What Good Can It (Psychotherapy) do?

What good can it ( psychotherapy) do?

The  question above is one that I encounter frequently in one form or another from friends, potential clients, close relatives.  It takes various forms:

1. What can they tell me that I haven’t already thought of myself?
2. Life will take its course no matter who I talk to.  My partner will die and I will be alone.
3. I’m going to die anyhow.
4. Talking won’t bring her/him back.
5. I’ll still have cancer/multiple sclerosis/end stage heart disease.
6. There really is no way out of my marital/familial/work dilemma.
7. My depression is a result of a chemical imbalance.

I’m frequently not quick enough on my feet to respond thoughtfully, so I’d like to take a moment to do so now.

Therapy, at least the kind that I know about, is not chiefly about finding solutions, i.e., problem solving.  Intelligent people are generally quite aware of a range of solutions to their problems.   They just can’t act on them.  They are frozen.

They  think that no potential solutions are really applicable to their situation or relevant or available to them.  Or they feel, and perhaps this is the  most frequent, that in their particular case there are no real solutions.   Its almost reflexive for the listener, the relative, the loved one, the good friend, the clergy person, even some therapists to offer some thoughts as to possible solutions.  Inevitably they fail.  Its not about that.

Within most adult folks there is an inner wisdom that would offer great assist in resolving the impasses of our life. Therapy is about accessing our inner, innate wisdom, not replacing it with someone else’s.  I can think of many instances where I felt that there were no solutions.  I was trapped.  In retrospect I knew the solutions and just found them totally unpalatable.  I could not end that destructive friendship, it was just too important to me.  I could not resolve a domestic or an economic problem, I just wasn’t strong enough.

So what are the elements of psychotherapy that  enable that inner compass.

1. the magic of relationship.  When researchers have tried to isolate the “active” ingredient in successful psychotherapies, across many theoretical approaches (CBT, psychoanalysis, mind/body  approaches)  they frequently come up with the same answer:  “it’s the relationship, stupid,” the connection between therapist and patient is the key remedial. 

Neuroscientists have a more exact way of stating this, it’s about “limbic (a key brain structure) resonance.”   Simply stated,  therapy is not so much about the rational, linear, thinking mind.  It’s more like music.  In the best situation the therapist hears the particular melodic essence of the individual, playing softly in the background and is able to tune in and hum along, maybe even in harmony.  Just this tuning in is deeply healing.  How many people in your life have actually heard your “melodic essence”?  Do you think even you have heard it?

2.  A therapist listens differently than other people. I heard a story once of a psychotherapist describe his occupation, at a cocktail party, as one of  listening  “I listen for a living.”

A therapist’s training and experience sharpen and educate their musical ear.  It has been called “listening with the third ear, (Theodore Reik)” among other things.   When things go well, a good therapist hears what others do not, even the speaker.

A therapist may hear anger where others only hear hopelessness, fear where others hear anger, shame where others hear belligerence.   Truly thrilling for both the patient and the therapist is the moment when a door opens and the narrator gets a slightly different perspective, a different way of hearing their own feelings/problems.   “Maybe its not my inadequacy, maybe I am feeling truly alone in this intimate relationship.”  “Perhaps my adversary doesn’t hate me, perhaps they are deeply ashamed of their failures in life and feel humiliated.”  And most powerfully, “maybe there is meaning embedded in my confusion and in my unremitting pain.”   Meaning can set one free.

Certainly there is much more to be said on this subject.  But I will pause here and invite readers, both those who have experienced therapy and those contemplating dipping a toe in, to share their thoughts.

Happy New Year to all!!

MENTAL HEALTH NOTES: Personal Transformation and Wrestling with the Dark Side

After writing my last post (www.huffingtonpost.com/may-benatar-phd-lcsw/neuroplasticity_b_1729070.html)  and reviewing the comments I received, it occurred to me that I hadn’t told Stuart Smiley’s entire story.  Stuart’s  dark side is an important part of his story, indeed an important part of all of our stories.  I did mention that he was a mess.

I’m going to switch characters here.  The story of  Jacob’s struggle with an angel in (Genesis 32:24-30), provides a more sober and profound metaphor for the following exploration.  Personal transformation is not just about affirming the positive, it’s about investigating the negative as well; its about struggle.   The task of psychotherapy,  at its most profound and meaningful level is all about transformation, inhabiting more fully who we are.  And that is Jacob’s story as well.

In Genesis (32:24-30), the first book of the Bible, the first book of the Jewish Torah, Jacob leaves home to meet his nemesis and twin brother Esau.  Esau  wants to kill him.  Esau is angry with Jacob for having stolen his birthright, his father’s blessing, many year’s before.

