Category: Therapeutic Issue

Russian Doll as Case Study: Lessons for Therapists

Posted on by Psychotherapy.net Team

Russian Doll is the mind-boggling Netflix series created by Natasha Lyonne, who stars in and also directs several of the episodes. Intensely psychological, the show explores the life and mind of its main character, Nadia, as she repeatedly emerges from death to relive her life.

Lyonne was famously addicted to heroin in her twenties, as a result of which she developed a heart infection requiring open-heart surgery. She recovered (she is now 39) to achieve acclaim as an actress, most notably in her role as the heroin-addicted inmate Nicky in the Netflix series Orange is the New Black.

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Since Russian Doll is inescapably about loss, self-destruction and addiction, reviewers tend to focus on standard treatment bromides in their reviews, including the determinative role of trauma and the need for treatment. But in fact, the show is brilliant because it smashes all these therapy icons, replacing them with the truths of lived experience, human connection and purpose.

Here are those truths:

Trauma is not definitive. The series uncovers Nadia’s trauma, seen through a little girl’s eyes, in the form of her mother’s madness that causes Nadia to be taken from her. Nadia’s problem wasn’t an event, but the absence of a fundamental relationship in a child’s life, which family friend and therapist, Ruth (played by Elizabeth Ashley) jumped in to fill as her foster mother.

But the series is about overcoming trauma. Rachel Syme describes this existential recovery process in The New Republic:

“With every death scene, Lyonne peels back another layer to show us a new trick. After months of dying, Nadia finally wants to live. She wants more joy, more pain, more music, more dancing.”¹

Nadia’s recovery is also not, as some drug policy reviews of the series suggest, due to her inadvertently taking the therapeutic hallucinogen ketamine. That this drug caused her epiphany is refuted when her friend points out that they had taken ketamine together before. Besides, no one else at the party who consumed the drug went down her existential rabbit hole.

Lesson: Trauma is not a permanently life-altering event, but one experience people encounter on their life journeys.

Recovery occurs through lived experience. Nadia consumes many drugs, drinks heavily, and is addicted to cigarettes. But she undergoes no therapy, doesn’t enter rehab, and attends no 12-step groups. Nor does she embark on traditional recovery, announce that she’s an addict, or take a vow of abstinence.

Instead, after repeatedly dying, each time due to self-inflicted or seemingly random traumas, she seeks a path to affirm life. Having once been addicted is an experience that can add value to life, as Nadia illustrates through the twists in her tale as she ripens her personal pain into a valuable, worthwhile existence.

Lyonne herself followed this process, as suggested by Joy Press in a Vanity Fair piece, titled, “Natasha Lyonne Can’t Stop Living.”

“Lyonne has a way of making everyday life feel like a tremendous, defiant adventure. A larger-than-life personality, she wields wit like it’s an Olympic sport, and exudes a sense of hard-earned wisdom. I wouldn’t describe her as someone “at peace” so much as a person O.K. with where she stands.”²

There is therapy in Doll, as practiced by Ruth, Nadia’s surrogate mother. Ruth practices Eye Movement Desensitization and Reprocessing (EMDR) therapy as a way for her clients to unlearn trauma. But Ruth never administers this therapy to foster daughter Nadia. And she downplays its consequence to an EMDR client; when she releases the man into the street, she instructs him to convert what he has learned into actual life changes.

Lesson: Change occurs on the street, in life, not in the therapist’s office.

Recovery is built on human connection. Nadia constantly returns, after dying, to the bathroom of an apartment filled with “friends” with whom she is celebrating her 36th birthday. But she doesn’t seem to care about any of them, other than a polysexual female couple who are her best friends. Nadia lives alone–except for her missing cat, who has seemingly abandoned her. Yet she interacts with many people in meaningful ways, including a resident of Tompkins Square Park who cuts her hair and she provides with shoes, and a helpful, concerned, all-night deli-grocery store owner.

It is in this deli that Nadia finds her alter ego, a co-sufferer in her life-and-death-and-life syndrome, Alan (Charlie Burnett). Alan is also undergoing a life crisis stemming from loss, a loss that resulted from his own rigidity and personal limitations. Their shared experience is, understandably, a strong bond between the two existential argonauts. Thus, Nadia and Alan help one another. They cure themselves when they reverse their ingrained tendency to ignore other people’s pain and misery (including each other’s when they first unknowingly met). Their two-person support group involves each performing acts of unsolicited kindness for strangers.

When they emerge at the end, their cure is not centered around happiness.

“You promise if I don’t jump, I’ll be happy?” Alan asks.

“No, man,” Nadia says. “Absolutely not. But I can promise you won’t be alone.”

Lyonne herself acknowledges her indebtedness to many people, starting with series co-creators Leslye Headland and Amy Poehler. She shares her deepest intimacy with Chloë Sevigny, who plays her deranged mother:

“Chloë is my closest person in life, and there was really only one person that it felt like it was safe to entrust that role to. Probably the most incredible moment for me was walking home with my little director’s binder in the East Village and watching the sun begin to rise. And I’m like, this is a very different kind of sunrise than what I’ve experienced historically at this hour. This was the good guy’s version of that, and it was deep stuff. Chloë and I had walked those streets so many times, and now it was this world that we had built.”³

Lesson: Recovery occurs when people create rewarding worlds marked by control, connection, and purpose.

And this is exactly the journey therapists should undertake with their clients.

References

(1) Rachel Syme (Jan. 30, 2019). Russian Doll is a Spiky Comedy About Self Destruction. The New Republic.

(2) Joy Press (Jan. 31, 2019). Natasha Lyonne Can’t Stop Living. Vanity Fair.

(3)Kathryn Shattuck (Jan. 25, 2019). Natasha Lyonne Has a New Life: It’s Just That She Keeps Dying. New York Times.

Introducing Multi-Lens Therapy

Posted on by Psychotherapy.net Team

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

Posted on by Psychotherapy.net Team

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.
 

Let’s Meet in the Middle

Posted on by Psychotherapy.net Team

We all want our feelings to be understood. But even if we have a significant other with whom we feel understood, we may find that we become misaligned as career and family life evolve and change. Nowhere is this more true than with professional couples and dual-career families as they take on new role-based challenges.

Recent research¹ indicates that the dynamics affecting the quality of a couple’s relationship stem from differences in motivation (approach/avoidance orientations) and patterns of interpersonal behavior. I look at both factors in the case of Meg and Paul, two highly educated professionals, each with histories of neglect in childhood. What I also consider is a style of engagement that seems well-matched to the experience and expectations of professional couples.

Couples Issues

By the time strain and conflict have become chronic, partners have often done a good deal of blaming and fault-finding with one another. It doesn’t help, but it’s almost unavoidable, as people lose their capacity to see things as they really are. Only later, after bumping up against the reality that they are stuck and that it's probably not entirely their or their partner’s fault, might they conclude that outside help, objectivity and perspective are needed.

I believe we can learn a great deal from working through our issues—their causes, course, and resolution—as couples. Doing so not only makes us happier in our couples, it makes us smarter managers, leaders and collaborators in the workplace. But of course, these truths can seem rather remote when we are in the throes of relational conflict and cannot yet see a pathway forward.

Even with awareness of our need for help, we retain the need to protect ourselves against being found lacking. We may privately hope that a therapist will take our side and that we’ll be vindicated. Couples are often ambivalent, wanting perspective but simultaneously maintaining defenses. Disarming them is about eliminating threats to emotional safety and ensuring that each person has the chance to be heard. To satisfy these conditions, we must be an empathic and assertive mediating presence.

