Category: Approach

The Spinoza Problem: An Excerpt

Posted on by Psychotherapy.net Team

Prologue

Spinoza has long intrigued me, and for years I’ve wanted to write about this valiant seventeenth-century thinker, so alone in the world—without a family, without a community—who authored books that truly changed the world. He anticipated secularization, the liberal democratic political state, and the rise of natural science, and he paved the way for the Enlightenment. The fact that he was excommunicated by the Jews at the age of twenty-four and censored for the rest of his life by the Christians had always fascinated me, perhaps because of my own iconoclastic proclivities. And this strange sense of kinship with Spinoza was strengthened by the knowledge that Einstein, one of my first heroes, was a Spinozist. When Einstein spoke of God, he spoke of Spinoza’s God—a God entirely equivalent to nature, a God that includes all substance, and a God “that doesn’t play dice with the universe”—by which he means that everything that happens, without exception, follows the orderly laws of nature.

I also believe that Spinoza, like Nietzsche and Schopenhauer, on whose lives and philosophy I have based two earlier novels, wrote much that is highly relevant to my field of psychiatry and psychotherapy—for example, that ideas, thoughts, and feelings are caused by previous experiences, that passions may be studied dispassionately, that understanding leads to transcendence—and I wished to celebrate his contributions through a novel of ideas.

But how to write about a man who lived such a contemplative life marked by so few striking external events? He was extraordinarily private, and he kept his own person invisible in his writing. I had none of the material that ordinarily lends itself to narrative—no family dramas, no love affairs, jealousies, curious anecdotes, feuds, spats, or reunions. He had a large correspondence, but after his death his colleagues followed his instructions and removed almost all personal comments from his letters. No, not much external drama in his life: most scholars regard Spinoza as a placid and gentle soul—some compare his life to that of Christian saints, some even to Jesus.

So I resolved to write a novel about his inner life. That was where my personal expertise might help in telling Spinoza’s story. After all, he was a human being and therefore must have struggled with the same basic human conflicts that troubled me and the many patients I’ve worked with over the decades. He must have had a strong emotional response to being excommunicated, at the age of twenty-four, by the Jewish community in Amsterdam—an irreversible edict that ordered every Jew, including his own family, to shun him forever. No Jew would ever again speak to him, have commerce with him, read his words, or come within fifteen feet of his physical presence. And of course no one lives without an inner life of fantasies, dreams, passions, and a yearning for love. About a fourth of Spinoza’s major work, Ethics, is devoted to “overcoming the bondage of the passions.” As a psychiatrist, I felt convinced that he could not have written this section unless he had experienced a conscious struggle with his own passions.

Yet I was stumped for years because I could not find the story that a novel requires—until a visit to Holland five years ago changed everything. I had come to lecture and, as part of my compensation, requested and was granted a “Spinoza day.” The secretary of the Dutch Spinoza Association and a leading Spinoza philosopher agreed to spend a day with me visiting all the important Spinoza sites—his dwellings, his burial place, and, the main attraction, the Spinoza Museum in Rijnsburg. It was there I had an epiphany.

I entered the Spinoza Museum in Rijnsburg, about a forty-five-minute drive from Amsterdam, with keen anticipation, looking for—what? Perhaps an encounter with the spirit of Spinoza. Perhaps a story. But entering the museum, I was immediately disappointed. I doubted that this small, sparse museum could bring me closer to Spinoza. The only remotely personal items were the 151 volumes of Spinoza’s own library, and I turned immediately to them. My hosts permitted me free access, and I picked up one seventeenth-century book after another, smelling and holding them, thrilled to touch objects that had once been touched by Spinoza’s hands.

But my reverie was soon interrupted by my host: “Of course, Dr. Yalom, his possessions—bed, clothes, shoes, pens and books—were auctioned off after his death to pay funeral expenses. The books were sold and scattered far and wide, but fortunately, the notary made a complete list of those books prior to the auction, and over two hundred years later a Jewish philanthropist reassembled most of the same titles, the same editions from the same years and cities of publication. So we call it Spinoza’s library, but it’s really a replica. His fingers never touched these books.”

I turned away from the library and gazed at the portrait of Spinoza hanging on the wall and soon felt myself melting into those huge, sad, oval, heavy-lidded eyes, almost a mystical experience—a rare thing for me. But then my host said, “You may not know this, but that’s not really Spinoza’s likeness. It’s merely an image from some artist’s imagination, derived from a few lines of written description. If there were drawings of Spinoza made during his lifetime, none have survived.”

Maybe a story about sheer elusiveness, I wondered.

While I was examining the lens-grinding apparatus in the second room—also not his own equipment, the museum placard stated, but equipment similar to it—I heard one of my hosts in the library room mention the Nazis.

I stepped back into the library. “What? The Nazis were here? In this museum?”

“Yes—several months after the blitzkrieg of Holland, the ERR troops drove up in their big limousines and stole everything—the books, a bust, and a portrait of Spinoza—everything. They carted it all away, then sealed and expropriated the
museum.”

“ERR? What do the letters stand for?”

“Einsatzstab Reichsleiter Rosenberg. The taskforce of Reich leader Rosenberg—that’s Alfred Rosenberg, the major Nazi anti-Semitic ideologue. He was in charge of looting for the Third Reich, and under Rosenberg’s orders, the ERR plundered all of Europe—first, just the Jewish things and then, later in the war, anything of value.”

“So then these books are twice removed from Spinoza?” I asked. “You mean that books had to be purchased again and the library reassembled a second time?”

“No—miraculously these books survived and were returned here after the war with just a few missing copies.”

“Amazing!” There’s a story here, I thought. “But why did Rosenberg even bother with these books in the first place? I know they have some modest value—being seventeenth-century and older—but why didn’t they just march into the Amsterdam Rijksmuseum and pluck a single Rembrandt worth fifty times this whole collection?”

“No, that’s not the point. The money had nothing to do with it. The ERR had some mysterious interest in Spinoza. In his official report, Rosenberg’s officer, the Nazi who did the hands-on looting of the library, added a significant sentence: ‘They contain valuable early works of great importance for the exploration of the Spinoza problem.’ You can see the report on the web, if you like—it’s in the official Nuremberg documents.”

I felt stunned. “‘Exploration of the Nazis’ Spinoza problem’? I don’t understand. What did he mean? What was the Nazi Spinoza problem?”

Like a mime duo, my hosts hunched their shoulders and turned up their palms.

I pressed on. “You’re saying that because of this Spinoza problem, they protected these books rather than burn them, as they burned so much of Europe?”

They nodded.

“And where was the library kept during the war?”

“No one knows. The books just vanished for five years and turned up again in 1946 in a German salt mine.”

“A salt mine? Amazing!” I picked up one of the books—a sixteenth-century copy of the Iliad—and said, as I caressed it, “So this old storybook has its own story to tell.”

My hosts took me to look at the rest of the house. I had come at a fortunate time—few visitors had ever seen the other half of the building, for it had been occupied for centuries by a working-class family. But the last family member had recently died, and the Spinoza Society had promptly purchased the property and was just now beginning reconstruction to incorporate it into the museum. I wandered amid the construction debris through the modest kitchen and living room and then climbed the narrow, steep stairway to the small, unremarkable bedroom. I scanned the simple room quickly and began to descend, when my eye caught sight of a thin, two-by-two-foot crease in a corner of the ceiling.

“What’s that?”

The old caretaker climbed up a few stairs to look and told me it was a trap door that led to a tiny attic space where two Jews, an elderly mother and her daughter, were hidden from the Nazis for the entire duration of the war. “We fed them and took good care of them.”

A firestorm outside! Four out of five Dutch Jews murdered by the Nazis! Yet upstairs in the Spinoza house, hidden in the attic, two Jewish women were tenderly cared for throughout the war. And downstairs, the tiny Spinoza Museum was looted, sealed, and expropriated by an officer of the Rosenberg task force, who believed that its library could help the Nazis solve their “Spinoza problem.” And what was their Spinoza problem? I wondered if this Nazi, Alfred Rosenberg, had also, in his own way, for his own reasons, been looking for Spinoza. I had entered the museum with one mystery and now left it with two.

Shortly thereafter, I began writing.

Chapter One

AMSTERDAM—APRIL 1656
As the final rays of light glance off the water of the Zwanenburgwal, Amsterdam closes down. The dyers gather up their magenta and crimson fabrics drying on the stone banks of the canal. Merchants roll up their awnings and shutter their outdoor market stalls. A few workers plodding home stop for a snack with Dutch gin at the herring stands on the canal and then continue on their way. Amsterdam moves slowly: the city mourns, still recovering from the plague that, only a few months earlier, killed one person in nine.

A few meters from the canal, at Breestraat No. 4, the bankrupt and slightly tipsy Rembrandt van Rijn applies a last brushstroke to his painting Jacob Blessing the Sons of Joseph, signs his name in the lower right corner, tosses his palette to the floor, and turns to descend his narrow winding staircase. The house, destined three centuries later to become his museum and memorial, is on this day witness to his shame. It swarms with bidders anticipating the auction of all of the artist’s possessions. Gruffly pushing aside the gawkers on the staircase, he steps outside the front door, inhales the salty air, and stumbles toward the corner tavern.

In Delft, seventy kilometers south, another artist begins his ascent. The twenty-five-year-old Johannes Vermeer takes a final look at his new painting, The Procuress. He scans from right to left. First, the prostitute in a gloriously yellow jacket. Good. Good. The yellow gleams like polished sunlight. And the group of men surrounding her. Excellent—each could easily stroll off the canvas and begin a conversation. He bends closer to catch the tiny but piercing gaze of the leering young man with the foppish hat. Vermeer nods to his miniature self. Greatly pleased, he signs his name with a flourish in the lower right corner.

Back in Amsterdam at Breestraat No. 57, only two blocks from the auction preparations at Rembrandt’s home, a twenty-three-year-old merchant (born only a few days earlier than Vermeer, whom he would admire but never meet) prepares to close his import-export shop. He appears too delicate and beautiful to be a shopkeeper. His features are perfect, his olive skin unblemished, his dark eyes large, and soulful.

He takes a last look around: many shelves are as empty as his pockets. Pirates intercepted his last shipment from Bahia, and there is no coffee, sugar, or cocoa. For a generation, the Spinoza family operated a prosperous import-export wholesale business, but now the brothers Spinoza—Gabriel and Bento—are reduced to running a small retail shop. Inhaling the dusty air, Bento Spinoza identifies, with resignation, the fetid rat droppings accompanying the odor of dried figs, raisins, candied ginger, almonds, and chickpeas and the fumes of acrid Spanish wine. He walks outside and commences his daily duel with the rusted padlock on the shop door. An unfamiliar voice speaking in stilted Portuguese startles him.

“Are you Bento Spinoza?”

Spinoza turns to face two strangers, young weary men who seem to have traveled far. One is tall, with a massive, burly head that hangs forward as though it were too heavy to be held erect. His clothes are of good quality but soiled and wrinkled. The other, dressed in tattered peasant’s clothes, stands behind his companion. He has long, matted hair, dark eyes, a strong chin and forceful nose. He holds himself stiffly. Only his eyes move, darting like frightened tadpoles.

Spinoza offers a wary nod.

“I am Jacob Mendoza,” says the taller of the two. “We must see you. We must talk to you. This is my cousin, Franco Benitez, whom I’ve just brought from Portugal. My cousin,” Jacob clasps Franco’s shoulder, “is in crisis.”

“Yes,” Spinoza answers. “And?”

“In severe crisis.”

“Yes. And why seek me?”

“We’ve been told that you’re the one to render help. Perhaps the only one.”

“Help?”

“Franco has lost his faith. He doubts everything. All religious ritual. Prayer. Even the presence of God. He is frightened all the time. He doesn’t sleep. He talks of killing himself.”

“And who has misled you by sending you here? I am only a merchant who operates a small business. And not very profitably, as you see.” Spinoza points at the dusty window through which the half-empty shelves are visible. “Rabbi Mortera is our spiritual leader. You must go to him.”

“We arrived yesterday, and this morning we set out to do exactly that. But our landlord, a distant cousin, advised against it. ‘Franco needs a helper, not a judge,’ he said. He told us that Rabbi Mortera is severe with doubters, that he believes all Jews in Portugal who converted to Christianity face eternal damnation, even if they were forced to choose between conversion and death. ‘Rabbi Mortera,’ he said, ‘will only make Franco feel worse. Go see Bento Spinoza. He is wise in such matters.’”

“What talk is this? I am but a merchant—”

“He claims that if you had not been forced into business because of the death of your older brother and your father, you would have been the next great rabbi of Amsterdam.”

“I must go. I have a meeting I must attend.”

“You’re going to the Sabbath service at the synagogue? Yes? We too. I am taking Franco, for he must return to his faith. Can we walk with you?”

“No, I go to another kind of meeting.”

“What other kind?” says Jacob, but then immediately reverses himself. “Sorry. It’s not my affair. Can we meet tomorrow? Would you be willing to help us on the Sabbath? It is permitted, since it is a mitzvah. We need you. My cousin is in danger.”

“Strange.” Spinoza shakes his head. “Never have I heard such a request. I’m sorry, but you are mistaken. I can offer nothing.”

Franco, who had been staring at the ground as Jacob spoke, now lifts his eyes and utters his first words: “I ask for little, for only a few words with you. Do you refuse a fellow Jew? It is your duty to a traveler. I had to flee Portugal just as your father and your family had to flee, to escape the Inquisition.”

“But what can I—”

“My father was burned at the stake just a year ago. His crime? They found pages of the Torah buried in the soil behind our home. My father’s brother, Jacob’s father, was murdered soon after. I have a question. Consider this world where a son smells the odor of his father’s burning flesh. Where is the God that created this kind of world? Why does He permit such things? Do you blame me for asking that?” Franco looks deeply into Spinoza’s eyes for several moments and then continues. “Surely a man named ‘blessed’—Bento in Portuguese and Baruch in Hebrew—will not refuse to speak to me?”

Spinoza nods solemnly. “I will speak to you, Franco. Tomorrow midday?”

“At the synagogue?” Franco asks.

“No, here. Meet me here at the shop. It will be open.”

“The shop? Open?” Jacob interjects. “But the Sabbath?”

“My younger brother, Gabriel, represents the Spinoza family at the synagogue.”

“But the holy Torah,” Jacob insists, ignoring Franco’s tugging at his sleeve, “states God’s wish that we not work on the Sabbath, that we must spend that holy day offering prayers to Him and performing mitzvahs.”

Spinoza turns and speaks gently, as a teacher to a young student, “Tell me, Jacob, do you believe that God is all powerful?”

Jacob nods.

“That God is perfect? Complete unto Himself.”

Again Jacob agrees.

“Then surely you would agree that, by definition, a perfect and complete being has no needs, no insufficiencies, no wants, no wishes. Is that not so?”

Jacob thinks, hesitates, and then nods warily. Spinoza notes the beginnings of a smile on Franco’s lips.

“Then,” Spinoza continues, “I submit that God has no wishes about how, or even if, we glorify Him. Allow me, then, Jacob, to love God in my own fashion.”

Franco’s eyes widen. He turns toward Jacob as though to say, “You see, you see? This is the man I seek.”

Psychotherapy with Older Adults: Unjustified Fears, Unrecognized Rewards

Posted on by rezendevknowfully.com

I am a geriatric clinical psychologist. I love working with older adults. I have often wondered, though, why there are so few of us around. Ten thousand people in America turn 65 every single day now. There is an accelerating rate of this already underserved segment of our society, and there is a huge and growing but untapped market of potential revenue for psychotherapists wanting to expand their practices. Why, then, are there so few psychotherapists actively working with older adults? While it is estimated that 70% of psychotherapists see adults on their caseload, only 3% of them have had formal training in working with older adults. What has stopped clinicians from getting training that could be so valuable in their professional development? Despite the general finding that the motivation and attitude of the older adult toward psychotherapy is as positive as it is in other age groups, many clinicians doubt this nevertheless. As I began working with older adults, I confronted these issues, and as I did, I found new joy in my work. What I discovered was this: I have as much to learn from my older clients as they may have to learn from me.

Many clinicians prefer not to work with older adults, and I have a great deal of respect for those preferences. In my own practice, I'm not inclined to work with children or adolescents. Oftentimes, though, the therapist’s preference is based on a view of older adulthood that is grounded less in fact and more in myth. When I first started seeing people in nursing homes, I felt like a fish out of water. I was trained in two of the best graduate psychology programs around, but when I was in a nursing home, I was consumed with doubt and fear.

It was 1999. I had just become licensed as a psychologist, and I was offered a job with a firm that brokered psychological services to nursing home residents. I was excited about making a living as a psychologist, energized about venturing into this new application of my skills, and eager to ply my trade—that is, up until the first week I actually saw clients! It was then that the reality of working with older adults eclipsed my fantasies of doing so. It was then that I confronted my awareness that this was incredibly challenging work for which I felt ill prepared.

My main fear: could my cognitively compromised clients even benefit from psychotherapy? I asked myself, How much of my work with them could they actually comprehend? How capable were they of working through their emotional struggles and inner conflicts? To what end would our psychotherapy serve if their lives would soon come to a close? I was overwhelmed with confusion, uncertain of my effectiveness, and scared I might be practicing outside my area of competence. Out of an amalgam of fear, guilt, and good sense came a series of consultations with a wise geropsychologist, and it was there that I began my schooling about the cognitive, emotional, and functional eccentricities of the older adult.

I am here to tell you, though, that 13 years later, I have come full circle. My acquired knowledge and experience in geriatrics have been invaluable, but I see now that, with respect to the essence of effective psychotherapy, it turned out that I had been sufficiently trained to do the work all along. Becoming technically proficient as a gerontologist has taken me on an invaluable path, but I see now that my former fears about conducting psychotherapy with older adults were driven almost entirely by my own introjects from the social stigma of aging. That’s what this article is about—to describe my own journey as a clinician framed within the cultural mythology around aging.

Myth #1: Psychotherapy with the elderly is time wasted, because the elderly client has so little time to enjoy any gains that might be made.

There is a film released in 2011 entitled Beginners, for which Christopher Plummer won the Oscar for Best Supporting Actor. The story involves a widower who, at age 75, joyously begins living a sexually authentic life as a gay man. To justify such a change, how many years should this man have left to live? Is the length of time he would have to enjoy his newfound emotional freedom really the issue? I am reminded of the elderly client who responded to her therapist’s query why she wanted psychotherapy by saying, “It’s simple; all I have left is my future.” At age 49, Freud is well known for having contended that anyone over 50 was uneducable, and I wonder if some of our biases working with older adults might stem from this overstated assertion.

Due to a very severe stroke, Estelle had for some four years been living in a nursing home. At 75, this was her home now. She was referred to me because she could not stop getting into heated arguments with other residents, and she was sad a lot. She had a history of drinking moonshine; she had been an ironworker and a barmaid, drove a semi, and had graduated high school with honors.

As with most nursing home residents, she was on a ton of meds, including an antidepressant, two anxiolytics, and an antipsychotic. When I first met her, she told me she had multiple personality disorder (which wasn’t the case), but due to her stroke, she did have memory problems and severe aphasia (difficulty expressing herself with language). In fact, her aphasia was so pronounced that it took her as long as a minute to express a complete sentence. She grinded out each word—one by one—with persistent determination. Her desire to communicate was relentless, and this was what allowed her to stay connected to others.

My psychotherapy with Estelle lasted two years, and I learned a great deal from her. I learned about the incredible courage and fortitude it takes to cope with an abusive upbringing, the loneliness and isolation that can accompany nursing home life, and the debilitating physical ravages of vascular dementia. I also learned about the connection that occurs between two souls—where words are often not needed.

