Friday, July 30, 2010

Why Does Psychotherapy Treatment Take So Long?

This is a question I have heard, in one form or another, many times from my
clients/patients.

Sometimes the question is not posed explicitly, but the client assumes at the opening of our work together that he/she will be in and out in six weeks (said client having just told me that she has a long history of failed relationships, periodic dark depressions, and an eating disorder).

There are of course treatments that are shorter, but I tend to think in terms of years, if a client is suffering a great deal and has for some time.

Explaining why psychotherapy treatments are not generally brief affairs is complicated. My model of therapy is of course not everyone’s model. Models of short term therapy exist. I am not a practitioner, although I am aware of these modalities and have read their literature.

I think of the realtor’s motto—there are three things important in the sale of a home “location, location, and location.” In the kind of psychotherapy treatment that I practice, those three important things are : “relationship, relationship, and relationship.” What happens between therapist and patient is the cornerstone for effective change with and for the patient. The relationship is the crucible for change. Obviously building a trustworthy resilient (if not perfect), mostly predictable relationship takes time. If there has been a major betrayal at the heart of a person’s life experience, building trust can take a very, very long time.

In the ordinary course of events the relationship stumbles, there are crises, loss of faith, mistakes made, failures of understanding and empathy. As in life, so in therapy, it is in the repair of those rents in the fabric of the connection that hold the real promise of lasting change in the structure of the self. This is a basic tenet in many theories of therapeutic change.

Within the context of the mostly safe relationship, our clients have the opportunity to develop new skills. Most of us developed our coping skills early in life. We adapted to whatever conditions we faced with the best tools available to us at the time, that time being childhood. Checking out (dissociation), cheerful denial, taking care of others, distancing ourselves from others, controlling others, numbing ourselves, living in a fantasy world are only a few of the popular choices.

As circumstances in our life change we fail to update the toolkit. We go on automatic. This is true for all of us. If you have always been cheerfully unaware of thunderclouds on the horizon you will probably continue to be so, even if the consequences are dire. It takes a lot to get us to reconsider our choices or even to become aware that we are making choices(!) and to re-evaluate the appropriateness of our adaptations.

That’s where the therapist comes in. Its their job to identify those automatic choices and to help the client evaluate them. Dissociation, to take an obvious example, is wonderfully adaptive for a child trapped in an abusive family. Why not check out, if there’s nothing you can do to remediate the situation? Obviously this is not so adaptive for an adult who needs to find the wherewithal to get out of an abusive marriage, a heinous job situation, a sadomasochistic friendship. But now the dissociation is ingrained and it takes real work and real time (!) to turn that around.

So the blood, sweat, and tears that it takes to build a relationship and the difficulties of learning new tricks are two important factors contributing to the long term investment involved in change.

These are only two of several factors that make therapy very hard work. I will leave more commentary for another post.

Tuesday, July 6, 2010

CHOICE AND CONSEQUENCE: Terry Gross and One Life to Live

We went to hear terry gross of NPR fame a few weeks past. It was wonderful. She is wonderful.

There was an interesting moment when she answered a question in the q & a period that was never asked by this particular audience. Undoubtedly she had been asked the question at some other time.

She never had children. It was a deliberate choice. She is probably 60 or close to it. But I guess she knew early on that her life as a journalist, whether it was on her current show “Fresh Air” or not, was going to be all consuming. What she said was (and of course I am paraphrasing as best I can), “I never could figure out how I could do it—do my job and have a child and raise that child well. I know other people do it, but I couldn’t figure out how I could do it.”

For those who don’t know Terry Gross, she has a wonderful interview show on NPR, 5 days a week, interviewing novelists, biographers, historians, political analysts, pundits, musicians, movie and theatre people, etc., etc. The level of conversation she promotes is unusually high for radio and other media. This requires intensive preparation, she reads and understands the books, she listens and understands the music, the theatre, the geopolitical situation under discussion. She facilitates conversation at a very high level. Her job is terrifically demanding.

