Spirituality, Mental Health and Desperate Housewives?

I didn't see it coming, honest. All set to write about spirituality and mental health, my show comes back on the air. And it's about spirituality, and maybe mental health.

We really took a hit with that writer's strike. Three months of no Desperate. No Boston Legal. Let's not let this happen again. Please.

Warning: Although I only reveal one subplot, the following post might be a spoiler if you haven't seen the April 13, 2008 episode of Desperate Housewives.

As soon as I saw the listing in TV guide this morning I emailed all my kids between patients to tell them Desperate would be on tonight. I inserted this announcement in a thread FD started about all the topics we can't talk about at the Passover seder. Only Empath Daught cared in the least bit about my show.

"We'll talk tomorrow!" she said.

Indeed.

Did I tell you that I shlepped the exercycle up from the basement so that I could watch cable and fake a little cardiovascular at the same time? It's a compact little thing that my significant other lifted from someone's basement for fifty dollars, but it weighs a ton. He couldn't believe I got it upstairs myself, having sworn off furniture years ago.

This is what happens when that ant gets going at the rubber tree plant.

Anyway, a few years ago I had a patient who experienced an Aha spirituality moment. Spirituality is a big thing in mental health. I think I wrote in a previous post that the HMO's ask therapists to check off ten or so "specialties" for referrals and that spirituality is on a list of about thirty "areas of interest."

At the time I saw way too many patients for my own health and didn't turn down many HMO panels. This is probably the default reason therapists get cranky, too many patients, too much stress. And to merit too many patients and too much stress, one fills out managed care applications and checks off specialties like, spirituality.

Being kind of religious person, I thought maybe I should check that, since I felt that I could empathize with anyone who used the Higher Power coping strategy thing.

Except on occasion I'd get a call like this:

You're a Christian therapist, right?

Uh, no.

Never mind.

Click.

This made me feel bad, especially since I really like people no matter their race, color, creed, etc., assuming they're not into terrorism or any kind of violent belief system, and yes, I have reservations about taking patients who believe in incest, statutory rape, bigamy, polygamy, and the like.

What's good about being religious, however, is that when a patient wants to talk about spirituality, or his or her concept of the Old Mighty, I'm not afraid of the discussion. In fact I'm totally open to all of it: atheism, agnosticism, as well as a belief in something out there. I'll even tip my hat to aliens, and have.

How DID we ever get on this subject, anyway?

Oh yes. What I wanted to put out here is an Aha moment, a patient's Aha moment. (all identifying details are changed, of course, as always)

Our unidentified patient obsessed about relationships, not unlike many of us. She obsessed about her boyfriends, she obsessed about her mother. She obsessed about her children and her neighbors, the clerks at Nordstrom, even the people she typed for at the office.

Then one day, in the throes of depression, she sat in a chair totally wrecked with despair. She talked out loud to what she thought of as the Old Mighty (what my grandfather, not terribly familiar with English, called Him or Her). She talked to her Higher Power and she cried. She prayed and talked, discussed and argued with her Maker. Would it be so terrible, she asked, if.. . Would it spoil, some vast eternal plan?

Sure, she was Jewish. We do this, argue, try to reason on occasion.

When all of a sudden she had that Aha moment. As she tells it, "All my life I've been wasting my time obsessing about people, thinking what I want to tell them, worrying about what they'll think of me! I should really be talking to Him! I get nowhere with people, and when I talk to Him, not only do I feel He's listening, but it's possible, certainly, that He'll answer. And no one else does, honestly. There's nothing to lose. It's a win-win!"

Do I plug assertiveness training or social skills at this point? What would you do?

It is a tough call. But of course not. What she's talking about is a major coping strategy, one that millions of people use every day. They are believers. They have, at least in their minds, a relationship with their Big Guy/Gal.

So of course, all I do is raise an eyebrow and smile. Whereas, it could be a You go girl moment for another therapydoc. But I'd never say that. These are moments in therapy where the support is all in the look, the understanding, the empathy, it's all in the eye contact. Words pale.