More than her aggravated depression, though, Estelle wanted to work on emotional abuse issues from her childhood and the disparaging way her mother and father had treated her. She was open to the idea that those images—and the ways she coped with them—were influencing how she related to others and to herself. And this was how we approached her psychotherapy.

I am tempted to say that Estelle was a wonderful psychotherapy client, but the temptation to do so implies that it was Estelle’s characteristics that made the therapy meaningful. It was not. What made the psychotherapy beautiful—even reverent—evolved from the exceptionally meaningful way the two of us found to communicate with each other. And not unlike Victor Frankl’s odyssey through Auschwitz, what was most meaningful to me was to witness Estelle’s search for meaning in the limitations of her own life.

In the beginning, our therapy focused on relieving her depressive and angry feelings, and Estelle made comments like,

I have been fighting lately—it’s enjoyable … and it’s not enjoyable. It relieves tension, but I am crying all the time. If I told you all that is going on inside of me now we would have to meet all day!

Take a minute and think about her, though—grinding out each sentence—me wondering where in the world it was going to go—waiting almost interminably for each idea to unveil itself—and to eventually experience just how wondrous it was to witness such life-revealing self-reflection. How could a therapist not marvel at the human capability that was co-existing with such daunting a physical disability!

As our therapy progressed, the emotional work Estelle and I did together chronicled her evolution in becoming a more whole person. She created a process where she found her inner self in a way she had never done—developing her own autonomy and independence by resolving longstanding introjects that, for the first time in her life, she was now ready to expel. Toward the end of our work together, she proclaimed,

I’ve overlooked myself … but I can discover me … I can see the good inside me now. That surprises me to hear myself say that, but I see I will make it … and I know now who I’ve been angry at, and I see that I don’t need to be angry at everybody anymore. I’m not quite proud yet, but I do like being alone with me now … I really do enjoy my company. I’m on my way.

When I began doing psychotherapy with older adults, I didn’t realize that the kind of emotional and spiritual trek that Estelle would make was more similar than different from the journey I made with clients in other age groups. This is my joy of working with older adults—to see them unveil to themselves and to me their indomitable wisdom. For me, this is a revelation perhaps most profound in those who have lived with their darkness for so long.

Myth #2: The grief, loss, and somatic and socioeconomic burdens of the elderly are too excessive to warrant believing they could get better.

There is a great deal of pessimism about doing effective psychotherapy with older adults. Many of these clients have limited resources to face unimaginable social, medical, and economic struggles, and many clinicians tacitly believe that the elderly’s frustration, deprivation, fear, and dependence are so emotionally injurious that no amount of psychotherapy could really help them. When I began my psychotherapy career with the elderly, I wondered about these things too. With experience, though, what I learned was that it was not my clients’ deprivation and burden that was too excessive—it was my own. It was my inability to cope with my fears and frustrations working with excessively burdened people, and I was projecting these issues into my elder clients.

Marge was a ten-year resident of her nursing home. Legally blind, she had a longstanding diagnosis of mild mental retardation and had been institutionalized with paranoid schizophrenia for much of her life. When her mobility began to fail and her dementia and other medical conditions became too much for her family caretakers to manage, she was admitted to a skilled nursing facility. In order to address issues of depression and to help her manage her psychotic symptoms, for almost three years I saw Marge weekly for psychotherapy. I wondered if the odds of Marge overcoming her burdens were too great. I wondered if she could fight the good fight. What I came to learn, though, was that I was actually asking that of myself.

Like many people with schizophrenia, Marge was an isolationist, and this often exacerbated her psychotic symptoms. The structure and consistency of our weekly visits, though, allowed her to quell many of her paranoid thoughts, and she made remarkable progress. For the first time in many years, she was successfully managing most of her troubling and longstanding paranoid symptoms. Her solitary lifestyle, however, unintentionally reinforced her chronic feelings of loneliness.

As does happen sometimes, changes in my own life forced me to turn her psychological care over to another clinician, and we spent two months planning for the transfer. As you might imagine, my concern was that my departure would lead her to regress into further isolation. As it turned out, though, my underestimation of her strengths and concerns about her succumbing to her fears were a projection of my own issues.

In the waning weeks before my departure, Marge began to voice her sadness with our impending termination, and this was clinically therapeutic for her. She also began to tell me about the new and pleasant experience she was having on "the boat," so asked her about it.

Marge: "I will miss you."
Dr. Kraus: "Yes. It's sad that our therapy together is going to end. You have made great progress, and I am proud of you. I know you will continue your good work with Dr. Hamilton. … You had mentioned to me about a boat. Can you tell me more about it?”
Marge: "Oh, yes! We travel around."
Dr. Kraus: "Do you, now! Where have you been?"
Marge: "Well, we're going to France."
Dr. Kraus: "Really! How nice! It sounds like a cruise ship."
Marge: "Not really.{whispering} It's a submarine, but you can't tell anyone."
Dr. Kraus: {with curiosity} "How come?"
Marge: "Because they might throw me off!"
Dr. Kraus: "I see. What's it like for you traveling to all these places?"
Marge: "There's a group of us … my roommate … and a few more … and Nancy {one of her nursing assistants} … I like it."
Dr. Kraus: "That's terrific. It sounds like you're seeing that while you are sad our therapy is ending, you also see that you will have some good friends here with you after I am gone."
Marge: {Smiling and in a very calm and self-assured voice} "Yes, I will." 1

And so it was with Marge that I learned two very important lessons: 1) even with a mentally retarded, schizophrenic, aging nursing home patient with dementia, extraordinary things can be accomplished, and 2) the fears and discounting of her strengths that I imagined within her were really projections of my own.

Myth #3: Old people are staid in their ways; they are too stubborn to change.

In some of my geriatric workshops, I ask the audience what the four essential signs of aging are. Invariably, they will say things like grey hair, illness, and memory loss. Then I tell them my four: wisdom, confidence, character, and strength! I tell them that I threw them a little curve-ball, but they get the point that we often ignore or minimize the tremendous assets and capacities possessed by older adults. We overfocus on their liabilities and underrecognize their strengths. We miss how many competencies increase with age: appreciation, authenticity, desire to help, maturity, patience. Being stubborn can imply having mettle to take a stand and stick to it, and it is often quite effective for a psychotherapist to run with a resistance than to try to overcome it. It also occurs to me that to say that the elderly are staid may again say more about the patience, optimism, and confidence of those who serve them than anything else.

In Psychotherapy with the Elderly, psychologist George Bouklas offers an extraordinary account of a conversation with Errol, an 82-year-old patient of his with mild dementia, who entered a nursing facility for rehab following a colostomy. Errol never accepted his surgery, was constantly angry and agitated, and would routinely resist medical care. He was referred to Bouklas for ripping off his colostomy bag and spreading its contents across the room. He then would ask the staff what the fuss was all about! Here’s a powerful and provocative excerpt from their therapy:

Errol: (in an angry tone) "I stopped spreading shit on the floor.”
Bouklas: (silence)
Errol: "I told you, I stopped spreading shit on the floor! You act like that doesn’t matter! Well, does it matter to you?”
Bouklas: "Should it matter to me?”
Errol: "I thought you might be proud. The room doesn’t smell like shit anymore.”
Bouklas: "What’s wrong with the smell of shit?”
Errol: "You mean you liked it?”
Bouklas: “I like everything about you, no matter what it looks like, what it sounds like, or what it smells like.”
Errol: (now weeping) “You son of a bitch, if you’re lying to me I’ll kill you.”
Bouklas: “If I was lying to you I would deserve it.”2

Errol is typical of most elderly clients in that their stubbornness is a defense, albeit maladaptive—an indication that something more loathsome, more unacceptable, more humiliating may lie beneath. From my point of view, the word “staid” is an exemplar to some extent characterizing every psychotherapy client.

All clients resist—they all hold on to old patterns of thought and action. Resistance is the sin qua non of all psychotherapy, and it is no less true of the elderly. But when clients are unblocked, when resistance evaporates, psychotherapy with the elderly is an amazing thing. When we can help our clients abandon their defenses—even for just a moment—we create in the therapy a transcendent experience that elevates and inspires. It takes something special to really dare to live, and I feel privileged to witness them doing it. If we are open to our undeniable emotional connection to our clients, we can truly witness their transcendence—and it then emphatically becomes our own. With the elderly client, the metamorphosis is no less exalting, no less divine.

Growing old changes the way people relate to themselves and to others. The aged are often dealing with three principal issues: (1) how to adapt to the biggest transition of their lives—their changing health, the idea of getting older, and their changing family and work roles, (2) how to cope with the grief and loss that accompany their advancing age and decreasing abilities, and (3) how to manage their interpersonal relationships with others. As people advance in age, they go through an immense life transition—their role in their family changes, their view of themselves as a healthy person changes, and their sense of their own longevity and mortality changes. If kept silent or hidden, the feelings underlying these transitions often get acted out in disguised forms. Listening to and being there for the elderly client is invaluable to them not only because it makes available a problem-solving process that may ameliorate their distress, but also because it brings a heightened sense of connectedness and bonding with you. When this happens, they are not alone, and in that moment, neither are you.

Grief over family that's passed on, sadness over their sense of lost usefulness, loss of their former and more active pursuits that once gave them so much pleasure all make it more difficult for aging people to emotionally cope with their circumstances. Simply listening with supportive understanding and making meaningful emotional contact can bring them a sense of calm and solace. More than that, though, most of my older clients have the capacity for and can benefit from deeper emotional work. Not always are they aware they are engaged in such work, but my experience has been that it doesn’t really matter whether they are aware of it or not. It can go on, and they can reap the benefits of it nevertheless. Although the person's memory for recent events may be lacking, long-term memory, especially for well-learned actions, events, and knowledge, is one of the last cognitive abilities to decline. By helping them share something important and meaningful about their own lives, you bring into your here-and-now relationship with them the feelings of closeness they have experienced or longed to experience with others. In my view, this is so important in facilitating the growth process.

Geraldine was one of my depressed nursing home patients. Her Alzheimer's was at a moderate stage, and she could not remember my name to save her life. I met with her every week for months, and at every session she had trouble recognizing me. "Its Dr. Sparky," I would say. The social worker at the nursing home who introduced me to each of the residents there liked telling them my nickname, and that's how everybody soon started knowing me. When she would hear this, Geraldine's brow and eyelids would rise ever so slightly. "I'm your psychologist," I would say. I would prompt her recall with a verbal sketch of my role and why we were meeting. With this, you could begin to see her recognition building and she began feeling more at ease with me. I never really knew for sure that she actually was recognizing me, but it really didn’t matter, because she felt more comfortable with me.

As a rule, Geraldine's mood was irritable, she had a cynical view of the world, and she isolated herself excessively. Keeping to herself was a real problem for her, because she had begun to develop sores on her backside from lying in bed so much. When she wasn't in her bed, she was lying in her recliner. Her sores were becoming so severe that the medical staff felt they would soon threaten her life. Despite forgetting who I was and what we had talked about the week before, after a number of sessions together she began to learn that she could trust me. This is not learning that is taking place in the cerebral cortex but learning that new neuroscience research explains is occurring at a subcortical level. One thing was true—I enjoyed her sarcasm, and she could see that. I encouraged her to socialize more with others, to give others a second chance, but it was not my expertise or even my words that made a difference—it was her trust in me that eventually allowed her to risk taking my suggestions to heart.

You see, underneath her rough exterior, Geraldine really was a sweetheart. As she allowed herself to trust me, she learned that she just might be able to trust others as well. As she allowed others to know her, they began to see her sweetness, too, and as she socialized more, her depression began to lift, she spent less time in her bed and chair, and her sores began to heal.

Along with her physical healing, Geraldine experienced a significant emotional healing. Just how emotional healing occurs in therapy is still quite a mystery, but for Geraldine, it seemed to occur at a level that went well beyond what she could articulate in words or what she could remember. In this sense, her Alzheimer's did not prevent her emotional recovery. Her learning seemed to take place not within her cognitive self but as a consequence of how she felt about her relationship with me and, later, with others. Communication with her took place beyond words, beyond logic, beyond conscious thought.

“What I learned from Geraldine was that in psychotherapy, words are overrated—I learned that it is the relationship that can heal.” I have often mused about how insightful my interpretations were in a session and believed how it may have been my pithy comment that was a turning point in the therapy. That seems almost never to have been the case. When my clients recall their own turning points in therapy, it almost never has to do with anything I have said but almost always relates to something I have done or been for them. Being with them in their “staidness” may be the most effective thing I do with my older clients.

This type of healing occurs because an emotional reconciliation is reached within the aging client that has more to do with restored faith, with renewed hope, and with enhanced trust in the world, in themselves, and in their relationships with others than it has to do with cognitive functioning per se. Granted, cognitive decline generates fear, anger, suspiciousness, loss, and any number of other difficult and challenging emotional experiences—but the aging process impairs emotional functioning on a biological level only in its final stages. And that's why many people with Alzheimer's can be comforted and counseled, can feel support from others, and can reach a greater sense of peace with their experience. It's your empathy that eases their suffering. It's your empathy that cultivates their sense of joy in the life they might see they are blessed to be living and can give thanks to have lived.

How Clinicians Get Stuck: Some Emotional Risks in Working with the Aged

For several years, I led a biweekly consultation group with psychologists and master’s-level clinicians interested in learning from their own experience with their elderly clients. Some of what we discussed had to do with gerontology, cognition, testing, contracting, and the like, but much of what we discussed related to the emotional lives of the clinicians when they were with their clients.

Despite the growing evidence on the effectiveness of psychotherapy with the elderly—even with those who have dementia—psychotherapists underserve this population of clients. One of the reasons for this stems from how clinicians defend against the knowledge of their own physical and emotional mortality and the terror of their own vulnerability and dependency. I believe that this is especially true in psychotherapy with the dementia patient, where, in some form, the death of the cognitive self is confronted.

Another reason psychotherapists shy from involvement with older adults arises from the necessity for therapists to manage their own unresolved internal representations of parental and grandparental figures. Much has been written about how the older client sees a younger therapist as a younger (adult) child. When this occurs, the client needs to work through issues within the therapeutic relationship that mirror unresolved issues in the client’s relationship with his or her own children. Younger therapists, especially, can have a difficult time addressing an older client’s provocative comments like “You’re just a kid. What do you think you know about what I am going through?” In the reality of older adulthood—where the older client is increasingly dependent on younger caretakers—the unjustified but prejudicial attitude that older clients can develop toward their younger therapists can be exceptionally challenging.

It is generally understood that psychotherapy occurs within an intersubjective field—where the therapist and the client affects and is affected by the other. At some level, the therapist is always experiencing what is emanating from the client, and the client is always projecting into the therapist his or her needs, fantasies, and stereotypes. And the therapist cannot help but do the same. When skillfully observed, this can lay the groundwork for significant therapeutic gains. The therapy progresses when the therapist is aware of these processes and can use them to move the therapy forward. The less therapists are trained to do so, or the more they are hampered by their own complete internal resolution, the more likely that these processes will be acted out within the therapeutic relationship, and the less likely these processes will be therapeutically worked through. The less therapists are aware of their own projections, the more their idealized and devalued stereotypes of “old age” will unknowingly creep into the therapy, and the meaning they unknowingly assign to “old age” will color their relationships with their clients. Signifiers that should alert therapists that they may be developing distorted attitudes toward their clients are:

  • the assumption that an elderly client would not benefit from therapy,
  • the assumption that medication would be preferable to psychotherapy,
  • the attitude that a client may be too old, too stubborn, or too burdened to benefit from psychotherapy, and
  • prominent feelings of boredom, anxiety, or frustration when with a client.

In America, we honor the young for their beauty, strength, and vitality. However, in other places on the globe, old men and women are objects of veneration. This leads to a curious consequence: the less we acknowledge what can be respected, admired, or even venerated in the parents and grandparents of the world, the more we make ourselves orphans who lose a piece of our faith, security, and connection to a past that we risk repeating. This has been part of my joy in working with older adults: I am able to honor them, to sit at their feet, marvel, and learn. As their therapist, I have become their faithful student, their privileged witness, and my life is ever richer because of it.

Footnotes

1 Kraus, G. (2006). At wit's end: plain talk on Alzheimer's for families and clinicians. West Lafayette, IN: Purdue University Press.

2 Bouklas, G. (1997). Psychotherapy with the elderly: Becoming Methuselah’s echo.Lanham, MD: Rowman and Littlefield.

Esther Perel on Mating in Captivity

Posted on by rezendevknowfully.com
Lori Schwanbeck: You are widely known around the world for your unique and thought-provoking stance on what makes marriage work. Can you tell us a little bit about your perspective and what makes it unique?
Esther Perel: I was originally trained in psychodynamic psychotherapy, but my real home for many years has been in family systems theory—I trained with Salvador Minuchin, and then in psychodrama, expressive arts therapies, and bioenergetics. And for many years, I worked extensively as a cross-cultural psychologist with couples and families in cultural transition, primarily refugees, internationals, and mixed marriages—interracial, interreligious, and intercultural couples.
LS: So you saw a lot of different people’s lives.
EP: Yes, I'm interested in difference. I'm interested in the relationship between the individual and the larger context, looking specifically at gender relations and childbearing practices. I then added my interest in sexuality, so that I'm now working at the intersection between culture, couples, and sexuality.

I also like to work with clinicians, be they physicians or mental health professionals, to promote the integration of sexuality within the couples therapy world, and to integrate relational thinking within the sexuality world.
LS: What do you think is missing in most clinicians’ approaches to working with sexuality and intimacy in the Western world?
EP: I just read a whole review article by Eli Coleman about sexuality training in medical schools, and it has undergone yet another major decline since 2010. We would have thought we were finally creating comprehensive training in sexuality for physicians, but we are not. So what is missing? First and foremost, for mental health professionals as well as for all health professionals, is training: the acknowledgment of sexual health as an integrated part of general mental and physical health. The vast majority of couples therapists have had no training in sexuality whatsoever—maybe an hour here and there. Couples therapy has become, over the years, a desexualized practice. Sex is the elephant in the room.
Couples therapy has become a desexualized practice. Sex is the elephant in the room.
Most therapists do not talk about it, don't know how to talk about it, and often wait for a couple to bring it up. And the couple themselves are often uncomfortable talking about it, so it remains the unaddressed subject, though it's often hardly insignificant.

A Better Sexual Relation

LS: You see our sexuality, our erotic life, as vital in the health of a couple.
EP: I see a couple's erotic life as an important dimension of their relationship because it is an integral part of the romantic ideal that is the dominant model of modern love. We took love and brought it to marriage or committed relationships. We then sexualized love. Then with the democratization of contraception, we liberated women from the mortal dangers that were associated with sex, and sex got separated from its sole reproduction function—as Anthony Giddens says, it became a reflexive project of the self, an ongoing process of self-definition. We have, for the first time in history, a sexuality within long-term relationships that isn't about having ten kids or a woman's marital duty, but that is rooted in desire, i.e., in the sovereign free will of individuals to engage sexually with their partners. And in the process, we have linked sexual satisfaction with marital happiness; that is what has made sexuality an important element of modern marriages.

I realized in writing Mating in Captivity that I was not interested only in sexuality, per se. And I certainly was not so interested in, "Are people having sex? How often? How hard? How many? How long? Are you a sexless couple because you have less than 11 sexual interactions a year?" and so forth. My interests lie not in the statistics of sex or the perfect performance industry that pervade our society.

