How to Have an Afffair

I wanted to read more about the Congressman caught in his second affair last week, but couldn't remember any details. So I Googled affair and half-way down the first page found, "How to Have an Affair,"  subtext, "And Not Get Caught."

Turns out the Tennessee congressman's name is Scott DesJarlais. It is an ugly story, probably only half true.  (My mother-in-law tells us that we should believe only half of what we hear, and in this she is probably correct.)  We can only hope.

Google landed on How to Have an Affair, however, and crazy thing is I had no interest in reading the article, assumed it a teaser for an e-book.  I'm all about the affair being between two committed partners, preferably married partners, but not necessarily.  This is satisfying, too, and less time-consuming.

The usually tepid, if sometimes torrential, intramarital love affair has no beginning and no end, mitigates conflict naturally, and is not as rare as people who have extramarital affairs seem to think.

No need to elaborate much on the benefits, but marriage has  many inherent stresses, and the intramarital affair buffers stress, as it is designed to do.  The sense that one has a dedicated-to-exclusivity-with-a-vengeance  life-partner, one who works at love (because this takes much work) under any and all circumstances, even if it doesn't feel like love all of the time, even when communication seems to indicate the opposite of love, even when a person has no clothes on, perhaps even more for that, is highly rewarding.

It is more rewarding still if one can whip a lackadaisical partner into shape, not literally, not unless that is what he or she desires, rather can shape said partner into the role, for lack of a better word, of true partner. Meaning get him or her to wash and put away dishes, serve once in awhile, perhaps fix a broken bicycle or hire someone to fix the doorknob.

I prefer reading about this sort of thing to reading about behavior that jeopardizes this sort of thing.

It doesn't take tremendous imagination to see why people still want to have extramarital affairs, however, and do so, and to see why they don't want to get caught, although wanting to get caught is likely the impetus for the affair in the first place.  Why would anyone want to get caught?

Still working out cutting school is why, or not cutting school, not having pushed limits enough as children.Or still working out the identified patient role.  Children misbehave, they act out, to get caught.  They want to draw their parents into therapy, at least get them to talk to one another, to bond, if necessary, over the problem at hand, their errant child.

Being a problem child can be about expressing frustration over bullies, abuse, difficult teachers, learning disabilities, Pediatric Bipolar Disorder, Diisruptive Mood Dysregulation Disorder, or a host of other childhood issues, but it isn't always.  Often it is about looking to fix their broken families, expressing the pain of the family, or merely needing more time and attention.

As the saying goes: Any attention beats no attention, even negative attention.  Negative attention being an angry response or punishment from a parent.

So getting caught is the objective.

And we get better at it, acting out to get caught, as we age and need to individuate, to be our own persons.  We do it by stretching parental limits, by saying, "You're not the boss of me," and breaking rules,  getting away with breaking all kinds of rules, especially the ones that matter most to their parents.

Fast forward.

therapydoc

Panic, Family Systems, and Psychoeducation

Sometimes it's easier not to blog at all than to try to explain systems in plain talk. But let's try anyway.

I'll just go stream of consciousness, if you don't mind, and you guys put it together, because there's so much work to do (other than this) and time is always nagging at me. I just grocery shopped, for example, something normal people just do, worry-free(not thinking about time) and did the self check-out. It all went fairly well, but as I left, it was clear-- a waste of time, self check-out, if you have a big order, if you're me.

And those beeps are louder when you're the one making them.

THE STORY:

Last night I got a call from a patient, one of the handfuls of patients I encourage to call me when they're under the influence of panic. The job, of course, is to teach the family to do this, to address the panic, to get myself out of the system. But often it is the family that is stirring the panic.

So the therapist has to treat the family members, too, for they have to know how they're doing it, stirring the panic, and they have to want not do it. Getting all of the above to happen requires time.

So we're not there yet, not last night, the family is just beginning to get the big picture, and the patient calls me, and it's good timing, actually, so I start a game of Spider and take the call, because for some crazy reason, I can play Spider Solitaire and concentrate on words at the same time. I'm no longer addicted to this game is the truth, rarely even play it, but FD started to play it, and as a result, I'm playing it again when I need something to do and have to concentrate at the same time, hear what someone's saying.

