons, are the second-class citizens that feminism seeks to graduate, the heart and soul of the equal rights and women's liberation movement.

You might need to know that Peggy Olson (Elisabeth Moss) has been raised Catholic and that she steps out of her family script to express herself in advertizing, and that she's never been lucky in love.
Mad Men

And that Joan Harris (Christina Hendricks) has always been the subject of sexual harassment in advertising, for she is stunning, an iconic female, but she will persevere, become a partner in the firm.

 It is the Don Draper story, one that surely can be found on a summary at AMC, that captivates us. We find him in California in this last show, having walked away from his success in New York, disliking the powers and politic of the company buy-out. He has hit the road, in search of what, we're not sure and neither is he. The walking away, the dropping out, searching, is so symbolic of that era, the late sixties and early seventies, and the costumes, the execution of the plot, bring me back, nostalgically, to a time when it was all up for grabs. Everyone could be an adolescent. A pox on your stage theories.

Even the group therapy of the times, we see much of it in this episode, is perfectly rendered as both impossibly ineffectual, and then. . . a work of beauty.  The stories they must have told on that set at lunchtime.

I can't do it, won't give away the ending, or even much of the middle, but suffice it to say that this one show will be, should be required watching, on the syllabus, for those who like the idea of art therapy, of art as therapy. Out of existential conflict, creativity is born, assuming one thinks this way, is trained to think this way. And from creativity, happiness, serotonin surging, surely, and what feels like psychological growth, resolution, not necessarily all in that order.

But because it is so hard to train people to think creatively, this particular season finale of a popular television show is serious business, a commodity, valuable art, a teaching moment, make that hour and fifteen minutes.

Think creatively, or learn to do so, and no matter what happens, we can make something new out of something that is wearing us down, make it better. We are, basically, in charge of that, making it, as the Beatles sing in Hey Jude, Better, Better, Better. Good therapy, can bring us close, but we have to add that final dab of paint ourselves.


Friday, May 08, 2015

Snapshots: Baseball, Fishing and Mothers Day

Over St. Louis
1. Mother's Day

This will be a big weekend for many of us. I'm invited to a picnic for Mother's Day, and since it is likely to rain in Chicago, it will probably be take-out indoors.

I'm not working, have always loved this particular excuse to take off the whole weekend. But let's move on, take a look at a water snake at Lake Kinkaid. It doesn't get any more interesting than that.

No, I didn't take the picture.
Water snake

2. Vulnerability  

FD took off earlier in the week to go fishing in southern Illinois with his brother and a couple of his brother's friends. As a pri-care, he really needed it, needed to be out of cell phone range.

The first night he was gone I had a home invader dream, haven't had one in ages. So disturbing. But the dream clarified my subconscious appreciation that he's around most of the time, reinforcing my belief that we don't consciously know what people really mean to us.

3. Men Pack, Women Pack

When he did have cellular service he called, heard the story, and thinking he could take advantage asked, "Any chance we could put my tackle box in your carry-on for the trip home?" Perfectly serious. (The plan, meet him mid-week in St. Louis, after the fishing trip.)
tackle box

Was he kidding?

4. Hope

His brother caught fish, made it look easy, but the rest of the crew only managed one catch apiece. It is a competition with men, although nobody really begrudges a good fisherman, and everyone had their role to play. FD fried up the bluegill. It tasted amazing, they say.

Great seats to the Cardinals-Cubs game Wednesday served as the seduction to get me to St. Louis. And I was fairly certain they would all have showered by then.

The Cardinals are a Cubs fan's arch-enemy, but Chicago has a new manager, and some new sluggers, and they have won more games than lost this season. So I've been watching the highlights of most games.  Because you know, hope springs eternal, especially if you're a Cubs fan.

5. The Worse Loss of the Two

There will be no one else to blame if I miss the early afternoon flight. An evening game, but the pressure is on.

Reasons to miss it included a trip to the orthodontist for one of the kids, and ice cream, naturally, and picking up a last minute gift for my host and hostess, then little things, like going to the bank.

But even at the bank, which can be really slow, it is like butter. I know the woman in front of me, the one with five business deposits all lined up on the counter. She turns, surprised, and suggests I go first.

And then we commiserate about it being Mothers Day this Sunday, as only women will do in a familiar bank in a random line, she for her son, me for my mom, four eyes with tears. And I show her a picture that I carry with me, but tell her that her loss is worse, because we both knew that to be true.

6. The Flight

All amazingly chic-chak at remote parking and security (Pre-TSA helps), except that at the gate the attendant announces that our plane is unflyable and they are looking for a new one. It will be about an hour, he thinks, but it isn't. It takes three hours to find a new plane.

And all I have with me is a thin paperback and my phone, so there's no writing, either, not with a computer. Paper and pen will have to do.

And there's nobody to talk to in the middle of the day, nobody to call, because everyone is at work, and American has no electrical outlets at the "K" terminal to charge your phone, so even reading the dozen samples you've downloaded on Amazon feels dangerous.