What struck me about her disclosure was her humility, her maturity. She accepted, probably at a fairly young age, that she was a limited human being, that she could do this or should could do that but she couldn’t do both and she needed to choose.

Elizabeth Gilbert whose book “Committed” I just finished, said something similar about her own choice to remain childless.

This post is not about the decision to remain childless. Both Gilbert and Terry Gross helped me think about the omnipresent work life/balance struggle that so many, maybe all young parents struggle with; women maybe more than men. I certainly struggled with it.   Coming to terms with the push/pull of career choices and family life style choices for those who indeed do have a choice (a privileged class, those who have a choice to work or not), requires humility.

We can neither do everything or have everything. Every decision has consequences: to have a child, to not have a child, to work full time, or to not work full time, to forego the career, to pursue the career full tilt, to have one child, or two, or many.

This is an obvious point I’m making, perhaps, but I have a sneaking suspicion that there is a barely acknowledged assumption buried in the heart of young parents, that if one does it just right, there will be no great pain or sacrifice. The children will not suffer, our careers will not suffer, our spouse will not suffer, our marriages will not suffer, we will not suffer.

I think there is always sacrifice, at the very least there is always consequence, and we can’t always forsee what that will be when we make our choices, or how we will feel on the other end. What’s important in my estimation is an acceptance of that truth.

Terry Gross struck me as surpassingly wise and humble when she decided she couldn’t have it all.

Wednesday, June 16, 2010

Parenting: Where do “bad” feelings come from?

My last post was about the negative feelings that are as ubiquitous in the process of parenting as are loving feelings and the intense desire to hold and nurture.

In my exploration of parenting blogs I came across an interesting post on Motherlode
the NY Times parenting blog:
http://community.nytimes.com/comments/parenting.blogs.nytimes.com/2010/06/01/not-loving-your-child/?src=tp

Rebecca Abrams, a novelist, writes about having “fallen out of love” with her firstborn after the arrival of her son. This was a courageous and frank confession of not-so-nice feelings towards daughter #1.

The comments on this post were numerous, and generous. Most commenters applauded the frankness of Ms. Abrams and openly owned their own negative impulses toward their children. Alas, outside of the blogosphere, this admission is not so common.

Reviewing these comments, I thought about what I would do as a therapist with mother’s (more likely than fathers) whispered their horror and shame. I and most other therapist would get very interested in the well-springs of these feelings: where does this all come from? Where were you in the birth order? Do you know how your mother fared after giving birth to your sibling(s)? Or to yourself? What was going on in the family around that time? What do you know about the early relationship with your siblings, younger and older?

Creating a family of one’s own, inevitably invites “re-enactments.” Not all memories are conscious. We stumble somewhat blindly through unconscious re-enactments from our own early dramas.

A friend of mine spoke frankly to me about flashbacks, horrifying flashbacks, of physical abuse from her own childhood. These pictures came unbidden when her first child was born. She had no impulse to harm the baby, but she became very afraid in caring for her first-born. Her confidence in caring was undermined.

Having a chance to explore all of that, creates a context for the present moment, helps us to be both compassionate with ourselves, which is key to handling all of this, and leavens the guilt, allowing us to be creative in solving the present dilemma.

One never knows what is going to trigger the flashback or the enactment. One can sail through the early days and years of our children’s childhood and then hit a wall when they go to school, or they hit adolescence, or they threaten to go to college and leave us, or they fail to leave home at what we deem the appropriate time, or they act up in a surprising and distressing way. If its not happening now, it probably will after awhile.

When in trouble: think “context.”

Thursday, June 10, 2010

Good parents/Bad feelings: The view from a child therapist

Guest post from Elana Benatar:  Elana is a family and child therapist at Virginia Frank Center in Chicago, IL.

