Do therapy docs really listen?

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

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

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

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

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

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

WHO LISTENS?

Okay. Maybe so.

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

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

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

But I think we're getting somewhere.

Copyright 2006, TherapyDoc

Evil Step-Mother-First Installment

EVIL STEP-MOTHER

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

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

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

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

Here's a common scene.

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

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

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

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

EDDIE: Go to hell.

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

Eddie ignores her.

MIRANDA: Eddie! GET GOING!

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

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

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


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

Pseudo-intimacy and triangles

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

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


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

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

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

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

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

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

HER is the EVIL STEP-MOTHER.

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

Copyright 2006, TherapyDoc

POT

This is less about self-medicating with marijuana than it is about how complicated and unmanageable emotions can be. One day it's depression, the next day anxiety; one day we're manic, the next day obsessive-compulsive. We get the symptom of the week, too, whatever we read about on the Internet, hear about on Oprah. We’re complicated organisms, humans.

This conversation isn’t fiction, I’ve had it many, many times.

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

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

PATIENT: I don't know. Maybe three months, maybe more.

THERAPY DOC: Sad.

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

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

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

THERAPY DOC (wondering if there are co-existing disorders, two Axis I disorders, maybe a personality disorder, too): So what do you want to work on?

PATIENT: I’d say the depression right now.

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

PATIENT: Right.

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

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

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

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

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

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

THERAPY DOC: But it's killing you.

PATIENT: Not really. It calms me down.

THERAPY DOC: Did you ever try an self-relaxation?

PATIENT: Not really, a little yoga once.

THERAPY DOC: Yoga is great. What did you learn?

PATIENT: I don’t remember, stretching, mostly.

THERAPY DOC: Before you reach for a joint, do that, get down on the floor and stretch for fifteen minutes. This is harder than you think, but do it. Then try some other distraction before the toke.

PATIENT: I’ll try. But I have these feelings all the time.

THERAPY DOC: Which is why you need more portable strategies to regulate your anxiety. That’s the problem right now, so that’s what we’ll treat right now, since you told me you don’t want to spend the time going over childhood issues.

PATIENT: Right, what’s the point?

THERAPY DOC: If you have the time, that life review thing can feel very, very good. But okay. Today you’re just needing something to depend upon other than sucking down poison, and smoking pot, so I’ll teach you a quick muscle-relaxation exercise. Would you like that?

PATIENT: I believe I have no choice.

THERAPY DOC: Not if you want to be happy if you reach retirement age. If you want to be an old drug addict, you can make that happen, too.

PATIENT: Uh, I don’t think that’s what I want.

THERAPY DOC: Grab a couple of thick markers and squeeze the hell out of them until your biceps quiver. Can you do that? Let me demonstrate. (I demonstrate, offer markers to the patient). You can do this by just making a fist and squeezing it, behind your back if you like in public. It’s not so easy if your nails are long. You can squeeze any part of your body. Getting yourself into a push-up position, for example, and not doing the push-up, just holding it, makes those muscles shake quite nicely, or leaning on your hands in that position standing against a wall. Oh, and get out and walk, run, exercise. This shakes off some of the anxiety, too, wakes up the serotonin in the brain, shakes it out of the walls of the neurons in your brain. We don’t call it runner’s high for nothing. Play basketball, tennis. DANCE!

.
People do much better with these kinds of interventions than they do getting stoned, crazy though it may sound. Not a cure-all for everyone, certainly, but eliminating the downer, the pot or the alcohol, substances that serve as depressants to the central nervous system, surely helps the depression.

A good evaluation by a therapist, and a psychiatrist, too, sometimes, saves you a lot of money on the street. And you might lose a lot of weight, too.

therapydoc

Deception

Dear Therapy Doc,

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

He looks me right in the eye and lies!

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

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

Feeling Like a Failure

Dear Feeling Like a Failure,

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

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

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

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

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

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

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

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

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

Therapy Doc

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

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

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

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

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

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

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

Or are you?

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

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

Gotta' run, T.D.


Copyright Therapy Doc, 2006

Blood is thicker than water.

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

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

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

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

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

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

Susan thought,

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

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

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

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

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

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

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

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

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

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

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

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

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

Preferably BEFORE the wedding.

Copyright Therapy Doc, 2006

Gone Postal

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

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

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

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

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

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

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

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

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

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

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

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

You want to know what happened? Sure you do.

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

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

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

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

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

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

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

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

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

But he never did.

Copyright Therapy Doc, 2006