Instead, I found I was really interested in what makes a couple feel a sense of aliveness, vibrancy, vitality—of Eros as a life force. When couples complain about the listlessness of their sex lives, they sometimes may want to have more sex, but they will always want a better sexual relation. And they will invoke the experience of renewal, of connectedness, of playfulness, of mystery, of regeneration, of power.

My distinction between sex and eroticism actually came out of my work in trauma. My husband directs the International Trauma Studies Program at Columbia, and he works a lot with torture survivors. I would wonder, "When do you know that you have reconnected with life after a traumatic experience?" It's when people are once again able to be creative and playful, to go back into the world and into the parts of them that invite discovery, exploration, and expansiveness—when they're once again able to claim the free elements of themselves and not only the security-oriented parts of themselves.

In the community of Holocaust concentration camp survivors in Antwerp, Belgium where I grew up, there were two groups: those who didn't die, and those who came back to life. And those who didn't die were people who lived tethered to the ground, afraid, untrusting. The world was dangerous, and pleasure was not an option. You cannot play, take risks, or be creative when you don't have a minimum of safety, because you need a level of unself-consciousness to be able to experience excitement and pleasure. Those who came back to life were those who understood eroticism as an antidote to death.
LS: That’s a very powerful statement. Do you find many couples that come to you dead in their relationships?
EP: Yes, but it's not always in their relationships. Sometimes they feel deadened inside of themselves as individuals.
I think that one of the prime motives for transgression is trying to beat back a feeling of deadness.
I think that one of the prime motives for transgression is trying to beat back a feeling of deadness. And the deadness isn't the fault of the other person at all. It may be a slow progression of an atrophy that has taken place inside themselves. I think that when people miss a sexual connection, there's often one partner who misses it more than the other. That longing, that yearning for that feeling of aliveness, of connection, of transcendence, of vitality, of energy, of rush is what people talk about. And on the other side of that, they will talk about feeling flat, feeling numb, feeling shut down, feeling dead.
LS: It sounds like you’re really talking about eroticism as an expression of libido, of life energy. How do you support couples in reinvigorating the passion in their lives?
EP: There’s a little exercise that I like to do, which I borrowed from the work of Gina Ogden. I ask the each partner in the couple to complete the statement, “I shut myself down when… I turn myself off when…”

We tend to talk about “what shuts me off” and “what turns me off”; we say, “You turn me off,” but we don’t often ask the question, “When do I turn myself off?” “I turn myself off when I look at an email just before going to bed. I turn myself off when I am disinterested in what you’re talking about. I turn myself off when I worry about the kids. I turn myself off when I remember my childhood.” What do I do to shut myself down? “I turn myself off when I don’t take time for myself.”
LS: It’s really about personal responsibility.
EP: That's exactly it. So the partners go back and forth, and they can come up with a list of 10 or 15 each. And then we come to, "I turn myself on when…I become alive when…"—not just sexually. Because if you're feeling dead, the other person can wear the nicest Victoria's Secret lingerie (and there is no Victor's Secret, you know), and it's not going to do anything because there's nobody at the reception desk.

Most of the time, in response to the "I turn myself on" question, people will say things like, "When I am with friends. When I go out dancing. When I take time in nature. When I take time for myself. When I've accomplished something that I'm proud of"—things that have to do with our sense of self-worth, our connection to meaning, and our sense of pleasure—things that make us feel alive.

Then you ask a person, "You tell me you like to dance. When's the last time you went to dance?" And if they tell you, "It's been months," or, "It's been years," then, before you start to work on anything connected to sexuality, you say to them, "I think it's high time you went dancing, since it seems to be something you really love to do."
LS: When you say that modern couples therapy has become a desexualized profession, it really sounds like you’re talking about more than just sex, but really about tracking and supporting aliveness in people.
EP: I think that there are a few forces that desexualize couples therapy today. One is the notion that sexual problems are the consequence of relational problems. Then it follows that, if you fix the relationship, the sex will follow. Therefore, if all sexual problems are relational problems of complicity, of intimacy, of communication, of trust, and all of that, then there are no sexual problems. So we don’t talk about sex because sex is just a consequence of something else.
LS: And you’re saying it stands alone as a phenomenon in a relationship.
EP: I don't think that sexuality is only a metaphor: "Tell me about the state of the union and I know by extension what happens in the bedroom." I think that sexuality is a parallel narrative. I think, in fact, that when you change a couple's sexual relationship, it has an effect on every other part of their lives.
When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core.
When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core, because it's everything: mind, body, spirit, breath.

Love and desire both relate and conflict. Looking at the way people connect and their emotional history is very important, but it gets translated into the physicality of self, and then it inhabits its own narrative. They are parallel stories and they need to be looked at as such. So that's one.

Another element of the desexualization, which is, I would say, stronger here in the United States, is related to the fact that the focus over the last decades has been on security, attachment theory, the need for safety, and much less on the need for freedom, sovereignty, and self-determination. This is because we are working within a context that is among the more egalitarian contexts of the West, and one where people are often so individual and so alone that all the theories that have proliferated have been theories of connection. In the few decades before, they were all theories of individuation. It's like in art: you have one wave succeeding another. This is not a time when, in this country, people are very interested in investigating the need for freedom. That happens in environments where people are a lot more oppressed, and where they are overly connected in layers of extended family. That is not the dominant concern here, existentially or socially. And sexuality plays itself in both realms. You need a certain security for sex, for some people—not for everybody. But you certainly need a lot of freedom for sex.

Balancing Security and Freedom

LS: Tell us more about how that need for security and need for freedom can coexist.
EP: For me, the reference person is Stephen Mitchell, who in his work in Can Love Last? looked at how modern love and romanticism have brought us to try to reconcile within one relationship, within one person, fundamentally sets of opposing human needs.

In every epic story—in The Odyssey, for example—there is the home and the journey, the travel and the base. Today we want our needs for security, predictability, stability, reliability, dependability—all the anchoring, grounding elements of our lives—to be met in the same relationship with the person from whom we also expect adventure, novelty, mystery, and all of that. We still want what marriage always gave us, which was about economic support, companionship, family life, and social respectability, and on top of it, we want our partner to want us, to cherish us, to be our trusted confidant and our best friend. In effect, we are asking one person to give us what once an entire community used to provide.
LS: It’s a lot to ask for.
EP: We've never tried to experience both like that at that level in the history of human relationships. We also live twice as long—a hundred years ago, we died seven years after we were done raising children. So the longevity of what we expect from a monogamous, committed relationship is also unprecedented.

There is something about the enshrinement of the modern couple that has basically made it this hermetic unit where we have get all our needs met, rather than understand that there are certain things you're going to get from your sister, your aunt, your grandmother, your best friend, your colleague. I think that we can have multiple intimacies that are friendships and deep relationships with other people.

The model for me is really seeing the movement between freedom and security, which are the two pillars of development—connection and autonomy, independence and dependence. I think they are the two main pillars of growing up. And it is the same as any system. Every system needs to balance homeostasis and growth. It isn't just on an individual level. And every system regulates change and stability. So do individuals regulate connection and separateness.

The image that I often use in my work with couples is little kids: if everything is nice and going accordingly, you will have your child sit on your lap very cozy, nested, at ease, comfortable. And at some point, the child needs to jump out and go into the world to meet what are called the exploratory needs: freedom, independence, separateness, autonomy, all of that. If the little kid turns around, which kids always do, and looks to see what's going on with the adult, and the adult says, "Kiddo, the world's a beautiful place. Go for it. Enjoy it. I'm here," often the child will turn around and go further, and experience at the same time connection and independence, freedom and security. At some point, she has enough, and comes back to base and plops herself into your lap again, happily returning as an act of freedom to a place where she feels welcome because it offers security as well as the respect for freedom.

But if, on the other hand, the little child turns around and the adult says, "I need you. I'm alone. I miss you. I'm depressed. I'm anxious. I'm worried. What is so great out there? Why don't you want to be with me? My partner hasn't paid any attention to me"—any of the messages that basically say to the child, without ever saying it in words, "Come back"—then there are a number of dominant responses. One common one is that the child comes back, because we'll do anything not to lose the connection, since that's the primary need.

But we will sometimes lose a part of ourselves in order not to lose the other. We will forgo our need for freedom and space and separateness in order not to lose the other and the connection. And we will learn a way of loving that will have a certain excess emotional burden, responsibility, worry, that is beyond the normal elements of love that have to do with mutuality, reciprocity, care, and responsibility—so much so that once I love you, I can no longer leave you enough to be able to experience the freedom and the unself-consciousness that are necessary for sexual excitement and sexual pleasure. The adult makes that motion into sex: the ability to be inside myself while I am with another. If, when I am with another, I have to leave myself, stay outside of myself, basically, I can't even culminate. Physiologically, we cannot come if we don't have a moment where we can be completely with ourselves and inside ourselves in the presence of another.
LS: So it’s really holding that dialectic of being both within yourself while also connected.
EP: Yes. But when you talk about intimacy, you need attachment as a precondition for connection. In the realm of desire, separateness is a precondition for connection.
Love needs closeness. Desire needs space.
Love needs closeness. Desire needs space.
LS: Could you give us a practical example from a couple that you’ve worked with of how someone can have both connection and separateness? And what does separateness mean within a relationship?
EP: Imagine the person says, "I turn myself on when I go to the movies alone." Not sexually, right? "I come to life. I connect to my desires in the realm of pleasure"—that broad sense of the word "sex."
Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter.
Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter. I work in the erotic space, if you want. It's not an act. People have had sex for generations and felt nothing. I am not into promoting people having sex, but having a certain relationship with a certain dimension of your life.

So, if they say, "I like to go to the movies," then the next question will be, "Do you go?" And you will listen to the degree to which they tell you, "It's hard for me to leave," or, "It's hard for my partner when I leave," or, "No, it's just a matter of circumstances. Lately, I haven't had a chance to go, but it's never been an issue for me," or, "When I come back, I'm always worried." The third child I didn't describe is the one who does go, but is constantly looking over his shoulder, making sure that the adult here isn't going to punish him, reject him, become depressed, or collapse on him when he returns.

So the person says, "I don't go often to the movies alone, or listen to music, or play my music for that matter"—or whatever it is—"because when I come home, I experience that anxiety, that knot in my stomach that I'm not going to be told, 'How was it? How wonderful,' or I'm not going to be told, 'Stay out as long as you want. Everything's fine. Enjoy yourself.' I'm going to be told when I leave, 'Again you have to go? When are you coming back? Why are you staying out so late? Why do you not want to go with me?' I'm going to hear comments that basically say, 'Give up your freedom so that I can feel secure.'"

That is a classic transaction in the couple, versus, "I'm happy for whatever it is that you are experiencing elsewhere, even when it has nothing to do with me, because you bring this back, and that makes you a more interesting and alive person that maintains a certain vitality between us."
LS: If we use attachment language, it sounds like you’re trying to cultivate secure attachment.
EP: Yes, and a secure attachment for me isn't a singular experience: there is not always just one person to whom we turn. And I think it's a difference in culture. There are loads of places in the world that are more likely to think that your partner is the person with whom you experience parts of your life, while friends and family provide the existence of multiple safe harbors.
LS: So secure attachment for you is about feeling securely attached in the world, in your life, but not exclusively attached to one person. That’s a big difference.
EP: Right. The enshrinement of the modern couple is connected to the exclusiveness. I don't think we are more insecure today than we were before, but I think
We bring all our security needs to one person, and then we blame them for whatever is missing in our lives.
we bring all our security needs to one person, and then we blame them for whatever is missing in our lives. God forbid you have conversations with others that you should be having with your partner, because that becomes an emotional infidelity. The system is rigged with injunctions against leaving the relationship in any way possible—not just in sexual terms.

A Vibrant Field Has Multiple Voices

LS: How are you finding your ideas are holding up in our Western culture? Are other therapists embracing them, or is there a push back that you’re finding when you teach?
EP: I think that a vibrant field is a field that has multiple voices. When I wrote my book, it wasn't written for professionals. I did not think that it was going to become one of those voices—that it would be embraced in the couples and sexuality fields, as it has by some. I'm happy that it is one of the many voices. One of the things that you get when you work cross-culturally, as I do, is that every time you hear a truth in one place, you know that another place is thinking of it completely differently. The pacifier, the baby's bed, the baby's crying don't mean the same thing in every culture. And it's very refreshing to be located in a much more multicultural, nuanced, nonjudgmental, relative way of thinking. It works for me.

I think that there are people who have difficulty with what I talk about, and there are people who find a tremendous sense of affirmation in what I talk about—this is how they have been thinking, and they've been looking for that approach. I'm glad to be part of the conversation, and I'm glad to be a stimulant in the conversation.
LS: You're certainly that, and it is very refreshing. It's almost like you're bringing that multicultural perspective of relationships into a multicultural perspective of how to do therapy, as well—how to hold and look at a relationship and embrace different perspectives
EP: I think that romanticism has appeared in every part of the world, even in very traditional cultures. And wherever romanticism has appeared, people are investing more in love than ever before, and divorcing more in the name of love—or the disillusions of love—than ever before. And
I think that wherever romanticism has appeared, there's a crisis of desire.
I think that wherever romanticism has appeared, there's a crisis of desire.

Originally, I wrote my book from the perspective of a European therapist observing American sexuality. I started the original article during the Clinton and Lewinsky scandal because I was very intrigued as to why this society was so tolerant towards divorce—you can divorce three, four times without much stigma these days—but it was very intransigent towards any transgression or infidelity, whereas the more traditional family-oriented world had always compromised towards infidelity (a burden carried primarily by women, I should add), in the name of preserving the family, and separated the well-being of the couple from the well-being of the family.

I had no idea that I would be going to 20 countries on book tour. In the process, I began to realize that a crisis of desire was nothing unique to this country. It is really part of the romantic model and the changing meanings of sexuality in modern committed relationship.

But there are some unique features to this culture that have to do certainly with its relationship to sexuality. First, it's a society that often relates to sexuality as smut or sanctimony, titillation on the one side, and condemnation on the other side. It vacillates between extremes.

Second, it's a society that has certain views about transparency, and about transparency as essential to intimacy: wholesale sharing, telling it all, being explicit, not beating around the bush. I think that this is a society that looks at honesty from the point of view of a confession. Minimal tolerance for ambiguity and the imponderables is what makes American business great, but it's not necessarily what other cultures bring into the private sphere.

Keeping Secrets

LS: You’re saying that the emphasis on complete transparency and honesty actually gets in the way of creating a vital relationship?
EP: I think that one should know that, while it is obvious in some cultures, like here, that if I can tell you everything then we are closer, there are other cultures—sometimes your own neighbors—who actually think that the ability to maintain privacy is what enhances intimacy, and not necessarily transparency.
LS: It’s a big difference.
EP: It’s a difference. And I think each one evolves in its own context. But it’s very refreshing to know that there is a whole other way of looking and thinking out there that totally throws off what you take for granted. Working in New York City, I get people from 15 countries coming into my office. I practice in many languages. I cannot assume that that a couple who came at nine o’clock and wants to tell each other everything is the same as the couple who comes at ten o’clock with a completely different notion of boundaries, individual space, the mandate for sharing, the hegemony of the word as a form of intimacy, gender structures, power dynamics, and so forth.
LS: The policy of not keeping secrets within the couple is also widely held among therapists here. I’m wondering if you have a different perspective. As a therapist, do you have the same policy that many therapists have of not holding secrets?
EP: There is a clear hierarchy of secrets. There is only one particular secret that therapists really grapple with in terms of credibility, ethics, and mode of working. If you tell your therapist that you have had a miserable sexual relationship with your partner for years, that you’ve been faking it forever, that you can’t stand his smell, or her looks, or whatever it is, you rarely will hear a therapist say, “Either you need to tell your spouse, or you have to go to individual therapy.” That’s also a big sexual secret. I cannot imagine a partner one day after 27 years finding out that their wife or their husband has been lying and faking to them all these years. They’d be no less crushed. But somehow that one doesn’t do it. It is really any one of the secrets in the range of the infidelity spectrum. And even if you raided your bank account, a therapist would not usually say, “If you don’t tell, I can’t start working with you.”
LS: So you have more of a subjective stance to the issue of whether or not full transparency between your clients is ultimately serving them.
EP: I think it needs to be examined. Sometimes it's dangerous. In the field of infidelity, I would align myself very much with the work of Janis Spring, Michele Scheinkman, Tammy Nelson, or Stephen Levine, who are examining the concept of keeping a secret. Today, in the first session with any couple, I will say, "I will see you as sometimes together and sometimes apart—I don't know how much of each. When I will meet you apart, it's because I think that there's certain conversations that may be better held alone, because you will be less defensive. You will take more responsibility. You will be more able to examine yourself quietly. You won't be in the reactive stance. And those will be confidential conversations, which means that each of you will probably tell me things that your partner may not know. And you will decide at what point you want to share that."

I'm often asked, "What do I do with the secret of infidelity?" I sit with it, because sometimes the secret is the therapy. Or, as Janis Spring says, "Giving up on the secret is the therapy." Then the question is, is revelation mandatory? It is often seen as mandatory here. The concept that intimacy needs to be rebuilt through transparency and revelation doesn't take into account that for some people, revelation may be more traumatic, which then is answered by other people who say, "But, somehow experiencing the trauma is part of rebuilding the relationship." But that's one view.

So I work with secrets. If I agree to work with the couple, I take the couple as it comes to me. It's not for me to decide what risks people need to take in terms of revealing their secrets. There are major power imbalances in society—major risks involved for women to reveal certain secrets, for instance. I very carefully assess with them what is safe. I've learned that when I go to Cuba, Mexico, and other places, I can't just take transparency as a norm without looking at the political and social implications of gender politics. In that sense, the dominant theories and trends du jour are not as contextual as systemic thinking used to be.
LS: What advice would you give to therapists in looking at their own erotic lives, in terms of how that’s going to affect the way they show up with clients?
EP: There are two levels: the professional and the personal. On the professional level, I think you want to continue to learn, renew yourself, grow. I think it's particularly important for experienced therapists to not stop growing, to not stop listening to other people.

Every time I go to a workshop or a conference, I know that I work differently the week that follows. I am filled up. I am renewed. I'm trying out new things, stepping outside of my own comfort zone. Every time I go and I lecture some place, I ask people, "Has my work grown? Has it changed? Have the ideas matured? I hope I'm not repeating the same thing." At this moment in my work, I have made new choices, different choices than the ones I certainly was trained with—or indoctrinated with, we could say, because they were never questioned.

I also think that it's very important for me, anyway, as a therapist, to read anthropology, history, poetry. The arts are a lot more able to deal with the complexities of love, sex, desire, and transgression than psychotherapy is. The greatest novels, movies, and poems capture the complexities and the contradictions of our life. I strive towards the embrace of the contradictions, or the dialectic, and not necessarily towards the dogma. I tend to work more on the side of art than on the side of science. And to work in the realm of art is to work with the unknown, rather than to want to simplify the known and to make it predictable and organized. I don't have a set model in that sense.

Maybe what people have appreciated about my work is the fact that I am questioning our assumptions. I really don't think I have the truth on things, even though I sometimes sound very confident. But I am willing to ask myself, "Is this the only way? And who says? And must it be this way? And for whom?" The people who come to study with me do so because I'm out of the box, not because they're going to get a nicely structured framework. There are a lot of other important elements to couples' lives, but it happens to be that this existential dimension is the one I have become very interested in. So I write about that.

And personally, make sure you stay alive. Make sure you stay in touch with your own experience of pleasure, of receiving, of giving, of sexuality, of your body. Don't disconnect, or you will bring that into your work, and it doesn't benefit anybody.