Once on the plane, however, the flight crew is jovial. Perhaps they have had time to commiserate with one another at a bar. A flight attendant offers me a full can of Coke Zero, always a good thing, then she leans over and whispers, "You know, you better be careful wearing that hat where you're going. Kinda' like enemy territory, you know?"

And I nod. "They'd best not mess with me. You do know, don't you, that the Cards are going to lose tonight, right?"
therapydoc in a Cubs hat

She smiles sympathetically.

7. The Game

Lambert airport in St Louis
FD never looked better as he approached me on foot at Passenger Pick Up at Lambert International. Sporting his Cardinals jersey and Cardinals hat, he looked like he hadn't shaven in weeks, but he tans easily, to make up for that, and three days fishing, well, there's no amount of sunscreen to save him.

We had to rush to the game because of my lateness (American finally found a plane). It was a challenge getting photos of downtown St Louis at stoplights but I jumped out and got one.
The St Louis Arch

Busch Stadium
Finding our seats at the ballpark the sea of red is intimidating. This picture doesn't do it justice, but 50,000 Cardinals fans, all in red jerseys swarming into the stadium is stupefying.

Every time the Cubs do anything remotely wonderful I am shouting Hey, hey, hey, stuff like that, and nobody really pays any attention because they all assume it is a done deal, the Cardinals will win this like they always do.

But they don't! Cubs win, 6-5!

Cubs Cards scoreboard

Happy Mothers Day, friends.


Sunday, May 03, 2015

New Ways of Seeing: The Art of Therapeutic Reframing

We've talked about looking for the big personal or family theme, a generalization that feeds a person's history and worldview, a belief that might hold the patient, maybe the whole family, back.  A well-placed reframe, usually with a metaphor, teases away the old way of thinking. No turning back. 

Board games are making a comeback, but Monopoly never did go away.

I stopped playing for a third of a century, but on a visit to hang out with my grandkids (their parents trusted us to take care of them while they took a work vacation) revisited the game again.

Is there anything worse than losing at this?  Losing fair and square? To a six-year old? Early in the game there is a sinking feeling that the outcome is obvious, the game is over. For the very first time you learn the true meaning of Connecticut Avenue. You never valued it before. Now, landing on a hotel, you are shelling out six hundred Monopoly dollars. He has shattered your world view about how to win (buy everything). Three out of four railroads is meaningless in the big picture when you keep landing on his stinking hotels.

How do play therapists do it? They must not play Monopoly.

This is a metaphor, you tell yourself, for losing in life. Over half your patients think they are losers. Although you think you are, too, in random moments, now you relate in a different way. Being a loser is a hopeless place to be, a self-loathing, self-blaming place, and when we lose at a game it is so obvious. We have been outplayed. This time.

Losing at a game we have a sinking, negative feeling of inevitability. But the good news is that you have a new metaphor, and the metaphor by its very nature has the power to paradox, to tweak thinking in a direction that is not hopeless. Laughing at ourselves, it turns out, is the best medicine.

You think you're a loser? Have you ever lost at Monopoly, lost to a person who has yet to graduate kindergarten? Huh?

It has to make a person laugh, which is one of the more curative features of good therapy.

Mark Tyrrell would second that opinion. I had the pleasure of meeting him (via Skype, which is aggravating but does the job, unless you keep trying to move the tablet as far away as possible to look better but your arms don't stretch that far).

By Mark Tyrrell, MD
New Ways of Seeing

Mark is shirt-sleeved, and from the accent, British. His publicist sent me the book and it cost ten pounds to mail it from the United Kingdom, so I'm especially flattered. I had automatically assumed him to be older, because his book has so much wisdom packed into these short blurbs of hypnotic suggestion.

That is what a metaphor really is, a hypnotic suggestion. It reaches into our head and we find it either funny, or calming, or more sensible than the negative ideas we've had about things that are sometimes remotely related.

Many of us understand, for example, the idea of learned helplessness. A woman endures various hardships in life, foster homes, abusive relationships, and is wired to be anxious all the time, unhappy. She finally meets a kind, gentle man and knows he will be good to her, but she is terrified that the future will surely end up wrong, as if she doesn't deserve to be happy.

Her therapist has her imagine a young bird, set free for the first few days of life, then captured and locked up in a cage. The bird is beautiful and has a wonderful song but cannot sing or fly free. Then one day, through sheer hard work and some luck, the cage door is open. At last she can fly and sing as much as she wishes. But she won't. She just stays in the cage.

The doctor then asks the patient: If you could speak to the bird, what would you say?"

The patient answers: "Well, I would tell it to fly free, of course. . .because now it can, only it just doesn't know it."

Dozens of gems like this in New Ways of Seeing.

"Must one study hypnosis to do this?" I ask Mark, knowing full well that at the Chicago Family Institute we learned about the metaphor and that have been using it for thirty years, but most of us don't consider ourselves hypnotists.

"No, but it helps.  It is really the relationship that makes the difference, the trust in the doctor is key. We relax automatically when we are in a trusting relationship, and what is hypnosis if not deep relaxation?"

Thanks Mark.

The Amazon link to New Ways of Seeing: The Art of Therapeutic Reframe

To read other things about this prolific therapydoc check out his website.