Being heard, in this context, is more than an auditory task, and it involves more than an exchange between therapist and patient. When therapists listen actively, they provide a hearing for all three persons in the room. As the therapist and couple together reflect upon this active listening process, the couple notices how different it is than what normally happens in their exchanges at home. Thus, safety and learning depend upon how the therapist facilitates, moderates and contains the listening process.

Individual or Couples Therapy

There are times when individual therapy prior to or in addition to conjoint therapy may be indicated. When either or both members of the couple suffer from an acute mood disorder or chronic mental health problems, their capacity to participate in couples therapy may be limited. And sometimes they just can’t believe that something different and good can come from discussing their issues with their partner, not yet. But I’ve found that they’re likely to underestimate their readiness to participate in couples therapy.

In my practice, I work mostly with professional couples, the same demographic I’ve served for over 25 years in my executive coaching practice. When it comes to helping relationships, they seem to welcome an active, norm-setting agent who is willing to reign in behaviors that threaten conditions of safety and openness, or that derail productive engagement. Their basic ego strength is usually adequate. They tend to default to a practical sense of urgency to “fix” things. While their impatience and an action bias can impede progress, initially I find it helpful to leverage these attitudes to generate motivation.

They may be more skeptical and scared than they’re willing to admit, but they know they need help. They haven’t found a way to do it themselves. So, the therapist must find ways to intervene early, to validate their decision to seek therapy, and to change the way they communicate and interact. When we can model a tolerance for conflict and an ability to notice and discuss how their polarized attitudes and behaviors operate reciprocally to sustain conflict, we earn credibility. And that’s critical. Professional couples more than others will be looking for evidence that we’re competent.

Meg and Paul

When I met Paul, he was presenting with anxiety stemming from work and marriage. He was on an SSRI for anxiety and on Ritalin for ADHD. He reported a childhood replete with dysfunction and less than good-enough parenting. Raised in a small town in Alabama, he adapted by retreating to a rich imagination and creative talents, later attending a top art school in the Northeast and then settling in Brooklyn. I didn’t have to tell him his family of origin was dysfunctional. He knew it and ran as fast as he could to escape it.

Soon, it became clear that adapting at work (from artist to manager) was not nearly as challenging as making things work at home with Meg. Like Paul, Meg had a history of insecure attachment, growing up in a pastor’s home in rural Connecticut. After a failed marriage that produced two boys, she met and married Paul, who hadn’t had much success in dating or sexual intimacy. She, too, was bright and won a scholarship to an Ivy League college, but she had responded differently to childhood issues.

Meg was a fighter with an excitable temperament and a penchant for order and control. Both had suffered neglect, but Paul had taken a route of pathological accommodation and escape, while Meg had gone the way of rebellion and escape. Neither had healed the wounds of neglect. As their lives became more complicated by a third child, increased financial demands, chronic patterns of conflict and naïve hopes gave way to long-standing vulnerabilities, and each sought individual therapy.

The Circumplex Emerges

When Meg and Paul came in for their intake interview, the tension was almost immediately manifest. Sitting at either end of my six-foot sofa, they made no attempt to conceal the distance that had grown between them. I asked them to tell me what caused them to seek therapy at this time and suggested that Paul, the meeker of the two, talk first. He spoke carefully, haltingly at times, always rounding if not blunting the point of the issues he raised. I conjured an image of one navigating a minefield.

Meg sat stern-faced with arms crossed as he spoke, casting dismissive glances his way as he struggled to express himself. There was eye-rolling too, which caused me to wonder how far he got in speaking his mind at home. It was all she could do to limit her dissent to nonverbal communications as Paul spoke. Then, when it was her turn, Meg’s voice rose in angry criticism. Her first aim was to correct Paul. As she flushed with anger, Paul went pale with fear.

Her fault-finding with Paul was peppered with global accusations prefaced by “you never” and “you always.” She painted a picture of his inconsiderateness, broken promises and selfishness. Neglected as a child, she suffered it again in her marriage to Paul. Her voice rose well above the norms for my office–yes, I have such norms. So, I intervened. With a hand gesture signaling a timeout, I said, “Meg, do you have any idea how overwhelming your energy is right now?” She halted and I continued, “You’ll have to turn it down a bit if we are to communicate.”

She was taken aback and flushed from red to rose as a sudden pause prevailed. Paul sat quietly, still pale, anxiously awaiting the next steps. I can imagine the reader might wonder about the force of my presence and the effects of my behavior. Most of my clients (consulting practice) and patients (clinical practice) describe me as down-to-earth, caring, sincere and constructive. Even in my most direct moments I believe they recognize a positive intent in my face, words, and actions.

I expressed a grounded confidence. I assured them that they need not accept nor reject anything I said too quickly. I encouraged them to simply consider how it might be relevant for them. My tone with Meg and Paul was neither harsh nor timid. It was not aggressive; it was assertive. It was not out of control; it was tempered and composed. My first intervention was to invoke norms of propriety in the consulting room. This atmosphere of civility became the defining quality of dyadic communication in the therapy.

After the “flareup” was extinguished, discussion resumed. I asked how representative this episode was of the problems they’d been experiencing. They admitted that it was all too common. The difference was that at home Paul would usually not get the initial words out. Rather, Meg would define the violation Paul had committed (being late or forgetting an errand), and he would go quiet, retreat for a while, and then later try to explain himself and perhaps become defensive.

Meg would later remark on how being with Paul was like having another child. Paul didn’t agree with this characterization, but fighting it only meant extending the quarrel. So, he usually quit at this point, believing it was not worth the pain and wouldn’t change the outcome anyway. The more she played the role of his parent, the more he was cast in the role of a child.

We used the interpersonal circumplex² to consider this chronic pattern. I have found this model quite useful with couples. It plots interpersonal behavior in two-dimensional space using two axes, Dominant/Submissive and Friendly/Hostile. Using the model, we’re able to see how our expressed behavior is likely to “pull” a style of behavior from others. On the one hand, a dominant expression tends to pull a submissive response, and a submissive expressive style pulls a dominant response. On the other hand, friendly and hostile expressions seem to invite others to respond in suit. So, how did this apply to Meg and Paul?

They had been interacting in the hostile side of the circumplex, Paul from the submissive area (passive style) and Meg from the dominant area (aggressive style). We also observed that my intervention came from the friendly dominant area (assertive style). Finally, we noticed that the pause arose from the “neutral” space in the middle of the circumplex as a pause for reflection on communication style. Thus, the title of this article and my suggestion to couples that when they notice tension building, and before it becomes entrenched conflict, they tell themselves that it may be time to “meet in the middle.”

Communication Styles Chart

 Figure 2 Communication Styles (Penberthy, 2016)
 


About Motivation

Of the many ways to characterize motivation, a fundamental way of conceptualizing it is through the approach/avoidance paradigm. It’s been around since Neo-Freudian thinkers like Karen Horney, Erik Erikson and Harry Stack Sullivan, and builds upon the interpersonal point of view. It gained even more support from the observational studies of mother-infant attachment. Its central thesis is that we are essentially social beings with needs for connection and intimacy. As adults, these needs manifest in our intimate relationships with others, and also in our interdependency in the workplace.

“What we learn early in life from caregiver relationships shapes our beliefs and expectations about what is possible and probable”. When our caregivers are attentive and available, and as we and they learn how to jointly navigate nonverbally and pre-cognitively in ways that satisfy our needs, we develop a sense of trust: “I can rely on others to care, to read my behaviors, and when they fail, they don’t abandon me. No, they persist until my needs or insecurities are resolved.”

