Silence often makes people uncomfortable. In U.S. culture, particularly, we are prone to filling up silences in conversations as quickly as possible. One reason for this is that prolonged silence may be interpreted as a sign of discomfort or disapproval. For the same reason, new psychotherapy students often feel a need to jump in and ask questions when things become quiet. At times, this can be a supportive thing to do. But, there are other times when this may signal discomfort, and when a period of silence may be just what a client needs in order to process feelings or to reflect on what has just been said. When a client who is usually verbal begins to fall silent while talking about something difficult, corresponding silence by the therapist is often helpful and supportive. It may convey attention and interest, as well as the therapist’s commitment to not interfere with the client’s need to process what is going on. If the silence continues for a substantial period of time, the pressure to help the client by saying something becomes greater. Therapists differ in how they handle this situation, depending on their orientation to treatment and their own individual style. I, personally, rarely let a silence last more than a minute or two without saying something—even if it’s just “Would you like to say anything about what’s going on?” On the other hand, some therapists have had breakthrough sessions when they gave a client a significant period of attentive silence that no one else had ever offered them. While many clients can use periods of silence productively, there are others for whom silence is not a good strategy. In my experience, older children and younger adolescents generally fall into this latter category. This can present a double-bind because these young clients often do not want to talk but also hate to be questioned. I have worked with many adolescents who have had previous unsuccessful therapies. Their two most common complaints about previous therapists are “He asked too many questions!” and “He never said anything!” Over the years, I have come to the conclusion that while questioning may be painful to many adolescents, silence is often downright excruciating. So, what do you do with an early adolescent who finds questions painful, who can barely handle talking at all, but who also hates silence? Many therapists try to engage such clients by talking with them about things they like to do. This can be a good way to start therapy with an adolescent, but it is not always easy to do, and some adolescents also find it irritating and patronizing. This is especially true for adolescents who know that they are in therapy for serious problems and who may legitimately experience small talk as disingenuous or “fiddling while Rome burns.” I have found that it is often preferable to go a different route with these nonverbal youngsters, taking over most or all of the talking at first by gently describing what you know about the client and then gradually introducing some speculation as to why they may be acting as they do. My first experience with this was in working with a 13-year-old girl who had been hospitalized with borderline features and possible early-onset schizophrenia. She had been acting increasingly depressed, erratic, and withdrawn, and had begun engaging in drug use and self-mutilation. She was barely verbal, responding to questions with one-word answers minimizing her problems, or with silence or shrugging. With my supervisor’s help, I began relying less on questions and spending more time talking sympathetically to her about what her parents and the hospital staff had reported about her behavior, and making some guesses about how she must have been feeling at the time. Before long, she began to acknowledge some of these feelings, and eventually she started talking about other significant issues, including having frightening hallucinations and feeling stress about her father’s alcoholic behavior, which her parents had not revealed to us. Interestingly, very young children often tolerate silences quite well in the context of play therapy. They are used to playing on their own and may feel comfortable with an adult in the room quietly accepting what they do and making only the occasional comment. When they get older, however, children cross a certain threshold—typically around 8 years of age—when they start to become self-conscious about playing but are not yet accustomed to talking with adults, especially about personal issues. A few years after this—at, say, 14 or 15 years of age—they start to become sufficiently verbal to express themselves more easily and to tolerate some appropriate silence from therapists. It should also be noted that not all adults feel comfortable with therapists who are silent, especially adults who come from backgrounds in which it is not culturally normal to share personal information with an unknown professional. With these clients—and indeed with all clients—some preliminary assessment is usually advisable to determine how comfortable they are with a more exploratory approach in which some silences may occur, as opposed to a more problem-solving approach in which they probably will not. Looking back over the silences I have shared with my clients, I am struck by how full and how varied they have been—each with its own special meaning: anxiety, sadness, recalcitrance, closeness, and speechless perplexity, to name a few. Each one is different, and each can lead, potentially, to a greater understanding of the client.
Category: Advanced Clinical Skills
Introducing Multi-Lens Therapy
What’s Going On?
What exactly is causing the emotional difficulties that your client or your patient is experiencing? You would think that this would be the central question a practitioner is hoping to answer, since it is certainly reasonable to suppose that treatment should connect to causation. Yet a taste for investigating what is really going on has been lost over the decades. As helpers, we’ve moved toward too-easy labeling, and accepting the idea that it is reasonable to help our clients without understanding what is going on “with” or “in” them.
This taste for investigation has been lost for many reasons, among them:
1) The DSM is loudly silent on causation; 2) The idea of “symptoms” and “symptom pictures” has firmly taken hold; 3) Training programs which are psychologically-minded focus on one theoretical framework or another, reducing the complexities of causation to “what fits our model”; and 4) It is so darned hard to actually know what is going on “inside” and “with” a given person.
How can we restore something as essential to the healing and helping process as knowing what is going on? There is no perfect answer but a step in the right direction is the following:
providing helpers with multiple lenses through which to view their clients’ troubles. This multi-lens approach reminds practitioners that they shouldn’t be looking for some single cause, like faulty plumbing or a traumatic childhood, nor should they be operating from one orientation, say a biomedical or a psychodynamic one. Rather, a lot is almost certainly going on, each aspect of which may be contributing to your client’s difficulties.
This updated way of proceeding is called multi-lens therapy. It takes as it starting point that, as a helper, you do what you do because of what’s going on, not irrespective of what’s going on. The DSM seems not to care about “what is going on.” As therapists, we most certainly ought to. If your client has an actual biological problem, they need one sort of help. If they hate their job, another sort of help is required. If born with certain sensitivities, they need another sort of help. It is absurd (and not okay) that a helper would look only at putative “symptoms” rather than what’s going on. It is likewise absurd (and not okay) that a helper would throw up their hands and say, “I don’t do causes.” Therapists may have gotten into that habit but that is a habit to break.
It may indeed turn out to be impossible to identify the cause or causes of a given client’s distress. But that is no reason not to try and no reason to pretend amnesia about the whole matter of causation. So, how should a therapist or other helper think about causation as that word pertains to human beings? The first principle is to think expansively rather than reductively. Multi-lens therapy provides twenty-five lenses through which to view and think about a client’s distress. That may sound like a lot but that is as it should be. Causation in human affairs is neither transparent nor simple.
You can be of help to a client even if you can’t discern what’s going on. You can be of help by being warm and supportive. You can be of help by virtue of your listening skills and your ability to carefully reflect back what a client is saying. You can be of help because you understand human nature and can usefully wonder aloud about your client’s behaviors. But that you can be of help without knowing what’s causing your client’s distress doesn’t mean that you should dismiss causation as “not something I do.” To engage in that dismissal would be to shortchange your clients and, worse, to set the stage for big mistakes.
Multi-lens Therapy
In multi-lens therapy, you take the position that there is no single way to look at human affairs. That a client is presenting a problem that he or she is calling “depression” doesn’t mean that you suddenly know what is going on. You don’t know if your client is in existential despair about having no life purpose, in a dark mood because of chemicals they are taking that have darkened their mood, in anguish about an unravelling marital relationship, or announcing something that has always been true for them, a matter of temperament. You do not know and the very least you can do is announce to yourself, “I do not know, let me check.”
How you check on possible causation depends on your therapeutic style. But informing that style should be an understanding of what might be going on. “Multi-lens therapy provides you with twenty-five ways of thinking about what might be going on”. These twenty-five lenses include the lens of original personality, which helps you think about a client’s basic temperament, the lens of formed personality, which reminds you about how “stiff” and intractable personality becomes over time, and the lens of available personality, which is a useful way to conceptualize your client’s current “amount” of free will and ability to change. Also included are the lenses of biology, psychology, development, family, social connection, circumstance, trauma, stress, and more. (You’ll find the complete list at the end of this article.)
Acquiring a working sense of these twenty-five lenses and learning ways of using them in session make for more powerful and helpful work. By proceeding in this way, as a multi-lens therapist, you don’t reduce what’s going on to “treating the symptoms of mental disorders” and you don’t operate from any reductionist theoretical orientation. Rather, you accept the largeness of human reality, a largeness that includes the complex nature of causation as that word applies to human affairs. Multi-lens therapy returns the idea of causation to therapy and helps therapists work more deeply, more powerfully—and more truthfully—with their clients.
A key to practicing multi-lens therapy is listening for causal hints. Clients regularly hint in passing at what’s causing their distress. The hints we get from a client help us determine which of these many causes are more probable than the others or maybe even which is the central cause. Nor is it hard to hear these hints if we train ourselves to listen for them. For instance, say that a client is presenting a relentless “down-ness” which you’re both likely to call “chronic depression.” Imagine that your client says the following in passing:
“I was raised Catholic but eventually became a Buddhist.”
You might nod and allow this information to pass by. Or, as a multi-lens therapist, you might take this as a causal hint, suggesting at the possibility that your client has had problems making sense of meaning and life purpose, problems which were not answered by her birth Catholicism and which perhaps are not being answered by her adoptive Buddhism.
You would then investigate. A hint is a door waiting to be opened. In this case, one sort of investigatory question might be: “Has Buddhism done a good job of serving your meaning and life purpose needs?” Another might be, “That’s interesting. What did Catholicism lack that Buddhism provides?” A third might be, “What attracted you to Buddhism?” Each of these questions honors the possibility that your client’s despair may be connected to her inability to keep meaning afloat and her difficulties identifying and “owning” life purposes.
You don’t know for sure that this is the case and you’re treating her announcement as a hint and not a revelation. But you may be on to something, even something crucial. You can only know by stopping your client’s narrative and asking. Many therapists prefer to rarely interrupt or even to never interrupt, but a multi-lens therapist sees careful interrupting as a key principle of helping. “I find that if I interrupt in a spirit of genuine inquiry, clients are neither disturbed nor offended by the inquiry. Indeed, they relish it.”
Suppose that your client mentions in passing, “As far back as I can remember, I was sensitive.” You could simply nod. Or you might consider this a causal hint that perhaps some feature or features of her original personality are implicated in her despair or are even, maybe directly or maybe obliquely, the cause of her despair.
Taking her remark as a causal hint worth pursuing, you might ask “That’s interesting and maybe important. If your basic sensitivity somehow connects to you feeling down, what does that suggest, I wonder?” You might ask, “I wonder, wouldn’t a sensitive person be down more often than the next person just by virtue of her sensitivity?” Or you might ask, “If, as you say, you were born sensitive, that’s going to amount to a lifelong challenge, isn’t it?” Each of these questions opens the door to a fruitful and likely pertinent chat about original personality: about what it means, what it signifies, and how it matters.
Consider another sort of situation. Your client says, “I’m having a terrible time at work. I see things that aren’t making sense there and when I point them out I get yelled at. I tried to tell my parents about it when I visited them and they just put me down as “not a team player” and “not a realist.” All I could think about was what a failure I am. I can’t figure out why my life is such a mess!” This is a lot to unpack but a multi-lens therapeutic approach provides you with a straightforward way to proceed.
You might say, “You know, there are lots of different possible causes of your distress. What you just said brings to mind at least three or four possible causes. One is that stress may be a major culprit. You sound under a lot of stress. A second is that, since you were born with an incisive mind, you don’t take easily to humbug; and that may make it much harder to deal with dishonesty at work. A third is that your family is still tormenting you. A fourth is that you can’t get past the idea that you’re bound to fail. Do these all seem to be in play?”
By saying this, which may sound like a mouthful but which is quite easy to say with practice, you’ve looked at the situation through four different lenses (the lenses of stress, cognition, family dynamics, and original personality), helped your client better understand the multiple reasons for her distress, and provided a roadmap for your work together. You can work on whichever of these your client identifies as the most pressing. At the same time, you can keep the others “at the ready” to work on as time permits, when they reappear, or when it seems smart to return to them.