While on this journey to meet Esau, Jacob has the famous encounter with a mysterious entity.   It is an encounter marked by struggle and suffering.  They wrestle throughout the night.  They wrestle  to a draw and  Jacob is released by the angel who insists Jacob take a new name: Israel.

Interpreters of the Bible story have various ways of interpreting this narrative.  Who is the angel?    Is it G-d?  Is it Jacob’s own fear of the coming encounter with Esau?  Or is it Jacob's own dark side.   And it appears he had a very prominent dark side.  He manipulated his father and stole from his brother for one thing.   The latter explanation, the most psychological one, of course, appeals to me.  This interpretation has Jacob struggling with his own flawed character.   In the process he is both wounded and reborn.  He gets a new name,  he becomes more of who he really is.  And this is the nature of transformation.

What a wonderful paradigm for the best outcomes of psychotherapy.  And I emphasize best, over common.  While the power of positive thinking is an important and real possibility for us all in recasting our fates—the need to embrace the shadow,  those elements of our personality, our souls of which we are least proud, is a  necessary element of transformation.

Trudy wanted to retire and to begin working seriously at her bucket list:  to travel to Nepal,  to write more poems,  to read and garden to her heart’s delight.  She knew it was time.  She felt really burnt by her 40 years of work as an emergency room physician.  Nothing called to her any more about her profession.  The adrenaline generated by the high intensity work had in the end depleted her.  It was definitely time to move on.

Strangely she found that she couldn’t.  She was dogged by guilt, haunted by bad dreams.  And that was when she could fall asleep.  Insomnia and an exacerbation of her long dormant ulcer had her prescribing medications for herself.  Finally, feeling it was a last resort, she went into therapy.

It took about 6 months of pretty intensive work with her therapist to uncover the source of the guilt.

Trudy came from a high achieving, well to do, but essentially emotionally disconnected family.  The three children  had had to fend for themselves as their parents pursued their
own interests, their travel, and their careers.   Despite this the two oldest children adapted well.  They performed well in school, had many friends, and took care of each other. 
  
The youngest did less well.  He struggled in school,  seemed to be the odd man out socially, frequently got into trouble with the authorities, and was finally expelled from school.  As the oldest child, Trudy knew what was expected of her to help:  she needed to take care of  her little brother.  But she didn’t want to.  For one thing she didn’t know what to do about him,  although 5 years older, she was a kid herself.   For another she was successful both socially and academically and had no real interest in parenting. 
She had made half hearted tries but she resented anything she was asked to do for him.  And plenty was asked.  The parents were preoccupied and clueless themselves as to how to help their son.

The baby brother never did pull himself out of his troubles.  As an adolescent he got into harder and harder drugs and very tragically died of an overdose at age 20.

What Trudy discovered in psychotherapy was that she had never forgiven herself for abandoning her brother.  And she really had to acknowledge that it was an abandonment.  True, she was a child herself and did not have the knowledge or skills to help her brother,  but on a deeper level she just didn’t want to.  She didn’t much like him or sympathize with him—he was always a trouble maker and a drain on the very slim emotional  resources of the family.  The stain on her soul was not what she did or didn’t do,  it was what she felt.  

What she had to wrestle with was her own nature, or what she thought was her nature.  She had not wanted to help her brother and he had died of neglect.

It took another 18 months at least for Trudy to come to terms with all of this.  Actually it probably will take many years beyond these months.  Trudy had to seriously consider that she had become an ER doctor because it was an arena in which she could save people. And that she did.  And now she couldn’t leave it, because to do so would expose the wound: her own self-loathing.

The struggle (in this case her work in therapy) left its mark on Trudy—the wound that had been  there but invisible became visible.  For a short time she needed anti-depressant medication,  later something to help her with her anxiety.  But in the end, she knew her own name.   She became more of who she was.   And eventually she retired.

Mental Health Notes: Stuart Smalley and Neuroplasticity

Stuart Smalley was a  character on Saturday Night Live played by Al Franken,  now a distinguished member of congress, then a distinguished comedian. In the  90’s he was a regular on Saturday Night Live.   Blonde and dimpled, somewhat effeminate, Stuart was an earnest simpleton, distinctly un-cool in his cardigan he was “a member of several 12 step programs, not a licensed therapist.”   Actually he was a mess.

One of his funnier bits was staring into a mirror and speaking aloud affirmations, to be repeated daily? “I am good enough, I am smart enough,  and doggone it  people like me.”  There was also: “I am an attractive person, I deserve my share of happiness, I deserve good things.”