Such successes in adaptive learning and development promote an approach orientation. This includes beliefs that most problems can be solved with help, and that those with whom we share our lives at home and at work are usually willing and able to be helpful. We act from a benevolent hypothesis about others’ motivations and with optimistic beliefs about what we can do with their help. But absent this positive early-life experience, we may approach relationships with less trust and positivity, with more suspicion or doubt, and often with fears of abandonment.

Patterns of Avoidance

In the case of Meg and Paul, we observed histories of maltreatment that would understandably lead to lower expectations of what might be possible in relationships. They might look for (project) evidence of the betrayal and mistrust they experienced early in life in the contemporary behaviors of those they hoped would be there for them.

For Meg, it was an ostensibly kind and service-oriented father (pastor) who seemed to have little time and interest for her needs. He turned his attentions elsewhere, perhaps in ways that won him esteem in the eyes of those he helped. And her hopes of finding enduring love with her first husband failed. Like her father, he was “selfish.” And now, as life’s demands on Paul increased, she saw him too as neglecting her out self-interest. It was reinforced daily when he arrived home late or forgot to stop at the market.

Meg had been on alert for signs of neglect since she was a little girl, all to guard against more rejection, and she found them in her adult relationships with men. We could describe this motivational orientation as avoidance. She might ask Paul to do things, but her expectations of his delivering on these requests were very low. She was fully armed to express her anger and mistrust of him every time he fell short. In her eyes, he was breaking a promise, and she wasn’t taking it anymore. She increasingly threatened divorce in her moments of peak anger and frustration.

Paul’s mode of avoidance was more obvious. It was based on his fear of conflict learned as a child. Meg’s stern look and voice tone signaled a threat to which he reacted with an impulse to retreat. Neither he nor Meg could readily identify in the moment the fears and vulnerabilities they were replaying from childhood. They were both caught up in self-protective (defensive) routines intended to distance them from harm. That is, until in session we would enter the neutral zone represented on the circumplex model.

Noticing and suspending the visceral grip of legacy, avoidance-based emotions and motivations, adaptive approach-oriented motivations, goals, and behaviors became available. This pause simply hastened access to the approach-based responses that had been activated in Paul after Meg finally collapsed in emotional exhaustion and despair from her angry outbursts. Meg’s approach behavior was activated as she finally welcomed Paul’s concern, support, and sympathy when her aggressive energies had quieted. They both took roundabout routes to dialogue.

These, then, were the dispositional tendencies of motivation that energized their chronic patterns of conflict. The avoidance-based mindset had governed behavior with increasing frequency. I noticed that the approach-based resolution strategies were not working as often or as well. They were both feeling exhausted and discouraged. Both, especially Meg, were losing hope that things could change. Their differences in personality and behavior seemed unchanging, perhaps unchangeable.

It took concrete behavioral analysis of specific situations to shift their focus to variables that they could realistically influence or control. We had to do a great deal of situation analysis in our therapy sessions to acquire a basis of trust and positive expectations for change. We had to recognize the way they were both setting unrealistic and unattainable goals, and how they were neglecting adequate attention to the positive thoughts and behaviors that could interrupt their old routines.

Finally, we had to notice how different the results of our in-session problem solving were from their out-of-session efforts, and to ask ourselves why they were different. They recognized that there was little they were not able to do behaviorally if they approached it deliberately and thoughtfully. They had to own the responsibility for doing this work, and they had to recognize the payoff in doing the work, individually and as a couple.

Getting to the Point

The advantage of couples therapy for Meg and Paul was that it made them more responsible and accountable sooner. Their contributions to the problems were noticed and called out in real time. Faster-acting avenues of change became available. My observations were grounded in specific situations. It’s an approach that safeguarded them both and returned our focus to salient themes of reciprocal interaction that underlies their conflicts. Concrete "do’s and don’ts” emerged as takeaways.

They internalized a capacity for assertive problem solving that extended beyond the consulting room and their relationship, and into the workplace. Meg reported less ruminating, guilt and resentment. Paul described a growing sense of confidence and ease in his interactions with Meg. They regressed on occasion and learned how to grow from the experience. They deepened their insight and skills in the process of repairing one or two significant ruptures along the way.

“Disposition does not mean “chipped in stone.”” Their differences in temperament (Paul more laid back and Meg more intense) remained. However, both discovered a greater sense of freedom from the automatic expression of their avoidant motivations. They learned that their reactive tendencies from early life were important to notice (somatically, emotionally, cognitively, relationally). These tendencies were not to be dismissed, denied, or taken as fact; rather, they became valued as warning signs.

I accommodated their sense of practical urgency by anchoring change efforts in concrete behaviors and specific situations. In this way, they were able to more readily see the behaviors that help and hinder realization of their change goals. They learned to appraise and re-appraise their expectations for change against standards of what was realistic and achievable. In the process, they noticed how slowing down for a reflective pause could speed things up. They found reason for hope in these skilled practices.

Concluding Reflections

Each couple is unique, and the helping strategies of their therapists will vary in approach, length of treatment, and frequency and duration of sessions. Having said that, I usually tell couples that it will take us 4-6 weeks to determine if couples therapy is working for them. By then, we’ll have a good idea of what the core issues are and what is required to address them. And we’ll do that by actively engaging the couple in the process, which means they’ll be more able to make informed decisions.

Through early steps of progress in session and practical guidance for change between sessions, they acquire skills and build trust and confidence in the therapist and in each other. Guidance may be more directive in the early phase of therapy, but it becomes more non-directive as positive norms of attitude and behavior take effect. As an easier, less defensive quality of exchange becomes possible, the role of the therapist becomes more that of consultant and coach.

Couples’ gains are sometimes achieved in waves over longer periods of time (6 months or more). For others, significant change, for example restructuring relational dynamics and communications, might occur in 6-8 weeks. And when does it stop? That too varies, but insofar as our work is goal-focused, we are better able to jointly assess how they are doing, what they’ve learned, and when termination or transition to a maintenance schedule might be advisable.

My approach to helping others as a coach and therapist has always been assessment-based and goal-oriented. Goals in this sense represent purposive aims that give meaning to our actions and accomplishments. These are considerations that weigh heavily in the hearts and minds of most professionals. When these “stakes” are called out in terms of the people they want to be and what’s required to realize these aims, I’ve usually gotten their attention. And after a good deal of experimentation with new skills at home and at work, their attention is firmly planted in interpersonal space, knowing more than ever that success at home and at work is about relationships.

I have found that goals and commitments are most robust when they’re grounded in the personal truth we can only obtain from rigorous assessment. That’s why our assessment must be a joint process. Couples must play an active role in interpreting the data that I help them collect, including the patterns of behavior that I help them surface in our sessions. Couples must personally discover the power of meeting in the middle, in that neutral zone of reflection. It is there that defenses melt away and the consequential costs and benefits of change can be seen. In that way, we soon acquire a call to action—“Let’s meet in the middle”—which can give us reason to halt the cycle of escalating conflict and see things as they really are.

References

1. See for example Kuster, M., Bernecker, K., Bradbury, T. N., Nussbeck, F.W., Martin, M., Sutter-Stikel, D., & Bodenmann, G. (2015). Avoidance orientation and the escalation of negative communications in intimate relationships. Journal of Personality and Social Psychology, 109, 262-275

2. Thanks to Kim Penberthy for permission to use her version of the circumplex model: Penberthy, J. Kim (2016). Effective Treatment for Persistent Depression in Patients with Trauma Histories: Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Paper presented at the meeting of Anxiety and Depression Association of America (ADAA) Conference, Philadelphia, PA.

