One Snapshot, then other Bloggers

Here's the snap:

Impatient with Patients: The What Else Is New

It often happens that someone (in therapy) will say, "I’m doing great! So much better!"

And in the very next breath it is: "Actually, then (this happened), and (that happened). But still. . . I handled it so well. . ." 

And you are waiting. 

There is a pause. Maybe even a short one, the response could even be sans pause and pow! 

The patient looks right at you, the mood has changed, the patient narrows his eyes, might even scowl, becomes a different person, his old self, for he remembers. 

"I’m just really, really angry at . . ."

and another story tumbles out, same story, same offender, or some other offender, on a good day there may be multiple offenders, persons who share the responsibility, the blame for the change in mood. Even if the patient attributes a good reason, an empathetic reason for offender behavior, the narcissistic injury stings.  

A narcissistic injury, just to digress, can motivate people to positive action, or negative, depending upon one's point of view. There is a legend about a man, Donald Trump, roasted at the annual National Press Club dinner. This is traditionally a roast, a night of humor, sarcasm, good cheer. But apparently President Barack Obama roasted Mr. Trump, not yet a candidate, and kept it up, went on and on with jokes, all at Mr. Trump's expense, they kept coming, and coming. And at first he tried to take them, pursed his lips in a smile. Then the smile went away, and his face hardened, turned blank, emotionless, flat. Then the brow furrowed, an empty stare, the one we associate with dissociating. And at some moment, it might have been that moment, now President Trump elect consciously made a decision, determined to show President Obama, to show them all, to show everyone sitting at that dinner, all those people from the press cub laughing it up. He would show them exactly who they were messing with, embarrassing. Embarrassing someone is, in some circles, a very dangerous, negative, bad thing, even a huge sin. 

That said, my mother loved it when we made fun of her, thrived on it, embarrassed or not. To her, the most humble person on the planet, the family laughing, uproariously, even at her, especially at her, was a good thing, good fun.  

But back to our story, the What Else is New, story, about the pattern, when people start positive then get off track, have no staying power with a good emotion, also known as the

I can't be happy with just that, just having had a good week, it's not enough

pattern. Just doing great is not enough. Therapists wonder, will there ever be enough therapy to help this patient? Defining success is the answer, certainly. Will he ever get better? Again, define better. He will, if we are patient, don't impose our values or needs upon our client. All of us resist change, get married to our emotions, and usually lean towards a favorite emotion, the one that suits us best.

This is part of the job, working with difficult marriages, especially marriages to negative emotions. And we all have our pet peeves, our interface. We dislike particular character traits, certain responses in particular. So as a therapist who happens to be a person, too, one grateful for everything good in her life, for every good day, even the bad days, grateful for the people she knows and mostly loves, even her patients, as a person who is grateful when the elevator isn't slow, or when someone opens a door for her, who is happy when the phone call on voicemail isn't spam, or a relative from far away sends an email, one who feels blessed with the opportunity to have one more free day, who is not wrongly imprisoned, immobile from an accident, or dreading the next bout with her health, not that aging is a picnic, such a therapist's feeling, when that patient shoe finally drops, when that man's good day takes a turn to an angry day, evokes, for lack of a better word, impatience.

When the zinger comes, the story about whoever or whatever it was that burst the bubble, the sense of goodness, a therapist is likely to envision the silent cartoon bubble over her head, the one that says "And what else is new?"

The good therapist rarely says that, though, not aloud, and wouldn't repeat it, is embarrassed for thinking it. Because the "what else is new?" is not empathetic, and empathy is what is called for in therapy. Patience, not sarcasm. The job is to let the patient spleen (rant on angrily) until there are no more words, because THAT is what is therapeutic about therapy, 99% of the time. Then the processing, maybe, if the patient allows, if time allows. Otherwise, we're merely to let the patient spleen.