Your client is likely to reply, “All of that is true!” Then you can take any one of the following approaches (or others, of course). You could say, “Which of these four seem most important?” You could say, “Let’s pick one of these to focus on – which one do you think it should be?” You could say, “That’s a lot, isn’t it? That’s probably why you’re feeling down, because so many things are combining to get you down. What do you think you might like to try, given these several different challenges?”
Your client is likely to appreciate this approach, as it matches her experience of life and honors that many challenges are confronting her all at once. “Your client will therefore become more invested in the therapy, dig deeper for her own solutions”, and feel herself to be in a genuine collaboration. A solid direction for the work to take is likely to emerge; the groundwork will be laid for future work.
As to that future work, proceeding with it might sound like the following. Say that you’ve been working on stress reduction for some weeks. At some point you might say, “Remember that we agreed that there were multiple things going on causing your distress. We’ve been working on stress reduction, which is great. But I wonder if we should take a look again at those other challenges? Maybe those toxic family dynamics, those thoughts that aren’t serving you or how your talent for seeing through humbug is affecting you at work?” In this way, you can refocus the work through any of the twenty-five lenses when and as needed.
Building Talking Points
In addition to listening for and responding to causal hints, you might want to create talking points that you begin to use regularly to communicate important ideas to clients. You might want to create a talking point around the idea of multiple lenses, freeing your client from the belief that “exactly one thing” is causing her distress; a talking point around the relationship among original personality, formed personality, and available personality, which will help your client think about her basic temperament, her stuck places, and her remaining free will; and many other useful talking points. Here is how using one of these talking points in session might sound.
Imagine that you are in session with a client who has announced that she wants to make some changes in her life.
Therapist: “Okay, so you know that you want to make some changes.”
Client: “Yes.”
Therapist: “Because currently you’re pretty unhappy and pretty stuck?”
Client: “Exactly.”
Therapist: “Let’s say that we do come up with some changes that you might want to make. How free are you to change?”
Client: “What do you mean?”
Therapist: “Here’s what I mean. Let me present you with a model. Imagine that personality is made up of three parts, original personality, formed personality, and available personality. Original personality is who we are at birth: our temperament, our smarts, our native abilities, all of that. Formed personality is who we become—the hardened person we become over time. And available personality is our remaining freedom, the part of us that is still able to make changes, see through our own games, etc. I see available personality as a sort of amount that can and does fluctuate—sometimes we are less free, say when we’re caught up in an addiction, and sometimes we’re freer, say when we enter recovery. Does that make sense?”
Client: “It does.”
The preceding was a characteristic talking point of multi-lens therapy. Once you create these talking points, they are very easy to use in therapy. In this case, you’ve presented your client with three huge ideas in a simple paragraph. You’ve announced that temperament matters—that who she was at birth matters. Second, you’ve announced that her formed personality is likely to be hard to alter, given that it has “solidified” over time. Third, you’ve provided her with a picture of what “freedom” looks like, opening the door to important existential conversations.
If you can say the above, or something like it, you will have presented your client with some big ideas and a frame that she can use for the rest of her life to help her think about her own personality, about where she is stuck and where she is free, and about how she might want to “make use of her current available personality” while also “increasing the amount available to her.” That is a lot to provide a client!
Therapist: “So, thinking about this model, how much availability personality do you think you have?”
Client (thinking): “Not very much.”
Therapist: “Okay. That’s where most people are. That’s one of the things we have to contend with, that lack of freedom. So, what might help increase that freedom?”
Client (thinking): “I don’t know.”
Therapist: “Fair enough. Let’s think about it together. Imagine that you were just a little bit freer. What would that look like?”
Client: “I would tell Bill what I think. I would have more of a voice.”
Therapist: “And if you spoke up, you would feel freer?”
Client: “Yes.”
Therapist: “But?”
Client: “But that feels much too dangerous.”
Therapist: “Feels dangerous or is dangerous?”
Client (thinking): “Both.”
Therapist: “Okay. Let’s tease that apart. What’s the actual danger?”
Client: “We’d be in conflict. And I hate conflict. And it might put us on the path to divorce.”
Therapist: “Okay. What’s the feeling part?”
Client: “That’s all tied up with me having authoritarian parents and having my voice silenced again and again as a child. That still frightens me, the vision of my angry mother and my angry father. Those feelings are very large and very terrible.”
Therapist: “Okay. So, we have two truths. Speaking up is dangerous and feels dangerous. Let’s see if there’s anything to do for the one and anything to do for the other. Okay?”
Client: “Okay.”
Here’s another situation where responding to causal hints with a spirit of inquiry and careful talking points deepens the work. Your client says, “Visiting my in-laws, who are very old-fashioned and the opposite of progressive, makes me really anxious. I get so anxious that I get sick beforehand and sometimes get too sick to travel. This makes my husband really angry, because he’s sure that I’m getting sick on purpose just to get out of visiting. He scolds me and shuns me and my way of coping is to spend hours talking to my sisters, who are the only people I can trust.”
The issue here isn’t anxiety per se. The issue is the whole picture. To provide an anxiety “diagnosis” (that is, an anxiety label) and to opt for anxiety as the sole focus is the current reductionist practice. “A multi-lens therapist unpacks this narrative, looks at it through the lenses of culture and society, trauma, social connection, instinct, and perhaps other lenses as well”. She replies, “There’s a lot going on here. It sounds like you’re in conflict with your husband’s family’s values or they’re in conflict with yours. That’s one part of it. Then there’s the ongoing trauma of your husband’s scolding and shunning. There’s the wonderful, positive social connection piece with your sisters. And it sounds like your body is having an instinctive, self-protective reaction to the situation, warning you that things are not okay. Does that capture what you just expressed?”
It would be lovely if you are exactly right but it doesn’t matter if you are exactly right. You are simply inquiring; and your client will appreciate it that you are trying to get a real handle on her situation. A talking point that you might add in the course of this collaborative inquiry is the following: “When there’s a lot going on we have to be patient and tease apart the various threads. It won’t pay to just slap on a label and call you anxious. We want to figure out what’s going on that’s making you anxious and, more than that, we want to improve your whole life. Agreed?”
Focusing the Lenses
Your current way of doing therapy may not include much teaching, explaining, or using talking points like the ones above. But if you’re engaged in explorations and investigations with your clients, as I believe you should be, that requires that you help your clients understand what you have in mind. You want to be able to say, “That’s one possible way to look at what’s going on. But there are also other ways. Can we check those out?”
If your client agrees, then you will need your talking points so that you can introduce those “other ways of looking at what’s going on” in simple and clear ways. With those talking points at the ready, you’re much more likely to learn what’s really going on, which then allows you to aim your helping in the appropriate direction. By paying real attention to what may be causing your client’s distress, you greatly increase your therapeutic options.
Of course, that you have done some excellent work discerning causes doesn’t mean that you or your client will then know what to do. But that information must prove valuable, at the very least insofar as it prevents you and your client from misunderstanding what is going on. And it is bound to suggest possible avenues to try. Whether those avenues will prove fruitful must remain to be seen. But you are traveling down them for good reasons, because you have inquired and listened.
Psychotherapy as an idea and as a practice has not completely escaped critical scrutiny. But, on balance, the critical psychology movement and other critics of contemporary mental health practices have more often taken aim at deconstructing the mental disorder paradigm, as reified in the DSM, than deconstructing the psychotherapy paradigm. “Psychotherapy has managed to fly a bit below the radar of critique”.
But it has needed critiquing, in large measure because it has taken too cavalier an attitude toward causation. What a doctor does is generally well justified by virtue of the fact that he is treating the causes of things as well as their symptoms. He cares if it is a virus and he cares which virus it is. What a psychotherapist does is on much shakier ground, since psychotherapy has taken a cavalier attitude toward causation and not made “investigating causes” a central activity of the practice. Therapists, provided by psychiatry with a checklist way of labeling clients, have been rather left off the hook when it comes to tackling the matter of causation.
A multi-lens therapist is on much more solid footing, since he or she can say, “I check carefully for causes by investigating the causal hints I hear and the causal clues I get. I then connect my helping strategies to what I learn. If I can’t discern what is causing my client’s distress, I can still be of help, because talk helps and support helps. But I don’t act like causes don’t matter and I do my human best to figure out what’s really going on. This is no easy task, as causation in human affairs is typically complex and obscure. But I try.”
The following is a list of 25 lenses gathered over the course of my clinical career through which to investigate causation. It is not meant to be comprehensive, but it does a good job of not being reductionist and allows for a lot of rich thinking and investigating.
1. The Lens of Original Personality
2. The Lens of Formed Personality
3. The Lens of Available Personality
4. The Lens of Circumstance
5. The Lens of Time Passing
6. The Lens of Mind Space
7. The Lens of Instinct
8. The Lens of Individual Psychology
9. The Lens of Social Psychology
10. The Lens of Development
11. The Lens of Biology
12. The Lens of Family
13. The Lens of Cognition
14. The Lens of Behavior
15. The Lens of Social Connection
16. The Lens of Experience
17. The Lens of Endowment
18. The Lens of Stress
19. The Lens of Trauma
20. The Lens of Emotion
21. The Lens of Culture and Society
22. The Lens of Environmental Factors
23. The Lens of Psychiatric Medication and Chemicals
24. The Lens of Creativity
25. The Lens of Life Purpose and Meaning
Multi-lens therapy asserts that if you are leaving out temperament, social and cultural realities, life purpose and meaning issues, and the other lenses through which a multi-lens therapist looks at her clients, you are leaving out too much. You are operating from too limited a place and making it harder on yourself to be effective by virtue of not meeting your client where she is “really at.” If you do meet her there, she will trust you more, warm to you more, engage responsively, and do more work out of session. Multi-lens therapy paints a truer-to-life picture of human reality and also makes the work of psychotherapy much easier. There’s a lot to value there.
Dreaming of the Future
What if it were possible to detect the moment during sleep when you were about to be woken up by a nightmare, and you could be sent soothing messages (or smells, or sensations) to shift the valence and prevent the dream from waking you up? Or what if you could wake up and actually see a list of topics or even a movie of the images from your dreams from the previous night even if you had no recall? These are just a couple of the dozens of ideas that were raised in brainstorming sessions at the inaugural Dream Engineering Symposium at MIT in January 2019.
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Dream researchers from around the world gathered to present findings, while MIT innovators presented what is or could be possible to aid in answering the challenging questions about what dreams are and what they do. The participants in past and current sleep laboratory studies often look like something from a nightmare, with equipment strapped to their bodies and countless wires sprouting from electrodes stuck to their scalp. By contrast, at MIT they are developing lightweight, flexible, wireless sleep masks that can collect sleep physiology data unobtrusively, and even remotely.
I was privileged to be one of the presenters at this symposium. As a former science writer, touring the media lab felt like a familiar part of my former work life, as I used to regularly talk to innovators about their technology. But at the conference I was blown away by what is already possible could be possible in the not-too-distant future. In the two decades intervening since my science writing days the state of the art has changed dramatically.
Much of the technology presented at the symposium was aimed at opening the door to lucid dreaming, in which the dreamer is aware that they are dreaming, because this is an optimal vehicle for obtaining real-time dream data. Dream researchers have the difficult problem of trying to study something that is not amenable to direct observation. All they have to go on is real-time sleep physiology data, and then later, people’s reports of what they dreamt about. But these may not be accurate reflections of the actual dream. To work around this, dream researchers watch for the brain signals that the participant is dreaming and wake them up immediately for dream reports, but this is not an ideal solution because it interferes with natural dreaming.