For further information on the circumplex model, it’s history and use, see Horowitz, L., Wilson, K.R., Turan, B., Zolotsev, P., Constantino, M., & Nenderson, L. (2006). How interpersonal motives clarify the meaning of interpersonal behavior: A revised circumplex model. Personality and Social Psychology Review, 10, 67-86. 

The Masculinity Trap: A Science-Based Response to the APA Guidelines

Posted on by Psychotherapy.net Team

Andrew was a 13-year-old boy who walked into my counseling office with a lot of issues. He had been diagnosed with a learning disorder and ADD, and his parents felt he might be depressed. Like many male clients, he would quickly decide if I as his potential counselor knew how to work with him as a male. If I did not, he would start trying to leave therapy in a few weeks or less.

After normal intake, the first thing we did together was walk outside, talking shoulder-to-shoulder. Because the male brain is often cerebellum-dependent (it often needs physical movement) in order to connect words to feelings and memories, we sat down only after our walk was finished. By then, a great deal had happened emotionally for Andrew.

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Once in our chairs, we talked with a ball in hand, tossing it back and forth, like fathers often do with children. This cerebellum and spatial involvement help the male brain move neuro-transmission between the limbic system and frontal lobe, where word centers are. We also used visual images, including video games, to trigger emotion centers, and we discussed manhood and masculinity a great deal, since Andrew, like every boy, yearns for mentoring in the human ontology of how to be a man.

I’ve seen hundreds of girls and women in my therapy practice. Few of them needed walking, physical movement and visual-spatial stimulation to help access memories, emotions, and feelings because most girls are better able to access words-for-feelings than boys and men are while sitting still. Girls and women have language centers on both sides of the brain connected to memory, emotion, and sensorial data, while the male brain mainly has word centers and word-feeling connectivity on the left side.

Without our realizing it over the last fifty years, we’ve set up counseling and psychological services for girls and women. “Come into my office,” we say kindly. “Sit down. Tell me how you feel/felt.” Boys and men fail out of counseling and therapy because we have not taught our psychologists and therapists about the male and female brain. Only 15% of new counselors are male. Clients in therapy skew almost 80% female–males are dragged in by moms or spouses, but generally find an environment unequipped for the nature of males.

Male nature, the male brain, and the need to contextualize boyhood into an important masculine journey to manhood are missing from the American Psychological Association’s new “Guidelines for Psychological Practice with Boys and Men.” While the document calls attention to male developmental needs and crises in our culture, which I celebrate as a researcher and practitioner in the field, it then falls into an ideological swamp.

Males, we are told, are born with dominion created by their inherent privilege; females (and males) are victims of this male privilege. The authors go further to discuss what they see as the main problem facing males—too much masculinity. They call it the root of all or most male issues including suicide, early death, depression, substance abuse, family breakups, school failure, and violence. They claim that fewer males than females seek out therapy or stay in therapy and health services because of “masculinity.” Never is the skewed female-friendly mental health environment discussed. The assumption that all systems skew in favor of males, not females, is so deeply entrenched in our culture today, the APA never has to prove it.

Perhaps most worrisome, the APA should be a science-based organization, but its guidelines lack hard science. Daniel Amen, Ruben and Raquel Gur, Tracey Shors, Louanne Brizendine, Sandra Witelson, Richard Haier, Laurie Allen, and the hundreds of scientists worldwide who use brain scan technology to understand male/female brain difference do not appear in the new Guidelines. Practitioners like myself and Leonard Sax, MD, PhD, who have conducted multiple studies in the practical application of neuroscience to male nurturance in schools, homes, and communities are not included.

Included are mainly socio-psychologists who push the idea that boys and men are socialized into “masculinities” that destroy male development. Stephanie Pappas on the APA website sums up the APA’s enemy; “Traditional masculinity—marked by stoicism, competitiveness, dominance, and aggression—is, on the whole, harmful.” Our job as therapists, the authors teach, should be to remove all but the ideologically sound “masculinities” from boys and men, and specifically remove masculinities that involve competition, aggression, strength, and power.

How much longer can our society and its professionals pretend we are developing a saner society by condemning the very parts of males that help them succeed, heal, and grow? In the same way that it is misogynistic to claim femininity is inherently flawed, it is misandrist to claim that masculinity is also thus.

And it is just plain wrong. Stoicism, aggression, self-reliance, and strength are helpful to human growth, healing, and self-development. Steven Pinker recently made this point when he asked the APA to revise its Guidelines, and put to rest “the folk theory that masculine stoicism is harmful.” And, a new study published in January 2019 in Psychology of Men and Masculinities, echoes Pinker, showing that boys and men who adhere to masculine training do better in life, are happier, and become better husbands, fathers, and partners.

I am an example: I was a sexual abuse victim in my boyhood, and a very sensitive boy. My ten years of healing from the abuse came as much from tapping into masculine strength as it did from expanding my sense of self in the 1970s toward the feminine. Both are good; neither is zero-sum, but I could not have healed without the very masculinity Pappas finds suspect.

Part of the problem with the APA guidelines is that, from a neuroscience point of view, masculinity is not as limited as Pappas’ assessment would have us believe. Masculinity is a social construct made of biological material, an amalgam of nature, nurture, and culture that forms an ontology in which a male of any race, creed, or ethnicity commits to developing and exercising strength, perseverance, work, love, honor, compassion, responsibility, character, service, and self-sacrifice.

What professional in the psychology field would not want to embolden these characteristics? Most fathers and mothers would want counselors to embolden them because, as the APA authors themselves point out (somewhat unaware, I think, of their self-contradiction), fathering and mentoring boys in masculine development has been proven among the most important determinants of child safety, school success, and emotional and physical health.

Not the erasure of masculinity but the accomplishment of it is required if we are to save our sons from the crises outlined in the APA guidelines. Without counselors and parents understanding how to raise and protect brain-based masculine development, boys like Andrew drift in and out of video games, depression, substances, half-love, and, often, violence.

As all of us in our profession know, the most dangerous males in the world are not those who feel powerful but, rather, those who feel powerless. “Toxic masculinity” is a convenient academic avenue for condemning males who search for strength, healing, and love by conflating things bad men do with an ontology that is necessary for human survival and thriving.

The masculine journey is not perfect and expanding what “masculine,” “male power,” and “man” mean to a given family and person is a point well made by the APA authors, but trying to hook mental health professionals into this ideological trinity of false ideas—

*masculinity is the problem, always on the verge of toxicity
*males do not need nurturing in male-specific ways because men have it all in society anyway; and
*masculinity is not an ontology, a way of healthy being, but a form of oppression,

—ignores one of the primary reasons for the existence of our psychology profession: not just to help girls, women, and everyone on the gender spectrum be empowered and find themselves, but also to help boys and men find their strength, their purpose, and their success in what will be, for them, a complex male and masculine journey through an increasingly difficult lifespan.

Sources:

Amen, D.G., et.al., “Women Have More Active Brains Than Men." August 7, 2017 Journal of Alzheimer’s Disease

Halpern, D.F., et.al., “The Science of Sex Differences in Science and Mathematics.” Psychological Science in the Public Interest. August 8, 2007

Burman, D., et.al., "Sex Differences in Neural Processing of Language Among Children." March 2007. Neuropsychologia

Benedict Carey, “Need Therapy: A Good Man Is Hard to Find.” New York Times. May 21,2011

APA Guidelines for Psychological Practice with Boys and Men

Stephanie Pappas, “APA issues first-ever guidelines for practice with men and boys.” APA Monitor. January 2019

Steven Pinker. Male Psychology: What is Wrong with APA’s Masculinity Guidelines.