That, so they come back. Once when I was consulting with a very high end group, an academic medical group, the director told me, "Whatever you do, just keep them coming back," and I never forgot it. "Are you serious," I asked. And he said, "Yes." This is a people pleasing job.

The odds are therapists will be empathetic, not mean. We're not going to say, What else is new? The drop of the other shoe is predictable, the same things still bother the same people, which is why the go-to response will be:

"Wow, so inappropriate!"  when it is about what the other person did or didn't say, did or didn't do. Whatever it was that made the patient, who had been doing so well, so angry, cannot be minimized, not ever.  Empathy, not sarcasm, not even a joke.  

therapydoc

That would be enough, that snapshot.  But it is a holiday, and folks do sit around, hunt for things to read, and it seems to me, before life got in the way, that I used to post a blog every so often and link to or recommend other blogs. That was when there was time to read other bloggers, but there's something else. Bloggers, back in the day, were not in it to find business, or maybe they were and I just didn't notice. But there was an innocence, a real creative thing going on. 

And you know, things change. Yet, there's still good reading out there, and it is formatted so well. It wasn't hard to find good blogs. So without endorsing, or even agreeing with the following therapist-writers, for your entertainment and erudition, here you go. 

Being partial to AA and AA bloggers, we have to begin with Drinking Diaries, especially this time of year, when the booze and drugging opportunities play.

And Syd, I'm Just F.I.N.E (hi Syd!)

Anita Sanz, in I've Got Your Back, on boundaries. You could say, life is like a bowl of Halloween candy, without any boundaries. You go girl.

Therese Borchard, an old blogger buddy, writes on the New Science of Exercise (and depression), because who are we kidding? Unless you move around, physically shake the lead out, the symptoms of depression, i.e., vegetating, hyper-hypo eating, lethargy, anomie, thoughts of worthlessness, hopelessness, etc., move in. Friday, do more than shop. Take a real power walk.

And Lindsay Holmes, of the Huffington Post, brilliant. Watch where you seat people at the table this Thanksgiving. But you already knew that. .

A Handy Self-Care Guide For When Politics Come Up At Thanksgiving

Kim Bowen, at The Marriage Place has some thoughts on verbal abuse. My own can't be verbalized (it brings out the warrior female, just saying). MEN WHO RAGE AND THE WOMEN WHO LOVE THEM  Also, just an fyi, all due respect, women who rage aren't exactly rare. But you knew that.

Karen Franklin, a forensic psychologist presents the another side to the crimes that make us cringe, abductions, physical-sexual assault, and a review of the numbing podcasts that chew them up. For those who don't mind taking a walk on the dark side, she's prolific.  

If you're into transitional objects, and object to the latest hysteria about how to properly put your baby to sleep, Claudia Gold, an MD has a terrific post, one that debunks the myths. Old fashioned pediatrics in the New AAP Sleep Guidelines, the Baby Box. . .Child In Mind is her blog. Thanks Doc!

And of course, if you're in the mood for a little education, you should check out SocialWorkSpeaks, where you'll find research snaps and news about mental health professions who get out of the office and do, what I call, real social work.

There are more, for sure, but you have cooking to do, or moping, and you have to love yourself either way. Happy Thanksgiving, and Go Cubs! (smiley face there)

therapydoc

Anarchist Soccer Mom: A modest proposal to VP-elect Mike Pence. (on abortion). 

Extremes, Exaggeration, Cut-offs, Boundaries and Homeostasis

Or: How Failing to Establish Boundaries, thus Needing to Cut Someone Off, an Exaggerated and Extreme but Sometimes Necessary Measure, Can Be Avoided 

(1) Extremes and Exaggerations

There was a Jewish sage, the Rambam, I think, Maimonides, who lived in the twelfth century. A doctor, (they didn't specialize then) he recommended that if you want to change something about yourself, your life, then err on side of extreme. If you are shy, exaggerate working the room. Act social.  Make yourself talk until people are bored listening to you. (All this my interpretation of a distant memory, probably wrong.)