Researchers are interested in inducing lucid dreaming and establishing two-way communication so that they can get a dream report in real time. The trouble is, it is very difficult to ask someone questions and/or suggest they look around and notice that they are dreaming without actually waking them up. Symposium organizer Dr. Michelle Carr has developed a fairly reliable way to train even inexperienced lucid dreamers to become lucid enough in a dream to signal their consciousness by moving their eyes back and forth while staying asleep. She has used a combination of training prior to sleep followed by sound and light signals during sleep that are intense enough to be tangible to the dreamer, but not so intense that the dreamer wakes up—a very fine line.
My part in the event was to ask if we could direct some of this creative energy towards questions of clinical relevance, and I was the lone voice in the crowd. In my clinical practice, I have found experiential dreamwork to be one of the most efficient and effective ways to promote clinical change. Experiential dreamwork is the practice of inviting the dreamer to re-immerse themselves into their dream rather than standing back and analyzing it from the outside. Examples include telling the dream in first-person present-tense, entering into the subjective experience of a dream element or character, and allowing the dream to continue forward from where it ended. I told the researchers how the elements of dreams, and nightmares in particular, contain the perfect raw material for changing deep implicit memories. Dreams contain intense emotional material that is profoundly personal and relevant to the dreamer. Dreams very often surprise us with paradoxical information that, if truly absorbed, contains tremendous energy for transformation. Fairly recent brain and memory research (within the last 15 years) has shown that implicit emotional memories, which previously were thought to be indelible, can actually be erased and overwritten under specific circumstances. Memory reconsolidation research has shown that if a person holds two incompatible ideas in experiential awareness at the same time, the memory becomes unstable and can be permanently changed.
I have observed this kind of change in clinical practice and would love to have a clearer conception of how this happens so I can repeat it more reliably. For example, one client who worked with me confronting a black dog in her nightmare came to session the next week and said she had been cured of a lifelong phobia of grocery shopping, a wonderful but unexpected outcome. I also worked with a rape victim whose recurring nightmare of this trauma shifted to dreaming of more enjoyable and consensual sex after he reimagined a new dream ending. This coincided with a significant drop in his PTSD symptoms.
The idea that such a change in the dream narrative could be made in real time, while the dreamer is asleep, seemed like a distant prospect, but may not be as far off as I thought.
Shame Part 4: I Deserve to Feel Bad, Because I am Bad
In my previous blog posts, I discussed the difference between shame and guilt; both of which are painful, self-evaluative affects. Guilt involves the evaluation of a specific behavior and therefore, offers the opportunity for reparation. If Gary fails a test and feels guilty, he believes he can do things—like study harder—that will relieve some of his guilt. Even the thought that he is able to do something, alleviates some of the distress from his self-evaluation.
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If Gary perceives himself to be a loser who can never do anything right, then he is experiencing shame. Although shame can be transient, there are people whose experience of shame (shame-proneness) is pervasive; meaning that at the very core of their sense of self is the feeling of being small, insignificant and/or bad.
In my most recent blog post in this series, I discussed how shame-proneness compromised empathy, causing conflict and turmoil in relationships. Another lasting and painful consequence of unresolved shame is shame-based depression.
Depression is at best, an umbrella concept, not easily understood or reducible to a diagnostic label. Just because people share symptoms does not mean the cause is the same. Think of all the different underlying reasons for a headache. If we are to hope for good psychotherapy outcomes, we need to understand the causes of the symptoms, not an easy endeavor with distress as broad as depression.
When depression is shame-based, it is not only the symptoms that debilitate, but also the ingrained belief that the person does not deserve to feel better. Because fundamentally they feel bad, small, unimportant, the suffering feels congruent. Relief feels foreign and undeserved. If the shame basis of the depression is left unidentified, improvement will be a tortuous, uphill battle for both you and your patient.
Take Madeline (an amalgam of patients suffering from shame-based depression), for example. She’s a 39-year-old woman who came in for depression and reported a lifelong history of related symptoms. She described apathy, anhedonia, problems with motivation and concentration, appetite and sleep disturbances as well as feelings of worthlessness. As the therapy progressed over the first year, it became clear that Madeline experienced deep-rooted and chronic shame.
She regarded herself as unintelligent, unattractive and uninteresting. In response to these feelings, she developed grandiose aspirations to compensate for her supposed deficiencies that no one could ever live up to. Consequently, she experienced continuous and inevitable failures which confirmed and perpetuated her shame-narrative.
“I’ll never be intelligent. Everyone knows more than me,” she said, averting my gaze.
“Can you tell me more about that?”
“I need to read every single book on a particular topic before I’ll feel knowledgeable enough to have a conversation about it.”
“Does that seem a realistic endeavor?”
“I have to. It’s the only way I’ll feel smart enough,” she said flatly, fighting a frown.
“I worry that you are setting yourself up to fail by having expectations that are impossible to reach.”
“I never meet any of my goals, anyway.” She crossed her arms.
“You’ll never find a feeling of accomplishment or meaning if you keep setting insurmountable goals. I’d like to understand why you’re doing that. What would happen if we worked together to set realistic goals, things you can accomplish?”
“Well, then I might feel better.” She released a sarcastic laugh. “I wish that was a joke. I don’t feel like I deserve to feel better.”
“Tell me more about that.”
“No one ever supported me or any of my interests. I was told I wasn’t good enough. And it’s the truth, isn’t it? Look at my life. I’ve done nothing to be proud of. Failed at everything I ever tried or ever wanted.”
After I better understood her shame, I realized that despite our seemingly strong relationship, Madeline continually undermined the therapeutic process. Every time she started to feel better, she’d set these impossible standards, which ultimately confirmed her feelings of not being good enough, of being a failure. Of not deserving any relief.
Madeline knew nothing but her depression. She held onto it as if without it she would descend into an unfathomable void without it. When patients have a history of emotional abuse, as she did, where disparaging statements are woven through the fabric of their identity, the depression is often shame-based. And the treatment is extremely challenging. We have to help our patients to find ways to question, then challenge and finally close the book on their shame-narrative.
To some degree, all depressions contain an element of shame. But in Madeline’s case, it was pervasive, evolving more like a personality trait than a cluster of symptoms, making it harder to treat. Her shame caused her to perpetuate her own distress.
I combined humanistic, psychodynamic and cognitive-behavior therapy for Madeline. Psychodynamic, to help her understand how the shame evolved through her childhood experiences of emotional abuse; humanistic to focus on helping her identify and foster the many strengths she did have and to help her find meaningful pursuits where she could feel her endowments; cognitive-behavioral to help her with her thought distortions. I had her keep a journal of the false narratives. Every time she had an experience that disconfirmed them, I had her write it down. For example, she thought no one liked her and as a result, she was socially isolated. Every interaction where someone complimented her or showed interest in her, every time someone asked her for advice, she wrote it down. This was to reinforce different statements about who she was.
The more Madeline discovered her unique strengths and used them and felt them, the better she became at recognizing the falseness of her narratives. And the more she understood the distortions, the better she became at pursuing goals that were attainable.
I also did some psychoeducation in the second year of our treatment. I explained the shame and tried to help her understand her depression. Madeline had become curious and open and was able to introspect even in areas that were very painful.
Madeline developed an observing ego. She became more cognizant of her distortions and began to question their validity. In order to help patients recognize their shame, we need to listen closely to these narratives. We need to identify the shame. And then, we can adjust our therapeutic techniques to meet our client’s unique needs. We need to believe they deserve to get better and can get better, even when they are undermining every step of the process. But for the deepest and most lasting change to occur, they need to believe in a narrative free of shame.
Deliberate Practice in Psychotherapy
Editor’s note: The following is an excerpt taken from Mastering the Inner Skills of Psychotherapy, by Tony Rousmaniere, published by Gold Lantern Books © 2018 and reprinted with permission of the author.
“Could there be a better way for therapists to acquire the inner skills of psychotherapy?” To explore this question, let’s look to other fields. Most professions have developed specific exercises that help trainees acquire the capacity necessary for professional performance. For example, musicians rehearse challenging pieces repeatedly, so they will sound effortless during the actual performance. Pilot trainees spend hours intentionally stalling their plane, so they can practice recoveries. Athletes engage in physical conditioning, so they will have improved performance in competitions. In deliberate practice, therapists use practical exercises to build their inner skills and psychological capacity to improve their psychotherapy performance.
Deliberate Practice
I lead deliberate practice workshops around the world on developing therapists’ psychological capacity. Participants who are new to the idea of psychological capacity often ask, “How can this help me be more effective with my clients?” To answer this question, let’s begin with a case example of how deliberate practice helped me with a challenging case a few years ago.
My client was a man in his early twenties. He had recently been fired from his job and was discouraged about applying for work. He struggled with depression and had started to have thoughts of suicide. His goal for our work was to improve his mood and morale so he could find new employment.
My client and I formed a good working relationship in our first few sessions. However, despite my best efforts, he did not improve. Over the following weeks his mood gradually worsened, and he became more socially isolated. The outcome monitoring software I was using indicated that he was at a high risk of deterioration and possible suicide. With the client’s consent, I recorded a video of one of our sessions and showed it to my supervisor.
When we reviewed the video together, my supervisor noticed that the client looked disassociated during our session. He said, “Notice that after you ask your client a question, his eyes glaze over and he is slow to respond? Notice how he is nodding his head but not really engaging your questions? This could be a sign that your client is experiencing so much anxiety that he is disassociating. He may be politely going along with you but not fully understanding what you are asking him or benefiting from the therapy.”
As I watched the video closely, I could see what my supervisor was pointing out. My client’s eyes were unfocused, and his speech was slow. Although he was able to follow our conversation, his comments seemed superficial or compliant, like he was going along with me rather than really expressing himself.
I was surprised that I had not seen these obvious signs of disassociation in session with my client. I had learned about disassociation years prior and had successfully helped many clients with these symptoms. “Why was I unable to help this client?”
I said, “It’s so strange that I didn’t see these symptoms in session with my client. They seem so obvious when you point them out right now.”
My supervisor replied, “I wonder if you may be having an unconscious internal reaction that is blocking your conscious awareness?”
I said, “How can I tell if I am having such a reaction?”
He replied, “They often are accompanied by thoughts, emotions, physical sensations or behavioral urges. You can look for these as signals.”
“How?” I asked.
“I’ll show you,” he replied.
Seeing in Real Time
My supervisor said, “Play the video again. Turn the volume down low so you can hear the sound of your client’s voice but not get caught up in the content of the conversation in the video.”
I did as my supervisor instructed. It felt strange to watch the video without following the content of the conversation.
He continued, “Now, try to notice any thoughts, emotions, physical sensations, or behavioral urges you may feel while watching the video.”
I tried this for a few seconds and noted that paying attention to my internal experience while simultaneously watching the video was hard. I said, “My attention keeps trying to follow what the client is saying.”
“That’s normal,” he replied, “just keep trying.”
I watched the video while trying to tune in to my internal experience. After a few moments, I noticed I was clenching my fists. I told my supervisor.
“Great,” he said, “what else do you notice?”
“My chest feels tense,” I replied.
“What else?” he asked.
“I’m holding my breath.”
“What else?”
“As I tuned in to my internal world, I realized that I was having many uncomfortable reactions I had previously not noticed”. “My legs are tense, my mouth is dry, and my palms are sweaty. There’s also a slight ringing in my ears.”
He said, “Great that you can see all of these reactions within you. Let the video keep playing so you can continue. Do you notice any thoughts? You don’t have to tell me the details, but it’s important for you to see them.”
I noticed I was having strong doubts about myself as a therapist. How could I be effective if I was having all these unconscious reactions? Was something wrong with me? Should I give up and leave the profession? I felt some shame and didn’t want to reveal the details of all these thoughts to my supervisor. Instead, I simply said, “I’m having negative thoughts about myself.”
My supervisor could probably tell that I was experiencing some shame. He looked at me with kind eyes and normalized my experience, saying, “Great that you can notice those thoughts. Self-doubt, shame, or other negative thoughts about yourself are a normal and very common response to reaching your own psychological capacity limits. Consider these thoughts to be like how an athlete will sweat or get out of breath during a tough workout. It’s just part of the process.”