Good parents DO have bad feelings, and those feelings need to be expressed and processed so that the child does not bear the brunt of it. When those feelings are kept in, and pushed to the realm of the unconscious – that’s when the child begins to take it on for themselves

My clients often come in wanting parenting advice. They want to know what is the right way, and what is the wrong way. They want books, articles, and concise Google search terms. Unfortunately, there is no cookbook for parenting.

Parenting is a dynamic process and there is no one right way of doing it. And parenting is not about being perfect, it is about being “good enough.” Part of being good enough is acknowledging that parents are people, with their own feelings, projections, and past experiences – and sometimes this makes for bad feelings about your kids.

I’ve learned from my clients that parenting is a mixed bag of emotions -- sometimes beautiful, loving, hopeful, blissful; other times utterly maddening. So when clients ask me for book recommendations – there is usually only one that I turn to: Parenting from the Inside Out, by Daniel Siegel. It is a practical guide helping parents tune into their own emotional state.

Siegel cites research studies that indicate that parents who have developed their own life narrative, even if it is a painful one, tend to have children with more secure attachment than parents who have no narrative. So often my clients are reluctant to look at themselves. They come in because their child has a problem – not them. It’s too painful. Turning towards their own painful childhoods, makes them feel vulnerable.

What can take years to tap into in therapy can be opened up in one second by a child. Young children are aces at tuning into their parents' issues and sore spots. They have spent most of their early lives in non-verbal communication with the caregiver – their survival literally depending on it. If a parent has a lot of unexpressed anger, you can bet their children will get that anger out, one way or another. The child can feel it there looming, and what is not said or expressed is often much scarier to a child than what is. Children learn from us how to handle emotions, When we can admit that we have angry, sad, frustrated feelings and model what to do with those feelings – they will learn how to handle their own range of affect.

The parent who unconsciously hates their child raises a child who becomes worthy of being hated. But when that same parent can stop and wonder – Why do I hate this child? Who hated me when I was a child? That is when there is an opening for change. And the wonderful thing about children is that development is in process, and change can happen quickly and dramatically. I will never tire of watching a parent and child, of varying ages and backgrounds, get past the unconscious projections and psychic pain and finally connect, fall in love, and attach.

Friday, May 28, 2010

GOOD PARENTS/BAD FEELINGS

All day long I listen to stories. I listen to stories of survival, stories of triumph. As a trauma therapist, I am a witness to tales of brutality, unimaginable savagery and cruelty directed toward children.

I also witness the more mundane struggles of adult life, including the struggle to be a good, maybe excellent parent. I can identify, as a parent, with both the struggle and the not-so-rare failures. Parents share with me their shame, their deep disappointment in themselves when they have not been able to love as fully, as un-ambivalently, as perfectly as they had hoped and planned.

This is the best kept secret in “parentland.” Good, loving, well meaning, well educated, even well-“therapized” parents sometimes, maybe often, have bad feelings toward their own children.

Parents envy their own children, compete with them, resent their advantages, desire parenting from them, seek to have them enhance their social status, repair their wounds, improve their marriages, redeem their suffering. They are angry when their children get in very public trouble, not only because of the consequences to the child, but also, maybe chiefly, because of the shame of being exposed in all their imperfection themselves. Parents find themselves not always wishing the best for their children.

So what? Why do we need to know this? Why not suppress all of this and do what we can to keep the beast from emerging. The culture has long ignored this phenomena, isn’t their some wisdom in this? I think not.

I share the following parable (from Jack Kornfield) of the poisoned tree. A lone traveler coming upon a “poison” tree is understandably frightened and cuts the tree to the ground, chopping at whatever roots are within reach. The traveler seeks to protect himself/herself from the dangers of being poisoned.

The next traveler, coming upon a similar tree of poison, recognizes the tree, honors its right to exist and decides not to cut it down: “I will build a fence around the tree so that the tree may have its life, but I will be safe from it.”
The wisest person in the story coming upon the tree, thinks a moment and says “oh, goody, just what I’ve been looking for, a poison tree.” The wisdom of traveler #3, is to see the tree as a gift, an opportunity to transform the poison into that which can heal. Medicine is sometimes made of that which causes the sickness. The poison from the tree be transformed into an important remedy for our ills.