Or can't sleep and it's too late to learn anything and have canceled all the fashion mag scripts and am tired of reading and writing blogs.

Anyway, I talk her down via psychoeducation. The beauty and the beast of psychoeducation is that people want to know why things are happening to them, that's the beauty. But we can't explain it all on one foot, is the beast. And the irony is that although we know about the triggers, can recognize things that aggravate arousal, we can't explain everything, not that it isn’t a worthy endeavor to try. The investigative process, however, should be something you do in the office. But sometimes things need to be reinforced, and sometimes, in pre-panic mode, you get new insight, new information, never been told before, not yet processed.

Raw.

So I like to get that information, as long as it's before 9 o'clock.

I need it pre-panic because people can’t process rationally while under panic. Panic turns the brain to junk, basically. Which is why I say, Catch it pre-panic. If you’re going to call, call me pre-panic. We can head it off.

So we take a quick look at the thought, air it out and examine it, and we find, lo and behold, that someone else in the family has expressed the same thing in the past, the same negative thought.

And since personal boundaries just stink at some stages of life, certainly young adulthood, when the thought pops into our minds we don't know why it's there. It can happen that someone else’s thought becomes our thought. And this is really scary. The thought itself is scary, and not knowing where the hell it came from is scary, or why we have it. You can see how people think they're possessed.

But they're not. They just have poor boundaries.

Sometimes the person who has expressed the negative thought originally in the past is doing it now, in the here and now, stressing the patient unknowingly. Or maybe knowingly.

(As an aside, panic isn't always triggered by negative thoughts, and it’s not always about boundaries, it’s never always about anything. We're just looking at this slice of psychology right now).

So a family therapist will yank the original thought-keeper into the therapy, the one who also has this thought (usually a parent, but not always), or something similar, and will work on a multi-system level, will address this person's thoughts and how negative thoughts originated, how they still disturb, and how they are affecting others, meaning the identified patient, my patient.

And we can help this person cope without dragging vulnerable others into the coping process, polluting the identified patient's thoughts. We set all kinds of boundaries in therapy. Someone asked me to post on boundaries, and you see I can't, post on them in any generic way. There are simply too many.

Hopefully, depending upon how deeply the original thought-keeper suffers from features of personality disorders (how oppositional, usually, or narcissistic) we'll get a good result. Voila. Magic. Everybody begins to heal.

What if, however, you can't do that, can't get that other person in the family into therapy, can't engage the one still triggering emotional distress?

It's harder, but we help the identified patient with insight, understanding, and work towards behavioral change. We look at the negative thoughts and tag them as old stuff as unresolved childhood junk, and counter them. Ultimately it is about shoring up the boundaries of self, differentiating, becoming one's own person, impervious, if not insensitive, to the noise and distressing energy in the family. There can be so much of that.

Family therapists find at least one significant other, a sibling perhaps, or all of them if possible, and their spouses, educate everyone about the situation, the patient’s needs. We’ll have the patient do it as much as possible, tell over the psychoeducation that has been learned in therapy. This reinforces the learning. This is extremely intimate, you know, telling someone you have a problem and need that person to help you on occasion.

With time a person doesn't need anyone to reinforce rational thought. The brain will go there naturally, and you'll be okay.

And I'll miss that solitaire game, you know. But I lost it anyway.

therapydoc

History and Strategy

You might find this question and answer interesting.

A reader writes in response to the shame post, The Bistro and the Date (below). First he answers those all important questions* then asks

How can I keep my boundaries tight when my family tries to sabotage what I think should be a moratorium (a.k.a. cut-off ) for the sake of my mental health?

The reader worked for years to distance himself from his verbally abusive father, a man who denies his emotionally violent parenting to this day.

If I were the reader's therapist, I would explain that it is shame that is buried under those layers of denial, that his father and he may not be all that different. The difference is subtle but important. His father's shame is so tragic, so toxic, that it is no longer conscious, he has successfully defended with that most primitive of defenses, denial, unconscious denial, the worst kind. He has to believe himself a good dad. Anything else would destroy him. He hasn't psychic permission, he hasn't given himself permission, to be imperfect.