He continued, “Do you notice any behavioral urges? Again, you don’t have to tell me the details. Just try to notice them within yourself.”
I noticed I felt the urge to stop following his instructions. I was glancing at the clock out of the corner of my eye and hoping our consultation would end soon. I was also surprised to notice that I was starting to feel frustrated with my supervisor. This felt awkward, as I liked him a lot personally and trusted his advice. I didn’t feel comfortable telling him all of this, so instead I just nodded my head.
My supervisor paused the video. “Congratulations,” he said, “you were able to observe your own experiential avoidance in real time as you had it. This is not easy! However, it is a very important skill for effective psychotherapy.”
I took some deep breaths. I felt shaken from this experience and a bit confused. “How can this help me with my client?” I asked.
He replied, “Your ability to be empathic and attuned with this client is being limited by the discomfort and experiential avoidance that he stirs up in you. To address this, we need to increase your ability to see your own experiential avoidance in real time. This will let you downregulate your emotional state, so you can be more empathic, attuned and helpful.”
He continued, “You know how to assess and treat disassociation. You could write a paper about it. You can perform it proficiently with many of your other clients. You could teach it to beginning trainees. However, we have discovered that your proficiency in this skill is conditional on your psychological state. When you have particularly strong experiential avoidance—such as with this client—you lose your ability to be helpful. We call this your psychological capacity threshold.”
“How can I increase my threshold?” I asked.
He replied, “By practicing therapy skills with stimuli that provoke your experiential avoidance. This is called state dependent learning. For example, this video will work well for practice. I’ll show you how.”
Engaging the Client
My supervisor said, “You are going to practice engaging the client with anxiety regulation techniques while simultaneously noticing your experiential avoidance. Do you remember the somatic anxiety regulation techniques we reviewed last week?”
I replied, “The technique where I ask the client where he notices his anxiety in his body?”
“Yes, we’ll use that,” he said, “Start the video again at low volume. Now, while watching the video, take a moment to notice your internal reactions. Raise your hand when you notice any experiential avoidance.”
After a few moments watching the video, I noticed my chest tightening and breath restricting. I raised my hand.
“Good,” he said, “now use the first technique we discussed last week.”
“Just say it to the video?” I asked.
“Yes,” he replied, “just say it to your client in the video.”
Looking at the video, I said, “Right now, where physically do you notice any anxiety in your body?” I felt strange talking to the video.
“Good,” said my supervisor, “now watch the video for about twenty more seconds while noticing your inner reactions.”
My supervisor used his watch to count down twenty seconds and then said, “Now use the anxiety regulation technique again.”
“The same one?” I asked.
“Yes,” he said, “you can play with the words if you like.”
Looking at the video, I said, “Right now, where do you notice any anxiety, physically in your body?”
“Good,” said my supervisor, “do this process again: twenty seconds of self-observation, followed by engaging the client.”
I watched the video for twenty seconds while noticing my inner reactions and then said, “Do you notice any anxiety physically in your body right now?”
“Good,” my supervisor said, “again.”
I repeated the process.
“Again,” he said.
As I repeated the process, I noticed I had conflicting feelings toward my supervisor: I was simultaneously frustrated at him and appreciative of his help.
“Again,” he said.
I repeated the process and noticed I was starting to feel fatigued.
“Okay, pause,” he said. “What did you notice while repeating the exercise?”
“It got easier,” I replied.
“Great!” he said. “”You are building your psychological capacity to engage the client” while you have experiential avoidance.”
I asked, “Why does this client provoke such a strong reaction in me?”
He replied, “We don’t know yet. I’ll give you some deliberate practice exercises to do as homework, and maybe you’ll find out.”
Doing the Homework
My supervisor said, “Between now and our next supervision session, try to do an hour of the same deliberate practice exercise we just did together. Doing these exercises on your own may be more challenging than it was here with me, so try to be patient and self-compassionate. Remember that the goal is just to notice your reactions and practice engaging the video. Do not try to change or ‘fix’ any of your reactions.”
Over the following week I did the deliberate practice homework in three sessions of twenty minutes each. Doing it myself was much harder than it had been with my supervisor. I had to fight strong urges to avoid it. I scheduled practice in the morning but put it off until the afternoon. When I sat down to practice in the afternoon, I felt tired and decided to do it the following morning. The next morning, I was tempted to put it off yet again. However, I summoned the willpower and did the exercise.
When I started the video, I noticed a general tension throughout my body and fogginess in my mind. I kept losing track of time, so I set my phone to count down in twenty second intervals. I found it hard to say the anxiety regulation words out loud to the video. I felt awkward and had strong thoughts of shame and self-doubt. When I stopped after about twenty minutes, I felt discouraged by how much harder it had felt doing the exercise on my own rather than with my supervisor.
Two days later I did the exercise for a second time. Like my first practice session, this took considerable willpower. However, this time I had less fogginess and noticed more distinct internal experiences, including dry mouth, sweaty palms, and ringing in my ears. I felt clearer when saying the anxiety regulation words out loud. My shame and self-doubt were less pronounced. I ended the practice after about twenty minutes feeling more optimistic.
Three days later I did the exercise again. This time felt very different. As I watched the video, I noticed strong waves of tension rising from my stomach through my chest to my throat. I almost choked as I said the anxiety regulation words. The waves increased in intensity as I repeated the exercise. With surprise, I noticed tears forming in my eyes. “I felt a sharp spike in my shame and self-doubt and a strong urge to end the exercise”. However, I gathered my willpower and persisted. As I watched the video, I realized my client reminded me of times as a teenage boy when I had felt anxious and disassociated. I remembered the pain of those days, along with the social isolation and confusion. As I spoke the words of anxiety regulation to the video, I pictured saying them to myself as a teenager. I started crying out of sadness for my younger self as my shame melted into self-compassion. Resisting the temptation to stop the video, I continued with the exercise. I cried throughout the last ten minutes of the practice session.
Deliberate Practice Helped
This experience helped in multiple ways. First, my effectiveness as a therapist improved dramatically. I felt less tense and foggy sitting with the depressed young client whom I had videotaped. I was better able to help him see his own disassociation and use anxiety regulation techniques to reduce his anxiety. Over time, his mood improved, and he became more socially engaged. My effectiveness with other clients improved similarly.
Second, my morale and confidence as a therapist improved. I experienced less shame and self-doubt in my work. I felt optimistic about resolving other clinical impasses I was encountering and enthusiastic to practice more.
Third, the effects of the practice carried over to my personal life. I grew more open and engaged with my friends and family. I felt like I had further healed an old wound.
“The impact of deliberate practice on my personal life has been surprising”. I had previously done years of my own therapy, in which I had talked extensively about my teenage years. I assumed I had finished processing these old wounds. However, empathizing with this client stirred up painful memories that I had not recalled in my own therapy. Deliberate practice with my session videos helped me process those memories. After having many similar experiences myself and hearing of many from my trainees, I have come to see that deliberate practice with session videos can be a valuable tool for therapists’ personal growth. Deliberate practice helped me build my psychological capacity to be more effective with this client—and with my other clients.
The Internal Critic: Friend or Foe?
Harsh, hurtful, degrading and depleting are just a few ways to describe the all-too-powerful words of our internal critic. We all have a critic, but the ferocity and loudness varies. As an EMDR and EFT-oriented psychotherapist, I am privileged to have a front and center view of just how universal and common the internal critic can be and the opportunity to confront that voice with my clients.
“You’re so stupid, incompetent and useless.”
“Why would you do that? You can’t do anything right.”
“That was a huge failure, you should have walked away.”
“You’re so ugly and fat.”
“You’re just not good enough.”
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Not surprisingly, my most compassionate and caring clients will say these things, never to others, but often to themselves. To put it simply, the critic is one component of our personality. The critic is also alternately referred to as an ego state, or a state of awareness. It is one member of our internal system presumably developed to help us make decisions, keep us safe and progress in life. The cohesion and integration of our system of parts varies depending upon our life experiences and relationships. Our attachment to our caregivers, experiences in school, successes, failures, mistreatment, trauma and adverse life experiences all impact the growth and development of this internal system.
Fortunately, the critic isn’t the only player on the internal mental team. Other characters may include the professional, nurturer, survivor, child, friend and parent, to name a few. The list is potentially exhaustive and unique to the individual. When working with my clients, I often reference my own rebellious teenager part that most mornings tries to induce me to skip work and sleep in. It takes a lot of energy from this professional part to push (or pull) me out of bed, but this daily internal struggle pales in comparison to the battles we have with our critic.
Through therapy, my clients begin the daunting challenge of identifying these core negative messages from the critic and discover what makes them tick. Often, I find that the critic develops at a young age, and often results from an internalization of negative messages from parents, coaches or other authority figures. I often find that the critic has good intentions and often has the same goals as the adult which is happiness, success, and safety from potential threats. Unfortunately, the critic’s approach to helping to meet these goals is ultimately misguided and damaging. After the all-too-frequent and ongoing critical barrage, my clients weaken, feel less confident, safe, secure or motivated to do the things that could otherwise propel them forward in life. The critic’s initial good intentions are inevitably thwarted, leaving clients feeling stuck, insecure, unmotivated and depleted.
So what is the therapist to do in order to befriend and redirect this formidable foe? My own therapeutic efforts begin with the practice of mindfulness—I ask clients simply become aware, to notice the voice. It helps to ask them to move to a different chair and speak the critic’s words out loud. In EFT we call this “chair work” and through this practice the client can begin to separate the critic from that part of their inner system that is not critical. By doing so, clients can better connect with the critic and begin to identify the triggers and needs of the critic that give this voice its power.
My clients notice that the critic often raises its voice prior to a challenging task, after they have made a mistake or when they fail to achieve a goal in their life (referring to when they notice it outside of the therapy office). When my client and I can hone in on those times when the critic is using a megaphone, so to speak, we are able to identify and tap into more supportive parts of their inner chorus. This often has the effect of subduing the critic—removing its bully pulpit. Doing so makes room for these other characters—the nurturer, the advocate, the cheerleader and all of those other softer and kinder empathetic elements of self that are crucial and necessary for healthy emotional survival. Calming, motivational and compassionate messages and affirmations are helpful tools which over time and hard work in therapy have helped my clients to manage, quiet and even befriend their inner critic.
By assisting my clients to increase their capacity for self-compassion, kindness and self-empathy, I have been able to help them move closer to the therapeutic goal of self-acceptance. I often ask them to consider that if self-kindness seems like a foreign concept, they think of something their nicest friend or family member might say to them, in other words, “What would ___________ tell you in this moment?” My clients will often laugh and say that they can picture their sweet grandmother comforting them during these times. In EMDR therapy, we would identify this as a new resource and the image of the grandmother’s comforting presence would come along for the therapeutic journey towards healing. Regardless of the therapeutic modalities utilized, identifying, connecting and working with the critic is crucial in helping our clients find inner peace and acceptance.
The Lose-Lose Comment: A Therapist
In my years of practicing therapy, I frequently would not know what to say. Once, a woman made a classic doorknob disclosure as the session was ending: “When I was 14,” she said, “my uncle sexually abused me.” A male patient made fun of me for not following a story organized around economic theory. A woman wanted me to praise her for resisting temptation the week before. At these moments, I would typically frame my predicament as egalitarian (be spontaneous and gratifying) versus authoritarian (be withholding and rule-bound), and I would choose the egalitarian path. Other therapists, I’ve noticed, have other ways of framing therapy dilemmas.