Videotaping Therapy

Posted on by Psychotherapy.net Team

Therapists have been using videotape to enhance psychotherapy training and supervision for decades. Recent technological advances have allowed for a range of creative new affordable ways to record “picture-in-picture”, so the video shows both the client and therapist. These setups do not require any video editing. Below is a list of instructions for picture-in-picture video setups, with links for more information. If you know of another recording setup, please email me, and I’ll add you to the list.  

(Updates to this list are available here:  http://istdpinstitute.com/resources/)

1. I use Wirecast software to combine two digital webcams, connected to my computer, into one picture-in-picture therapy video. Psychotherapy videos are stored on the computer and can be burned onto DVDs. No editing is required.

2. Nat Kuhn developed a system to video therapy sessions that uses two digital cameras, two DVD recorders and a Picture-in-picture (PIP) video mixer. Therapy videos are stored on DVDs and no computer editing is required. He provides very detailed equipment and setup instructions here: http://natkuhn.com/equipment/equipment.pdf.

3. Arno Goudsmit in the Netherlands has developed a psychotherapy recording tool for a 2-camera and computer setup (also adaptable for 1 camera), which gives a picture-in-picture effect on an mpg-file. He uses memory sticks which the patient can take home; and they keep a copy of the psychotherapy video for study purposes. (You could also burn the therapy video onto a DVD.) You can find his software at: http://www.edtmaastricht.nl/2cameras. His software is free and no video editing afterwards required.

4. Rick Savage is a producer in New York City who has experience helping setup therapy videotaping systems using Apple computers and digital cameras. He can be reached at 917-364-1866 and
www.savagetunes.com.

Also:  Jon Frederickson and I have been experimenting with the use of Skype for one-way-mirror supervision. Jon provided live, one-way-mirror supervision for me from Washington, DC, while I was working with clients in San Francisco. We have had very positive clinical and training outcomes with this new technology. If you would like setup instructions, email me.

Clinicians and supervisors may also find the following articles of interest:

1. Allan Abbass, a psychiatrist in Halifax, published “Small-Group Videotape Training for Psychotherapy Skills Development”, as well as “Web-Conference Supervision for Advanced Psychotherapy Training: A Practical Guide”

2. Peter Costello, a media ecologist and clinical psychologist at Adelphi University, wrote “The Influence of Videotaping on Theory and Technique in Psychotherapy: A Chapter in the Epistemology of Media”
 

Assessing Partner Abuse in Couples Therapy

Posted on by rezendevknowfully.com

Mark and Julie were in their late thirties, and had been married for seven years after living together for three. During their initial session with me, they expressed concern that they had been drifting apart over the past year. They were both under considerable stress. Julie’s planned six-month leave of absence from her job following the birth of their son Brandon had now lasted four years. Brandon required lots of Julie’s time: he was highly impulsive, displayed frequent temper tantrums, and recently bit another child at daycare. Mark supported the family as a salesman for a medical equipment firm, but getting along without Julie’s income meant longer hours and more frequent travel.

“We hardly ever have time for each other anymore,” said Mark. “And I’m out of town so often these days that it’s hard for us to readjust when I get home. Julie is always preoccupied, either with Brandon or something else, and our relationship isn’t a priority for her the way it used to be.”

“We don’t communicate well,” added Julie. “We argue about parenting Brandon, about my housekeeping, about Mark’s being gone so much of the time . . .”

“There’s an example of one of our problems,” Mark interrupted. “ I don’t feel like she appreciates how hard I work to support us. Traveling on business is no picnic, I can tell you. I miss being home with my wife and kid.”

To most outward appearances, this was a couple caught in the typical dilemmas of our age: how to balance work and home life, how to be both parents and intimate partners, how to get one’s own needs met while meeting the needs of the other.

Mark and Julie had been in conjoint therapy twice before; each stint had lasted about one and a half years. Their first therapist, they told me, helped them understand how their relationship replicated themes from childhood. A couple of years later, when their arguments grew more frequent, they decided to try a new therapist. Mark liked their new therapist’s pragmatic approach and appreciated learning how to make “I statements” and practicing reflective listening. Mark felt that he had finally gotten through to Julie about his concerns. Julie agreed that the therapy had been helpful, but wasn’t willing to continue because there was too much focus on Mark’s concerns and not enough on hers.

When I asked Mark and Julie how they argued, they reported that Mark frequently raised issues in an angry way. Julie would withdraw, and Mark would press for resolution. She sometimes burst into tears during these encounters, and he saw this as her way to avoid addressing his concerns. Yet they both reported that their arguments “never get physical.”

Over the next few sessions, I gave Mark and Julie typical homework assignments. We discussed taking time-outs when their interactions grew too heated. We reviewed and practiced reflective listening skills. They voiced an appreciation about each other every day. And despite difficulty finding a babysitter who could handle Brandon, they managed to schedule two “date nights” over the next two weeks.

I did not yet realize it yet, but I was making the same error as their two previous therapists: I was attempting to do couples therapy with an abusive relationship.

Obligation to Assess

Many therapists, including those of us with extensive clinical experience, frequently plunge into doing therapy before we have adequately assessed whom and what we are treating. It is in the nature of the therapist-client relationship that we cannot know the whole story from the outset. Our clients may be lost, confused, withholding, or in denial. They aren’t ready to divulge everything at a first session (and if they were, we would probably wonder why). In the cause of establishing a working alliance, we leave avenues of assessment unexplored until a more opportune moment. Assessment and treatment necessarily walk hand in hand as the ongoing process of discovery and healing unfolds.

However, none of this relieves us of the ethical and professional obligation to carefully assess factors that may undermine treatment. “Sometimes we collude with our clients’ denial systems, deliver services that are misdirected or even harmful, and allow problems to get worse, under the guise of providing treatment.” Meanwhile, our clients continue to believe they are getting help, and we continue to collect our fees. Whether the undiagnosed problem is addiction, bipolar illness, domestic violence, or some other weighty issue, part of our job is to make educated guesses and follow up on them.

One error I encounter with troubling frequency is the failure of couples therapists to assess adequately for partner abuse. By partner abuse, I mean the use of force, intimidation, or manipulation—or the threat to use any of those methods—to control, hurt, or frighten an intimate partner. Note that the definition can be met even if no physical violence is involved. Verbal and psychological tactics are more common; frequently, they are also more effective at controlling, hurting, or frightening another, and they can be more emotionally damaging in the long run.

I have met with couples whose seasoned therapists, over the course of several years’ treatment, missed the extent and severity of the physical and emotional abuse taking place at home. We might be tempted to believe that clients bear some responsibility for staying silent on the issue (whether out of fear or outright denial), but the obligation to assess rests firmly on our shoulders. For example, an abused partner may feel unsafe bringing up abuse in the presence of the other because of likely retaliation, yet many therapists have a policy of never meeting separately with one member of a couple they are treating jointly.

Regardless of the reason for the assessment failure, the tragic result can be months or years of continued abuse. “Suffering” is a pallid word to describe the soul-damaging, spirit-deadening impact of ongoing abuse on the abused partner and the children who live with it. The corrosive nature of some abuse leads to an erosion of the self that can be extremely difficult to reverse. The effects are cumulative and must stop before healing can begin. Additionally, abuse generally grows worse without intervention. Meanwhile, clients incur a sizable expenditure of time and money, and the therapist (and, by extension, our profession) loses credibility.

Common Misconceptions

Several common misconceptions hamper or prevent an adequate assessment of partner abuse.

“The couple report that they yell at each other, so they both contribute to the problem.”
Loud arguments should always suggest the possibility of partner abuse. Most abusive relationships involve some angry behavior by both parties; some involve mutually abusive behavior as well, although the degree of fear is generally much greater for one partner than the other. While both partners are responsible for their own behavior, one of them probably contributes disproportionately to the abuse.

“I spoke to them about partner abuse and they deny it is going on.”
As therapists, we know better than to accept clients’ analyses of their difficulties and to probe more deeply. “If an angry client reports that he believes in firm discipline but would never abuse his children, do we simply take his word for it?”

“It is my policy never to meet individually with clients I see in couples therapy.”
Adequate assessment for abuse cannot be accomplished with both partners in the room. Asking directly about abuse in a conjoint session puts the abused partner in a no-win position: to disclose and risk reprisal, or to deny and thereby avoid getting needed assistance.

“I have a ‘no secrets’ policy, so clients know that anything they share with me individually will be brought into the couples session.”
In my view, such a policy is designed to relieve the therapist’s anxiety and hinders rather than helps the client. As therapists, we often learn things we cannot or choose not to divulge. Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment.

“Even if there is undiagnosed partner abuse, I’m helping them resolve the underlying relationship dynamic.”
By its very nature, abusive behavior prevents the resolution of other issues. Abuse skews the relationship dynamic and leaves most of the power and control in one partner’s hands.

“I can teach them better communication skills until they trust me enough to disclose the issues they are withholding.”
Abusive partners easily subvert communication skills at home. “I” statements are meaningless if the intent is to hurt, control, or manipulate.

“I’m not taking a stand on the issue because I’m afraid the abusive partner will bolt from treatment.”
Again, the delusion here is that some treatment is better than none. What is needed is a referral to appropriate treatment, rather than maintaining the fiction that the couple is getting help while the abuse continues.

An Abusive Dynamic

At their next session, Mark and Julie reported that their second planned date night had started out well. They ate dinner at a quiet restaurant, reminisced affectionately about the first time they met, and held hands as they shared a frozen yogurt. Brandon was asleep when they got home, even though it was still relatively early. When they went to bed, Mark anticipated they would make love; Julie was tired and just wanted to curl up and go to sleep. Mark persisted, saying that this was the only chance they’d had for sex in a while so they’d better take advantage of it. Julie said she was tired of his “guilt trips.” He said she was frigid and accused her of withholding sex to punish him.

They had carried on late into the night as the argument broadened to include many other areas of disagreement. The conflict continued in my office the next evening.

” . . . And I appreciate how hard he works to support us,” Julie was saying. “But when he gets back from a business trip, he’s constantly finding fault with the way I keep the house, the things I wasn’t able to get to. He thinks I’m too soft with Brandon and that’s why he’s been acting up at daycare. It’s true that I could do a lot better job of housecleaning, and I paid the credit card late last month. My hands are so full with Brandon that everything else seems to take second place. I know I need to get better at setting priorities, like Mark says, but I feel like I’m doing the best I can and I wish he appreciated how hard my job is.”

Mark was restless but listened quietly while Julie spoke. When it was his turn, he spoke quickly, with increasing agitation and volume.

“She talks about not being appreciated. Well, she doesn’t do a very good job of appreciating me. I work really hard to support us at this level, and you’d think I could at least come home to a house that didn’t look like a bomb hit it. And Brandon is out of control because she doesn’t know how to set limits with him. He never acts up with me the way he does with her. Plus, she has the entire day to spend at home and take care of the things I can’t get to because I’m out of town. Brandon’s in daycare now, and she has so much free time to get together with her girlfriends for coffee . . .”

“Now, wait just a minute!” said Julie angrily. “That only started a couple of weeks ago!”

“No, you wait a minute!” replied Mark in a louder voice. “I don’t appreciate your angry tone, and I didn’t interrupt you when you were talking. I’d appreciate it if you could show me the same respect!”

“It’s hard to sit still while you misrepresent things,” she said petulantly, slumping in her chair.

“There you go again. When I give my point of view, I’m misrepresenting things. “ He turned to me. “You see how this goes. She never seems to respect my opinion. Everything I say, she counters it.” He raised his voice. “She treats me like she doesn’t even like me anymore! Ever since Brandon came along, our sex life has gone out the window. She always has something else on her mind, or she’s too tired, or I don’t know what.”

“Maybe if you treated me with more respect, I’d feel more like getting close to you,” Julie replied softly.

“See, there you go again. It’s always my fault!” said Mark. “We disagree on so many things, I’m really not sure what’s keeping us together anymore!”

There was a pause. Mark’s face grew darker and his brow furrowed as he spoke. The skin around Julie’s temples grew taut and her shoulders sagged.

“Tell me, is this kind of how things go at home?” I asked. “You start to talk about an issue, and things escalate? Mark, you seem angry and frustrated, and Julie, you seem angry and resigned. I can see that there are a number of issues on the table. But I’m wondering if I’m getting to see how your efforts at communication get off track. Is this how things go when they don’t go well?”

They answered simultaneously. “Pretty much,” said Mark. “This is mild by comparison,” said Julie.

“So what would typically happen at this point?” I asked.

“Mark usually kicks something, then leaves the room,” said Julie, hands crossed over her chest.

“Oh, really? What about you turning on the water works, then giving me the cold shoulder and playing the Ice Queen for three days?” said Mark, pointing his finger at her. “You left that part out. As usual!”

“OK, hold on a moment, both of you,” I said. With ten minutes left in the session, I felt the need to intervene, based on the growing escalation, the content and tone of the communication, and Mark’s increasing impulsiveness. I also feared that their disagreements were severe enough that continuing to talk about them would result in yet another argument as they left my office.

“There’s been a lot of heat expressed in this office today, and I’d like you both to cool off before you leave. I want you both to take a few nice deep breaths, s-l-o-w-l-y. Good. I want you to drop this argument, and I want you to agree not to talk anymore about these issues today.” We spent a few minutes addressing the difficulties they might experience in keeping to this agreement.

It was now clear to me that this couple was caught in an abusive dynamic. Mark had initially given the impression that he was listening to Julie, but he shifted restlessly as she spoke; when she finished, he responded quickly with an increasingly angry and critical tone. He blamed her for their problems and employed various strategies—such as exaggeration, distortion, and counterattack—to deflect any suggestion that he might also bear some responsibility for their difficulties. When Julie attempted to correct his misrepresentation of her coffee dates, he turned the tables by attacking her for the interruption and accused her of having less respect for him than he had for her. Mark felt free to express his anger but could not tolerate Julie expressing hers. He accused her of employing the very tactics he used (for example, “Everything I say, she counters it”). Mark demeaned Julie for the upset feelings she experienced following his angry outbursts and her subsequent need to pull away.

By contrast, Julie recognized some of her contributions and validated many of Mark’s concerns. Her brief efforts to defend herself were quickly overwhelmed by Mark’s responses. Her petulant tone and slumped posture were signs of defeat.

Indicators of Partner Abuse

Like Mark and Julie, clients in abusive relationships present with typical complaints: “We don’t know how to communicate with each other.” “We’ve been arguing a lot.” “We’re both under a lot of stress.” “We’ve needed counseling for a long time and he/she finally agreed.” “We disagree about disciplining the children.” Usually, their level of intimacy has declined.

More telling indicators are embedded in the relational dynamic that emerges in the consulting room. There may be unexplained tension in the room; certain topics appear to be off limits. “There may be a marked difference in the way and the degree to which each partner participates in the session.” The abusive partner may always start the session or, alternatively, always make the abused partner begin. One partner may be highly critical and judgmental, or exercise control through silence, intimidation, and manipulation. The other may speak hesitantly and haltingly—or, alternatively, may be hostile, resentful, and angry, seemingly out of proportion to the subject under discussion.

They may disagree on basic facts and have widely divergent views of the same events. Frequently, both partners are highly defensive and misconstrue what the other says, as though looking for an opportunity to act angry or hurt. They report or exhibit destructive communication patterns, such as escalation, invalidation, or a demanding/withdrawing dynamic. Impulse control may be poor. Problem-solving and conflict resolution skills are lacking.

Any of these symptoms are sufficient to raise suspicions of partner abuse. Alternatively, many abusive relationships present as typical relationships with occasional heated arguments that both parties have come to see as the necessary though undesirable price of an intimate partnership.

Assessment Protocol

When a couple comes to see me specifically because of my expertise in treating partner abuse, I typically employ a four-session protocol. I meet once with the couple, once separately with each partner, and then once more with the couple (or twice, if I need to gather further information or test hypotheses) to deliver my recommendations.

Alternatively, a couple like Mark and Julie may come to see me because they’re having difficulties and have decided to try therapy, and I might not begin to suspect partner abuse until they have seen me a few times. When I recognized the abusive dynamic in Mark and Julie’s relationship, I said to them:

“I think it would be helpful for me to set up an individual appointment with each of you so that you can share your concerns without having to worry about the other person’s reactions. I frequently do this in couples therapy, and given the volatility of today’s session, now seems like a good time.”

With an even more highly volatile couple, I might say something as innocuous as:

“During the last several sessions, I’ve had a chance to see how you interact with each other. As part of our work together, and in order to get to know you better, I’d like to schedule an individual appointment with each of you. I want to find out more about you, your childhood, family history—that sort of thing.”

I wait until the individual sessions to address the issue of confidentiality and “secrets.” With Mark and Julie, I began their separate sessions this way:

“This is a rare opportunity to get together with you, and I’m wondering if there’s anything you’d like me to know that you’re not comfortable saying with your partner in the room? If it’s something you want to tell me in confidence, I can keep it to myself. If it’s something I think would be helpful to discuss in a joint session, I’ll let you know that today, but I won’t disclose anything you don’t want me to.”

I also tell each partner that I would like to ask a series of questions about the kinds of behaviors that have occurred in their relationship. With the abusive partner, I am especially interested to learn whether similar behavior has occurred in any previous relationships, because it counters the common belief that the current partner is in some way responsible for the abuse. For this purpose, I use my own Abusive Behavior Inventory, an abridged version of which is included at the end of this article. I frequently supplement the specific questions on the inventory by inquiring about the first, last, and worst conflicts the couple has had.

Choice of Assessment Tools

To develop the Abusive Behavior Inventory, I spent one dreary weekend reflecting on all the variations of spousal abuse I had encountered during several years’ clinical experience and incorporated them with similar questionnaires employed at two agencies where I worked. I also referred to Patricia Evans’s The Verbally Abusive Relationship: How to Recognize It and How to Respond (Bob Adams, Inc., 1992) and Ann Jones and Susan Schechter’s When Love Goes Wrong: What to Do When You Can’t Do Anything Right (Harper Collins, 1992). An instrument similar to mine is R. M. Tolman’s Psychological Maltreatment Inventory (see “The development of a measure of psychological maltreatment of women by their male partners,” Violence and Victims 4 (3): 159B177, 1989).

I do not employ the self-administered Conflict Tactics Scale, developed and revised by noted researchers Murray Straus, Richard Gelles, and Susan Steinmetz. Despite broad acceptance as a research tool, it has numerous shortcomings in a clinical setting. For example, it measures violence only during the preceding 12 months, even though just one violent incident from many years ago may still be casting a shadow over the relationship. It does not ask whether the violence occurred in self-defense. And it equates acts that are inherently unequal due to men’s generally greater physical size and strength and women’s generally greater level of fear that men’s anger will erupt into abuse.

Using the Abusive Behavior Inventory in the individual interview allows me to uncover whether a pattern of abusive or controlling behaviors exists. This is accomplished best in the context of a clinical interview, for two principal reasons. First, clients provide much more information—factual, psychological, and emotional—than they would with a self-administered questionnaire. Second, clients may be so disturbed by their answers that they need an opportunity to process their reactions.

Comparing their answers side by side is an exceptionally useful diagnostic tool. Couples who corroborate each other’s answers generally exhibit greater awareness of problems in their relationships and are more often motivated to do something about them.