An identified patient like our reader will sometimes try to cut off communication with people in the family who were "dysfunctional" "toxic" "violent." He may try to hang onto one limb, to save a relationships with a sibling, the seemingly healthiest member of the family.

But this last branch, his only connection, will eventually become angry and resentful, may even threaten to cut him off unless he reconnects when parents become elderly and physically unwell. Siblings needs one another when that happens, when there's family work to share.

We're addressing cut-offs here, obviously. The reason people cut-off their families is not that they don't need them or feel responsible and connected to them, but their families became sources of pain. Families do abuse and shame, betray members. Mis-steps such as these (including addicted siblings who visit and steal the silverware) make us wary. We put up boundaries.

It's the permeability of the boundary that concerns me. Boundaries need to breathe.

Parents who emotionally abuse with words, who shame their children, who fertilize a child's self-doubt, sense of inadequacy, and unworthiness have to be sealed off for a little while. The fence needs some sturdy nails. Not electricity. No, I won't block the metaphor, let's keep it going.

See, you need a fence, because children who grow up with verbal abuse believe it and when it's a steady stream of negativity will join the dissension, believe the words, find someone else who will abuse them, or do the dirty work themselves, continue the lashing, cut, try suicide. Maybe succeed.

This is why therapists will advise conflicted patients to stay away from the source, to protect themselves from further emotionally violent communications with family. Heal.

But we're all human. We will want to cling to the healthiest member of the family, perhaps the one who saw the abuse, who may have also been a victim. And ultimately cut-offs fail. The family guilt and invasiveness is stronger than the average soul can stand. Therapists often get cases like these when they're sinking, shored up by a quick but ineffective hospital stay.

Sometimes during that stay the family has been involved. A family therapist like me will keep that going if I can, at discharge, will contact family members (with the patient's permission and release of information). I work to convince the family to let me take over for awhile, to give the patient less of themselves, not more. But don't worry. We'll be in touch.

And I stay in touch.

It takes time, but if a family therapist can work with the healthiest branches, things can change, really change for the best. Branches only need be a little green to grow. People change late in life, given the chance, given the relabel, the opportunity to be a hero.

But what do we do when it's too late for that, when the cut-off is fragile and not working, and Dad is sick in the hospital and our Identified Patient hasn't the strength to deal?

Not at all uncommon. The sibling, the one care-taking Dad, wielding the chain-saw (help me or you're no longer my brother/sister), is clearly of the tougher child variety. But even the tougher children wear down when they have to care-take sick parents. They look tough. But it's just for show.

Family therapists push for direct communication. First the identified patient has to be straight with his or her sibling(s), the care-taker(s), either by writing (under a therapist's direction and editorial skill) or calling (in the therapist's presence) to communicate something along these lines:

I'm going to call Dad or write to him and tell him what's going on with me. I'm sorry you're stuck with this, but for the time being I probably won't be visiting. I'm not quite healthy enough yet, but I'm working on it. Here's what I'm going to tell our father:

And here is what the identified patient would tell his or her father, either by telephone or in a letter, not face to face, something along these lines

I'm sorry that I'm too sick to reconnect with you right now, that I'm no good to you. Some children, the ones with big issues, get a little funky when parents get sick, and that's what I am right now, laid a little low, too depressed and withdrawn to get out of my shell to help out with you, visit with you.

I know you don't believe in mental illness, but you and I are different like that. You probably see this as a weakness and an excuse. So be it. It's real enough to me to make visiting impossible right now. I just can't do it. I hope that you don't hate me for it. I imagine you do.

One day I'm sure I'll regret this decision, not seeing you, not helping you. It doesn't seem fair to do this to you, especially now. But I don't see life as fair. A parent raises his kids, gives them his all, and just when he needs them, they're gone.

I have bad memories of us, and they haunt me (this is called chipping denial, you're not accusing him of anything). I have to work through things, mostly negative thoughts about myself, nobody else. You did the best you could. You tried to parent the best you could.

I feel like a bad person, a failure, for not meeting your expectations.