If you are angry, become the Dalai Lama.

If you are late, strive to make every appointment really, really early.

Pushed too far it is ridiculous. If you are old, work at being young. If you are sick, make yourself well. Exaggerating doesn't work for everything, and surely the Rambam knew that.

The chachma (Soft "ch" not like the "ch" in "chuck", but sounds like "chuck", roughly; means wisdom in Hebrew or Yiddish or both), the chachma is that if you try to exaggerate a behavioral trait, if you over-shoot, aim for much more or much less, you are likely to fail, to miss that faraway objective. But the arrow will fall center, and you will be in a better place than before you tried.

I'd add, keep those expectations low (he may have said that, too). We all lose weight, then gain weight, then lose weight, then gain it back, hundreds of thousands of times in a lifetime, and the goals are usually unrealistic. Expect less, try for just a little success, and be grateful that on occasion you still enjoy eating.

Over-shooting works in that we improve, if only temporarily. Systems are homeostatic, especially behavioral systems, depressingly predictable. And yet: if we can handle failure, adopt a benign pick yourself up, brush yourself off, start all over again mentality, then at least we won't completely go to seed. We'll succeed some of the time. The job is to keep those times coming with practice.

Rambam's cognitive-behavioral therapy is useful in that way. The problem, of course, is that someone who is too shy to walk into a room isn't able to work one, not right away, not even for a day. So most behaviorists suggest baby steps. We'll get to those.

But first, what about the hocus pocus of The Secret, that book I never read but heard about from at least a dozen patients when it made the rounds and spotted right away as a great visual cognitive therapy.

The idea, seemingly, is that we all want to be different, better, but before we shoot off our new great idea, or buy new clothes, or invest in a weight-loss pill, maybe even get therapy or a lottery ticket, before doing anything to improve, best to imagine the change.

Start with a vision, a picture of more of a good quality, a picture of less of an undesirable one. If we mentally focus on the new me (rich!) and do it often, spend significant amounts of time imagining what change looks like, we are likely to wear it. In that Iphone video in your head, you are the star:

 No thanks, I'll pass on the cake.  

First you see yourself saying that. There you are, passing on the cake.

As opposed to everyone's favorite lyric, a send-off on a maudlin, yet wonderful Les Mis song, A little drop of rain can hardly hurt me now, that spawned my family's concessionary joke

A little piece of cake can hardly hurt me now.It's here, that's all I need to knowwww.

Better: See me. See the cake. See me taking the classic pass on the cake.

No thanks, I'll pass on the cake.

Too extreme for some people, and too time consuming, all that imagining, if it is going to be effective. And there may be something about depending upon the spirit world and who knows how that will go? Thus many of us recommend moderation.

I'll have just a little piece of cake. Please.

Moderation is the go-to strategy, most likely, of every great philosopher. (All of us don't make it through Philosophy 101, so I really don't know.  But probably even the Rambam loves moderation in another chapter of the same book, or a different book. Ask a scholar.)

So that's good. But as I said, I like Baby Steps, made famous in some movie or another. A toe in the water, then the entire foot, ankle. Take it slow. No need to do everything in a week, no need to accomplish everything in a month, think the year. The New Year's resolution but break that puppy down. Don't swim every day, not at first. Don't jog every day. Don't eat well every day, you won't anyway; why beat yourself up about it. Plan only your next step. Even with religion, slow it down. Baby steps.

Get used to the water.

It's all good, any attempt at change is good, but the extremes get us into trouble if we go there directly. The problem with extremes, even wanting to go there, is that they are so extreme. Never eat chocolate. Never get angry. Can we battle homeostasis, a law of nature? Hardly. The consequence of never get angry is blowing up out of context, scaring the daylights out of everyone.

And as long as we're rambling and losing focus something else happens when we deny our anger. We lose self. Nobody knows who we are. We lose such a huge piece of ourselves, our passion, we become unidentifiable, blend in with the sofa.