In my application here, the poison of the tree is of course all our nastiest thoughts and feelings. Our impulse is to rid ourselves as quickly as possible of what can be terribly destructive and poisonous within ourselves.

If, for instance, one should stumble upon, become conscious of, envy toward our tender offspring we would surely seek to squelch this un-admirable feeling. How can one begrudge the good fortune of our children even if it makes us feel our own deprivation keenly? “Lets cut it down,” Lets banish the thoughts of anger and jealousy and replace them with those of intensified duty, or displaced anger.

Unlike real trees, however, unacceptable feelings can be displaced or even turned inside out, but they cannot really be destroyed. As in the second law of thermodynamics wherein energy can be transformed into different forms but never destroyed, so it is with passionate feelings. Acted out, denied, displaced, walled off , they are nonetheless there. And they make trouble.

The lessons of the consulting room, the lessons taught by my patient patients, have converged with the lessons of child-rearing for me. There are dark feelings associated with parenting, they are as an important a part of the topography of parenting as loving, instructing, and playing with our children.

Unfortunately a parenthood “mystique” permeates the culture in which such feelings are unspoken, forbidden. As a result guilt, shame, and abject horror As a result guilt, shame, and abject horror are automatic in the parent encountering these dark thoughts and feelings. We move quickly to cut down the tree: we deny, suppress, and dissociate when we can. The result are symptoms, unresolvable conflicts with the children, paralysis in the our own lives, and acting out at key transitional phases.

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I would like to write more on this subject, but would very much like some feedback from readers: comments on how this strikes you: horror, relief, boredom? Thanks.

Tuesday, April 27, 2010

LEFT BRAIN/ RIGHT BRAIN

I was listening to NPR one afternoon. Judith Shulevitz was talking about her book, The Sabbath World: Glimpse of a Different Order of Time. The book is described as both a scholarly exploration of Sabbath practices and an exploration of her own recently acquired practice of Sabbath observance. It was interesting.

There was one thought that she expressed that I both recognized and found paradoxical. To paraphrase: “ I love synagogue, the Sabbath observance, but I don’t believe in Gd.” I have heard many variations of this sentiment expressed. I really don’t get it. I don’t understand what “I don’t believe in Gd” means in this context. What is happening to people who attend synagogue, enjoy prayer, or the observance of prescribed practices, like the observance of Sabbath? What do they mean it has nothing to do with Gd?

A few years back I saw a short clip on the web of a lecture given by Jill Bolte Taylor http://www.ted.com/talks/lang/eng/jill_bolte_taylor_s_powerful_stroke_of_insight.html)

Dr, Taylor was a neuroanatomist, a researcher of the brain at Harvard who suffered a devastating stroke on the left side of her brain at age 37. Her story is about both her recovery and what she learned about “right brain consciousness” as a result of her stroke. I was so moved and fascinated by the lecture that I bought and read her book when it came out several months later and followed her on the talk show circuit, whenever I could.

Dr. Taylor suffered a “slow bleed” into the left hemisphere of her brain, the location of her stroke. For a while she experienced only what could be apprehended from the right hemisphere. Undistracted by the linear, verbal, linguistic, rational, logical and autobiographical left hemisphere, she had access to a unique experience of consciousness.

The right hemisphere of our brains are affective, non-verbal, non-linear. There is no time, only the present moment. There are no boundaries, all is one and one is all. As Dr. Taylor describes it, the right brain experience is close to “nirvana,” or the state of ecstatic oneness, that meditative adepts have been able to achieve.

The right brain seems to house the organ of spiritual receptivity. That is what this brain scientist experienced and came to believe in fervently.
We are two-brained. And we forget this. We think of the logical left brain as being the true mind, and the right brain, which is online much earlier in our development (and maybe is the last to go), as being somehow less valid, less reliable, less real.