Suspicions Confirmed

As I suspected, my individual meetings with Mark and Julie revealed a long-standing pattern of moderate partner abuse. Despite their earlier contention that their arguments “never get physical,” on several occasions Mark had prevented Julie from leaving the room during an argument by standing in the doorway. Once or twice, he had slapped her shoulder as she walked away. He had grabbed her wrist a few times, in one instance hard enough to leave a bruise. He had also thrown several television remote controls and a cell phone when angry, and he frequently punched walls and slammed doors.

Mark sometimes used what he had learned in couples therapy against Julie: for example, by couching frequent critical and demeaning comments using a distorted version of an “I” statement, or by asserting that she was projecting her father onto him. When Julie raised a sensitive subject, Mark frequently got angry, yelled in her face, declared a time-out, stomped out of the room, and never returned to the issue.

Julie reported that her self-confidence had plummeted over the past few years, and she was feeling helpless and hopeless about her marriage. She said Mark had little sympathy for the chilling effect his behavior had on her libido and often criticized her for her infrequent interest in making love.

Recommendations for Treatment

When Mark, Julie, and I came together following my individual sessions with each of them, my recommendations went something like this:

“I have some thoughts about your therapy and where we go from here. We’ve discussed the issues and difficulties you experience together. For example, neither of you feels adequately appreciated, and you both report difficulty getting the other person to recognize and meet your needs. You’re both pretty good about identifying each other’s shortcomings but not so good about identifying your own. And it’s hard for you, even with me in the room, to discuss sensitive issues without getting into a heated argument.

“I think it’s clear to all of us that the two of you need couples therapy. But I think it’s premature at this point. It’s really just a matter of timing. You’re going to be spinning your wheels until you both have a chance to address your own issues. Then you’ll be able to take advantage of what couples therapy has to offer.”

In recommending separate treatment, there is a risk that the abusive partner will accuse the abused partner of having disclosed sensitive or confidential information that led to the recommendation. To minimize that risk, I cite only the behavior I observed or heard about in meeting with the two of them together when explaining my recommendation. If the abusive partner has acknowledged any abusive behavior—and it is extremely rare for the Abusive Behavior Inventory to bring no abusive behavior to light—I will refer to that as well.

In his individual session, Mark confessed that he had grabbed Julie’s arm once and frequently got so angry that he hit things. He also expressed remorse about it and a desire to change. So I added:

“And I appreciate your forthrightness, Mark, in acknowledging that you grabbed Julie’s arm and you don’t like the way you act when you get angry. That’s definitely something I can help you with.”

In the typical abusive heterosexual relationship, I generally refer the man to a men’s group with a focus on partner abuse (one of my own groups, or a colleague’s). I refer his partner to a group for women in abusive relationships. Other options include individual therapy with a therapist who has experience treating partner abuse, and group therapy for abusive women. I generally refer men who are being abused to individual therapy, since groups for this population are rare.

It is important to be resolute about my recommendations prior to the final assessment session so that I keep to them, whether or not the couple finds them acceptable. One or both partners will sometimes attempt to mount a persuasive argument for being seen together, and occasionally one of them will insist on having therapy together or not at all. My express purpose is to send a clear and unwavering message at this stage of treatment that couples therapy is premature—just as I would regarding family therapy with a parent who currently abused the children or who was an active alcoholic.

Arguments for and against conjoint treatment in cases of partner abuse are often heated and polarized among treatment professionals, in a process that runs parallel to the typical dynamics in an abusive relationship. By training and experience, I believe in the paramount importance of holding the abusive partner (or partners) accountable for his or her actions, regardless of what the other partner says or does. In abusive relationships, couples therapy undermines this goal by communicating, either overtly or by implication, that both partners bear some responsibility for the abuse.

There are practical considerations as well. Abusive couples who leave a session with unresolved issues are more likely to erupt afterwards. (I know, because many years ago I heard them yelling outside my office or pealing out in separate cars!) Additionally, conjoint therapy is generally not productive when control issues distort the therapeutic process or when either party fears serious repercussions for speaking the truth.

When is Couples Therapy Indicated?

Before I would consider treating an abusive couple together, they would have to meet several conditions.

  1. Their answers to the Abusive Behavior Inventory match closely.
  2. Past abuse was moderate to mild; currently, abuse is extremely mild or entirely absent.
  3. The couple can adhere to a contract of no further abuse.
  4. The abused partner is safe, unafraid, and able to mobilize resources if needed.
  5. Both partners are motivated for treatment out of a sincere desire to grow and change.
  6. Both partners are willing to be accountable for their behavior, without blaming the other.
  7. The couple can use basic communication skills in a non-manipulative manner.

In short, couples therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment.

I presented Mark and Julie with two choices. They could each seek treatment with other professionals and keep me in reserve as their couples therapist at some future date. Or I could take Mark into one of my men’s groups, refer Julie to another therapist, and help them find a new couples therapist when Julie’s therapist and I thought they were ready. Mark’s reluctance to join a group, much less one led by a different therapist, led us to conclude that the second option was preferable.

Over the next three years, Mark and Julie both participated in group therapy supplemented by short bouts of individual work. I consulted regularly with Julie’s therapist to coordinate our treatment efforts, and we met together with the two of them from time to time to coach the couple through especially difficult logjams. Once Mark had achieved more than six months of abuse-free behavior, he and Julie began working with a seasoned marriage therapist who understood the dynamics of abuse. Julie ended her group work, but Mark remained for another six months because he had discovered that being accountable to other men helped ensure his continued recovery.

Conclusion

Treating partner abuse is a specialized field. Trainings in recognizing and treating the problem are helpful, but the only way to develop real expertise is through direct experience. To that end, I recommend that you become familiar with an assessment tool like the Abusive Behavior Inventory and practice administering it to a few colleagues. As with any new tool you add to your clinical repertoire, the greater your comfort in using it, the more at ease your clients will be.

Then, the next time you suspect partner abuse, you’ll be ready to assess for it. When you do, share your findings with colleagues, a supervisor, or an expert. If you discover your suspicions are groundless, you can breathe a sigh of relief. If your suspicions are confirmed, refer the couple immediately for further assessment, if necessary, and appropriate treatment. The hazard of proving your suspicions incorrect is small compared to the danger of leaving partner abuse undiagnosed and untreated.

In many ways, Mark and Julie experienced an ideal outcome. Their commitment to each other and to the process of change allowed them to leave their abusive dynamic behind. Mark was able to give up his sense of entitlement and develop greater empathy for Julie. Although some emotional scars remained, the damage was not so severe that Julie was unable to reclaim the genuine affection she had once felt for Mark.

But they were lucky: without any of these factors, a divorce was likely. And without appropriate intervention, the probable outcome would have been an uninterrupted, escalating pattern of abusive behavior, accompanied by additional years of unnecessary pain and suffering and the possible transmission of abuse to the next generation.

Is Self-Regulation or Co-Regulation Better for Couples?

Posted on by Psychotherapy.net Team

Should couples in distress attempt to change their partner or themselves? Recent research discusses concerns about both of these strategies, and raises an interesting third option. Shreena Hira and Nickola Overall examined 160 couples attempting to change their partner or themselves. As they expected, attempts to change their partner didn’t make either their partner or themselves feel better. Surprisingly, however, a focus on self-change did not consistently help the relationship either. Instead, the researchers discovered that the most beneficial change occurred when one or both partners in the relationship perceived the other as changing themselves (self-regulating.)

This poses an interesting challenge for couples therapists, as partners don’t always perceive the change (or effort) made by their partners, and rarely does either partner want to “go first”.  One idea to address this dilemma, proposed by Victor Yalom, is for the therapist to help clients  tune into the changes and effort made by their partner, even if the change or effort is very small.  This can help build trust, morale and set the stage for greater changes later.  Likewise, therapists could use recognition of small-item effort or change as an assessment tool for determining when the couple is ready to work on more challenging change goals.

There is currently a hot debate in the field between therapists who promote self-regulation (differentiation) and therapists who promote co-regulation (attachment). This research suggests that couples may in fact improve co-regulation capacity by witnessing self-regulation efforts by their partner. 

From: Shreena N. Hira & Nickola C. Overall. (2010). Improving intimate relationships: Targeting the partner versus changing the self. Journal of Social and Personal Relationships 28, 610-633.

John Arden on Brain-Based Therapy

Posted on by rezendevknowfully.com

Why Brain-Based?

Rebecca Aponte: Why did you call your book Brain-Based Therapy? What does “brain-based therapy" mean?
John B. Arden: I've got to say that the actual title of the book was chosen by Wiley, the publisher. The earlier title had something to do with neuroscience—I forget, actually, what it was. But when this one was chosen, my initial reaction was, "Geez, that sounds so reductionist."
RA: That’s what I thought, too.
JA: And there's so much out there about neuroscience. A good friend of mine, Lou Cozolino, wrote a book called The Neuroscience of Psychotherapy, so maybe it was too close to his title. But from my point of view, it doesn't have anything to do with reductionism. I still regard Jung's analysis of culture and fairy tales and religion to be fascinating. In fact, I spent a lot of time sitting in yoga ashrams in different parts of the world meditating, and those parts of my development are still with me. I'm still interested in all of that, but I want to integrate it all. And it has to be integrated from a nondualistic perspective. It seems to me that for many years we were in what I call the Cartesian era.

RA: The separation of the body and the mind.
JA: Right. Between 1890 and about 1980, we were in the Cartesian era with no scientific grounding for this view whatsoever because, despite the fact that Freud was a neurologist and wrote a hundred articles in neurophysiology, on such things as the neurophysiology of the crayfish, we didn't really know much about the brain at the time. So the schools of psychotherapy just splintered all over the place—everything from primal scream all the way to radical behaviorism—because there was no common language, no common integrative core.

The picture changed around 1979 to 1981 due to the convergence of a number of different factors. For one thing, the DSM-III—the third Book of Bad Names—developed. And it was a whole lot better than DSM-II and DSM-I, because you didn't have a lot of terms like "neurosis." Even homosexuality, believe it or not, was in the DSM-I. Finally, in 1974, when the DSM-II came out, millions of Americans and Europeans became cured of their disorder. That's why people get really caught up with the diagnostic terms. So DSM-III came about, and there was a whole lot more science to it. People were saying, "Wow, geez, this is so much better. This makes a little bit more sense."

Also, up until about 1980, the efficacy studies for psychotherapy were pathetic. Way back to Hans Eysenck, the mere passage of time was as effective as psychotherapy. Before Timothy Leary went to Harvard, he actually worked for us as a chief psychologist at Kaiser Oakland. He was a pretty bright guy before he started taking acid and flipping out. And he did a study there where he found that people on the waitlist did as well as people in psychotherapy. So imagine all that.
RA: A huge crisis for the field to go through.
JA:

The Age of Pax Medica

Exactly, until the Smith and Glass studies, which came out in 1979 or 1980. I was at University of New Mexico at the time, and we were pretty excited because this big meta-analysis found that, actually, psychotherapy worked. "Oh, my god. What we're studying and what we're doing really makes sense. We're helping people. Thank God!" Then, too, the development of these SSRIs in the '80s was a major factor in the development of what we call Pax Medica.
RA: Can you elaborate on that term?
JA: Pax Romana was a term used to describe the Roman world roughly 2,000 years ago. You could travel anywhere in the Roman world, and as long as you didn't insult Roman gods and Roman law, everything was cool. Similarly, since 1980, as long as you recognize that that psychiatry is in charge and that the number one factor is psychotropic medication, everything's going to be cool. That's why we call it Pax Medica. We've been operating in Pax Medica roughly since 1980. I think we're ready to leave it.
RA: Yet you recently said in a lecture that, in some ways, Pax Medica benefitted mental health.
JA: Because it got us all on the same page. We were all over the place. We were talking about interjected self-objects on one side and behavioral reinforcement paradigms on the other. We didn’t have a common language.

But Pax Medica’s page is extremely one-dimensional. In fact, the common language that we began to use is rather clunky and presumptuous. So we became a medicalized group, and the psychotherapy world became medicalized psychotherapy. And instead of being called “psychotherapists,” we became “clinicians.” “Now, you’re talking.”
RA: “Now you sound medical.”
JA: Now you’re clinically speaking, but what were you speaking before? Is this a new language or something? I’ve sat around in these big meetings where people say, “So what’s the diagnostic picture here?” In other words, they want a name quick, from the Book of Bad Names. And then they say, “What’s medically necessary?” Medically necessary, what? The guy just had a divorce. He’s really bummed out. “Medically necessary” sounds kind of silly.
RA: It sounds you're saying there's a fundamental disagreement about what the role of the therapist is.
JA: Yeah, and I think that the disagreement resulted in a compromised agreement. And the compromised agreement became the clinical role. And the clinical role is, I think, very antiseptic and one-dimensional, and in some ways very subservient to the so-called "principal treatment," which was medication.

Now we know the efficacy studies for antidepressants are rather suspect. The negative studies outnumber the positive studies by 12 times. So the pillars of Pax Medica are actually falling apart in major studies in JAMA and New England Journal of Medicine and other places.
RA: Within the Pax Medica frame, what do you think has been the cumulative effect of the outcome studies that focus on a specific treatment for a specific problem?
JA: Another part of Pax Medica was evidence-based practice. From roughly the early '80s on, various CBT-oriented therapists were the ones doing a lot of the studies on specific methods. David Barlow and others were showing that specific approaches to panic or OCD were more efficacious, and that dovetailed really nicely with the Pax Medica model, whereby you had a diagnosis and you had a prescribed treatment for the diagnosis. There was a positive part of that, because, come on, now—a person with a panic disorder, you want to sit around and analyze their feelings about their mother endlessly? No, you want to get them doing interoceptive exposure and other approaches that have been found for the last 35 years to be much more efficacious than sitting around analyzing archetypes and other things that, even though I find them intellectually stimulating, are a waste of time with somebody with a panic disorder.

So there's a lot more science in Pax Medica, and that's a good thing. But I think we're ready to integrate many strata of science now, to emerge out of the one-dimensionality. Evidence-based practice is still going to be part of the picture, despite the knowledge that the outcome management people have provided us, which is that there are diffuse boundaries between these psychotherapeutic schools.

I'm arguing that we don't need any more gurus.
I'm arguing that we don't need any more gurus. I certainly don't want to be anybody's guru. We don't need another school. I'm not suggesting brain-based therapy is a school and now everybody's got to be an Ardenian. Oh, what a terrible burden it would be to be one of these gurus—and a hollow experience, at that.

Rather, I think we have the opportunity to integrate evidence-based practice—which still is part of the picture for anxiety disorders and depression—with a better look, for instance, at the building of the alliance. The Adult Attachment Inventory and things like that give us insight into the various types of relationships we have been taught to develop, that are going to be replicated in the therapeutic encounter anyway. So why not include that as part of the overall picture? And we know that certain types of brain dynamics and temperament are associated with relationships—neuroscience is a big part of this new equation, as well.
RA: The brain is a popular topic right now, but do you feel that we’re really there yet with the science backing biological theories about how the brain works?
JA: More than we ever have been. I’m also convinced that in five years, I’ll be looking back at what I’m saying to you right now and thinking, “God, John, you had such a limited understanding of what’s going on.” And I think that’s a good thing. So, yes, I think that we can begin to have a dialogue about neuroscience, but are we there yet? No. I don’t think we’re ever going to be totally there. There is no “there.” But we’re going to be far more enlightened about what’s going on. And certainly, not everybody’s brain is exactly the same, but we know that there are psychological syndromes, like anxiety and depression, that have some commonality across people. We ought to be talking about that among ourselves as therapists, and also in therapy with our clients. I’m always talking about the brain with my clients.
RA: A lot of people feel that there’s been an overemphasis on the brain and that therapy has really moved away from focusing on emotions and the human experience. Related to what we were talking about with Pax Medica, there’s a concern that overfocusing on biology closely ties in with overfocusing on pharmaceutical therapy.
JA: I think otherwise. In fact, I think it's an opportunity to focus less on psychopharmacology. Out of the 2,000 of us in the Kaiser system, I'm among the people who refer my clients less for medication evaluations, because I want to work with emotion. That's our province. So how do you work with emotion? Well, if you have people narcotized, you're not going to have access. And certainly with people who have anxiety disorders, anybody on a benzo I'm trying to get off of benzos as quickly as possible.

SSRIs I'm less concerned about, but I only go there when I exhaust all other avenues, including diet, which I'm always talking about at length. Exercise is the most effective biochemical boost that there is—as effective as psychotherapy. Exercise is as good as psychotherapy in alleviating depression. We ought to be doing that and psychotherapy together.

Including all these biophysiological dimensions that don't include the drug cartels is a good thing. Now, the reductionism to a specific neuron—no, I don't go there. Remember, I'm a guy steeped in psychodynamic theory, and I still love all the allure associated with it and all these characters that are battling with one another. It's fun, and it's enlightening in many ways. I think the new psychodynamic perspectives are quite a bit more advanced than the original psychoanalysis.
RA: So you see the new role of the therapist incorporating biology, traditional psychology, but also sleep hygiene, exercise, and nutrition.
JA: Absolutely. I'm not suggesting that we don't pay attention to the alliance. In fact, that's one of the principal effective agents. And we know that from psychotherapy research; the outcome management people have shown that to be pretty powerful. But why not pay attention to those parts of the brain that make that possible mirror neurons, the anterior cingulate, the orbital frontal cortex, the insula, the spindle cells? It's interesting for us to know that some people, if they've had a poor attachment history, have underdeveloped areas like the ones I just mentioned.
RA: You mentioned that you can see this information as a opportunity to teach clients about what may be happening in their brains. How does that help?
JA: Let me give a fairly common example. Say you have a client who says to you, "I just don't know why in the first part of the day, when I lie there in bed, I get so overwhelmed and I get paralyzed with this totality of anxiety. I don't know what's going on there. I get anxious and depressed. What am I going to do?"

Well, we know now from all these affective symmetry studies that people who get hyperactive right prefrontal cortex plus underactive left prefrontal cortex get more anxious and more depressed. And what kindles the right prefrontal side are withdrawal and avoidant behaviors. So when she gets into the withdraw-avoidant behavioral response, she's kindling up the right prefrontal cortex.

Now, how to get out of that? You've got to do what are called approach behaviors. The CBT people have known this a long time—it's called behavior activation. What do you do with depressed clients? Do you sit around and analyze things to death? No, you get them doing stuff. And you get them doing it quick. As soon as you start to feel overwhelmed, it's time to do something, because that kindles the left prefrontal cortex, which is about approach behaviors. But you do it incrementally, because it's always very overwhelming to do big, big projects.

We're not talking about the left hemisphere as being the new cool one now and the right hemisphere as passé, where it was the right hemisphere that was the cool one before. No, we're going to be talking about a relative activation of the two hemispheres. In fact, we know, too, that if you get the right prefrontal cortex knocked out, you lose your sense of humor. What's that about? Well, you want to have a sense of humor, right? A sense of humor is about plays on words, metaphors, juxtapositions, and all of that. You want to have that larger picture.
RA: So all of that also really speaks to how behavior changes the brain.
JA: Absolutely.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other. Pax Medica had it one way: “Brain changes behavior. All you’ve got to do is tweak up some neurotransmitter system like serotonin, and everything’s going to be fine.”
RA: “Because you have a chemical imbalance.”
JA: "Chemical imbalance" is so American, isn't it? "Okay, let's just go in there and change that chemical imbalance. I want to fix it quick, will you, Doc?"

Come Together

RA: Where do you think we are in the grand scheme of integration?
JA: I think it's slowly developing. There will always be tidal pools that pull back. For example, you mentioned earlier that some people are saying, "Oh, neuroscience. What's the big deal? Neuroscience isn't going to be part of the picture. Get over it." It's going to be, but how is the bigger picture? I think that there are a lot of people jumping in the bandwagon who aren't paying attention to the science in neuroscience. I'm not going to get into names, but some people make it rather New-Agey, and that kind of turns my stomach.