The hilarious implication was of course how silly and self indulgent it was to think flattering yourself in front of a mirror really meant anything.

But you know what, it turns out that Stuart Smalley was on to something.

What we now know about neural functioning indicates pretty strongly that what we think can and does change our brain.   In the last twenty years there has been an explosion of new understanding in brain science.  There is more sophisticated, detail mapping of the brain and its functions and very importantly we have learned that the brain is malleable, not fixed as we once thought.  This is why a meditation practice, learning a language, and taking up a musical instrument can demonstrably change brain structure, even quite late in life.

What changes the brain, and/or the mind, changes the body, the immune system, blood pressure, cardiac function, stroke recovery and so much more.    Sophisticated methods of brain scanning have given us access to how all of this works.

The slogan is : what fires together, wires together.  As neurons fire (which is what happens with thought),  they connect to each other.  The more they fire, the stronger the wire.   If you practice weight lifting, or swimming, or piano, or French, you gain more facility, you get better and better—the neural connections grow stronger and stronger.  So if you think good thoughts, that might have an effect also, right?

I have just read the book Freedom from Pain: Discover Your Body’s Power to Overcome Physical Pain, by Peter Levine, Ph.D. and Maggie Phillips, Ph.D.  This book is chock full of exercises and regular practices, that can help people in acute or chronic pain, manage their pain.  Many of the exercises are based on Somatic Experiencing (SE), many on energy medicine.  Somatic Experiencing developed by Peter Levine, is a body awareness approach to treating trauma  http://www.traumahealing.com/ 
Pain is a form of trauma.

See previous posts on this site on the subject of SE: http://www.postsfromtheunconscious.blogspot.com/2012/06/ptsd-kills.html
http://www.postsfromtheunconscious.blogspot.com/2012/04/orange-biographies-healing-narrative.html

Pain management is a very challenging area of healthcare with pain conditions nearly epidemic.  Medication can be helpful, but sometimes falls far short of bringing comfort, and almost always has side effects that can be distressing.  So practices that depend only on our ability to focus attention have enormous potential benefit.   And no side effects.

I was somewhat amused to see that Stuart Smiley’s methodology was one of the practices recommended by Levine and Phillips.  Here is the scientific justification:

Neuroplasticity research has turned this theory (genetic determination)on its head and gives us an entirely new way to look at the impact of our thoughts and beliefs.We know that thoughts literally change brain chemistry.  Research indicates that the chemical composition of the body can change in relation to a specific thought within twenty seconds (Levine and Phillips )p. 112.
…Research indicates that the chemical composition of the body can change in relation to a specific thought within twenty seconds p. 11.

Neuroscience has caught up to Saturday Night Live!

Try it.  And if you need inspiration, consider where Stuart Smiley is today:  The United States Senate.

PTSD KILLS

I hope that cardiologists everywhere are paying attention to a startling finding  reported online in PloS One.  A review of over 20 observational studies of  cardiac patients found that 1 in 8 (12.5%)  heart attack victims, or patients with unstable angina  had diagnosable PTSD (post traumatic stress disorder).     That’s almost double the  (lifetime) rate for PTSD in the general population.   Even more alarmingly this subgroup had double the  mortality rate of those without  PTSD within 3 to  5 years.  In these studies PTSD is very strictly defined as meeting the criteria in the current Diagnostic Manual of mental disorders.  If post traumatic effects like depression are factored in, the rates would undoubtedly be higher.  These findings were broadcast on mainstream media as well.

The study of the effects of war trauma have also reached the headlines as  the rate of suicide among active duty  military personnel now surpasses  the rate of battlefield deaths. ( The New York Times,  6/8/12).  The rate is nearly one a day.

Think about that.   Young men and women serving in  combat zones are more at risk for killing themselves than they are for being killed by enemy combatants. The war moves inside and destroys from within, at a devastating rate.

Long before PTSD reached the headlines, long before the shock and carnage of 911 made knowledge of the sequelae of trauma practically mainstream,  mental health clinicians were reporting back from the front lines of the  child abuse wars that a goodly portion of adults who had suffered as children from sexual abuse, neglect, physical violence,  sex trafficking and child pornography suffered from chronic PTSD;  victims of domestic and sexual violence, ditto.   Suicide rates may not be as high, but soul deaths, certainly.

The articles that I read that  reviewed the heart attack studies, noted that psychotherapy and medications were the treatment of choice for cardiac patients demonstrating trauma symptomatology.