I'm in therapy, working on my own set of expectations, and how I'm going to live with myself when you're gone.

Maybe I'll get it together soon. Who knows? I don't expect you to forgive me for this or to really understand me. But despite your take on mental illness, I think everyone gets depressed sometimes. Maybe even you.

And then the identified patient stops talking or signs off (he doesn't have to write "Love" that's up to him) and hopes his father begins to talk about his own feelings, his own depression, his own childhood abuse, knowing he probably won't.

But he might. They sometimes do.

This is a strategic intervention, full of lies. The identified patient is not remorseful, probably doesn't even believe his father did the best that he could. The identified patient may never regret not talking to his father, cutting him off.

With good therapy, he will live with himself just fine once his father has passed on. He probably won't care. Some celebrate. It is survival we're talking about here. And you can't always sleep with a person you perceive as the enemy. You can't always go home just because they're ringing the dinner bell.

The therapy, surely, is about changing that perception, the one that identifies the parent as the enemy. If that's possible.

To do that, you need history. You need the extent to which the parent suffered abuse during childhood. If the identified patient doesn't know the history or denies transgenerational abuse, I make finding out a therapeutic objective. It's there.

He was criticized, abused, shamed. Not loved. Abandoned. The child who cuts him off finishes the job. It's the unkindest cut.

In family therapy you want to get to a point with an abusive parent that you can admit you're not so tough. You don't know how he survived his childhood. How did he do it?

Families can toughen us up or wear us down. The resilience variable is having a healthy adult around who counters the abuse, one who puts a hand on the abused child's shoulder and says, "You're a good kid, a wonderful kid. You'll grow up. You'll get out. Talk to me any time. Tell me everything."

We can get into calling authorities about child abuse another day. In a word, Yes. Call.


therapydoc

*Those questions include:

Did (your father/mother/guardian) call (you) lazy?
Retarded?
A loser?
A fool?
Stupid?
With gusto? With sarcasm? With hate? Disgust?
Were there tirades directed at making people feel badly about themselves?

The Kingpin

We'll just go right to the story.

A few years ago I got a call from a colleague who wanted to refer me a patient. Not just any patient, of course. A really, really difficult patient, a complicated patient (like there are people who aren't difficult, who aren't complicated).

The details and demographics in this post have all been changed, so no, this isn't about you or anyone else that you know; it's fiction, and even if you think you're the colleague, believe me, you're not.

We'll make the identified patient a teenager, a girl of 14 who acts more like a 4-year old with an advanced vocabulary. She's physically violent, verbally abusive, self-centered, infantile, and ALD, A Little Different, although I think my friend's exact words were,

"She's very weird."

Some kids can be a little weird. They're kids. I don't like diagnosing them or making them into outliers* because they're just kids. A little different is much better than a little weird, but we're colleagues, and when we get to talking we might get a little loose, may not always be so p.c.

But we like different. Or we should. Why go into this field if not to meet all kinds of people? Don't tell me it's to help. Help is the process, that's what we do. It's not necessarily our motivation for doing it.

I get these kinds of consults on occasion. The colleague will say,

I've never met anyone like her in my life!

Code for,

Surely you want to take her off my hands!

Sometimes, when I listen to the details of the case, I'll whisper under my breath, Marvelous. I'm not saying the case is marvelous or happy, or good. I'm saying: This is so interesting. And it is.

So I'll listen and then I'll make some suggestions, tell the doc what to try to do differently, maybe even take the case. But I try to avoid kids who are reputedly violent, unless they're under a medical doctor's care, as in a psychiatrist. And I need to know that the kid's been quiet for awhile, has moments of wellness, as this little girl, the one my colleague wants to refer to me, has when she's in school. And I need to know that the family is willing to pop the kid into the hospital if necessary.

Why would I be abused? One lamp flying at a person in a lifetime (by a nine year old, I ducked) in a career is enough. Kids can do that, beat up therapists, both physically and verbally. And they come in with weapons. We live in a violent world. Kids have showed me their weapons. I say, Leave your knives at the door, and they smile, take out knives, leave them at the door.