As the left hemisphere was blinking on and off at the moment of the stroke, Dr. T. found herself unable to focus on calling for help, dialing or even reading the phone, forming or understanding words. Remarkably she did not die. More remarkably she has almost completely recovered. But most remarkably she has had the experience, and is able to convey the experience, of having full access to right-brained consciousness:living in a space that was truly spiritual.

So this is what I think is happening with Judith Shulevitz and the rest of us wrestling with being drawn to something that we do not “believe” in. I believe that Sabbath observance, prayer, meditation practice, yoga give us a glimpse of right-brained consciousness. If you do not have the ill fortune of a left hemispheric stroke it is not a simple thing to “feel” your right brain. The chatter of the left drowns out the timelessness and serenity of the right. We all have to work really, really hard to get access to that other form of consciousness. Music may get us there, poetry, meditation, prayer, and ritual are some popular routes. For Judith Shulevitz it may be Sabbath observance. But I’m just guessing.

Belief is a function of left brain work, that which is logical,
rational, linguistic. “Is there a GD” is a left brained question.” And there is no left brain answer. If “answer” is a relevant word, and I’m not sure it is, we need to turn to the other side.

Thursday, April 8, 2010

IT'S THE PATRIARCHY, STUPID

IT’S THE PATRIARCHY, STUPID

I thought if I waited long enough, procrastinated long enough, this would go away and I would not have to write this post. Not that the crisis would go away, just the headlines about the church/sexual abuse scandal. My comments would be moot. Then yesterday, front page, New York Times: Vatican Priest Likens Criticism Over Abuse to Anti-Semitism. That pushed me over the edge. Perpetrators as victims, that sounded oh, too familiar.

As a long time psychotherapist, the church scandal that broke several years ago, came as no surprise, not to me, not to many of my colleagues. We had been hearing about severe sexual , physical and emotional abuse of children by priests and even nuns for many, many years. It was validating and freeing for our patients to have this out of the closet and to know that it was institutional.

I have treated many victims of sexual violence, some at the hands of priests. I have treated a priest who was a sexual offender. They have been my teachers.

I have one thing to add to the conversation on the church, the systemic denial and cover up of the scandal and the recent revelations of how high in the hierarchy these matters reach.

Commentators looking to understand what is institutional and systemic have pointed to two factors: celibacy and more offensively, homosexuality. The have also pointed to the probable homosexuality of a substantial number of offenders. This analysis fails to explain why children are the objects of sexual desire, rather than adults, and why the church has failed so miserably to protect children from pedophilic behavior, once the pedophile has been identified. Why is the expression of compassion and protection for child victims of rape so much more tepid than the protection afforded perpetrators? Why does the church view itself as victim, rather than perpetrator?

I believe much about these matters can be explained better by reference to power relationships. In a word its about patriarchy. Power that is “infallible,” where the rule of obedience supersedes all other (moral!) considerations there is bound to be corruption and victimization of those weak and without voice.

Several years before the church abuse crisis, feminist scholars were observing that patriarchal, hierarchal institutions were much more likely to tolerate and produce violence against women and children than less rigidly hierarchal organizations where power and authority is more egalitarian in expression. This applies to family, cultural, and religious organizations.

Judith Lewis Herman, a psychiatrist and scholar in the area of sexual abuse and the effects of sexual abuse on children betrayed by trusted authority figures, writes eloquently about “the rule of the father” in an incestuous family. Herman argues persuasively and with scientifically supported data, that where father’s rule and mother’s nurture , where father’s power is paramount and mother’s power minimal, children are more at risk for the father breaking the incest taboo with his daughter. Children are undoubtedly more at risk for all kinds of violence from the father, where mother’s power is absent.

I believe the stunning insensitivity of the church, the absence of compassion for victims, the decades of denial and cover-up, the arrogation of canon law above civil law and ordinary morality, all make more sense in the context of an understanding of the perils of institutional patriarchy.

If the patriarchal nature of the church could be addressed we might see some real change in victimization within the Catholic church.