We have to manage anger, obviously, but losing it altogether is like losing salt and pepper. The food is missing something and we're not interested. We're not even going to discuss chocolate.

(2) Cut-offs and Boundaries

A social cut-off is extreme. Doing it feels extreme, and being cut-off is sometimes a call to panic. No one there to tell you, No need to freak out. Homeostasis.

Years ago a friend told me that her father-in-law was such an impossibly insensitive man, he said so many insensitive things, that she couldn't be around him, had an averse response to just being with him. Panic attacks at family dinners. Her therapist suggested she cut him off. She called the dad-in-law "borderline."

As if this is a reason to cut someone off. Understandable, but extreme. There are books about difficult people, understanding why a person is difficult. I prefer the word, complicated.

But it happens quite often, therapists recommending cut-offs, usually when someone won't respect boundaries. Figuring that out, how to set a boundary, and keep it set, is an objective of many therapies. Loosening boundaries to open up to more intimacy, is another.

Not going to lie, it is healing to cut off  contact for awhile with particular people, maybe for months, even longer. But it should be discussed. Anyone with the chutzpa to blast through personal boundaries can handle our labeling their behavior. And it shouldn't be forever, the cut-off.

It is easy to cut people off by moving away. Too busy to call anyone back, hoping the needier, more dependent, or difficult individuals will lose our scent, it is a lovely, expensive way to emotional relief.

Inconvenient and cowardly. Better to assert, label the hurt, the criticism, the panic attacks at the sound of criticism, the negativity dripping from that someone's mouth, even when it is negativity about others, not us, when the negativity is about the universe, or one of the protected classes, those gays, those whatever.

All of it, label it all. Make a splash in a calm, assertive, no need to get emotional fashion.

I disagree, why bring yourself up by putting other people down? 

Not that this will necessarily work. But we script it in therapy. Nothing to lose. Nothing. (We're not talking about physically abusive relationships).

Those who are cut off seek help, too.They are sad, don't like that they chase and lose. They are often seeking intimacy, ironically.

That's why it is so admirable when a person doesn't want to be the bad guy, when we want to say, in so many words, Don't call me anymore, don't visit, and I'm de-friending you on FaceBook, when we want to do this, say it, but don't. We just can't bring ourselves to it. To survive, we make an occasional process comment like the one above about putting people down, or we're straight about why we don't spend so much time with the other person.

I'm a conflict avoider, and you're really negative, a lot.

Such strength to say those words. Feels impossible. It isn't.

People who don't cut off difficult others (again, a disclaimer, not talking about sociopaths or even almost sociopaths) have learned that when there is a reunion, a party, when backed into a corner, our boundaries about to be seriously compromised, we need an exit strategy or a magazine, a puzzle, a game, something to rip out and use to disappear.

You know that cutting someone off is shooting them in the heart.

How do we mend that particular broken heart when it is our heart and we have been cut off?

Best to assume that the one who cut us off is self-protecting, setting a boundary. Most of us, if we rationally examine our behavior, can see our own faults. If we can't, we should ask someone who knows us well. We may not think our words or actions are hurtful, but if someone isn't talking to us, then they may have been hurt. Apologies upon that epiphany, what we did wrong, sometimes work, but are no magic bullet. And if someone doesn't take our apology, at least we tried.

And if rapproachment, or detente, never happen? If the relationship stays disengaged, cut off, a seeming non-relationship (as if there ever could be a non-relationship) wait.

Have it in mind, always, to wait. In the interim, both of you grow, become infinitely more interesting, funnier, smarter, wiser, less-judgmental. Deeper. Not always, but often.  When people change, there's nothing quite like it. We want to be their friend. They want to be ours. We have to respect those boundaries until that happens, even after we have grown.

Those who cut off, who set what feels like an impermeable boundary, can only hope that the ones shut out will still want to be with them by then.

therapydoc