Psychology of Men and Masculinities

Coalition to Create a White House Council on Boys and Men’s meta-study

Embracing Chronic Anger: A Prescription for Disempowerment

Posted on by Psychotherapy.net Team

“I’ve had a problem with anger all of my life… at work, in my relationships and everywhere in between. I was court referred because I assaulted a guy at a bar when I was drunk. That’s how I got this (pointing to the cast on his left wrist). I also took a class five years ago because I had slapped my wife. But she dropped the charges. In the past ten years, I’ve been married twice. I know my anger contributed to my divorces and I really don’t want to lose my current girlfriend.”

Anger Chose Him

Keith, a participant in one of my anger management classes, introduced himself in a deep, resonant voice. As an anger management specialist, I have offered these classes for over thirty years, with participants who have been self-referred as well as referred by their workplace, partners, friends and the courts. They have included individuals from various socio-economic levels, including professionals, blue-collar workers and students ranging in age from eighteen to seventy-five years old. Surprisingly, Keith became increasingly candid throughout the first session.

“You know, there are times I feel like maybe I was just born being angry. My father had a lot of anger too. So did his father. Maybe it’s just in my genes.” Keith described a life of chronic anger–anger that was frequent and pervasive, evidenced in his workplace, personal relationships and daily life. It entailed anger arousal not just as a situational reaction to a specific triggering event, but reflective of a general predisposition to hostility. Chronic anger encompasses “trait” versus “state” anger, which is more situational and short-lived. And like others who report issues with chronic anger, “Keith described his anger as if it chose him”, as if he was the victim of his anger and did not have free agency to choose it.

Keith, like others with chronic anger, views the world through a filter constricted by his anger. This filter inhibits self-reflection and access to more rational thought. And, like others with chronic anger, his narrowed vision, along with the rigidity of his reactions, saps his capacity to genuinely satisfy his desires and needs.

It appeared that disappointment in his life, coupled with an increased curiosity about his anger, enhanced his motivation for further exploration. The most recent arrest and being almost 40 years old also provided an impetus for his seeking help. As I later learned, he was also dealing with his father’s death two years before. Keith seemed increasingly committed to his desire to change, reflected in his active participation in the class as well as his request for individual therapy upon completing the course.

Keith, like others who exhibit chronic anger, appeared to embrace it as a core aspect of his identity. Chronic anger became a major aspect of his inner sense of sameness and continuity over time.

A Word on Identity

Consciously cultivating our identity requires that we answer the following questions:
“Who am I?” “What is my purpose?” “What kind of individual do I wish to be?” “What gives me meaning?”

Many of us fail to ask these questions of ourselves. Absent such reflection, we may subsequently become subject to a “script”, one that is defined for us by others. This script becomes the blueprint for the structure of our lives. It provides the guidelines for how we live, informing habits in how to think, feel and behave. And each time we practice these habits, we reinforce the connections in our neuronal pathways in ways that only increase our propensity for them. For this reason, it may require some life-altering event to prompt us to more fully examine what we are doing.

The self-reflection required to address these questions pits us against our fears, our sense of self-worth, and our difficulties in making decisions and choices and committing ourselves to them. Such reflection also moves us to address barriers we create regarding the opinions of others—those voiced by others as well as those we hear from the imaginary audience in our minds. It is then understandable that we may seek distraction from engaging in this daunting task–through our work, the immediate demands of our daily lives, our relationships and even our addictions. Embracing chronic anger as a major component of our identity may yet be another form of bypassing this intensely difficult challenge.

Chronic Anger

Anger, a natural emotion, stems from a perceived threat to our physical or mental well-being. Additionally, it’s a reaction to and distraction from uncomfortable negative feelings that precede it–feelings such as shame, guilt, rejection, powerlessness, inadequacy or devaluation. I’ve come to view anger, like other symptoms we may encounter, as originating from an initial impulse of self-compassion–an attempt to alleviate our suffering. Such anger hijacks our attention away from our our internal landscape and in effect offers us a temporary reprieve from enduring the intense suffering caused by these more uncomfortable feelings.

When managed in a healthy manner, we’re able to pause to take the time that is essential for understanding our anger–whether regarding our feelings behind it, our expectations or our key desires and needs. Anger can empower us to seek constructive ways to satisfy our desires and needs. It can fuel healthy assertiveness that moves us to act in ways consistent with who we are and who we wish to become.

By contrast, destructive anger moves us further away from satisfying our core desires and needs. It can lead to poor work performance, a stalled career, relational conflict, social isolation, depression, excessive guilt or shame and even the loss of one’s freedom. Additionally, extensive research shows that anger can contribute to illnesses like heart disease, high blood pressure and even back pain.

Chronic anger is one form of destructive anger. For some of us, such anger serves as psychological armor, intended to protect us from the sting of our inner pain. Such anger can be viewed as a form of “experiential avoidance,” as described by Stephen Hayes, and involves the suppression, minimization and denial of our feelings.

It is against the lack of a solid identity that individuals with chronic anger may be characterized as embodying a “negative identity,” described by Erik Erikson as an identity in opposition to what is expected of them. Lacking self-awareness and the self-reflection essential for such awareness, their default is to react. They may gravitate toward this resolution when they believe the roles their parents and society expect them to fulfill are unattainable. The psychological underpinning of this stance is reflected in the attitude “I don’t know whom I wish to be, but I certainly don’t want to be like you.”

Unfortunately for Keith and others, embracing chronic anger was a formula for disempowerment that only strengthened the tendency for anger arousal. And for Keith, like others with chronic anger, it appeared to be an outgrowth of aspects very much consistent with a negative identity.

Chronic anger has many forms. It’s reflected by the quickness to experience anger in daily life, in one’s relationships and especially with authority. Chronic anger appears in the numerous comments on the Internet, statements of opinion that are predominantly expressions of anger rather than rational argument. Such anger impairs the capacity to be civil, open, understanding or compassionate with others and ourselves. “It is a cataract that clouds our vision to the possibilities of looking for and noticing the positive in others and in ourselves”.

Chronic anger promotes disempowerment, which only furthers the propensity for anger. It undermines taking responsibility for our own lives. In doing so, it constricts the range of possibilities and minimizes the freedom for personal evolution and life fulfillment. It’s so much easier to blame others or circumstances for a difficult or painful situation and by doing so, renounce all our power to help alter our situation. In the process, however, we only further bolster our sense of victimhood. Even when others have truly contributed to our pain, embracing chronic anger may serve to protect us from the hard work of identifying and choosing alternative courses of action.

It then makes sense that individuals with chronic anger may resort to drug or alcohol use, or blame or hate others for their own misery. Certainly, such anger might foster or be a symptom of depression, especially when it is self-directed.

Furthermore, this vicious cycle of chronic anger and disempowerment fuels pessimism that inherently diminishes the capacity to envision a future without anger–a future that holds greater happiness, meaning and fulfillment. And, further, it undermines the capacity to develop an identity marked by greater individuation and resilience.

Like so many symptoms we observe in our clinical work, chronic anger is most often rooted in wounds–deeply felt hurt and trauma that have not been fully acknowledged. It is often a reaction to emotional or physical abuse, neglect, or loss. And while some studies suggest a genetic influence, as with much of personality, nurture helps determine whether these genetic predispositions are expressed. And while such anger may also originate with experiences in adulthood, being prone to chronic anger further strengthens it as a go-to reaction.