Science is a good thing. We ought to be paying attention to how the research actually shows this or that instead of, "Well, that's kind of a cool thing. Why don't you just talk about the so-called limbic system?"
How we incorporate neuroscience, I think, is going to be a big part of how we advance toward the future. And it's not going to be reductionistic. It's going to be a part of the picture. We're still going to talk about the relationship and pay very close attention to the alliance. And as I said earlier, it works both ways, because there are parts of the brain and parts of our nervous system that respond to close relationships, and that's something we ought to be paying attention to.

The psychological theories and all the alphabet-soup therapists—EMDR, EFT, CBT—the advances in some of those areas, I think, are going to be part of the picture. But I think the allegiance to the schools is going to be increasingly less of an issue.

Reshaping Memories

RA: I think a lot of people in the field really hope that your view is right. What evidence do you see that indicates the field is moving in this direction?
JA: It seems to me that the studies that show actual change in the brain resulting from psychotherapy are what will convince everybody that we’re moving in the right direction. And there’s a wealth of information out there that’s developing and will become stronger and stronger, and it’ll be undeniable that there’s an intersection here. Again, it’s all not reductionism: it’s integration. And memory is a major part of the picture here.
RA: Say more about that.
JA: Understanding memory and the complexities of our various memory systems, including the various types of implicit and explicit memory and how those systems work together to make us who we are, and how we, as therapists, interact with these memory systems—that, to me, is the foundation of therapy. Our job is to help people reconsolidate memory in a much more adaptive and effective way, because there is no such thing as a memory encapsulated in some sealed-off portion of time, where you go back in and you pull it up. That's where the early psychodynamic theorists had it all wrong. Every time we bring up a memory, we change the memory.

That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way.
That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way. I regard memory as one of the major foundational aspects to psychotherapy in this unfolding sea change—not a paradigm shift, but actually a sea change—that's occurring in mental health.
RA: You’ve said that it really seems like we’re moving beyond brand-name therapies, but do you think we’ve just substituted techniques? You mentioned CBT. I’m not completely clear on what the theory behind CBT is, other than that it seems very removed from things like memory and emotional experience.
JA: Actually, it does incorporate them. If you think in terms of anxiety, for example, it's quite clear that avoidant behaviors make anxiety worse even though, over the short term, they make it feel less severe.

Let's say I'm a socialphobe and I walk into a room. I feel better for the first minute, and then I feel terrible, and my amygdala gets hyperactive as a result. In other words, I'm painting myself into a corner. Exposure is the antidote—the therapeutic direction that we ought to be working in. And that goes back to Joseph Wolpe, who doesn't get enough credit now, even in the CBT community. The whole idea of incremental exposure is critically important in psychotherapy for people with anxiety disorders. So the CBT people are talking about the brain even though they're not using the brain in their dialogue. They're not mentioning the brain because they haven't been really incorporating it into their understanding. But they are changing the brain, because exposure actually changes the brain. It could make the anxiety worse by flooding too quickly, but incremental change could make it much more resilient and adaptive.
RA: Let me see if I’ve got this right. It sounds like you’re expecting that there would be a much more integrated theory about how psychotherapy works, because it’s going to include neuroscience. And because we have more technology now, we’re going to be able to actually see these changes and understand it, and we’ll continue to see even more levels of complexity.
JA: We are seeing these changes. And in fact, with psychodynamic theory, the whole concept of working through is the same thing as incremental exposure. A book that I like to recommend that's now 20 years old is Psychodynamics in Cognition, by Mardi Horowitz. I really like that book. It was Horowitz's attempt by to talk about the overlap between psychodynamic theorists and cognitive theorists-maybe they aren't talking about something so different. Let's talk about how defense mechanisms and schemata have an overlap. That's what I'm talking about: finding the overlap between these therapy types. Just because they use different language doesn't necessarily mean that they're not talking about the same thing. Where there is an overlap, I get excited about it.
RA: So neuroscience is going to be what shows us that we’re all talking about the same thing.
JA: Neuroscience, and a look at these therapeutic styles. Defensive maneuvers are still relevant, and we can look at them from a cognitive perspective, and from this whole affective symmetry dynamic, as well. In other words, we could look at them from a number of different vantage points, and if all those vantage points have a cohesive quality to them, then I feel much more confident about it.

So we’re not just talking neuroscience or just talking psychodynamic or just talking CBT or memory, but rather how these all can overlap and say the same thing to give us a much more robust understanding of what goes on in psychotherapy and what goes on in our own heads.
RA: Do you believe this integrationist’s frame of reference changes the way that you work with clients?
JA: Absolutely. I've been in the mental health world for 35 years, and when I first started, I was part of this whole the institutionalization movement—we were creating alternatives to hospitals in San Francisco, and then wrote a bill for the New Mexico state legislature in 1980 to do the same thing. What I thought was going on back then is quite a bit different from what I think about what's going on now.

Even in 1976, when I was working with autistic kids—God, we had a stupid understanding of what was going on with those kids back then, because we didn't understand what was happening in their brains. We thought it had to do with these really cold mothers. Bettelheim was our popular hero. My God, what a dumb, dumb way of understanding.

It didn't mean, though, that what we were trying to do, in terms of developing a good relationship with the kids, wasn't a good thing to do. We called it reparenting, but nowadays we'd think about it as being helpful to the kids so they could acquire better social skills and develop a better ability to have human relationships.
RA: This makes me think about some of the preliminary studies in the news now about sudden-onset OCD in children after they have strep infections.
JA: And that has helped us to understand the role of the striatum very well, because that’s the area of the brain that gets attacked viciously in these kids during the infection. And we know that the front part of the striatum is kind of like a spam filter. In people with OCD, unfortunately, that striatum doesn’t work like a spam filter, and the orbital frontal cortex gets flooded with all this nuisance information: “This is wrong, this is wrong, we’ve got to do something, wash your hands, wash your hands,” or whatever it is. Baxter’s group down at UCLA showed very clearly the orbital frontal cortex being flooded with all this nuisance information, and that what can help alleviate the OCD is to “rescue” the orbital frontal cortex with the dorsal lateral prefrontal cortex (which has a lot to do with working memory) via CBT with a mindfulness approach. In these imaging studies, you could see OCD patients before and after the treatment. And the strep infection material was supports the idea that OCD involves this “gate” that is left open in the striatum.

But How Does It Work?

RA: Let's walk through a hypothetical. I come to see you because I feel depressed and generally anxious, and this has been going on for some months now. Where would you start to look for the cause of my feelings and some relief?
JA: It's interesting that you say depressed and anxious, because under Pax Medica, if you were depressed and anxious together we would have two diagnoses on Axis I—a comorbid problem. Well, you're one person. Are these two genetic disorders you have? What a silly idea. And the prescribed pharmacological agents actually work against one another. These stupid benzos, which are really a nuisance in the mental health world, would actually contribute not only to addiction, tolerance, and withdrawal problems, but also to depression. And then you'd toss in an SSRI or something like that, so you'd have this weird cocktail.

There is an interesting neurochemistry that occurs with anxiety and depression. For example, for 90 minutes after you experience a severe stressful incident, your levels of dopamine, norepinephrine, and serotonin will be down. Let's say that you've just found out that you can't get into school. All the PhD programs have turned you down. That's a pretty big blow, right?

So you're going to get a downregulation of all those neurotransmitter systems, and you're going to withdraw a little bit. But it's what you do with that neurochemistry and those neurodynamics that can tumble you into more anxiety and more depression, or get you out of it. If you do things that kindle up the same systems that would get you more anxious and depressed, you'll get more anxious and depressed.

Now, we're going to have bumps in the road. It's what you do in response—it's that resiliency. Some of the positive psychology spinoffs are paying attention to that, and of course the counseling psychologists have long done that.
RA: So, if I were your client, would you want me to tell you about something stressful that happened and what I did afterwards?
JA: I often do that, just to get an idea of how people react to certain events in their lives—to get a characteristic description. I'm also paying attention to the way they describe them to me, because that interaction between us is so important. It replicates other relationships they're having that might have great continuity with the earlier attachment-based relationships. It tells me a lot about how I can intervene, because I don't want to create more resistance. I do like Milton Erickson a lot—that indirect approach. I'm not going to want to shut you down and have you screen me off, but rather do some motivational interviewing to some degree—which is very Rogerian, in fact. Bill Miller was a Rogerian from the school that I came from.
RA: Out of curiosity, did you study with him at UNM?
JA: No, I didn't. In fact, I didn't know about him until after I left. I don't know if he was there then—that was 30 years ago. But had he been there and I missed him, I would have been disappointed, because I really like his contribution to the substance abuse community.

Addiction: A Sliding Scale?

RA: And substance abuse is one thing that we haven't really touched much on in terms of what neuroscience is really teaching us. There's big debate about whether addiction is a genetic disorder.
JA: There is some literature to suggest that if you have two alcoholic parents, your vulnerability to become an alcoholic is heightened. But let's say the concordance rate is 50 percent. Well, what about the other 50 percent? It isn't a one-and-one factor.

In a discussion I had with Fred Blume, one of the pushers of the alcohol gene concept, I asked, "How about an acquired disease? You guys are really into this disease concept." AA's really into it. AA and NA are the most powerful self-help groups in the world, in my opinion. My sister-in-law's life was saved as a result. Fantastic groups. I love their little jingles and all that. But they're too into this disease concept. It's useful in early recovery, but you could create a disease. It's bidirectional. The more I drink alcohol, the more I feel like I need alcohol, because my biology changes. I downregulate various neurotransmitter systems, so now I feel like I need to mellow out because now I'm downregulating the synthesis of GABA. That means I need more GABA-like effect because I'm always dampening down glutamate.

What I think therapists ought to be paying attention to is how these various substance abuse habits, if you want to call it that, create psychological symptomatology. “I see all sorts of people here in the North Bay who are suffering from anxiety and/or depression, and I find out they're just drinking a glass or two of wine at night.”
RA: That’s a lot of wine, though.
JA: I think it’s a lot of wine. I drink a glass every week or two. It would be nice if you could have two glasses of wine a night, but my sleep gets all messed up. You get the mid-sleep-cycle awakening and all that. And that’s a small snapshot. What about the next week? These are subtle effects, but when I used to do neuropsychological testing and psychological testing, and then later teach it, we used to say, “Don’t test a wet brain for up to three months after your last drink.” There are all sorts of artifacts to subtle alcohol consumption.

And red wine isn’t that cool, you know. It’s the resveratrol in the skin of the red grape. You can drink Welch’s grape juice and still get the same effect. You don’t need the alcohol.
RA: And what about other drugs? I haven’t heard too many therapists saying that they necessarily ask their clients, “Do you smoke pot?”
JA: Everybody here does. And pot is one that I really pay close attention to in the North Bay, because of all these people on medical marijuana cards. They have a sore back. Well, give me a break. So do I, but I don’t smoke marijuana now. I did 40 some years ago as a young hipster, but I’m glad I stopped 40 years ago, because otherwise I’d be muddled and kind of down. THC is chemically structured like a neuromodulator called anandamide, which is Sanskrit for “bliss.” It orchestrates the activity of a number of neurotransmitters, so when you’re stoned you get what we call virtual novelty. “Look at this cup! God, that is so incredible. Look at the way it’s shaped, and the colors! This is amazing.” Then the next day you get what we would call in the ’60s “jelly brain,” because everything’s downregulated now. And you never get the same high.

So now what we see are all these people smoking medical marijuana who have low-grade depression. They can’t remember much, because they downregulate the acetylcholine release in their hippocampus and have symptoms very much like ADD. God, I get people with ADD evals all the time who are smoking marijuana.

So with regard to substance abuse, psychotherapists should perform a full analysis of everything the clients are doing, instead of saying such things as, “Do you abuse alcohol?” I want to know what they’re consuming rather than ask blanket questions.
RA: Well, what’s abuse? “Yeah, I have five beers a night, but I’m fine.”
JA: Exactly. But if somebody’s drinking two, I’m concerned about that, especially if she’s anxious or depressed. Or if somebody’s taking a toke of marijuana a night, and he’s coming in with this low-grade depression, muddled thinking, and attentional problems, I’m concerned about that.

Defining Therapeutic Success

RA: In the way that you’re visualizing therapy, how do you define therapeutic success?
JA: We're always a little too symptom focused. I still think we ought to be paying attention to symptoms—that's an important part of the picture—but we also ought to pay attention to what clients are telling us about their overall improvement and their perspective in life: "I'm feeling so much more hopeful and so much more resilient and I'm not as easily stressed." And we're getting more of that from the outcome management process, instead of, "You originally came in with these panic symptoms. How's the panic doing?" "Oh, I don't have those panic symptoms anymore." Well, that's good. That's only part of the picture, though. There's got to be a larger look at things: is the relationship improved, for instance?

Therapists: The Next Generation

RA: As a mental health training director for Northern California for Kaiser, you work constantly with the next generation of therapists. What do you see in their training that concerns you?
JA: What got me intensely concerned and preceded the development of Brain-Based Therapy was typified by an answer to the question, "What do you want to do in the next year?" In the Kaiser Northern California, we have 60 postdocs in 20 medical centers, and another 50 interns. When I interview a postdoc and ask, "What do you want to do over the next year?" they say, "I really want to find my theoretical home." You want to what? We're certainly not going to be helping you find your theoretical home. In fact, I want to dissolve those theoretical homes into a grand unified area. So that's a concern.

And a lot of young therapists come out of these schools too young and inexperienced—they haven't had to go out in the world and learn business and all this, to augment their academic understanding. Between undergraduate and graduate, I spent a year in Asia and the Middle East, and I just kept circling the globe. I was gone for a year, and I don't know how many countries I visited. What an incredible education. I matured so much during that period.

Life experience is critically important. Having to deal with some stressful events can really help a therapist. Just being pumped out of all these professional schools with all these fancy degrees and all that, boy, that's such a limited area. I get a little concerned about too-young therapists being plopped out and wanting to be Dr. Somebody-or-other.
RA: That seems to address my next question: do your intern therapists seem to come with a broad base of knowledge about other aspects of the human condition—literature and art and history?
JA: That's a pretty interesting question. I remember when I was being interviewed for my PhD program, that was a question in the interview. I was in the Counseling Psych department, even though I later got involved in both departments. I was really into talking about Dostoevsky and D. H. Lawrence, and that perked up the interest of the interviewers. Contrast this with the clinical program applicants—I call them the GREs. All they got was a high GRE score and a good GPA. Big deal!
RA: In the next generation, are you seeing much of that?
JA: If you immediately go from a bachelor's to a master's and, usually, especially the professional schools, straight to a PhD program, I see a lot of that. And physicians, unfortunately, hardly read at all. It's just shocking that the educational system kills the quest for reading in diverse areas. It's amazing.

Therapists don't read enough. And when they do read, unfortunately, they read in their own little clubhouse. Where you get more cognitive reserve, if you will, is where you step out of your own zone of comfort. I particularly like to step out of all these mental health areas completely and pay attention to what other scientists are doing.

Particularly, I love complexity theory. When I'm back in Santa Fe, I like to go to the Santa Fe Institute. This place is incredible—founded by three Nobel laureates, two physicists, and an economist. And then there are biologists and computer scientists and archaeologists, all talking about the change in complex systems. Well, aren't we a complex system?

So I think we don't read enough, and not only of another psychotherapeutic school, but, also another area of science. It would be really good for us to do that on a regular basis. I'm perpetually advocating for that.
RA: There are some people who are advocating for academia to do something similar to what you’re saying psychotherapy should do, arguing that there really shouldn’t be such big walls in between each department.
JA: Yeah. In fact, in the Sonoma State University, there’s the Hutchins School, which is very much like St. John’s College in Santa Fe, whereby you have more of an interdisciplinary approach. At St. John’s it’s more of a classics approach, but at Hutchins, you have a department with anthropologists and biologists and other people all there. It’s that interdisciplinary approach that I think is so valuable.

Inside Kaiser

RA: Do you think, working at a large health maintenance organization, that this move toward integration will also eventually break down some of the barriers for clinicians to be able to determine what kind of treatment they want to give to a particular client? Right now, HMOs rely very heavily on CBT because there are so many studies of a specific symptom with a specific treatment.
JA: I don’t necessarily see Kaiser as being a CBT mental-health dispensary. I’d look around at all my colleagues, and one person might be into EMDR, another person CBT, another person steeped in psychodynamic or narrative. But we do pay attention to evidence-based practice. In fact, we have a whole administrative structure just for that. But we also have an administrative structure just for outcome management. The convergence of the two is pretty important.
RA: I’m sure that you’ve heard some of the recent complaints about Kaiser that people have a difficult time getting timely access to mental health care.
JA: That's kind of old news—20 years old. All departments are graded for access right now. I was hired during the Model of Care, which was 20 years ago, where we tripled or quadrupled the size of many departments because it was all about access. Every department now is graded on how quickly a client can come to see someone. If you call in right now, we've got to give you an appointment within two weeks. That's called initial access for the new, and there's a seen-to-seen that we're being graded in, too. We've improved dramatically in the last 20 years.
RA: There is a recent report that union leaders and employees were asking for an investigation to make sure that it was happening in a timely manner. Do you feel like the treatment model that you’re describing can fit well into an organization like Kaiser?
JA: Kaiser's in a difficult position because it's swimming in this vast sea of other medical providers, and it's trying to survive at the same time as thrive—to use that term. So I know what those folks are saying, and we're not immune from any criticism. There are always these concerns about improving, and that's a good thing.
RA: And people having access.
JA: Absolutely. Access is critically important. I know that we're trying to do whatever we can. I'm in meeting after meeting about improving access. We're always talking about improving access, while at the same time we're talking about hiring new people. But where are you going to get the money to hire the new people unless the membership rates go up? It's a complex situation.
RA: You obviously have a very expansive knowledge base that you're integrating. What wisdom do you hope the clinicians that you're training will take away from it?
JA: That there is this exciting sea change occurring in mental health, if you pay close attention to it and if you read voraciously. Just because you’re out of graduate school, we don’t want you to stop reading. We don’t want you to get rigor mortis. In fact, we want you to now read more than you read before, and go to more workshops in areas that you don’t even have any interest in initially. That’s where you get the best change, really, is if you go, “I have no idea what that person is going to be presenting over there.” Those are the ones you want to go to, rather than, “Yeah, I’m really into that kind of therapy.” How many more times are you going to hear that particular frame with a little bit of a twist to it here and there? In fact, you get more neuroplasticity if you get into an area you have no knowledge about at all. What we want to do for this next generation of therapists is to be integrators and to be active consumers of diverse areas of science.
RA: What are your hopes and concerns about the future?
JA: I'm concerned about the economy affecting mental healthcare and, again, as somebody who in the '70s and '80s was helping people who were chronically mentally ill and homeless, I'm really concerned about mental healthcare for the poor. Here I'm in Kaiser right now, and who are the Kaiser members? Well, they're people with jobs. So I'm really concerned about the disadvantaged groups, and that has a political component, too, because if we go Tea Party zone, you're talking about massive cuts in the safety net, and it's pretty primitive.

Into the more advantaged stratum, I'm concerned that, even though I think there's a sea change going on, it could go the other way—the continued focus on these clubhouses. But I'm heartened that things are going to change eventually. I'm totally convinced that they will, because of these converging fields. When it will happen is another thing. It might be more in your generation and in my son's generation who, like you, is applying for graduate schools right now, than my generation. I think for quite a while, we're still going to have the gurus out there. But hopefully they will be talking in more integrative ways and less about themselves, so to speak.