Oh, you want to know what happened on Desperate Housewives. Well, Lynette has an Aha moment in tonight's show. It's Sunday morning and she's watching as her neighbors pile their families into their automobiles, all dressed up, going to church. She's the staunch non-believer in the community, has never had any formal religious education.

And she's married to a Catholic and has a bunch of children, so she's thinking maybe they should go to church. She watches her friends going off to pray and she makes a decision.

"We're going to church," she tells her husband. He fights it but she wins in the end when her son says, "Sure I know who Jesus is. He helps Santa Claus."

But which church? She relies upon Bree's church initially since Bree is the most religious of her friends. It's obvious that Bree has made it through some serious problems and she credits that resilience to her faith.

At the Presbyterian church, Lynette, unfamiliar with the formal culture, raises her hand and asks a question, something you just don't do in a Presbyterian house of worship, apparently. The minister is truly surprised, but patiently answers Lynette's questions. Bree is mortified. "You don't do that here," she whispers to her friend, desperately trying to get her to stop interrupting the service and asking the minister questions. Everyone just wants to get out of there, apparently.

Lynette continues peppering the minister in front of the congregation and Bree is dying of embarrassment. Later Bree tells Lynette, "We just don't do that in our church, ask questions of the minister."

"Huh?" Lynette asks. "I thought religion was for answering questions."

"Well, yes, but we wait for the minister to answer them in his sermons. We don't ask him anything. We hope that he'll get to answering everything eventually." Then Bree does the unthinkable, she intimates somehow that Lynette embarrassed her. Lynette gets upset and decides her family will go to the Catholic church down the street.

The next week the Presbyterian minister asks Bree, Where is your nice new friend? He's so happy she came to their church. He thanks Bree for introducing the Scavos to him, for bringing them to church.

"But she asked questions!" Bree objects, seeing the error of her ways, regretting sending Lynette away. "I thought the church is about answers, not questions!"

He corrects her, "Of course it's about questions. It's more about the questions than answers. First the questions."

You'd think he's a Jew.

Bree hurries over to the Catholic church. "You must come back, Lynette! I miss you! Please. Please leave this place and come with me to my church." Lynette doesn't fall for it.

Bree persists, "Please, let's talk outside."

They go outside to talk and Lynette tearfully confides to Bree, "I've been through cancer and a tornado and I've survived both of them. I need to know why!"

Bree gets it. Lynette isn't going to church because she feels she has to go, like everyone else. She's going because she wants to go. She's looking for answers. "Why didn't you talk to me? I had no idea. Of course you're right. Faith shouldn't be blind. We should question things. I want you to have faith, and I want you to have faith in our friendship, too."

So they make up, and I'm happy, because I hate to see friends fighting. And Lynette, bottom line, does trust her friend and they talk about the ideas of faith as the camera fades to the next scene about Susan catching her cousin in bed with. . .

Those Aha moments are really fantastic, you know. I'm pretty sure they're all about slowing it down, stepping outside of our lives and reexamining what we're doing, how we're doing it, and thinking, I should change. And the funny thing is, that although those moments surely happen in therapy, and we do speed them along, we really do, there's no reason they can't happen at home.


copyright 2008, therapydoc

Leave your religion at the door?

I'm only writing this because I've done it myself. I'm guilty of it (well, not all of it).

I've let patients feel closer to me, better understood because we share the same Judeo-Christian values. That's not bad per se, but I think when it comes at the expense of someone else, it is bad.

It's a very subtle form of triangling and I don't think we, as therapists, need to triangle anyone, least of all someone's partner or spouse, mother or sibling, to have a good therapeutic relationship. Yet it's such a temptation.

Almost anytime a therapist disses someone else this process is probably insidiously at work.

Occasionally I'll get a caller looking for a frum therapist. Frum, in my world is a reference to religious observance. In this case, Jewish and Orthodox. This kind of call is really about the importance of ethnic and ideological values in people's lives.

People want their therapist to validate, not confront, their religious values. We all want a cheer-leader sometimes. We want someone who is culturally sympathetic when we talk about what bothers us.

A religious parent with a gay child, for example, does not want or need to be told, Hey, you're out of touch. Get with reality. He's not going to get married to a nice Catholic (Jewish, Baptist, Christian) girl. Lose the dream.