I would like to add that body based techniques such as Somatic Experiencing and Sensorimotor Psychotherapy, as well as EMDR, are  good choices in the treatment of  a trauma that is essentially body based.   A heart attack is an attack on the  heart.  It is a "mugging"  within the body that is life threatening, not unlike a near fatal automobile accident, a rape, surviving an airplane crash,  or other near death experience.

The principal behind these body based approaches is that trauma triggers biologically based mechanisms of defense: fight, flight, and freeze.  PTSD and other serious problems will follow when the tremendous reservoir of energy that is recruited when we are threatened and overwhelmed gets locked in the body and can not be discharged.  A heart attack victim doesn’t have a lot of ways to discharge the impulse to flee the “attack,” or unlock from the freeze induced by overwhelming terror (I’m going to die!”).  A child victim cannot fight the predator even though the impulse to do so might be very present.

These body based treatments, or more accurately sensory  based approaches, like Somatic Experiencing or  Sensorimotor Psychotherapy are designed to address and rebalance  the nervous system by addressing it directly and not by way of  the higher cognitive functions.

A heart attack victim coming for treatment for PTSD may be gently and progressively lead  through the body memories of what it was like to experience the crushing pain, the terror, the helplessness, the uncertainty, all this on  a sensory level.  Where is it stored in the body?  What happens when we pay attention to those sensations of the body?    Together patient and therapist track sensation, imagery, and maybe motor inclinations.  All of these activities in the interest of discharging  all that pent up energy.  The work is done from the grass roots, so to speak, from the bottom up.  Cognitive approaches might be aptly described as from the top down.

This method is direct, gentle and amazingly effective.  For more information see
www.traumahealing.com  and

www.sensorimotorpsychotherapy.org/

or write to me.

The Orange Biographies, The Healing Narrative, and Somatic Techniques

I was delighted to see in Sunday’s New York  Times that David Sedaris read the orange biographies as child.  I  believe I read them all—everything that the children’s library in Marblehead,  MA had to offer.  These were the stories of “great Americans.”   The list that I recall included Abraham Lincoln, Clara Barton, and Wyatt Earp.

Looking back I think that even in third grade I found the personal narrative captivating and inspiring.  If I was going to be a great American, these were the books to read.

I suppose I have given up my aspiration for greatness.  But I have not relinquished my passion for stories, the stories of a life.  This has sustained me over decades in the practice of psychotherapy.  My job is mostly about helping people tell their stories.  I wrote in a blog several months ago (May 16, 2011 http://www.huffingtonpost.com/may-benatar-phd-lcsw/personal-narrative-healing_b_862285.html) about the value of creating the coherent personal narrative and the role of the therapist in this creation, this construction.  Sometimes it’s like solving a thousand piece puzzle, the story is jumbled, chaotic, fragmented.  Sometimes it is like picking out threads from a weave tangled with other people’s version of our story—“Mom said I was this kind of a child/person.  Auntie M. thought I was better than that.”

Sometimes there are holes as big as a truck in the story of one’s life—the individual seemingly retaining only crumbs of a history.   Figuring out what one’s own story is, from one’s own perspective, is both challenging and fascinating. 

The enterprise of constructing a coherent narrative of one’s life is mostly a cognitive process.    With the support and guidance of a skilled, empathic and alert listener, i.e. the psychotherapist, we come to understand how we got where we are, what has motivated, shaped, and had meaning for us.  We get to claim our own experience, from the inside out.  This is powerfully healing all by itself.

I have recently been learning about another kind of narrative:  the narrative of the body or the “felt sense.”  There are two new-ish techniques in which therapist’s are being trained, adding to their store of tools.  These techniques go beyond the verbal, the cognitive, beyond the prefrontal cortex so to speak.  Developed to work with trauma, Somatic Experiencing (SE) and Sensorimotor Psychotherapy (SP) focus attention from the grass roots, so to speak: Pat Ogden (founder of the Sensorimotor Psychotherapy Institute) refers to this as moving from the bottom up, felt experience, versus working from the top down, a more cognitive process.  The basic assumption is that the human nervous system is not unlike other mammalian nervous systems which have a self correcting, self healing potential.  Peter Levine (the developer of SE) reports that wild animals face trauma every day, and seem to bounce back within minutes of surviving a life threatening experience.  Trauma does not de-rail them.  There is no PTSD in the wild.

These new technologies which are being learned and mastered by practitioners around the world, tune in to a very different story:  the story stored in our body, in our “felt sense.”  Interestingly the stories that have been lost to the cognitive narrative, may be stored in the body and be accessible if one pays a certain kind of attention.  The body may have a very different story than the “remembered” story.