I wish I’d known at the time how to make a lose-lose comment. For example, with the first patient, I might have said, “If I just say goodbye right now, I seem to be communicating that what you said is not that big a deal. But if I ask you about it, I seem to be communicating that it’s such a big deal that our relationship can’t take it in stride. I don’t think this dilemma is new to you in dealing with the abuse. Since both alternatives have disadvantages, I guess I’d like to keep our agreements intact, while assuring you that we will talk it over next time.”
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Two of the many ways of understanding therapeutic success make sense of the lose-lose comment’s effectiveness. First, Gregory Bateson, the anthropologist, observed therapy in a VA hospital and concluded that therapists teach patients how to metacommunicate. He meant that many people do not take advantage of their capacity for reflection before taking action, largely because they never learned to talk things over in a reflective space, much less in their own heads. He said that almost all therapies of every orientation excel at this because virtually all therapies talk things over. The dilemmas I mentioned above pressured me to act, and the lose-lose comment demonstrates that even intense pressure can be reflected upon.
Transference resolution seems outdated as a therapy construct, but it can be understood in contemporary terms. Jonathan Shedler has said that therapy teaches the patient, “That was then; this is now.” I have long maintained that successful therapy depends on the fact that the patient will mess up the therapy in the same way that they mess up other relationships, and the therapist’s job is to help resolve these relational conflicts. In this context, many therapy dilemmas arise when the patient promotes a characteristic mode of relating and the therapist is trying to promote a therapeutic mode. The lose-lose comment is intrinsically therapeutic, even when the alternatives specified by the comment are not, so it restores or maintains the therapeutic relationship.
To the economist, I might have said, “If I fight back, our relationship becomes a stag fight, but if I don’t, I will lose your respect. I get the sense that you might not be too familiar with other ways of relating.” If the last sentence seems like a putdown, I could have said, instead, “I’m not sure how we got to this point.” To the woman wanting praise, I might have said, “If I praise you, then it might cast you as a little girl, the very image that precedes your yielding to temptation; if I don’t, you might feel lonely, which we have also identified as a precursor to temptation.”
The structure of the lose-lose comment can become monotonous, but it lends itself to other forms. I could follow up the lose-lose comment with something like “Are those my only choices? I wish I could think of a way to show you how important I think that is while also showing you that I think we can take this in stride.” Or, with the economist, just holding my hands up in a timeout signal might have gotten us back on track.
Shame Part 2: Shame Proneness
Megan came into session and sat down. Her eyes wandered around my face, but didn’t meet mine when she said, “I did it again. I went back to him.”
“Tell me,” I said, leaning forward.
“I’m a – a loser. I can’t stay away from him even though he’s bad for me.”
Megan had come into therapy after failing to sever ties with her most recent boyfriend, Tim, a man who repeatedly left her feeling emotionally abandoned and worthless. She reported a history of tumultuous intimate relationships that consistently left her feeling lonely and dissatisfied.
Tim was no different. Every time he dismissed her or invalidated her, it tore a little more of her heart out. Worse yet, it confirmed her inner fear: She was worthless and no one would ever, could ever love her. Trying to repair fractures to her self-esteem, she would search for the next man to love her, only to find herself in another relationship where she felt dismissed and worthless.
This isn’t unusual. It’s certainly a story I’ve heard variations of many times as a psychotherapist. Megan, who was thirty-five years old, reported that she had been going through this cycle since she was a teenager. She felt hopeless that she would ever find the stable, loving relationship she so wanted. I felt it as soon as we started our work together. Shame.
In my last blog post, I discussed the shame that entered the room in early sessions, when patients began exposing themselves. Megan’s shame was more complicated. Normal shame is transient, but for Megan, her inclination was to experience shame in all ambiguous situations. This proclivity has been assigned various names. I like to call it shame-proneness, which is the term June Price Tangney, one of the leaders in research on moral affects, (shame and guilt), named it.
When Megan came into situations that naturally elicited self-assessment, her emotional response would be feeling bad, small, defective. Self-esteem is a cognitive evaluation of the self; shame, on the other hand, is an affect, and therefore, permeates the entire self, spilling into every crack of someone’s being, coloring all their experience-darkly.
On some level, Megan believed that she deserved poor treatment from men, causing a repetition of the very pattern she was trying to stop. No matter how hard she tried to find a different outcome, she was always confronted with the same feelings of shame. Thus, the narrative – I am bad – that she desperately wanted to change, perpetuated itself.
Megan explained that she went back to Tim during the week when he promised it would be different, only to be left again. This was the fifth time she went back only to be left.
“He threw me out.” Tears trickled down her cheeks. “See, I’m weak. I’m a failure at everything. I’m never going to find what I want. It’s me.”
Her feeling bad about herself in the Tim situation pervaded other aspects of her life. That is, she felt bad all around, not just in relations to Tim.
I knew I had to help her see how her self-perception created a type of self-fulling prophecy. So, I reminded her of what we had been working on. “Remember what we talked about?” I often use psycho-education with patients, even when I’m working more psychoanalytically as I usually do with a shame-prone patient. I don’t find that keeping the nuances of therapeutic work undisclosed helps, especially for patients who feel so exposed already. It’s like throwing them outside in the cold without a coat, alone.
Megan and I had discussed shame. She knew that it tied back to early experiences of emotional neglect and abuse, where she unfortunately heard messages that she was bad and wouldn’t be anything different, ever.
“I remember, that just makes me feel worse. I should know better by now,” she whispered. This is where shame is so tricky; it’s very hard to intervene without evoking more shame.
I addressed her experience in the room. “We knew it would be hard not to go back if he called. Intellectual insight comes before the emotional connections that make change easier. You are working very hard to undo a narrative that took years to build. It takes time.” I leaned forward, again. “Remember, what we talked about last session, during the break from Tim.”
“Yes, I’ve – gosh, I can’t believe I forgot.” She pulled out her phone and showed me a schedule of all the workouts she had done the last week. Megan had been very athletic. I encouraged her to go back to exercising.
I wanted her to feel her strength and resilience. I wanted her to find her value in her activities. One of the most effective ways to help people combat these shame narratives is to help them access and activate their natural strengths, the parts of them that weren’t fostered, because no one acknowledged them when they were younger.
It’s our job as clinicians to discover these natural endowments and cultivate them for all of our patients. Shame-prone patients need more help figuring out what they are and more time to develop motivation.
Megan smiled as she showed me what she had accomplished that week. I saw pride glowing in her eyes. I observed it with her. “What are feeling?”
“I feel good.”
I smiled, thinking that we had found a space for Megan that was shame free. “What’s it like to feel good?”
“It’s something I knew I wanted to feel, but I could never quite find.”
“Now that you know what it feels like, it will start to get a little easier. Be hopeful.”
“I am.”
*Megan is an amalgamate of patients suffering from shame-proneness.
Allen Frances on the DSM-5, Mental Illness and Humane Treatment
Where DSM-5 Went Wrong
Lawrence Rubin: I first became familiar with your work around five years ago when I was teaching abnormal psychology. So, I’ll start off by saying that you’ve had a very interesting professional evolution. You were involved in the preparation of the DSM-III series, chaired the DSM-IV task force, but then became a strident critic of its successor, the DSM-5. Were you as critical of the DSM-III and IV, as you were of 5?
Allen Frances, MD: Well, I worked on the DSM-III, and I was one of the conservative voices trying to restrict the enthusiasm for expanding diagnoses beyond what I thought would be reasonable. I did my best, mostly unsuccessfully to provide the check on what seemed to me to be an ever-expanding diagnostic system. For DSM-IV, we established very high thresholds for making changes. And it turned out that we included only two diagnoses from the 94 that had been submitted to us as suggestions. We told the people working on DSM-IV that they would have to prove with very careful literature, if you used data reanalysis in the field trials, that any change would do more harm than good. And when you have high standards, very few new innovations get included.So, my concern about DSM-5 was that the experts doing it were given just the opposite instructions; to take the diagnostic system more as a blank slate and to be creative.
And if I’ve learned anything during these 40 years I’ve worked on DSM’s, it’s that if anything can be misused, it will be misused, especially if there’s a financial incentive.
And pharma, the big drug companies, have a tremendous financial incentive in making sure that every DSM decision is misused by expansion, so that people who are basically checked well are treated as if they’re sick. They become the best customers for pills. And drug companies have become experts in selling the ill to peddle the pill. So, I was very concerned the DSM-5 would have the negative effect of opening the floodgates even further to what seems to me to be fairly wild diagnosing, excessive use of medication, especially in kids, but also in adults and geriatric populations.
LR: So get as many new diagnoses out there as we can; make money, comport with the drug companies.
AF: I think that’s a misunderstanding. The people doing this were not doing this as an effort to curry favor among the drug companies, although many of them had some connection, a financial connection with pharma. I don’t think that that’s the motivation that lead to the DSM-5 expansions. I think intellectual conflicts of interest are much more important, and much more difficult to control than financial. And the experts in the field are always in the direction of expanding their pet diagnosis. They can always imagine a patient they’ve seen, who couldn’t fit into the existing criteria, and they worried very little about false positives.They were much more concerned about missing a patient, than mislabeling someone who shouldn’t be diagnosed. I think the people working on DSM-5 were honest. I don’t think that they had any inclination to help the drug companies, but their own experiences as experts in the field don’t generalize well to average practice.So, if you’re working as a research psychiatrist on a very exotic condition at a university clinic seeing highly selected patients, having lots of time with every patient, using careful diagnostic instruments, you get an idea about what might make sense. That’s completely inappropriate for primary care practice, where most of the diagnosis is done, and most of the medication is prescribed. I think experts were making decisions that might be reasonable in their own hands, but that would be absolutely dreadful once used widely in general practice.
LR: So, just a seeming disconnect between the researchers in these rarefied atmospheres and those frontline folks seeing people day to day!
AF: Exactly. And I think that this goes for all manifestations; what we see in psychiatry is not at all special to it. That every single branch of medicine has an inherent systematic bias towards overdiagnosis. Recently, the new guidelines on hypertension resulted in something like 40 million additional people being called hypertensive.Guidelines should not be left in the hands of professional associations. They should be done by people who are neutral. And use experts, but don’t allow them to call the final shots
A Diagnosis Should be Written in Pencil
LR: Have you seen any discernible impact of your anti DSM-5 sentiments in the last five years since its publication? Has the field shifted back to listening to some of the concerns that you and others have had in terms of overdiagnosis and lowering thresholds?
AF: Yeah. And again, it’s not just psychiatry. This has been a problem in every single medical and surgical specialty. And there is an increasing chorus of Davids fighting the huge Goliaths. The huge Goliaths in this case are the drug companies and the professional specialty organizations who have vested interest. The medical industrial complex is now a $3 trillion-dollar industry. And it is most profitable when people who are basically well, feel sick, and get treatments they don’t need. And so, its tremendous budgets are expanded by the demand of all medicine in the direction of increasing patienthood and recommending ever more expensive treatments.The Davids fighting this are just a small group of people with very limited budgets, but sometimes right does make for might. And the medical journals in general have become much more aware of overdiagnosis. I’ll be at two meetings this summer, one in Helsinki, and one in Copenhagen, both focused not just on psychiatry, but across medicine and surgery on the topic of overdiagnosis. There’s an institute called the Lown Institute that’s working very hard to promote right care rather than excessive care. And there’s a wonderful initiative called Choosing Wisely, in which the various medical specialties are identifying those areas, where there’s excessive diagnoses and treatment.And I think in psychiatry and psychology, there’s been an increased realization that there are risks to diagnoses as well as benefits. And seeing any individual patient, it’s very important to adapt the general guidelines to that person’s specific situation, and to ensure that a diagnosis will be more helpful than harmful. It’s the easiest thing in the world to give a diagnosis. It only takes a few mindless minutes, and very often diagnoses are given precisely that way. Eighty percent of medication is dispensed in primary care practice, often after visits of less than ten minutes. A diagnosis once given, can have terrible consequences that haunt and last a lifetime.