All too often, childhood trauma forms the underpinning of chronic anger. It may lead to a global sense of shame and accompanying feelings of inadequacy about oneself. This sense of shame is often the overriding and paralyzing feeling that creates a block to trusting one’s own thoughts, feelings or actions. These feelings then further weaken the capacity to engage in thoughts and behavior that would be essential for a more authentic choice in creating and living one’s identity.

The Case of Keith

Keith shared a history of physical abuse, occasionally being slapped or paddled by his father for his “bad” behavior. Like others with issues surrounding anger, he tended to minimize and deny the impact of these earlier experiences. And in doing so, he cut himself off from the range of feelings that surround such abuse. Unfortunately, a child in pain needs compassion and empathy from a caring parent but is unable to obtain it when a parent is the cause of that pain.

Keith learned to ignore his suffering by blaming himself for how he was treated. He experienced shame regarding his behavior but, more importantly, and without awareness, he experienced tremendous shame regarding the slightest surfacing of anger toward his father. As such, Keith, like others with early wounds, could describe the circumstances of early wounds as a matter of fact, but was unable to regard them as wounds–let alone be more fully in touch with the underlying emotions associated with them. “It didn’t hurt that much.” “I think I deserved it.” “That was how most parents disciplined their kids.” “I certainly wouldn’t call it abuse.”

Like others who have experienced such abuse and like many with chronic anger, these are just a few of the ways that Keith protected himself from experiencing his hurt and anger. This fear of experiencing anger with his father simply continued into his adulthood. Consequently, Keith had little awareness of how his earlier interactions and related wounds influenced his anger. “My father was a marine. He was always intensely demanding and perfectionistic. He constantly interrogated me, questioning me to justify myself, why I thought this or why I did that. He had little patience for pain or for a difference of opinion.”

Keith also revealed that if anything, he was angry with himself for not measuring up. This conclusion further informed his sense of shame and inadequacy. It’s important to note that, for Keith and others like him, chronic anger served as a powerful distraction from anger that was originally self-directed. While his father was perfectionistic and highly critical, his mother was distant and not available to help protect him or validate his pain. “She was quite anxious, quiet in general, and maybe depressed, I’m not sure. I know she was fearful of my dad. She always avoided conflicts and disappeared when they arose.”

Keith’s reported that his mother was closer with his younger sister who was rarely the target of his father’s anger. His ambivalent feelings toward his mother would only later become more apparent. His parents were divorced when he was in middle school and his father remarried within a year. Only then did Keith experience some relief, as his father became preoccupied with his new wife and stepchildren.

Keith reported that during this time, he experienced a growing distance from his parents and a sense of disorientation regarding his future. He described himself as kind of “floating” throughout high school. His tendency to be angry with teachers competed with any academic interest and, subsequently, his motivation to do well in school. Lacking a more solid connection with himself, he was unable to emotionally invest either academically or in his relationships.

“Like others with chronic anger, Keith was especially sensitive to criticism in many situations”, especially those involving authority. Clearly, his early interactions left him with an increased sensitivity for perceiving threat. As he candidly admitted, his tendency toward conflicts with authority undermined his ability to succeed in school and work and his capacity to maintain friendships. “I really wasn’t motivated in school and only did the minimum to get by. I spent most of my time playing video games, hanging out with friends, and I smoked marijuana often, beginning in my freshman year.”

Keith went to college for two years, primarily because he had no idea what he wanted to do, and his father had promised to pay the tuition for the first two years. His motivation and focus hadn’t changed during this time. While he occasionally dated, his quickness to have conflicts interfered with his developing any ongoing relationships. Unlike Keith, there are certainly individuals with chronic anger who are motivated to achieve, both academically and in their pursuit of a career. For some, the full impact of their anger may not surface until they are more involved in relationships, whether personal or work related.

Keith quit school after two years and his father suggested that he join him in a property management business, but Keith knew he could never work with him. Instead, he became a realtor, primarily motivated by his belief that he could make easy money with minimal effort. Within a year, he realized that he had little patience for dealing with the clients. After that he held a variety of jobs. He gravitated toward working with computers and by the time he enlisted in my anger management class, he had been working for several years in IT.

Keith also indicated a growing anger in recent years regarding the government. He complained a great deal, even commented on the Internet, but never demonstrated his anger in more aggressive ways. He didn’t consider himself an activist but he found himself also spending a good amount of time online, following the angry chatter of various groups.

Facing the Demon

Keith represents a small fraction of men with chronic anger who ultimately seek help for their anger. I view the courageous decision to seek therapy, although prompted by pain, as stemming from self-compassion–a desire to alleviate one’s pain. And while Keith had learned to renounce his need for such compassion, he sought help when he more fully recognized how anger contributed to his suffering.

Keith had grown to view the need for compassion as reflecting weakness and as threatening to his masculinity. He had learned to believe that being a “real” man involved cultivating an identity devoid of needing such compassion. However, ignoring his need for compassion further undermined his capacity to be more fully present with his feelings, in general, as well as with his underlying desires.

When we are truly compassionate and connected with ourselves, we know how we feel, recognize our key desires, and feel anchored in an identity that provides stability with flexibility to be open to both our thoughts and feelings. By contrast, the lack of such compassion and self-reflection can make us vulnerable to self-doubt. Keith’s lack of access to his feelings reduced his capacity to notice or be compassionate to the pain reported by his partners. This is very much consistent with individuals with chronic anger and was reflected in Keith’s description of a recent anger episode with his girlfriend.

“She’s always criticizing me. She’s always telling me that I don’t care for her–like I can’t do anything right. The other day she described a conflict she had with her supervisor. After listening, I told her that maybe her supervisor was right. I mean–based on what she told me–I could see his point of view.” It became evident that Keith was more concerned with facts than with feelings. His focus on facts competed with his capacity to be empathic with his girlfriend. Understandably, validating the supervisor’s criticism was experienced by his girlfriend as a demonstration of his empathy–with the supervisor. The argument escalated with Keith cursing and demeaning her. It ended by his leaving the house for a few hours, an evening of silence upon his return and then, the next day, gradually resuming their relationship as usual.

Consistent with his experiences in past relationships, if he couldn’t “fix” his partners’ problems, he would soon experience an overwhelming feeling of inadequacy. In effect, in his personal interactions, Keith re-experienced the feelings of inadequacy as well as his self-doubts triggered in his earlier interactions with his father. Additionally, he carried into his relationship the anger he had also experienced toward his mother for her lack of availability.

“The tendency to be vulnerable and to feel controlled is part of the fallout of not living a life grounded in self-connection”. A more mature identity allows us to hear opinions that stand in opposition to our own, living a life based on an identity of anger leads to hypervigilance to protect ourselves from self-doubt and feeling influenced by others. Others’ opinions may be experienced as threatening and viewed as overbearing and controlling. It is then no surprise that individuals with chronic anger feel isolated. And it is equally understandable how such anger promotes distrust that only strengthens the avoidance of genuine intimacy.

Keith had embraced this perspective for much of his life. The more he reacted to others in this manner, the more he cultivated his sense of victimhood and, in turn, had become more prone to anger arousal. His flight from responsibility was similarly reflected in our work together, most poignantly in his initial hesitation to actually practice the skills essential for cultivating healthy anger.

Part of my approach is to have clients complete an anger log, a structured journal that helps them review an anger-provoking episode and their thoughts and feelings related to such events. The log specifically asks them to identify feelings that immediately precede their anger, the knee-jerk conclusions they make about the event, expectations they may have held before the event occurred, body sensations and key desires that feel threatened by the event.