"Tell me about the case," I say.

The 14 year old has always been different, socially inappropriate, Asperger's-like, angry, sad. Whatever it is, the emotion that's expressed is always extreme. But that's only with family, rarely with peers, and it's escalated, her anger, her mood swings, her attention seeking, her non-stop dependent behavior and whining around her parents.

But in school she's under control. The girls in her class aren't mashugee** for her, but they don't socially ostracize her, either.

Let's say, to make it interesting, that she has four or five other siblings, two with severe developmental delays. One aunt has schizophrenia; her mother OCD, an uncle has bi-polar disorder, and her father has ADHD and depression. It's a vegetable soup of diagnoses, and this is just a phone consult. I've yet to ask a question.

My colleague has seen the patient and her parents in various combinations for over a year. The symptoms have escalated in the past few months. Parents get along with one another well, but they're both overwhelmed with their lot, their children.

"Any recent changes, deaths, perhaps?" I ask.

"No."

"Separations?"

"Uh, uh."

"Who pays for all the therapy?"

"Grandpa. He's loaded."

"And where does Grandpa live?"

She names a wealthy suburb.

"Is he involved in the patient's life?"

"He used to be, but since the kid got really bad, and since he read the psychological tests, he's distanced himself. The tests are packed with ugly diagnoses, a negative prognosis. And the kid insulted Grandpa, literally kicked him. Gramps can't take the disrespect. I understand the two of them were really close when she was a little younger."

"You have to get Grandpa into the therapy."

"They're afraid to stress him, afraid he'll stop paying the bills."

"They are? Or you are?"

"They're afraid of rocking the boat."

"So the kid does it for them. She won't get better without him. And with him, it's likely she will. There's your missing relationship. She needs him. Her parents are busy with the other kids. Sometimes if it looks like a duck, it's a duck. And they already love one another. Include another sib if you can, too. Maybe all of them in different combinations. People spend money on lesser things."

End of consult. I gotta' go.

It's funny. My father-in-law (OBS)*** believed that if you paid the bills, you called the shots. It's not true, though, when you have a sick kid, is it? When your kid or grandkid is sick, you can't will things to get better. You can't make a sick kid behave, make a kid show respect. You can't buy the cure.

But in a case like this one, the person who is paying the bills has some power, some leverage. He's left, he can come back. How hard is this?

He may have to change the way he is with his granddaughter, may have to change the way he talks to her, lower his expectations, add new ones. You're only a family therapist; he's the kid's grandfather. That's what you tell him on the phone. Who knows the kid better than him?

He's pumped up, respected. You tell him you're very sure that he knows how to work this kid, and you're interested in his opinions. People will obviously have to change the way they respond to her behavior, you suggest. Then you ask, Who should change what? How?

He has so much to tell you. He starts the ball rolling. You stop him somewhere in the middle. You say you have another patient. When can he come in? Soon, of course, he wants to continue to help. He makes an appointment.

Then the two of you strategize. He is the kingpin. You are a shlepper,**** a professional who knows nothing about this family system. We professionals are nothing without family input. The family has the answers. He, Grandpa, is your man.

More than likely you'll come up with this plan, or a variation of it.

He should expect to be called names. He should respond with kindness. "I won't reject you if you don't reject me," is his best response. He will need to say this over and over again, say it in different ways.

Everything, everything, depends upon his love. He can't give up on his granddaughter when she needs him the most.

You bring him into the therapy. You yourself, as a therapist, give him the respect he deserves. You engage that person who's paying the bills, who wants to call the shots, and you work the angles you know have to be worked, the relationship angles, the sweetness, the love.

You pull Grampa in and the kid has half a chance.

All that and a nickel, my father-in-law would have said, will get me a cup of coffee, which she owes me, come to think of it, my colleague.

therapydoc

*an outlier in a data set is a score that's Way higher or Way lower than the rest of the distribution.

**mashugee* is Yiddish for out there, but in this case it means, head over heels excited about, or wild about

***OBS is something like, Up in Heaven, or he should go up in peace

****Shlepper literally means someone who shleps, carries things, but here a shlepper is someone who is clearly not an executive.