And so, from my perspective, a diagnosis should be a very particular moment in a patient’s life. It should be, when done well, a very important positive moment.
A good diagnosis leads to feeling understood, to no longer having a sense of confusion and uncertainty about the future. It helps the patient develop, with the doctor or the psychologist a treatment plan that may have a tremendous positive influence on their future. An inaccurate diagnosis carries unnecessary stigma and the likelihood of medication that will do more harm than good. And again, that haunting inability to ever get it erased. Because things evolve over time and people change from week to week, people usually come for help at their worst moment, and how they look at that moment may not be characteristic of their past or predictive of their future. I think it’s crucially important to take diagnosis seriously. A great way of putting this is a diagnosis should be written in pencil.
LR: I like that.
AF: Especially in kids.
On the Diagnosis of Children
LR: It seems that what you’re saying is that there’s this overt and covert attempt to enfeeble consumers. And you’ve written a lot online recently and seem really upset about what’s going on with children. Research seems to say that one in five are diagnosable, and one in 68 is on the autism spectrum. And you talked about stigma lasting a lifetime. Do you see that this is particularly the case when we hand out diagnoses to kids at very tender ages?
AF: First of all, never believe survey results that say one in X number of kids has the diagnosis. There’s an enormous systematic bias in all epidemiological studies. These are usually done by telephone, or by self-report, and they can never judge clinical significance. So, they’re only screeners that would at best provide an upper limit on the regular diagnosis, never a true rate but they’re not reported that way. And once it gets out, you know, it used to be that 1 in 2,000 or fewer kids had a diagnosis of autism. We changed that. One of the changes in DSM-IV was adding Asperger’s, which did dramatically increase the rate. But we expected the rate to increase by three times, not to go from 1 in 2,000 to 1 in 50, which has happened over the period of these last 20 years.And I think that some of that is identification of people who previously didn’t get the diagnosis and needed it, but a lot of it has to do with wild generalist diagnoses, and survey methods that are very misleading. I think that kids are very changeable, from week to week, and month to month. There are changes in development that are responsive to family stress and school stress, peer pressure. And what happens instead is we have wild overdiagnosis in attention deficit disorder and autism and this is done in a way that doesn’t respect the fact that these are young brains.We don’t know the impact of long term medication on the developing brain. It’s like a public health experiment that’s being done without informed consent. And all the indications for ADHD is that the beneficial results are short term. That academic performance over the long term is not positively impacted. That we should be a lot more cautious, both in diagnosis and in treatment, especially with young kids where diagnosis is so difficult, and where treatment may have negative as well as positive impacts. The most dramatic example of this is attention deficit disorder. There are five studies in different countries with millions of patients – not millions of patients, but millions of kids –and these have found that the best predictor of getting a diagnosis of ADHD and being treated for it with medication is whether you’re the youngest kid in the class. The youngest in the class is almost twice as likely to be diagnosed and treated than the oldest kid, which is clear cut proof positive, slam-bang evidence of overdiagnosis. Their immaturity is being turned into a disease, and kids are being treated with medication for basically just their immaturity. And the fact that the classrooms they’re in are too chaotic, and don’t have enough gym time, and don’t have enough individual attention.
LR: A woman wrote a chapter for one of my books, Mental Illness in Popular Media, on the use of adenoidectomies and tonsillectomies in the early part of the 20th century to deal with the seeming epidemic of kids who would today be diagnosed with ADHD. There seems to be this history of medicalization of childhood that you’re alluding to, and this perverse need we seem to have to enfeeble kids. And if anything, it seems that it will keep them more dependent, less productive, and less competent than ever before-an unintended side effect.
AF: I was one of the kids, who might have gotten the tonsillectomy.
LR: Me too.
AF: I remember that well. My father said “no, we’re not going to do that,” but the doctor recommended it, and all the kids on the block had gotten tonsillectomies. Medical diagnosis and treatment tends to run in fads. Over the course of history, there have been diagnoses and treatments that have sudden runs of popularity that now seem absurd. And some of our practices today will seem very troubling when looked at in the coming decades.
LR: Do you see Disruptive Mood Dysregulation Disorder (DMDD) as being part of this fad bandwagon? And even though it’s got this fancy name, it’s still considered child bipolar disorder, and that’s really damming.
AF: What happened here was really nuts. There had been suggestions by psychiatrists heavily funded by the drug industry to include the child version of bipolar disorder in DSM-IV. And we rejected those suggestions, fearing that it would lead to a tremendous overdiagnosis of bipolar disorder in kids. Despite our rejection, the diagnosis suddenly became popular, partly because the drug companies finance these guys to go around the country giving conferences and partly because child psychiatrists can sometimes be very gullible. And very young children, even infants were getting antipsychotics for a fake bipolar disorder diagnosed in the early years of life. The field of child psychiatry became concerned about this and wanted to correct it, but the fix in DSM-5 was exactly wrongheaded. What should have been done is a black box, a warning in DSM-5 about the overdiagnosis of childhood bipolar disorder. And the caution that the kids should be seen carefully and over long periods of time, and that they should meet criteria before a diagnosis of bipolar was made.
LR: A black box warning?
AF: There should have been a warning about the dangerous fad. Instead, they substituted a new diagnosis that essentially is childhood temper tantrums, hoping the kids who previously had been mislabeled bipolar would get this lesser diagnosis instead, lesser because it wouldn’t imply the need for mood disorder medications that would imply a lifelong course. But why substitute a new diagnosis for temper tantrums that can be so easily misused.The system tends to accrete, rather than to sunset diagnoses. It tends to always be adding new things, rather than warning about, or eliminating things that are already in the system that may be dangerous. So, parents have to be very well-informed about their kids.
LR: And they’re not.
AF: And the concern often is, if I don’t get my kid a diagnosis, say of ADHD and medication, he’ll be behind in school. I think parents have to have the opposite concern, as well that the medications are being given out way too loosely, and they need to protect their kids from medication that may not be needed.That said, I get more criticism, from people who feel I defend medication too much. I’m absolutely convinced that medication is useful, when given carefully to the few. That it becomes harmful only when it’s handed out carelessly to the many. And the people who go in either direction, either blindly supporting the use of medication, or blindly opposing it, I think of both as extremist, and they do harm to the real needs of the people. But there will be, and are, a large number of people who need medication and can’t get it, either because of inadequate resources or problems with financing treatment. And we have to worry about the people who are neglected very much. At the same time, we have to be mindful of the fact that we have the paradox of over-treating people, who are basically well, while we’re neglecting those who are really in need and desperately unable to get the treatment that would be helpful for them.
LR: You wrote a blog post titled, “Please empathize with me, doctor!” And from what you’re describing Allen, it seems that we are struggling with a societal empathy deficit disorder. There seems to be a preference for scientizing our relationship with kids and with our patients at the expense of understanding, at the expense of taking the requisite time. And at the really painful expense of not empathizing with these people, who are just going to be tossed into the system with labels and scripts. Empathy deficit disorder, maybe it will be in DSM-VI, or DSM-2.0.
AF: We could use it for our president.
LR: We’ll save that for later.
AF: Actually, the issue goes all the way back to Hippocrates, the father of medicine 2,500 years ago.
But First, Do No Harm
LR: Do no harm.
AF: Do no harm. He also said that it’s more important to know the patient who has the disease, than the disease the patient has. I don’t trust clinicians who only do DSM check lists. They don’t know the patient. I don’t trust clinicians who don’t know DSM and do free-floating evaluations that don’t take into account the ways that the individual may have a problem that’s been well described and has a set of guidelines that will be very helpful. I think that every clinical encounter needs to be a combination of close person-to-person collaboration, that the DSM guideline should never be applied blindly to each individual because they vary within themselves. It has to be customized for that particular person’s own situation. At the same time, not knowing the DSM diagnoses is likely to result in missing things that would be crucially important in treatment planning.
LR: False negatives.
AF: Good interviewers are people who are able to form great relationships with their patients, work collaboratively in understanding the diagnosis and planning a treatment and able to use the DSM without worshiping it.
LR: It seems that what’s needed, as you say is more time, a deeper understanding and a reluctance to jump into a diagnosis. This seems antithetical to the way that psychiatry and even psychology are practiced today. And clinicians are under more and more pressure to assign a rapid diagnosis and develop a treatment plan within the first session or two. What advice do you have for clinicians who are under this type of pressure, and may not have the luxury of flexibility and time that we know is necessary?
AF: Well, first-off, the system is crazy. Insurance companies do this because they think it will restrict costs, but it has the perverse effect of forcing people to make premature decisions that often will result in more costly treatment. Giving a person a medication is likely to create a commitment to see that patient over a long period of time. Diagnosis can increase the lifelong cost of taking care of that person. If the insurance companies gave more time for evaluation, many, many of the problems that get a diagnosis and long-term treatment would pretty much go away on their own with time and simple advice.The system is counterproductive; the more time we spend upfront with people in the evaluation process, before diagnosis and before treatment, the fewer diagnoses will be necessary, the less lifetime treatment will be needed. And it will actually be much more cost effective to give people time to get to know the situation at the beginning. I think for practitioners, it’s important always to underdiagnose. That it’s crucial to first of all rule out the possible role of medication and symptoms. You know, very often, hundreds and hundreds of times in my career, new symptoms have been due to medication.
LR: Iatrogenic?
AF: The average person over 60 to 65 is taking five, six, seven pills. Recent studies showed how many of them have depression and anxiety as side effects. And the older people particularly are less able to clear medications. So, you have a combination of a bunch of medications that can cause side effects, and a person not being able to clear those medications. And new symptoms are often treated with yet another medication, rather than realizing it’s a side effect. I think that it’s important to rule out medications. It’s important to rule out substances. It’s important to rule out medical problems. That has to be done during the first sessions. I think that’s crucial. But beyond that, I think it’s important not to jump to lifelong diagnoses based on very limited information. And to tend, at the beginning at least, to normalize, rather than to pathologize the situation.We see people on the worst days of their lives and tend to draw conclusions about them. And their futures are often inaccurate. They look very different days and weeks later.
Mind, Body or Both
LR: How can the average psychotherapist develop a healthier relationship with the biopsychosocial model? I know you said, you have to look for substance abuse. You have to look at the iatrogenic effects of medication. You have to look at the psychotropics that they’re on. So, how does the average psychotherapist, who is not particularly savvy when it comes to psychotropics, really have a full biopsychosocial understanding of these complex organisms that are people?
AF: I think one of the great losses over time has been the biopsychosocial model, particularly because of the mindless warring between people who have narrow views that are biological, or just psychological, or just social. I think that it’s impossible to understand the complexities of human nature and of how we function and dysfunction without taking into account the biological, the psychological, and the social, and sometimes there’s spiritual issues that people come with. And I think it’s just as important that psychiatrists be good psychotherapists and understand the way that social pressures result in symptoms. And it’s equally important that psychologists understand diagnosis and also the use of medication. Even if you’re not prescribing it, it’s very important to understand when to and when not to use medication. If for no other reason, to make sure the patient’s not getting too much medication, as well as knowing when to refer. I think every clinician needs to be complete. I don’t think that training in one discipline gives permission not to be aware of the tools that are available more widely across disciplines.
LR: Do you think there’s such a thing as a psychosocial reductionism? I know there’s biomedical reductionism. Do you see a danger at the other end of the extreme, of psychosocial reductionism?
AF: Oh, definitely. Psychosocial reductionism, yeah, it’s alive and well, particularly in Britain where there’s an ongoing back and forth. An active segment of British psychologists has taken a pretty radical view that psychosis is on a continuum with normal. That biological elements have been way over-emphasized in schizophrenia. And that most of the problems patients present have to do with childhood trauma. And again, every point of view has value, but no one point of view is necessary and sufficient.