I advocate completing the log to review as many events as possible. Doing so promotes emotional intelligence not only regarding the reviewed event, but also fosters increased mindfulness to reactions for future events. Furthermore, completing the form helps to foster emotional awareness of one’s unique “hot buttons”–personal sensitivities regarding specific desires and the past experiences that intensify their current reactions. And, as always, “I emphasize that overly intense anger most often is a residual reaction to events of early wounds”. This is poignantly highlighted when I help them recognize that “It’s happening again!” is just one of their immediate responses to a triggering event. “At that distinct moment, it is as if your emotional brain is recalling all past hurts that are in any way similar to what you are currently experiencing. This is the power of global thinking and feeling.”

I emphasized with Keith that our global emotional mind has nothing to do with our age, intelligence or even our more rational thought. It is a part of us that, without our awareness, may override our rational mind as it impacts our thinking and behavior. Completing the log serves to offer psychological distance to the experience and fosters the cultivation of the “observing self” or “witness.” This strengthens one’s ability to not feel overwhelmed by such thoughts and feelings.

Keith repeatedly did not accept this recommendation. I suggested that it would be beneficial to understand what interfered with his completing the logs. I asked if he experienced my suggested assignments as controlling. His knee-jerk response was to deny this but after a pause he then admitted, “Maybe a little.” I then responded, “That makes perfect sense–to your emotional mind. You grew up with tremendous anxiety about expressing yourself. Understandably, you experienced safety by trying to avoid conflict with your father. Your inhibitions in expressing yourself contributed to feeling controlled.”

During the following session, I asked Keith if he was open to doing an exercise. He agreed. I then handed him a blank anger log. “Make yourself physically comfortable. Look at the anger log. Imagine that you are seated where you might be completing the form. Hold the pencil to the paper without writing anything. Now, think of an event that you would review if you were to complete the log. Do that for a few moments. Now, shift your attention from the event to what you are experiencing regarding writing it. What physical sensations are you experiencing? Are you feeling calm or tense? What are your thoughts about this task?”

Keith paused for a moment to reflect. With little hesitation, he answered, “Yeah. I guess I’m angry that I have to practice these skills while others don’t have to…others had it easier. They most likely didn’t go through what I went through.” I fully acknowledged and validated this belief that, yes, others may have had it easier in so many ways. And, yes, they may not have to do these exercises to better manage their anger. And, yes, engaging in this work arouses uncomfortable feeling regarding previous wounds and hurts. I then emphasized that he could choose to stay resentful and hold on to his anger or he could take steps to change, with the potential of having a more fulfilling life. Additionally, I highlighted to him that how we manage anger involves habits in our thoughts, feelings and behaviors–habits which he can change, but only with patience, commitment and practice.

Keith’s recognition of irritation with this task presented another opportunity to discuss mourning and grieving for what he didn’t have and felt he should have had. Much of anger is about this discrepancy. As part of such mourning, I encourage clients to find a picture of themselves at an earlier age. Over time, when they are ready, I help them recall the earlier suffering of that younger self. I help them work toward being able to fully express themselves as that younger version and say things like, “It made perfect sense that you suffered, were confused and even angry with your parents,” “How you were treated was not your fault” and “I’m sorry I could not help you.”

Such mourning and grieving is an ongoing process that in many ways never ends. Rather the rawness of such experiences just becomes more emotionally muted. Through our work together, “Keith increasingly began to develop a deeper connection with himself, his feelings and his thoughts”. He became more alert to his tendency toward anger and increasingly recognized it as a signal to direct his attention to self-reflection rather than act it out. He reported one incident, having to do with a homeless person that very much reflects this growth.

“You know that homeless guy who is always on the corner. I’ve always been annoyed when I walk by him. In the past, I’d usually tell myself that he was just lazy and that he should get a job. I started to think about that. I think that I was just feeling inadequate about not being able to fix him or others like him. I also reacted to feeling he was needy, a feeling I’ve always felt uncomfortable acknowledging in myself. There’s a lot in there!”

Keith continued with therapy and gained a variety of strategies to better understand and manage his anger. He expanded his compassionate self sufficiently to recognize and admit some of the hurt he had experienced that contributed to his shame and related anger.

As often happens when treating chronic anger, improving his ability to more constructively manage his anger reduced his motivation to more poignantly mourn and grieve his childhood. However, processing the loss of his father led him to attend to his earlier years. He became increasingly able to tolerate mixed and ambivalent feelings, essential for dealing with his complex relationship with his father.

Keith demonstrated progress in that he reacted with anger less frequently and it was shorter in duration when it did occur. At one point, Keith reported that he was pleased with his improvement and that he needed to take a break. Additionally, he was also able to recognize that spending more time on grieving and mourning had been very difficult for him.

Keith returned a year later, prompted in part by an anger-arousing episode that had surprised him. While he had continued to make progress, the event had pushed hard on one of his hot buttons. It was a reminder that learning new habits requires commitment, practice and patience.

Anger in Our Culture

It’s difficult to discuss chronic anger within the therapy session and ignore the larger expressions of chronic anger that we are witnessing in society. As previously indicated, we see evidence of such anger in statements made on the Internet, supported by anonymity and increased cultural support to “tell it like it is.” We see it on newscasts revealed by the “talking heads,” each predominantly focused on getting their points across rather than having a real discussion. Clearly, the media reflects our culture, but, unfortunately, it may only further influence those who already are defined by their chronic anger–just as violent videos have been shown to have an impact primarily with adolescents who are already prone to anger.

Additionally, we see increased evidence of anger as identity as the foundational core of the hatred of the “other”, those who may be different than us–whether regarding race, religion, ethnicity, gender or sexual orientation. A moment of intense anger brings with it a tendency to demonize the other. However, when chronic, it can lead to more fully dehumanizing them as well.

Furthermore, chronic anger may foster the belief that one’s happiness can’t be achieved because of one’s very existence. It is this rigidity of identity that gives far too much power to others and distracts those with such anger from the work required to explore and identify choices that can help them to feel and become more empowered. And far more serious for all of us, are individuals who associate with others with the same tendencies or, even on their own, promote activities to teach others a “lesson.” These facts only highlight the challenge we face as clinicians dealing with chronic anger.

Holding on to anger is often rooted in the need to protect ourselves from being hurt again as well as re-experiencing our past suffering. This is especially the case when this mindset becomes the foundation for one’s identity. So, while anger management strategies that focus primarily on behaviors and current knee-jerk thoughts can be effective, moving past chronic anger as one’s identity requires going deeper. It calls for helping individuals recognize and sit with the pain of grieving and mourning their past wounds. It requires that they become a witness to the suffering of their younger selves if they are to be able to live more fully and with greater emotional access in the present.

Dealing with chronic anger, as when dealing with so much of our client’s suffering, involves our sensitivity to dosage–sensitivity to the protective nature of symptoms, the degree to which they have become a part of a client’s identity and, of course, to their openness to change. For this reason, many individuals with chronic anger will never seek our services. Consequently, clinicians who address chronic anger may need to play a more active role as advocates for education and understanding of chronic anger in the courts, correctional facilities, substance abuse programs and schools.

One of my personal challenges as a therapist working with individuals with chronic anger is to “always be alert to look beyond the anger to the pain that it masks”. So, at any given moment within a session, I need to be mindful to be empathic with my client even when I find myself also focused on the pain they may cause for others. Such moments require my own comfort with anger and remembering the powerfully cohesive force that chronic anger may have in helping them to maintain their identity.     