Next time you have a back ache, a bellyache, an attack of anxiety:  tune in for a few minutes, place your attention on the sensation and track it with your awareness.  Watch what happens: does it change?  Does it move?  Does it yield any information, image, anything? Does tuning in make you want to move or gesture in a certain way?

 Doing this will give you a taste of what these new techniques are like. 

For more information see www.traumahealing.com and/or www.sensorimotorpsychotherapy.org

THE MIRACLE OF ADAPTATION AND MR. WHITE EGRET

I was on a walk the other day.  The sun was out after many days of rain.  The creek along which I walk so often had become almost a river.  For the very first time, I noticed a white egret standing motionless  by a man-made waterfall on the creek.  The elegant bird looked as if she were trying to figure out how to navigate the cascade.  The creek had been but a trickle all summer.  But this fall had been unusually wet and stormy.  And the water was high and fast.

Strangely the bird was still there in the same spot, standing like a statue, unchanged, 30 minutes later when I passed on my return trip.  I raced home for my camera, sure he/she would be there when I returned.  In the meantime I had an elaborate fantasy (the kind of fantasy only a psychotherapist would have!) about that poor bird.  It went something like this:  The bird, probably young, had adapted to the stream at its lowest ebb during the summer.   Growing up beside a trickle, it was well adapted to those conditions.  When the stream swelled, her/his adaptation style no longer sufficed and he/she could not figure out what to do.

Of course, this reminded me of the essential human dilemma.  We adapt as children,  with brains, nimble and flexible,  to the conditions of our environment:  the family we are born into,  the emotional surround be it one of privation or abundance.  We are veritable geniuses of adaptation.  Problems arise latter when our brilliant adaptation styles no long suffice.  When the floods of later life come, we are often at a loss.  The tools of the earlier years are more than likely useless.

The child Holocaust survivor who starved and had to scrounge for whatever food was available in order to live,  may well have trouble at the dinner table as a middle aged adult now seated at the groaning board of American abundance: obesity and diabetes II ensue. The woman who has witnessed the suffering of older siblings who resisted a controlling parent only to be vilified, and rejected by that parent, learns submissiveness at home and fails to develop the assertiveness she needs to succeed in adult life.

I returned with my camera,  maybe 15 minutes later.  Mr. White Egret was gone.  There goes my theory.  Somehow he had navigated the falls.  Maybe he was just a patient fisherman all along.

Days passed,  no egret.  No egret, but another lesson came my way.

A week or two later, I had the good fortune to reconnect with a client I had known over many decades.  She was in her mid twenties (I in my mid thirties) when we met.  We worked together for many years and then just on and off thereafter.   She was in tough shape in those early years, nearly mute in our sessions for probably two years.  I did the talking, guessing at her pain, her shame, her fear.  She cancelled more often than not.   But often I could talk her into coming.  She had adapted well to an early environment in which it was dangerous to speak up,  it was dangerous to be noticed at all.  From a very large family, dominated by alcohol, violence, including sexual violence,  she was denigrated, humiliated, unprotected.   She felt insignificant, unsafe, and unworthy. 

Most significantly she was separated from herself—to survive  her childhood her essential self had gone into hiding.  What was left was a child hovering in fear, whatever strength there was seemingly defeated.   She was the only one among 17 children who had managed to finish high school,  but there was very little evidence of pride, and certainly no accolade from the family.  Any sign of independence, strength, intelligence was seen as a negative not a positive by her family.

Fast forward 20 years.  In the interim this woman went to college, gave birth and raised a child single handedly  and successfully without a father. She bought a home,  rose in her profession to a role of leadership,  survived a life threatening illness through sheer grit.  On and off she used therapy to help her navigate these crises, at times I was the second parent to her daughter, but for long stretches of time she did not call or come in to see me.

The one longing unfulfilled,  was the inability to sustain an intimate relationship with a man.

Now in her 50’s we are again back in touch and this time because she is in an intimate connection with a man, someone who sounds mature, loving, and accepting and who wants to marry her.  She knows she needs a little extra support until she decides what to do. 

The white egret has adapted to the falls.  A sustaining relationship with me over the years was certainly part of that critical adaptation.  But the real wonder here,  the awesome reality, is that she had the capacity to use that relationship and all other positives in her life, the terrific child she gave birth to,  her teachers in school,  friends, neighbors,  a few members of the extended family that did not put her down—whatever came her way she used to grow and change and reconnected with all that was positive in her. 

She herself has described it as the child within, the one I saw cowering in the early days mute and frightened, has grown up.

This is not the only story I have of the awe-inspiring nature of our ongoing, life-long capacity for change.  It’s just the latest.

taking off for a good new year.