LR: There are many truths. There’s just as much psychosocial reductionism as there is biological reductionism in many of these debates. You know, talking about biomedical and psychosocial reductionism, I remember when, around the time that DSM-5 came out, NIMH really took a stand and said, “Yeah, nice work boys and girls, but we’re going to pretty much move to the RDoC.” A lot of psychotherapists practicing day to day, who don’t work in academia, don’t read a lot of the scholarly journals, don’t have the bloodiest idea of what the Research Domain Criteria is. Do you see that system as useful or valid? Specifically, how useful do you see it in alleviating some of these ills of overdiagnosis and wrongheaded treatment?
AF: Well, the DSM had tremendous promise as a research tool, but it’s failed in that the complexities of brain functioning, of genetics, have been so enormous, the more we learn, the more we realize how little we understand.The brain is the most complicated thing in the known universe. It reveals it secrets very slowly. And it turns out that there are hundreds of genes involved in schizophrenia and every other psychiatric disorder, not just a few. And all of the neuroscience research has been remarkably productive. One of the great intellectual adventures of our time is the research that’s been done on how the brain works; however it hasn’t helped a single patient!
I think we have to be aware of the fact that there are no low-hanging fruits. That we’re not going to have breakthroughs that will explain schizophrenia or bipolar disorder. That each of these conditions is probably hundreds of thousands of different conditions that share some clinical features, but probably have very different biological underpinnings. And we shouldn’t be so dazzled by the science that we lose track of taking care of real patients in the present. I think there’s so much promise, so many high promises in the future, and our NIMH budget is being spent almost exclusively on basic science research, almost not at all on clinical research, that we’re ignoring the needs of patient today.
To me, it’s a tragedy that we have 350,000 patients in prisons, and 250,000 homeless on the street that we’re taking minimal care of, we’re neglecting people desperately in need. And that most of the research has its head in the air trying to find out things that maybe are going to be helpful to a tiny percentage of patients in the future. Meanwhile, we know how to take care of people now, we’re just not doing it.
We’re not making the investment in community treatment, housing, recovery programs, that would be necessary to eliminate the shame on our country. Almost every other developed country takes much better care of their mentally ill than we do. The U.S. is the worst place in the country to be severely ill. And it’s not a matter of neuroscience or science in general, it’s just the common sense, practical taking care of people and treating them as citizens, not neglecting them. And what we do in this country is provide almost no funding for community treatment and support
LR: It goes back to this idea of empathy deficit disorder. You talk about science, I like the point you make about the RDoC. That it’s a magnificent academic tool, but maybe in the year 2635, we’ll find a gene for some component of bipolar disorder, but how many people are going to struggle and lose their lives before that?
AF: And I don’t think we will find the gene. I think what we’ll find, it’s like breast cancer, we’ll find that there are certain genes predisposed in a very small percentage of the people who have the disorder. And that’s the complexity. There’s a paper that came out that had 250 authors that found 105 genes for schizophrenia, each of them a tiny bit different than normal. And the permutations and combinations of those genes would be astronomical. What that says is that the complexity of these disorders is so great that there will be no simple answers. In the meantime, we shouldn’t be allowing people to not have treatment and not have housing and to wind up in jail. And the resources, the techniques, the ways of preventing this, of making our country less of a shameful outlier in how we treat the mentally ill are perfectly obvious, it’s just a matter of funding and political will. And the severely mentally ill are the most disadvantaged, the most vulnerable population in our country.
It is the Relationship That Heals
LR: I find a bizarre paradox in all this. When I think of psychosocial treatment, I think of the amount of money, time, resources, the human capital, that’s being spent to develop these empirically supported treatments, and ultimately you end up with cognitive behavior therapy at the top of the heap. There seems to be this manic pull in psychology and psychotherapy to develop empirically supported treatments, which many argue take the heart and soul out of the human connection, out of psychotherapy. Do you have any thoughts about this scientific perversion and how it’s affected the field of, and the practice of psychotherapy?
AF: I don’t think it’s so much scientific perversion. I think it’s economic pressures; that every therapy wants to gain a list of insurance companies who will pay for it. And this leads to a kind of competition to prove that your work is validated. I’ve been following this field now for 40 years. I was on the NIMH committee that used to fund psychotherapy projects that no longer exist, of course, because of NIMH’s current focus on the brain. But the overwhelming finding in the literature is that all of – this is a paper that was published 40 years ago by Lester Luborsky – all have run, all have won, and all deserve prizes. That all psychotherapies can be helpful. More of the outcome, of the variance in outcomes is returned by the therapist through a client relationship, than it is by specific techniques. That it’s kind of silly to have a competition amongst therapy techniques because all are necessary.I think to be a therapist, you should be well-versed in every single type of therapy, because patients vary between, and also even within themselves and what they need in a given moment. And it’s not as if one, as if cognitive techniques are inherently better than techniques that focus on psychology or the social situation. Different techniques are going to be different at different moments. And the technique in general is useful only in the context of a relationship that’s nurturing and healing. And the most important thing in the healing of psychotherapy is probably the nature of the relationship, and the need for a personal match between the two people. I think that it’s been an unfortunate – there’s been an unfortunate tendency to develop competitions. Competitions between medications versus psychosocial approaches. Competitions among the various psychotherapy techniques.A really well-rounded clinician has to be good at everything, and especially has to be good at relating to the people that they’re trying to treat.
LR: I have to tell you Allen, it’s refreshing to hear a medical man, a psychiatrist in particular, especially one who is that connected to the history of the DSM know about the Dodo effect, and to really appreciate that. So, you have the average therapist working in the average practice in a community mental health center, maybe even in a homeless shelter, recognizing that the technique is not nearly as important as the relationship. And then they come across a client, who seems psychotic in the moment, or seems to have a history from limited information of bipolar disorder or schizophrenia, and their knee-jerk reaction may be “I have to get this person to a psychiatrist. I have to find out what’s medically wrong with them.” What does that average line worker do, knowing in their heart that their relationship is critical, but that they have this biomedical pressure to refer to a psychiatrist, or even a primary care physician?
AF: Well, I think everything is important. You mentioned primary care physicians. People with schizophrenia die 20 years earlier than the rest of the population. And that gulf has increased in recent years and is much higher in the U.S. than it is in other country, because we neglect the people so much. There isn’t one answer.
Taking it to the Streets
There’s not one size fits all. And there isn’t one answer to people who have tremendous problems at every level. I mean, the first thing with a homeless person might be sharing some orange juice. It’s forming a relationship. It’s finding out a way where they can have housing. It’s not as if the answer to our blanket neglect is going to be getting an appointment once a month with the psychiatrist and getting a pill. That may be a necessary part of the plan, but certainly won’t be sufficient.
Los Angeles is now embarking on what may be the most encouraging experiment in taking care of the severely mentally ill that I’ve seen in this country in the least 40 years. It will be an approach that will be actually a combination of getting out to where the people are who need help, figuring out what they want, and helping them get it. You know, maybe the first step is providing showers, and a welcoming environment, and a place to have lunch. And the housing is going to be probably more important than treatment.
If you can’t get someone a decent place to live, the rest of the treatment is going to be very hard to carry out.
We have to figure out a way of getting the patients out of prisons and getting the people on the street into decent places to live. We had all of this until the Reagan Administration in 1980. The community mental health centers and housing were an increasing and exciting part of the care. We led the world in the ‘60s and ‘70s, in trying to devise community treatments. And now we are at the very bottom of the pack, one of the most heartless places in the world. One of the worst places in the world if you’re mentally ill. It’s not going to be a solution that takes into account just one need. It’s going to have to be a kind of total approach that includes the police, the sheriffs, the prisons, the district attorneys, the judges and the politicians. And that’s exactly what’s happening now in Los Angeles, and that may serve hopefully as a model for the rest of the country.
LR: As a psychotherapist, I listen to the inflections and the changing tone in your voice. And there’s such enthusiasm and energy when you talk about all that can be. And there’s a discernible lilt in your voice, almost a down-turning in your overall demeanor when you talk about the way things are.
AF: I think one of the things that’s crucially important to understand is that the symptoms we see in the very ill aren’t necessarily inherent to their condition, but rather maybe a reaction to the social context in which they’re living. The example 60 years ago was we kept people warehoused in terrible snake pit state hospitals. And the observation was that the hospitals were making them sicker, because of the social neglect within in. What’s happening now in the United States is that by neglecting people and leaving them without treatment and without housing on the street, we see much sicker patients here than in other countries that provide better care.So, the paradigm of good care here is Trieste. And I’ve heard over many years, how wonderful the Trieste system was in treating the severely ill, without hospitals, without restraint, and with minimal medication, but not the high doses and multiple medicines that are given in the United States. And I never believed it until I visited. And now I’ve been there three times over the last five years, and it’s an absolute miracle. Trieste takes good care of the people with severe mental illness and treats them like citizens. It has social clubs for them and a career path. The Trieste Mental Health System runs two hotels, five cafes, a car service, and a landscaping business, so that people who start out as patients, wind up working in the system. They have housing. They take good care, and they treat people with respect. And their patients are a lot less sick than ours.They just don’t get to the levels of psychopathology that we see in this country because there’s such neglect along the way. And the message in this is, treating the casualties, the train wrecks, is a lot more expensive and heart breaking than doing the right thing at the right time, earlier in the course before the illness progresses. I think there is a tremendous shame as a civilization that what we’ve done is fail to provide.
Ever since the Reagan Administration, we’ve failed to provide community housing and community treatment, rehab, and recovery. And instead we hospitalize hundreds of thousands of individuals in prison. We’ve imprisoned hundreds of thousands of individuals, who should be in community programs, and maybe very occasional inpatient stays. We see them on the street every day and I just pass them by. My hope is that Los Angeles will be a beacon that things can be different.
LR: Is the Trieste system similar to L’Arche?
AF: It actually started in the ‘60s, with the closing of the large mental hospitals in Italy. And the system is based on the idea that everyone can be helped, everyone’s a citizen, everyone deserves respect, and that the community funds adequate social programs and treatment programs, and housing programs, and job programs. And they make the assumption that each person can be a useful citizen in the community. And when people get sick, instead of throwing them in a hospital and keeping them there for a long time or throwing them into prison which is what we do, or instead of keeping them on the street, there is tremendous concern for them and individual attention for them in figuring out a way back to health. And it just works. It’s miraculous. And people don’t ever get as sick as the people we see on the streets and in our prisons and our emergency rooms, because they’re treated with respect and care.
Reaganomics and Mental Health Care
LR: What do you think happened back in the Reagan era that directed us away from compassion, and away from potential? What happened?
AF: I mean, it’s very clear, this history couldn’t be more explicit and disheartening. The Kennedy Family, because they had mistreated one of their family members, had a huge personal interest in this themselves. In the ‘60s, there was the first use of medications to help people who were previously hospitalized to live in the community. And there was a bill, the Community Mental Health Center Bill that established all across America, the notion that we could help the individuals better in the community than by warehousing them in state hospitals. The money was meant to come from the state hospitals, so it seemed like and was a tremendously cost-effective transformation that we would close the state hospitals, and instead spend the money on community services and housing. And with the provision the medication people could be managed, creating for them to live much better lives outside of hospitals than within, and it would be cheaper.All of this was working. I worked in places in the ‘60s and early ‘70s that were quite remarkable in helping people find new lives outside the hospital. What Reagan did in the ‘80s was to send block grants, and this should sound familiar because it’s exactly what Trump wants to be doing now. Instead of providing federal support for these programs, Reagan said we’ll take this money and send it back to the states and them let them spend it the way they want to spend it. And what the states did almost uniformly was either use the money to reduce taxes, or use the money for other priorities or general funds. And the community mental health centers were gradually defunded and privatized. And private systems will never take care of the severely ill, because they’re expensive to take care of. So, the community mental health centers that survived, did so by restricting themselves to healthier patients, who had more money and fewer needs.And some went out of business altogether, some switched into behavioral health centers, treating people who were much healthier and neglecting those who were really ill. So, what we did in the ‘80s was destroy what in the ‘60s and ‘70s was the most innovative and one of the most effective [community mental health] systems in the world. The rest of the world continued to care for the mentally ill in a much more humane way, and it gets much, much better results. And the paradox in the states was that with the closing of the community mental health centers, many of the individuals untreated on the street committed petty crimes and sometimes not so petty crimes that resulted in their being in prison. And we’ve had this tremendous increase in the number of prison beds so that the LA County Jail is the biggest psychiatric facility in America. And in many states, the biggest psychiatric facility is now a prison. That the money that should have been spent on community treatment that had been spent on snake pit hospitals is now spent on prisons, and there’s kind of prison industrial complex that keeps that going.