I actually don't think most therapists ever talk that way.

But I can see how a person might be afraid that we would. It's no longer cool to be homophobic. Heterosexism (the assumption that everyone is a heterosexual until proven otherwise) is a program that the American Psychiatric Association, American Psychological Association, and the National Association of Social Workers have deleted.

So our professional dogma, our authority isn't religiously-orthodox-friendly, exactly, and patients from this perspective might tiptoe carefully when choosing a therapist who will be emotionally supportive. One might even prefer to choose a professional who waves his or her religion like a flag, wearing their own personal orthodoxy assuredly. An organization for parents and friends of "ex-gays", Exodus International, has support groups and therapists who hope to change the sexual orientation of the conflicted many with love and twelve step programs.

It's not so farfetched that religiously orthodox patients worry that secular therapists might emphasize a modern agenda, not empathize with the pain of a parent, for example, who has to adjust to a child/spouse's sexual minority orientation. Or sexuality in general.

People worry about therapy hurting, sometimes legitimately. Hence that joke,
therapist = the-rapist.

These fears pop up over other issues, as well.
Pre-marital sex.
Abortion.
Intermarriage.

But despite what people think, it's not true that therapists will necessarily lack empathy for religious values that they do not share. Indeed, more "secular" therapists try even harder to understand languages that are new to them.

A good therapist will not preach liberal values or anything else, for that matter. Psychoeducation is not thumping a bible. Nor is it thumping a text book.

So the best way to choose a therapist is not to seek cultural sameness and the hope of shared values. What people really need to look for in a therapist is someone well-trained in the craft.

(So sure, get even more training somehow along the way, go beyond that masters. You don't have to get a PhD to get certification in most subspecialties.)

Someone who is well-educated, who keeps up with the profession, who has empathy, good diagnostic skill, and heart will take you where you want to go.

A good therapist knows how to zero in on the pain and knows whether or not to discuss it. The patient isn't supposed to be zeroing in on anything about the therapist, particularly, not the doc's religion, not the doc's shoes. The patient should be looking inside.

(It's why I personally don't wear much jewelry or loud clothing, you know, always an excuse for people to skip topic. I love your sweater, a present? And it's why I don't want to talk about Chanukah or the other Jewish holidays. )

Let's talk about you, I say.

But if a person wants a therapist of a certain color or creed, that's all well and good, it really is. It can be hard to explain one's world view, one's religious thinking, to someone who is unclear on the concept. Religious concepts affect how we think, and how we think affects how we feel. Religious cognition can play a huge role in psychotherapy.

One's ideology, such as a religion or ethnic value system, is also a cognitive map. So a patient might prefer a therapist who already knows his or her way around town.

The problem with that, of course, is that a religious or ethnic map is not the only map in the patient's head. Using this map to the exclusion of others will surely circumvent a therapy doc's direction, reinforce the confusion.

If you need to know how to get to Albany from New York City, having a map of Manhattan is nice, but it's not enough.

And people of the same religion and race are indeed a heterogeneous lot, very different from one another. Most people interpret and see things differently, even with shared values. More importantly, we live very different lives.

So knowing about religion, race, and cultural differences, while important, is not going to crack a case or even necessarily be much use to a therapydoc.

And yet, we have a professional responsibility to learn about cultural differences. Cultural diversity is taught to professionals in graduate schools (social work and psychology for sure) and has been since the 1990's.

Don't take those classes lightly, friends. One's cultural toolbox should always be open at the office. Even a cursory understanding of ritual observance and cultural mores will serve mightily. You might learn in school, if you pay attention, the answers to questions like these:

Do African Americans really need to hear how your day has been so far to be comfortable enough to open up? (some do).

Does it matter if a patient is a DOS or an SOS (daughter of a survivor/son of a survivor)? (uh, huh).

What are the laws of family purity?

Should an Indian woman from India expect to move into her father-in-law's home after marriage?

Oy. There's so much to know. How can we possibly know it all?

Which is exactly why some prefer talking to their local clergy person or finding a frum therapist.