Techniques, Therapeutic Relationship and the Importance of the Body

Posted on by Psychotherapy.net Team

Throughout my career as a psychotherapist I struggled to find the right balance between using specific techniques and the importance of establishing a safe therapeutic relationship. Toward the end I veered more to the latter as I realised, rather belatedly I admit, that people sought therapy not necessarily to get better but often just to be heard. A safe haven and a sensitive, empathic and caring individual can be enough; specific techniques can get in the way. Of course this is hard to square with the demand for evidence-based psychotherapy where therapy is defined as applying identifiable techniques and improvement seen in terms of symptom reduction. This quasi-medical model is rightly seen as simplistic, ignoring both individual meaning and the influence of socio-economic factors on mental health. Nevertheless, it has certain virtues. It enables those who know very little about psychotherapy to grasp what is supposed to be happening, something that both clients and commissioners of psychotherapy legitimately wish to know. Seeing a CBT therapist, for example, means that the approach is likely be collaborative, problem-focussed and address the client’s thoughts, feelings and behaviour in an open, adult and rational way. Seeing a psychodynamic therapist, on the other hand, means the therapist is likely to be passive, say relatively little, attend to underlying meanings and dynamics and use the therapeutic relationship as the main vehicle of gaining understanding from which change may or may not happen. Neither of these descriptions captures the subtlety and complexity of psychotherapy, nor the uncertainty that is part of all therapies. But they are not unimportant especially when it comes to making useful distinctions to those who know very little about what goes on behind the therapist’s closed doors.

In researching a book about peoples’ response to major traumas, I discovered some interesting and new (to me) therapies, ones that worked primarily through the body. I watched a DVD in which therapists trained in Emotional Freedom Techniques worked with highly disturbed combat veterans with strikingly positive results. I read up on the many and varied somatic therapies and began to understand how therapists who attend to the physical body gained much from not having to work verbally or at least not as the primary means of intervention.

Peter Levine is one of the best known exponents of “somato-sensory psychotherapy,” an approach that sees traumatic reactions as largely due to undischarged energy. Therapy is geared to enabling the person to discharge energy through more sensitive and balanced physical actions. Levine is adept at seeing the embodied person in a way that most psychotherapists are not. It is easy to equate the somatic therapies with their striking physical techniques. Tapping pre-defined meridian points in a particular sequence and in relation to a particular phrase or thought is clearly one such technique. But it also reflects a general therapeutic approach, one that conceptualises the psychological impact of trauma not in terms of trauma narratives or past history but in terms of physical experience. If, as seems to be the case, people can recover remarkably quickly, sometimes in a single session, then this different approach deserves to be taken seriously.

EMDR, essentially the precursor of the somatic therapies, was very critically received precisely because it seemed too good to be true. But it has proved its worth since. Similarly, it is easy to dismiss therapies as ‘wacky’ if they draw on traditional Chinese Medicine, focus on acupressor points, use an uncertain and vague term like “energy,” and involve rather simple physical actions like tapping. Beware of not seeing the wood for the trees. Energy psychology and somatic therapies offer something radical and different. Traditional (verbal) therapists would be well advised to keep an open mind. Seduced by our Freudian heritage, we plunged into the complexities of the mind and, with some notable exceptions, forgot the body. Isn’t it about time we brought the body back?

The Whole Truth: Coping Creatively with the Dark Side of Therapeutic Practice

Posted on by rezendevknowfully.com

We are sitting down to dinner, like we do every night. My oldest son, home briefly from college, has reclaimed his seat to the left of me. Across from me sit my other two children, sweaty and satisfied by their after-school sports practices. The four of us chirp out a collective, “Thank you,” to my husband, the cook, for such a good dinner. We eat and talk and wind down our day.

Only moments before, I was finishing up one of those long, intense days, hour after hour filled with client struggle and crisis and touching connection. I had silently shooed my last client out the door, my thoughts becoming a bit frantic when I thought she was going to stop at the bathroom, further delaying my departure. I swooped out—lights off, sound machine off, alarm set—hurrying to get on the road that would take me to my daughter’s soccer practice just in time to pick her up.

Most days are like this. I dive deeply into my commitment to healing and helping clients. I work with their internal worlds, and willingly make contact with some of the most painful aspects of life. And, just as quickly, I rush up from the depths, back into daily living.

Today was more difficult than average. A long-term client came in with the news that she’d been diagnosed with an aggressive form of cancer. A 15-year-old who had been successfully using art as an alternative to self-harm arrived to session with a freshly cut X in her shoulder. I struggled to engage a new client—a sullen, depressed teen. I listened patiently to a client tell a different version of the same story about her frustrating husband. And I hosted a culminating art show (both celebration and termination) with the work done in treatment by my client, a recovering addict, for her and her large extended family.

Yet when I sit at dinner now with my own amazing family, there is nothing to say in reply to my kids’ inquiries: “How was your day, Mom?” I can’t give them details; everything is confidential. Besides, it feels impossible to convey the depth of pain and joy that my job delivers. And while I think they are actually asking, “How are you, Mom?” I haven’t even had the time to figure that out. Between racing out of the office to soccer practice pickup, and then home for dinner, there hasn’t been an ounce of room for self-reflection. And if I use the time at dinner to really see how I am, I know I will come up with confusing and disparate adjectives: drained, energized, discouraged, overwhelmed, fascinated, curious, amazed, sad. The truth is I’m full of joy and gratitude for the opportunity to midwife significant changes in so many clients’ lives. At the same time, I also have my fill of others’ pain, their traumatic stories, and the experience of feeling helpless in the face of intransigent symptoms. I know too well that, if I’m not careful, this visceral awareness of human tragedy can lead me to disconnect from even the most basic dinner conversation, or worse, cause burnout at work and alienation from family and friends.

Confronting the Dark Side

I’ve come to learn that what I once held true about my profession is in fact not the whole truth. Being a therapist is not only about being effective at helping clients reach their goals. Aspiring to help clients make significant changes, achieve their treatment goals, and improve their functioning is a worthy pursuit that requires a lifetime of work and experience, but effectiveness is only part of the story.

In 2009, psychologists David Orlinsky and Michael Ronnestad studied over 5,000 therapists’ experience and careers, and brought to light the double-edged nature that psychotherapeutic work embodies. They found that, while over half of the therapists studied feel they have effective practices that yield feelings of competence, positive relational interactions, and flow states, another quarter have what the researchers deemed a challenging practice. The therapists studied were equally likely to experience this stress across orientations, career levels, and licenses. But what is fascinating is that those therapists with challenging practices—who experienced professional self-doubt, frustrations, and difficult feelings—still reported high engagement and positive relational interactions. This challenges what therapists might assume to be true: either you feel good because you’re doing your job well, or you feel bad because you are not helping your clients effectively enough. In fact, it offers an alternate view of our work: that there really is a way to experience difficulty without being inadequate, a way to hold self-doubt without feeling incompetent. Orlinsky and Ronnestad’s research reveals that while it is important to increase effectiveness for the therapist’s sense of healing involvement and for the client’s satisfaction with the services offered, effectiveness alone will not mitigate the stress of the profession. “If we do pursue ideal effectiveness as our one and only buffer for professional stress, it seems we are setting ourselves up for burnout.”

When I started seeing therapists as individual clients, I began to hear how easily this stressful involvement can easily turn into shame. If we don’t figure out ways to cope with the difficult feelings that accompany our work, burnout and self-doubt can begin to interfere with our well being and cause emotional disconnection from our therapeutic relationship with clients.

I’ve heard the narrative many times. It goes something like this: “I’m a therapist; I’m supposed to be emotionally healthy. But every single day, hour after hour, I have the chance to feel like a failure. Whether or not I succeed in empathizing with my clients, I feel struggle and pain and tragedy. I’m supposed to be healthy enough to withstand it. If I don’t feel emotionally resilient and instead feel bored and unconnected, or dread seeing my clients, I am a failure. But I can’t be a failure, so I will cover it all up and live with shame.” It’s a closed narrative that doesn’t provide alternative reactions to feeling stress and uncertainty.

Orlinskey and Ronnestad’s study identified a dual coping strategy as the key to therapists’ ability to sustain themselves and to stay engaged in their work. Besides the development of clinical skills, the other aspect of coping had to do with self-reflection. In order to tolerate difficulties such as the distress of feeling powerless to affect a client’s tragic life situation, or needing to regulate intense feelings in order to establish the one-way intimacy of a therapeutic relationship, therapists need to use their creativity to see the problem differently and to “give themselves permission” to experience disturbing or difficult feelings.

When I was an intern twenty-odd years ago, my supervisors coached me to practice good boundaries, and they implied that any struggles I did have with my role as therapist or career choice were due to my lack of experience, my unresolved personal issues, or the fact that I wasn’t seasoned enough and didn’t know how to “leave it at the office.” In his book, A Perilous Calling: The Hazards of Psychotherapy Practice, Michael Sussman suggests that the original blank-screen approach to the therapeutic task has dangerously infiltrated modern practice: “Throughout the history of psychotherapy, the personhood of the practitioner has been all but ignored. Successive generations of therapist have received and, in turn, passed along a professional culture that often leaves little room for the clinician’s humanity.” My own experience as an intern mirrors Sussman’s warning: “I didn’t feel I was allowed to have personal feelings about my professional work as a therapist, but these feelings didn’t stop rising to the surface.” Yet, because I didn’t have a safe place to bring them or a way to work through them, I also couldn’t let myself acknowledge their looming presence.

According to psychologists John Norcross and James Guy, 75% of therapists complain that work issues spill over into their family lives. Norcross and Guy highlight the fact that increased work stress is related to decreased marital satisfaction: the emotional exhaustion of our work can leave us too tired to engage in family relationships. One might think that we therapists could just share our work drama and download to our spouses like any other stressed professional would. But confidentiality rules prevent this from happening. Besides, if we don’t understand that powerlessness and uncertainty are difficult feelings that we need to learn to allow, and instead feel inadequate for having these feelings, we are even less likely to be able to share with family or colleagues how very hard our work is.

Having weathered two decades of this amazing vocation, it’s only now that I am able to turn and look without shame or inadequacy at the shadow side of this work: the part that is painful and dark and that can become toxic, breeding isolation and disillusionment. I’ve been down that path where ineffectiveness led to powerlessness and shame, where the mask of clinical expertise and emotional stability prevented me from connecting to what was true for me, where I bought into the idea that difficult feelings were a sign of inadequacy. At one time, I thought that feeling effective was a true salve against this shadow side. I was so set on being helpful, I was willing to sacrifice almost anything. I didn’t know how to use self-reflection to process the trauma and intense emotion being poured into the core of me again and again. This is the side of my work that I don’t really want to share with my family, and the side that so few of my colleagues readily admit to experiencing.

Finding Support

Externalizing: Painting by Lisa MitchellRonnestad and Orlinksy found that quality of the work setting and available peer support are crucial in assisting therapists to cope with isolation and the sense of helplessness. This seems to be an obvious solution: a work setting in which supervision and peer support groups invite discussions about these issues. Given that the researchers found many therapists to value personal therapy as a tool that helps them engage constructively with clients and feel they are thriving in their work, it would seem like validating these messier and darker inner-world experiences should be a regular work practice among colleagues as well—not just one hidden away in the private realm of individual therapy.

Certainly, there has to be a time and place for this kind of activity. When working directly with clients, we need to exercise appropriate boundaries. We don’t want to be processing our internal experience to the exclusion of tending to our clients’ experiences. But even when I invite fellow therapists to talk about and reveal their inner worlds in a safe non-clinical setting, they have a hard time doing it without relating it back to some kind of analysis of countertransference. We are so good at trying to understand our clients that even the act of excavating our inner experience of being a therapist becomes another avenue for more insight about our clients. So often I hear therapists report a feeling like irritation, and then immediately justify their irritation with a countertranference explanation about how their client reminds them of a mother-in-law, for instance. I have to ask: when can your inner experience of irritation simply be a by-product of being a therapist?

If, as Ronnestad and Orlinsky’s research suggests, nearly half of therapists feel pressured, overwhelmed, anxious, and trapped at least occasionally in session, why don’t we take these feelings more seriously? Why can’t we be open about them with ourselves and with colleagues—collectively honoring both the light and dark of our profession? Can we allow our knee-jerk therapeutic use of self-analysis to slow down just a little so that we can look at ourselves without wearing our therapist masks?

Taking Off the Mask

Just last week, in an altered book workshop that I was facilitating, I saw how sharing this inner world and this double-edged experience can benefit all who participate. The group was mixed: therapists who had been in practice for decades, a few interns, and one trainee. I invited them each to make collages that represented what they carry for themselves and for clients in their hearts. It’s always amazing to me the level of depth therapists are willing to bring to this kind of nonverbal self-reflection. The heart images were powerful and raw. One woman made a weaving that juxtaposed operating room images with strips of wholesome nature scenes. Another took large nails and screws and attached them as if they were impaling the walls of her heart. Many had innocent images of children: smooth skin, wide eyes, swaddling cloth.

Embodied: Painting by Lisa MitchellIn the course of the workshop, I coached these therapists about the creative process. The start of any artistic activity is always fraught with some level of fear. Sometimes the fear is so high, especially for people new to art making in adulthood, that they may have difficulty starting because they are not familiar with this line between stressful involvement and full engagement. But it often just takes a nudge to begin. I like to remind folks that they don’t have to know how it will turn out; they just have to start with a color or a brushstroke.

For the therapists I have encountered in my workshops, the first step in an art-making activity can be hard for this reason, and yet the process mirrors one all therapists are familiar with. Beginning without knowing where our efforts will end up is much like beginning a relationship with a new client, or starting a session and finding that the treatment plan has taken an entirely different direction, and things are no longer as they seemed.

Even for experienced artists, this starting can sometimes be hard, but it is also exhilarating at the most passionate level. Artists know, when they start, that if they plan too much, the process is going to be stifled, boring, and probably not very creative. If that exhilarating feeling of anxiety before the unknown is present—better call the feeling “anticipation”—it is an indicator of newness and risk, which will inevitably bring discovery of the highest order.

During the training, when we shared our images, there was a collective sigh of relief. One therapist said, “Sometimes there is a jolt of pain in my heart—the sheer rawness of it all. Who do you share this with? I could never go home and show this image to my husband. He wouldn’t understand. It’s so hard to express it honestly for yourself. But then to show it other people—I have so much gratitude that there are others who can see this, hold this, and still not judge me as inadequate.”

The opportunity to view others’ experience in a visceral way normalized the more difficult feelings that the group members carried as therapists. Hearing everybody talk about their art and the experiences that it represented allowed participants to stop pathologizing these feelings. “Seeing others’ openness made the darker side of being a therapist feel more okay in a very powerful way.”

In another activity, I invited the group members to make art that represented the gifts that clients had given them. They first had to get past the fear of admitting that they did actually benefit from client relationships. Then, when they were able to see how much each person’s life had been touched and changed as a result of real, concrete lessons or ideas clients had taught them, they cried. They were so relieved to see that things were actually coming in rather than just going out. One therapist would never have pursued her dream of being a professor if her client hadn’t showed her that it was possible. Another therapist credits her client with the fact that she survived cancer due to an alternative treatment approach that her client mentioned. I credit one particular teen client for teaching me how to show teens respect, and I use it every day with my own children and with all of my other teenage clients.

At the end of the workshop, after they had all made art and reflected honestly about how the profession affects their lives positively and negatively, one of the interns said that it had been an amazing gift to hear that even the most successful and seasoned therapists have difficulties in their work. She hadn’t heard about the difficulties, hadn’t seen others struggling, and hadn’t been well informed about what to expect and how to cope. The older therapists talked about the sense of validation and belongingness that the honest art expressions and discussions had allowed.

When therapists collectively allow there to be a dual experience of light and dark, abundance and depletion, there is a sigh of relief—an acceptance of the whole truth. And self-blame, inadequacy, and shame simply dissipate.

The Therapist as Artist

In the course of my trainings and also my own personal and creative life, the analogy of therapist as artist continues to take on richer, more profound meaning. Not only do therapists have amazing inner worlds that they are constantly mining for ideas, inspiration, and sustenance; to be creative, therapists have to know that anxiety, overwhelm, and uncertainty are all necessary aspects of making their art. This speaks to the idea that therapists can experience growth and depletion concurrently in their work. Just as for an artist, the therapist’s main objective becomes hanging in despite uncertainty, treating the unexpected as opportunity, seeing things from new and different perspectives, and maintaining involvement even when things get stressful. In other words, staying in flow feelings, maintaining a relational manner, and employing effective clinical skills even in the presence of stressful involvement are the ticket to being a creative therapist and staving off burnout.

Operating from the artist’s perspective, therapists can recognize that stressful involvement doesn’t have to block healing involvement. Rather, it is simply a necessary accompaniment to any creative endeavor. As Carl Rogers pointed out, constructive creativity requires openness to experience and tolerance for ambiguity: “It means the ability to receive much conflicting information without forcing closure.” The process of absorption or being wholly involved is characterized by Rollo May as “intensity of awareness and a heightened consciousness.” With this creative encounter come neurological changes—quickened heartbeat, narrowed vision, diminished appetite, loss of time awareness—that mirror physiological reactions to anxiety and fear. May suggests, however, that the artist doesn’t experience this arousal response as negative, but rather as joyful. In the creative process, flow feelings and arousal—whether experienced as anxiety or pleasure—go hand in hand. They are a result of engaging in a creative process. One without the other is impossible. The goal is not to eliminate the anxiety, but to make sure that it doesn’t block the flow.

When therapists see that their work is truly creative in nature and realize that the act of working with clients requires all the same components of any creative act, there is a built-in context for coping. How else do artists and other creatives endure their daily grind? Who else but the most creative know how to hold disparate experiences and make something of them? “Just like an artist, a therapist must hold the experience of being fully, heartfully engaged to painful experiences.” A therapist has to strive to connect on a vulnerable and intimate level with the client, yet maintain a professional boundary so as not to become merged in the relationship. And, despite scary or frustrating situations, a therapist must maintain engagement and strive to stay in contact with the relationship at hand.

As therapists then, we must stay creative: flexible, engaged, committed, willing to hang out in the unknown and greet newness and possibility as it comes. Be open to the process. This is not a passive state—it requires active exploration, self-reflection, sharing, curiosity, fearlessness to look at the unknown, risk taking to express that which is ugly, negative, or difficult. This commitment to staying creative must start with finding a way to communicate that inner-world experience to people who get it—to express these feelings without having to stay in the role of therapist, and to be in the presence of peers who understand that this kind of expression—can be the very key to sustaining self in our work. And because the creative process teaches us to welcome anxiety and other difficult feelings, doing art with other therapists can be a source of continual renewal.

At the End of the Day

If the creative process brings us freedom and new possibilities, it also brings us beauty. So when things aren’t seeming that beautiful around the office, when high healing involvement is giving way to self-doubt, frustration, and boredom, I’m remind myself that stress and flow are not mutually exclusive. I keep up a dialogue with myself on a daily basis. The question that I constantly ask is one that author Michael Ventura asks: “Where is the beauty in my work? Where is the beauty in this client?”

The other day, while sitting with a new teen client, I found myself melting into that beauty. She was reading a poem that she’d written as part of her therapy homework assignment. I instantly saw past her self-harm and angry outbursts, and said a deep thank you for the beauty that my work allows me to see. It’s been a long haul—from those days of meticulously monitoring client numbers and celebrating results to stepping into the quiet, reflective relationship between authentic self and work. I think I’m finally embracing that long, beautiful journey—no shell around my heart needed.