LR: So, it’s a reactionary swing back to the early part of the 20th Century, when criminals and the mentally ill were merged. And a misappropriation of funds.The Republican agenda to decentralize the federal government, combined with various historical, sociological and financial factors, and these poor people were and are just caught in the crosshairs.
AF: Yeah, until the early 1800s, psychiatric patients were criminalized, along with prisoners and the poor in horrible facilities. The father of psychiatry is Pinel. And in the early 1800s, he freed the patients from the chains, treated them like decent human beings and citizens, and got remarkable results. And that led to the state hospital movement which was originally a positive movement…
LR: A community.
AF: Yeah, gave people a place to live and work. And they usually had farms, they had workshops. And it was only if these became overcrowded in the early parts of the 20th Century, that they turned into snake pits and asylums. That led to the deinstitutionalization movement that began in the late ‘50s and early ‘60s. And it led to a community mental health center movement that was really quite encouraging and effective in the ‘60s, ‘70s, and early ‘80s. And that was pretty much destroyed from the mid ‘80s on. And at this point, we have very few effective community mental health center initiatives in our country, and we have lots of prisons treating the mentally ill, and the mentally ill on street corners in all the major cities.
LR: A reactionary swing back to the past.
AF: Privatization doesn’t work. I mean, if we’ve learned anything about healthcare, mental healthcare, and healthcare in general, it is that a for-profit system will result in way too much treatment for people who don’t need it, and way too little treatment for the people who do.
LR: So, we need psychotherapists out there as social workers more or less. Maybe more training at the graduate level, at least in psychology and counseling in the direction of community mental health and social advocacy.
AF: In all of the mental health fields, there’s been way too much attention to treating the easy patient and the well-paying patient, and way too little of taking care of the people, who really need our help. And I think that the most wonderful experiences of my life have been the saves of people who seem to be beyond saving. And anyone can treat someone who doesn’t really need treatment.
LR: Right.
AF: We should be trying to focus our attention on those who really need us.
The Twilight of American Sanity
LR: We’re sort of winding down and I wanted to ask about this irrepressible current in you…about the impetus for writing Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump, and what you think is going on in government and in our society? I see Trump as a symptom rather than the disease, but would you mind talking about what you think is going on, from a psychiatric, psychological point of view?
AF: I started writing the book well before Trump began running for office. I’m concerned for my children and grandchildren, and the future generations more generally, about the fact that our society was delusional in ignoring global warming, overpopulation and resource depletion. And a bunch of other problems that are so obvious and common sense just sliding right by, as if we can hand on to the next generation a world that’s degraded and dangerous. And so that was before Trump. Trump is a mirror to our soul and the reflection ain’t pretty.And he is a symptom, not the cause, but he’s certainly making the disease much worse. I think there has never been a threat to American democracy like this one since 1860. And this election, this midterm election is to me the third most consequential election in the history of our country, the other two being 1860 with Lincoln’s election, and 1932 with Roosevelt. I think that Trump is a direct danger to our democracy. His attack on the free press, on the court systems, on the institutional checks and balances is not a joke. And that at this point, the sides are fixed. I don’t think either side is going to give into the others. And I think the crucial thing will be the vote, getting out the vote. And anyone who cares about this country, and cares about – I think that Trump could be responsible for more deaths in the next century than Hitler or Stalin and Mao combined. I think global warming is an existential threat to our species. And that we don’t know where the tipping point is, but we’re likely approaching it without taking out an insurance policy.People in their individual lives have insurance policies even though they don’t expect to die tomorrow, or have a fire, or an accident, you just protect the future. And we’re tripping over the cliff of global warming without taking an insurance policy for our kids and grandkids, that the world will be livable for them. I feel a sense of despair if our country is not able to right itself. And it was a wonderful thing that we were able to elect a black president ten years ago. It will be a much worse horrible terrifying future if at this point we re-elect the people who have been willing to give Trump such a wide leeway in destroying our country and our world.
LR: Well said. I think that we have a responsibility as therapists, as mental health clinicians to be aware of what’s going on because many of our clients are the day-to-day recipients of some of the changes in policy that are being created. I think psychologist, psychotherapists, psychiatrists, need to be politically aware without becoming politically depressed.
AF: I think it’s important not to be psychologically name-calling Trump. Thinking of Trump as crazy, tremendously underestimates his evil and cunning. We have to fight Trump with political tools, not with psychological tools. I think as therapists, we need to help most of our patients – I think you can’t politicize treatment.And so, a good therapist should be able to treat someone who is a Trumpists and should not try to get into political discussions with their clients and patients. I think as citizens, it’s an important thing for every therapist who cares about the social safety net of our country. The biggest factors with mental illness don’t come from within psychology and psychiatry. The biggest factors of mental illness come from social forces.Inequality or poverty are tremendous drivers of mental illness. I think it’s a responsibility for therapists to be political, not in calling Trump names but rather in getting out the vote. There’s the Kansas thing and getting their friends to register, getting their family members to register. Because I think everything has to do at this point with the numbers of people who show up in November. And I think there may be some therapists who support Trump, it’s hard to imagine, but by and large, most therapists and most people they know will be on the side of trying to protect democracy and protect our environment. And so, I think the most important thing a therapist can do at this point is to help get out the vote.
LR: Do you think mental health treatment and funding for mental health at the community level is in danger, with this and similar administrations?
AF: Oh, yeah, Trump recently, yesterday, there was a news report that what the Republicans are going to try to do to cut Obamacare is to cut out the [mental health] parity elements in plans.
LR: All that work! All that work!
AF: And the Medicaid funding of the original Trumpcare bills was to do block grants, rather than to be supporting mental health, which is exactly what Reagan did.Our patients are being targeted by the irresponsible GOP Congress and by Trump.
LR: We don’t want to end this conversation on a depressing note.
AF: Well, the good news is that things are flexible, and that ten years ago we elected a black president, two years ago we elected a black-hearted president. And the country is fickle, and things are very much in the balance. And it is conceivable to me that we’re heading down the drain to a fascist autocracy. And billions of people dying in global warming in the next century. It’s also conceivable to me that there are fixers, and that this is a temporary worst moment and things have to look better. And really, I think it’s in the hands of who votes in November.
The Relationship is All
LR: I guess this is sort of a summary question – if you were to look back and advise a younger Allen Frances, what advice would you have given him early on his career that might have changed his direction, or are you pretty content the way it’s played out?
AF: It played out mostly by accident, and then it’s just doing your job. I don’t think that there’s – I think, there’s actually one advice to people; it’s listening to the clients/patients you’re working with and learn from them.
LR: They’re our best teachers if we let them.
AF: And be yourself. You can learn everything, but also be yourself.
LR: It’s refreshing, again coming from a psychiatrist, just on a personal note, my brother is a psychiatrist, retiring at the end of this month after 40 years. He’s cleaning up his slate of 350 patients. And I wonder what it will be like for him as he looks back on his career. How many did he help, and which ones stand out. Do you have any one particular client story that inspires you?
AF: I think this is the most telling thing, and this might be helpful to people. That I’ve treated people for 14 years and had no impact on their lives. I’ve worked in emergency rooms my whole career. And I’ve seen people for five minutes and they’d come back years later and said, you said that and it changed my life. You never know when what you say may have a tremendous impact on someone. And so, every contact with every person you see, at every moment, you should be thinking about what can I say that may make a difference. And if you treat people as humans, then every moment can be potentially impactful, not every pill, not every symptom, not every diagnosis. I guess the core message in our conversation has been that you really have to focus on the person.I mean, the two words that have had the most impact on people that I remember over the years is “do it,” because people would come in concerned, should I do this, or should I do that? I just say “do it.” And somehow at that moment it crystallized their energy and their motivation to do something that they wanted to do. We shouldn’t be shy in trying to figure out what it is that might help someone do something they couldn’t do.The relationship is all.
Imagine You Are a Smart Phone
Think of yourself as a smartphone—i-Phone, Android, doesn’t matter which. Push that thought to
its limit and see where it takes you. It might alter the way you experience the feeling of being
alive. And it might open up new paths in therapy.
Properly speaking, a smartphone is not strictly a phone. Rather, it is a device containing numerous
apps, a tool with multi-variant potentiality. Tap on the Facebook icon and the device becomes a
social-media tool; tap on the Gmail icon and it serves as an email-exchange tool; tap on Google
and it’s a search engine; tap on the phone icon and only then does it become what its name
suggests—a phone.
Consider now the human organism—you as a biological being, you in your pre-conscious state,
you before you think your thoughts about who you are, you before you occupy a role. You are in
that pre-somebody state, a bundle of potentiality, a device with uploaded apps. Tap on your
“therapist icon” and you inhabit the role of therapist. You become a certain kind of person, one
who engages with others and the world in a certain confined way. You operate in therapist-mode.
You take on an identity in the same way that a smartphone takes on an identity when an icon is
activated. Tap on your “spouse icon,” your “parent icon,” your “let’s-go-drinking icon” and you
inhabit the role of . . . . well, you get the point. You, the human organism, like the device we call
“a smartphone,” has no unitary identity.
To put it in grandiose terms, the Self is an illusion. There exist only ephemeral, highly contingent
selves within the human organism. Your identity is a function of whatever “app” has been
activated. Indeed, even your reductionist thoughts about yourself—I am this or that—is itself a
function of a certain app icon that has been activated. The implications of this are far-reaching
and profound.
A person highly prone to anger, you might say, is a human organism with a very large “anger-app
icon” on the home page, easily and frequently activated. One who is rarely aroused to anger has a
“small anger-app icon”—all human beings come equipped with an “anger app”—that is situated
far from the home page. You could say that your identifiable personality features—your
somebody-ness—are the readily accessible app icons on your home page.
Here’s the upshot for you to consider, so far as therapy is concerned. In many ways, therapy is an
enterprise of reconfiguring the app icons on a home page. Certain large icons on a home page
may not be the kind of apps a person wants to be easily activated (anger app, jealousy app,
addiction app, etc.). Therapy facilitates the shrinkage of those icons and the removal of them from
the home page. Therapy can also facilitate the placement of sought-after icons onto the home
page. This form of therapy engages with a client as a person without a unifying essence.
Therapy becomes an exploration of apps occupying space on a person’s homepage and a discovery of
long-neglected, even forgotten, apps lying dormant several swipes away from that home page.
Therapy under this paradigm diminishes the impulse to diagnose. To tag a person with a
diagnosis—say, as bipolar or borderline—is to risk engaging with that person as having a
unifying, definable identity. It is akin to treating a smartphone as strictly a phone, or a social-
media tool or an email-retrieval tool or so on.
Are there therapy paradigms that suit this I-am-a-smartphone mindset? In my next two blog posts,
I will investigate two paradigms as possible instantiations of this mindset: Internal Family
Systems and Buddhist-inspired therapies (e.g., mindfulness-based therapies).