It's the training that will matter in the long run, however, not knowing the patient's world view before the first session. Patients will teach us their world view if we shut up and listen. If we let them.

This is not to judge therapydocs who carves a niche solely based upon their cloth. On HMO panel applications sometimes there's a question asking providers to check off specialties. One of them is "spiritual counseling." Once I accidentally checked it. (These applications take a lot out of a person).

That meant MANY rejections from first time callers.

Oh, I wanted a CHRISTIAN therapist.

Never mind.

No matter what the world view or ideology of the therapist, to get back on topic, we have to address this triangulation thing.

It's not okay to ally with one person in therapy by beating up on someone else using cultural or religious values as sticks. (We're talking beating with words, obviously, insinuating that another family member or perhaps even boss, friend, is bad). This isn't a good idea even if the one taking the beating isn't there in the office.

When it comes to first degree relatives, no matter how awful you, as a therapist, think another family member has behaved, it's not your job to meet out the judgment.

It's pretty hard not to do that, believe it or not, not to call someone who has sexually abused a patient a bad name. Deep breaths, sighs, slow turns of the head, nods. These communicate disapproval just as well. And yes, when it comes to abuse of all kinds, feeling disapproval is okay.
It has to be. Communicating it and how, deciding IF you should be communicating it, is the issue.

Sometimes yes. Sometimes no. It's a call that should be based upon context. It's a thoughtful call.
Remember your patient either has chosen, birthed, and may share quite of bit of that other person's DNA. So it's best not to join with the patient's anger. It's not your job to be righteously indignant.

Someone has to stay level.

A nice example of what I call beating on the sinner is when one partner/spouse presents as a victim of another's infidelity. This spurned partner comes to therapy and says something like:

"My wife (husband/partner) came on to a co-worker (friend, tennis pal)

And they did it in our living room (bedroom/dining room/car)."

Disgusting, you want to say.

But do you? Do you even dare judge the partner who cheated? Do you even know that it's true? Is your patient such a virgin? So many other possibilities going on here.

In such a case the patient clearly wants empathy for the pain, the rejection. That's the therapist's job. And the patient needs where to go from here. Although punitive fantasies (don't you want to just kill him/her?) can be therapeutic, they're not to come from you. You're a therapist, not a cheerleader--not a judge. You look at your patient and say, Tell me more. This must have hurt, this indiscretion.

Believe it. It hurt.

There's no beating up the partner, whether he or she is around or not. No thumping or pointing to the Bible, and no assumption of guilt or that the complainant is even telling half of the story. But we can't intimate our doubt, diminish the power of a patient's narrative, regardless. We stay empathetic.

And when the "errant" partner is in therapy with us, we can't say, not ever, What were you thinking?! People beat themselves up enough without our help. (Okay, you actually can ask that question, but NO attitude. )

For not being a rabbi, I preach pretty well, no?

Religious values can and should be part of therapeutic dialogue. The values we talk about matter because they are the patient's values. They are what drive many of the patient's thoughts, and as such are clinically invaluable data.

Our values are irrelevant. Our values aren't under discussion. When a patient asks us, Well, what do you think? we turn it back on them, What do YOU think? Seriously. Tell me.

Or:
And how did that make you feel?
What did you want to do about that?
What would it be like, doing that?
Do you want to work on it?
Do you want to talk to her/him about it?
Does he/she want to talk to me?
Why not save this relationship?
Should we work to save this? Is that a goal?

Sometimes people don't want to save it. And that's okay, too. I always suggest they wait awhile, however, before signing on the dotted line, dissolving the relationship for good. Work on it in therapy, try to get past the hurt and anger in any case.

Anger especially, is never easy. Yes, it can take many months, sometimes over a year to get past the indiscretions and hurt. But most of us have time. And just leaving the "problem" doesn't always make us feel better. (Sometimes it does. Sometimes it doesn't).

Best first to look him or her in the eye. Take a good look at the reality of the situation. Talk about it. At length. Change. Both of you change. Because you know, after all, that everyone needs therapy.

And you can always talk about where that soul is going with your clergyperson.

copyright 2008, therapydoc