In my work with other therapists, I continue to emphasize what Jeffrey Kottler says in his wise book, On Being a Therapist: “[As therapists] we are touched by [our clients’] goodness and the joy and privilege we feel in being allowed to get so close to a human soul. And we are harmed by their malicious and destructive energy.” Having that focus, and the creative means with which to process all that comes with our work, will allow me to sustain myself and others for the long haul.

So the next time I’m sitting at dinner struggling to cross the bridge between my personal and professional lives, I’m going to consider that “How was your day, Mom?” as an invitation to take stock of my inner canvas. I’ll remember that my work is a creative process and feel more freedom in my reply. If it was one of those days, I think I will tell the kids all those disparate adjectives—drained, energized, discouraged, overwhelmed, fascinated, curious, amazed, sad—without feeling bad about my work. And then I will simply say, with a smile on my face, ”It’s great to be home.”

Suggested Activity

Individually, or with a group of safe colleagues, get together to create a representation of ‘Your Doorway to Therapeutic Presence.” You can do this by using magazine images and computer paper. As you prepare, think, write, and talk about the transition that you make when you begin work in session—from the moment that marks the transition between being alone in your office to your first encounter with your client in the waiting room. Consider what you leave behind as you transition—thoughts of other clients, preoccupation with family issues, plans for the weekend, etc. And consider what you welcome—awareness, presence, compassion, openness to the unknown. We do this transition over and over again, all day long. Some days we do it without effort. Other days our responses to disturbing material in client sessions or personal tragedy cause the transition to be arduous.

As you consider your internal experience of this transition and the state of being on either side of that doorway of therapeutic presence, find collage pictures that represent your experience. For most, the feeling of being present with a client comes with pictures of broad landscape, nature, the representation of awe and the feeling of being at peace with the world. And, depending on the current life situations, the experience outside of therapeutic presence ranges from blissful faces of children to painful images that depict life challenges such as illness, death, and other real struggles.

When you are finished with your doorway, share it. Really—go ahead. This opportunity to allow yourself to be seen outside of your role as therapist by other therapists is the very thing that we are conditioned not to do. This is also one of the most important coping strategies that so many of the researchers suggest. Allow difficulties to be there, honor the intense experience, increase knowledge of self and the therapeutic process, and embrace therapy as a creative process.

References

Kottler, J. (2010). On being a therapist. Jossey-Bass.
Kottler, J. (2005). The client who changed me: Stories of therapist personal transformation (p. 1). New York: Routledge.
May, Rollo. (1959). The nature of creativity. In Anderson, H. (Ed.).Creativity and its cultivation (pp. 55-68). New York, NY: Harper and Brothers.
Norcross, J., & Guy, J. (2009, August 19). Leaving it at the office: Taking care of yourself.
Orlinsky, D., & Ronnestad, M. (2009).How psychotherapists develop: A study of therapeutic work and professional growth. Washington, DC: American Psychological Association.
Rogers, Carl, R. (1954). Toward a theory of creativity. In Anderson, H. (Ed.) Creativity and its cultivation (pp.69-82). New York, NY: Harper and Brothers. 
Sussman, M. (Ed.). (1995). A perilous calling: The hazards of psychotherapy practice. New York: John Wiley and Sons, Inc.
Ventura, M. Beauty resurrected: Awakening wonder in the consulting room.

Eda Gorbis on Body Dysmorphic Disorder

Posted on by Psychotherapy.net Team

Characteristics of Body Dysmorphic Disorder (BDD)

David Bullard: To begin, could you give us a little background on BDD for our readers who may not be familiar with it?
Eda Gorbis: I began learning about treatment for obsessive-compulsive disorder (OCD) when I was helping to create day treatment protocols at UCLA Neuropsychiatric Institute in 1992, and then I furthered my knowledge by studying with Dr. Edna Foa in 1994. In 1996, I began work with a patient who had both OCD and BDD and was addicted to plastic surgery procedures. After successful treatment that was specifically designed to ameliorate the stress associated with her BDD, we were able to work with her on her remaining OCD, and my interest grew in this patient population.

Body dysmorphic disorder is self-perceived ugliness. It is when a person feels ugly inside about a minute anomaly—usually invisible to the naked eye of another—or has a markedly excessive preoccupation with even a slight defect, together with the feeling of being unable to make it right.

DB: So it’s a feeling and self-perception. I’ve noticed that, for some people with BDD, there is a vivid visual picture in their minds. One study highlighted the intrusive visual imagery these people have in addition to negative self-cognitions and feelings.
EG: When they look into the mirror, they see themselves as ugly.
They do not perceive themselves in the mirror as we perceive ourselves. They see a distortion that is invisible to others.
They do not perceive themselves in the mirror as we perceive ourselves. There is something wrong in their visual fields, from the eyes into the brain, that gives them inaccurate feedback. They see a distortion that is invisible to others.

What people with BDD perceive is actually similar to the reflection we have all seen in carnival funhouse mirrors. This differs from the common feelings of insecurity or self-consciousness about one's appearance that most people experience from time to time. Many people who have had cosmetic surgery are happy with the results and can move on with their lives without continuing to obsess about the original defect. With BDD, however, any surgical "correction" will itself be seen as imperfect, or an obsessive fixation with another body part will take over.

There are some theories, but the specific causes of BDD are not known. Many experts agree that sociological and biological factors play a role in the development of BDD.

DB: And it can be extremely debilitating.
EG: Yes, one of the most disabling conditions I know of. People experience extreme self-consciousness, and often avoid social situations, feeling others are judging and criticizing their self-perceived imperfections. The more the fixations intensify, the more it seems rational that others are also focusing on the “defect.” It can be a kind of paranoid ideation.

Then a person’s relationships suffer, along with many aspects of daily life. They can repeatedly request reassurances from others, but with no relief from their certainty about the ugliness. These compulsive requests for reassurance actually reinforce the false belief system and fixations; this leads to further compulsive questioning in a continuing cycle. They get so focused on their appearance that much time is spent hiding or trying to perfect the “flaw” cosmetically. These people are often unable to leave the house to make appointments, or to hold a job.

DB: Can you tell us about co-morbidity?
EG: BDD has a high co-morbidity with other anxiety disorders. The research is not perfect, but it seems that more men are treated for BDD than women. Perhaps female BDD symptoms are more likely to be interpreted as "normal" female behavior in our culture and are likely to be overlooked and remain untreated. The onset of BDD is not exclusive to a particular age, though symptoms often emerge during the teen-age years.

Treatment Considerations

DB: Could you give our readers an idea of how you work with someone with this particular disorder?
EG: More often than not, BDD is intertwined and co-morbid with OCD. Both disorders must be targeted at the same time—the perfectionistic concerns or fear of being criticized on a performance level that are characteristic of OCD, and also elements of social phobia that are associated with BDD.

BDD has certain expected features: for example, an exaggerated physical anomaly would be chin, eyelids, cheekbones—oftentimes in males, it would be penile size—with symmetry and exactness issues. I have found that women compare and contrast their breasts or their arms—any body part can be compared with the corresponding part on the other side of the body. The self-perceived anomaly also has a tendency to move from one body part into another: it can shift from the nose into the ear, for example.

DB: You mentioned that the first patient you worked with had had multiple surgeries. That’s a good example of how it shifts from one body part to another, and they get the surgery based on that.
EG: Right. That patient had more than a hundred cosmetic surgery interventions.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician, because you do not find this so much in strictly obsessive-compulsive disorder. Some of the patients with BDD have also met diagnostic criteria for sexual addiction and gambling. It is the exact opposite for people with OCD. Patients with OCD are not impulsive. They would be like Rodin's "Thinker."

With patients with body dysmorphic disorder, you have an overlap between impulsivity and compulsivity. Whereas people with OCD are extremely moral and truthful, people with this overlap of impulsivity and compulsivity would show no guilt or remorse. This overlap makes treatment extremely challenging. Some patients with BDD have also met diagnostic criteria for sexual addiction and gambling, which was a little bit surprising to me. Well, not really surprising, but interesting how impulsivity and the pleasure is associated with the alleviation of tension or excitation. For example, in gambling, it's not the reduction of anxiety that is the aim of the behavior. The aim is the attainment of tension release, like hair pulling or when they squeeze pimples, and excitation—the adrenaline rush in gambling or sexual addition. So you have very different aims of the behaviors that are intertwined in very complex ways.

DB: Some of the people who have written in the field make a distinction between delusional versus nondelusional BDD—for instance, someone who looks in the mirror and sees that his ears are too big, and he really thinks that they are too big, versus someone who looks in the mirror and knows he feels bad about it but accepts reassurance. He knows that his ears are really okay, and he recognizes that he has a problem in his perception. Do you see that distinction? Is it helpful to you in your work?
EG: Let's call it poor insight. That is a better term than "delusional." And it is classified along with other OC-spectrum disorders, such as Tourette's syndrome, eating disorders, trichotillimania, and compulsive skin picking. BDD is also often seen as part of the impulse control disorders—where impulsivity can be thought of as seeking a small, short-term gain at the expense of a large, long-term loss. People with BDD get completely dysfunctional, as I described earlier-becoming addicted to surgical procedures, getting stuck in front of mirrors, needing to ask constantly for reassurance, etc.

Cognitive-behavioral therapy

DB: Although each case is individualized, can you give us an overview of how a cognitive-behavioral approach can be utilized in treating OCD?
EG: With cognitive-behavior therapy (CBT) a person learns to change the way he or she thinks and acts. We know different people can have different attitudes about the same specific conditions: A large facial birthmark can certainly be noticeable to others, but may have no negative impact on someone who has accepted it, while being debilitating to someone with BDD. And, of course, even a nonexistent or minor flaw can be devastating to a person with BDD. It is important to help people change their thinking habits. Exposure and response prevention are taught to people with BDD to help them face their anxiety and any co-morbid BDD concerns. This means repeatedly learning to tolerate discomfort. Anxiety gradually subsides as they continue to confront situations without the avoidance response.

We also use the 4-step model of our colleague Jeffrey M. Schwartz, MD, as
outlined in his books Brain Lock and You Are Not Your Brain: The 4-step solution for changing bad habits, ending unhealthy thinking, and taking control of your life.

The steps we teach our patients to help them get freed from obsessional thinking are:
Step 1: Relabel (recognize that the intrusive obsessive thoughts and urges are the result of OCD).
Step 2: Reattribute (Realize that the intensity and intrusiveness of the thought or urge is caused by OCD).
Step 3: Refocus (Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: do another behavior).
Step 4: Revalue (Do not take the OCD thought at face value. It is not significant in itself).

The Role of Psychoeducation

DB: Yes, I've found that simple process very useful for some OCD clients, and it goes along with my favorite bumper sticker: "Don't Believe Everything You Think!"
How helpful do you find psychoeducational materials?
EG: I think psychoeducational materials are always very helpful and important, because then patients know they are not alone. In fact, we now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
We now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
DB: Isn’t it a characteristic of BDD that it feels so shameful that the majority have hidden it from the people who are closest to them?
EG: Well, the dysfunction is most often extreme, and usually afflicts young people by the time they are 18 and ready to get out of the house and into college. Then, because of the self-perceived ugliness, they are unable to get into social situations or attend lectures. They can't date. They camouflage themselves with glasses and excessive makeup. It is similar to an anorexic who is quite underweight and having cardiac problems and broken bones, and losing consciousness and so forth, but still worries that she's too fat. These people, in a very similar way, feel ugly, and there is a delusional component to this feeling ugly, as in anorexia. A distinction from anorexia, however, is that an individual with BDD would be preoccupied with the appearance of his or her face, while the anorexic will be more preoccupied with self-control strategies regarding weight and shape.
DB: Can you recommend some books for therapists who want to learn more about this disorder?
EG: The classic in the field of BDD is Dr. Katharine Phillips' The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (2005). She also has a newer one: Understanding Body Dysmorphic Disorder (2009). I have already mentioned the books of Dr. Schwartz. Other good ones are Feeling Good About the Way You Look (2006), The BDD Workbook (2002), and The Adonis Complex (2000).

We also have information on our website: hope4ocd.com. There are some other good ones such as Dr. Phillips' at www.butler.org; and the Massachusetts General Hospital BDD clinic; and www.bddcentral.com.

Mirror Externalization

DB: On the treatment end of it, would you say something about the mirror approach to your work?
EG: Because the physical anomaly is so exaggerated in the minds of these patients, I was thinking one day, "How do we externalize this self-perceived ugliness?" And I thought of the carnival funhouse mirrors, because they really exaggerate everything. It's a form of exposure. So we have a laboratory at the Westwood Institute in which a certain part is exaggerated when they're looking into a mirror. The room also has lighting controls, because different lighting and angles change our perception of the reflection. At this time the patients are just writing their anxiety levels.

We then cover all the mirrors for three days in a row, and all violations are recorded to track the compulsion. Compare-and-contrast behaviors—with those around them or with photos in magazines—are also counted as compulsive because they're done out of the anxiety. Or asking for reassurance: "Do I look good?"

The process of "externalization" works by causing the breakdown of maladaptive associations and repetitive manipulation of their external, material icons. In exposure therapy, BDD patients are provided with a symptoms list and must then induce the debilitating condition and self-monitor/rate objective signs, such as pulse rate, extent of nausea, dizziness, and cognitive distortions—for example, "My nose and forehead are too big." Cognitive restructuring through writing exercises and observational records are emphasized.

Our patients stay in the program from six to eight hours a day, and there are three clinicians working with them in shifts on a daily basis. After they work with the clinicians, I expose them in a controlled way to a regular mirror where they have to write a self-description, like someone in the police department is looking for them—a profile with no emotion associated with it.

We use cognitive-behavior therapy (CBT) with exposure and response prevention, and add mindful awareness training, cognitive restructuring, and Socratic questioning. We also use videotaping. Very often, I will use makeup artists to do an exaggerated prosthetic part. We have an interdisciplinary team. Treatment is tailored to each case. We also have six psychiatrists associated with us, who are OCD and anxiety disorder specialists.

DB: You have mentioned in the past that the model most clinicians have in private practice of the 50-minute session once or twice a week is inadequate for extreme cases of powerful dysfunctions such as BDD. It is wonderful that you are able to do such intensive work with those who are suffering with the most severe cases.
EG: We are able to do this work because we specialize only in OCD and BDD and other anxiety disorders. We don't treat anything else. And because of this narrow specialization, it is possible for one patient to work with three or four clinicians in a day. However, insurance companies just rejected one BDD case because they still don't accept the necessity for this intense treatment—they think it can be treated once a week, although this particular patient had been treated unsuccessfully once a week for years. It is a very debilitating illness—far more severe, I think, than OCD.

Medication

DB: That brings us to the issue of medications. SSRIs have been often prescribed to people with BDD. Would you say the majority of these people you work with are already on SSRIs, or do they end up on SSRIs?
EG: Based on my work with the six psychiatrists at the Institute, SSRIs alone do not seem to be helpful. There is no scientific evidence at this point for what really works with body dysmorphic disorder because of the delusional component and extremely poor insight. For people with high baseline anxiety, medication may be targeted to reduce anxiety. Depression and panic attacks can also be addressed with some medications, and atypical psychotic medications have also been used. But I have to emphasize that some kind of effective therapy is required, such as cognitive-behavioral therapy tailored to the individual case.

Families can also be a crucial part of the treatment.

It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption.
It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption. The love, support, and understanding of the family are very important, and they also have to be educated in how not to reinforce the obsessing and compulsions. Then, it is also important where they go after the treatment program.

Post-Treatment Care

DB: What are your experiences with post-treatment care?
EG: There are few referral possibilities for BDD patients to follow through. I think that these people are extremely high risk for relapse—maybe even more so than obsessive-compulsives, who have much greater compliance levels. Because of the impulsivity characteristic of BDD, you have less compliance, so even if patients do extremely well during the program, it is necessary to continue the self-therapy and self-treatment, because this illness is not really cured. I oftentimes give my patients examples: you can go through the best weight-loss program in the world, but if you then resort to your old eating habits, everything is going to come back right away. So really, I think it depends on finding out their interests or what they're best at while they're in the program, so that these dysfunctional compulsions can be immediately replaced with other activities. I tell them, "I don't care if you study Chinese, take a cooking class, or paint your house, as long as you get up in the morning and get going." Otherwise, all of the compulsions have a tendency to come back if the patients don't do anything that is productive.

Specialty Training in BDD

DB: I can see how important it is that they really understand what you're telling them about exposure and response prevention, and not reinforcing those dysfunctional behaviors. For any of the clinicians reading this who want to get the specific training needed to work in this arena, are you doing any training at the Westwood Institute or at UCLA?
EG: I would think that it's very important for them to go through training, but it would have to be hands on. It takes me approximately six months to train a good clinician for complicated cases, but I do specialize in extreme cases—patients who have failed a few other programs. Perhaps even a month of training would be sufficient if the clinicians saw a couple of cases that they would have to really work with intensively, because of the tailoring to the individual needs. It is not a cookie-cutter training; I couldn't tell you, "Here is a cookbook for any BDD case." Each case is like a snowflake. I've never seen two that were exactly alike, so we duly tailor the treatment to the individual needs of the patient.
DB: Absolutely. Finally, could you say something about the satisfaction you’ve gotten as a clinician in being able to help people who have experienced such terrible suffering and misery?
EG: My satisfactions are now taken with a grain of salt. Ten years ago, I was far more optimistic about the outcomes. I know now how debilitating and co-morbid this is with other illnesses, and how "feeling good" is dangerous for them. People with BDD have to be alert and vigilant to not fall into their old habits of dealing with their anxieties.

It's a medical illness that is extremely serious—like tremors of the mind. You could compare it a stroke or cancer that must be attended to. It is chronic; it waxes and wanes. People can definitely get to completely functional levels provided they attend to it on a daily basis. But, like a person with extremely high blood pressure or diabetes or even cancer, that person must be mindful and aware that there's a problem. Lately I've seen a few cases that had been in remission for 10 or 12 years and then they relapsed. I cannot tell you why. I don't even know if I have a hypothesis about the relapse after years in remission. And it sometimes takes longer to get them out of the condition the second time.

DB: That’s a very sobering indication of the great suffering and difficulty of having this disorder. I really appreciate your helping these people even without necessarily always having easy answers. On the other hand, I know of some people over the past several years that have made tremendous improvement in their functioning, even if they’ve had to come back and see you periodically. It’s made a big difference in the quality of their lives.
EG: I appreciate that, but the truth is I want to warn people against being extremely optimistic. There is no cure, and even if we ourselves have some of the highest levels of successful outcomes, let’s not forget that I’m extremely careful, having been trained by Dr. Foa to assess cases for hours and hours and to administer up to 15 tests to make our understanding of the individual even more precise. We also need to reject and refer elsewhere about 50% of the cases that come to us that I think we cannot help. People who come here are self-selected. We never have more than three cases at a time in the entire Institute, and we are able to pay a lot of personal attention to each individual and tailor the treatment. If something is not working from yesterday to today, we change it. We have that luxury. If I need to, I can dedicate the entire Saturday to this patient. That said, I don’t think other therapists have that luxury, and I think it’s very important to put this element into the level of success. It was never the quantity but the quality of the work that we have been focused on.
DB: I think that's one clear understanding that your patients have about your work—the intense dedication. Without being able to promise success, you are certainly one of the most dedicated people I know working in this challenging field
EG: You are most welcome.