Digital Technology and Parenting:

Posted on by Psychotherapy.net Team

As a trauma therapist I am always interested in learning about my clients’ childhood attachment patterns. Growing up with parents who were either emotionally unavailable, inconsistently responsive, frightened by or frightening to their child has a profoundly negative impact on social, behavioral, emotional, and neurological development. “Trauma-informed care” includes assessing for adverse childhood experiences and reframing clients’ subsequent “symptoms” and struggles as the inevitable by-products and coping strategies of attachment trauma. However, I am concerned that a newer version of attachment trauma has invaded even the most “loving” families. Our reliance on, and, in some cases addiction to, digital gadgets and technology has hijacked the face-to-face parent-child interactions that are necessary for consistent, sustained and secure attachment.

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Is this scenario familiar? After standing in line at the post office for fifteen minutes—a somewhat inherently traumatic experience in and of itself—I witnessed a two-year-old having a complete meltdown. Her mother’s immediate response was to hand her an iPad. In her wisdom, the child initially rejected it. In a soothing yet frustrated tone, the mother said “Use your iPad! Do you want to look at pictures? Play a game?” The child was not appeased and continued to wail. As the woman bent towards the stroller, I felt a sense of relief, assuming she was about to pick up her dysregulated child. Instead, she turned on the tablet and said with greater agitation, “look at the pictures on your screen!” After several more minutes of crying, the child realized that what she wanted and needed—to be comforted by her mother, not an inanimate object—was not going to happen. I watched as she went into collapse, emotionally shutting down and compliantly staring at the screen.

Believing her baby was now soothed allowed the embarrassed mother to comfort herself with a cellphone, tapping and swiping until it was her turn to buy stamps. In essence, they were two strangers in line together. I have seen similar scenarios countless times: in airports, malls, restaurants, and my waiting room. Preoccupied parents entranced as they stare at their iPhone, seemingly oblivious to their child’s needs. They are content to use digital gadgets as pacifiers and babysitters. They are not only modeling the excessive use of cellphones, tablets, video games, and laptops, they are actually encouraging their children to be just as hypnotized, and potentially, addicted.

At the risk of sounding old fashioned and judgmental, I believe this phenomenon is worrisome. Eye gaze, appropriate loving touch, and soothing words are the hallmark features of secure attachment. In families where there is abuse or neglect, these experiences get weaponized. Eye contact becomes a vehicle for threat or intimidation, or the neglecting parent avoids eye gaze, leaving the child feeling demeaned or invisible. Touch is either physically abusive, sexually inappropriate, or unavailable to the child. Words are bullying, shaming, hypercritical or lacking in love or support. This is why caretaker perpetration is such a betrayal and profound breach of trust.

But those three critical resources for attunement are also lost when a child is offered a screen rather than the loving and grounding experience of an available parent, which makes them feel safe, calm and connected to others. It may seem unfair to associate abuse or neglect with the disconnect that happens when a child is comforted, distracted, or cajoled by a digital appliance. But what is the long-term toll it takes on healthy attachment, affect regulation, and socialization skills? Mental health researchers and therapists alike need to assess for and explore that impact, as digital technology is not going away. Questions to consider:

  • Are kids with excessive exposure to digital gadgets less comfortable with face to face interactions and more likely to struggle socially?
  • Is it harder for them to read and accurately interpret nuanced facial expressions and body language?
  • Do these kids have a healthy ability to regulate their fluctuating or overwhelming emotional states?
  • Are these kids less likely to use relationships for soothing and comfort, and more likely to numb with endeavors that are hypnotic or dissociative?
  • Despite growing up in families that are well-meaning and financially secure, are these kids actually experiencing avoidant or insecure attachment?
  • And if they are, will they struggle with the same emotional fall-out and symptomatology as abused or neglected kids?

Since technology has made our lives much easier and resources more accessible, stakeholders may be reticent about tackling this issue head-on. I believe it is our ethical responsibility to address these dynamics with the families we treat. We must empower parents to set much stricter limits on screen time and to reconnect with the relational, face-to-face-benefits of parent-child time and family time. Many kids and teenagers need to be weaned from their overuse of digital gadgets—a kind of digital detoxification—so that they can reconnect with peers and re-access their own imaginations.

For traumatized clients, the reparative experience of secure attachment often happens within the therapeutic relationship. Therapists may need to be more mindful of addressing this issue with kids who have been overexposed to digital gadgets as a resource for comfort and soothing. They should keep technology out of the therapy room and model attunement, eye gaze and appropriate words and touch so that kids and parents alike can rediscover the power of relationship. Otherwise, the next generation risks losing the ability and the desire to be fully present with others and fully engaged in the world. 

Erica Anderson on Working Therapeutically Across the Gender Spectrum

Posted on by rezendevknowfully.com

Transgender 101

Lawrence Rubin: Thank you for taking the time to speak with me this morning. Transgender issues have gained much attention in the last several years, but most therapists do not have experience working with these clients. What are some of the issues a therapist needs to know?
Erica Anderson: Thank you for this opportunity. I think it is a topic much discussed in society these days, and you're right that very few psychotherapists are trained to work with people with gender issues. One of the most important things to point out is that in years gone by, those of us in the mental health field were trained to understand gender development in a very limited, binary way, namely that one was born either male or female; "M" or "F" on their birth certificate, and then they just grew up. Puberty constituted a pretty significant change, and maybe at some point, someone would declare that they were gay, but otherwise there wasn't really much to do about the development of gender.

very few psychotherapists are trained to work with people with gender issues
What we now have come to appreciate is that gender identity exists on a spectrum, and that just as Kinsey pointed out more than half-century ago, many more people have complex sexual attractions or are bisexual than we ever thought. The same is true with gender differences. We used to think that transgender people were very rare, but in fact, people who are not binary in their gender identity or whose gender identity differs from the sex that they were assigned at birth, are in greater numbers in society than we ever really understood.

Society has become more accepting of some of these differences so more patients who are questioning their gender are coming forward to therapists. They are exploring who they are and may actually be willing to talk about some of their own self-doubts or self-realizations. So, therapists need to begin to understand how to work with such people by acquiring new knowledge, developing new skills and examining their own biases or potential biases around gender issues.
LR: Can you say more about the knowledge and skills therapists need to have when working with clients presenting with gender identity issues?
EA: The first point about knowledge is reflected in what I said a moment ago; that many people have presumed that gender really is simply a binary trait of human beings, and that is not the case. If you look at the history of human civilization, there have always been people who have not lined up in their gender identity with the sex they were assigned at birth. There have always been transgender people in society. Some of them have been acknowledged, and in some cultures, there is actually recognition of this. Many native peoples have something called "two spirit," which is a recognition of someone whose gender doesn't line up with their anatomical sex—it is a mixture of gender identities. And then there are some other cultures, in India, Brazil and Asia, where there have been transgender people recognized throughout history. We now know that, depending upon what you include in the category transgender, perhaps as many as one in 200 people in America could be said to be transgender (according to a recent study from UCLA).
LR: When we think of addressing diversity issues in counseling and therapy, we think of gender, race, age and religion. You're suggesting that within some populations, their spiritual-cultural practices may intertwine with gender identity issues?
EA: That's right and it’s a very important point here that gender identity cannot be dissected apart from the other aspects of a person. We talk these days about intersectionality and multiple identities, and that becomes acute when we then consider gender issues. This is because the experience of someone who is transgender of a certain cohort and a certain racial, ethnic or economic background might be very different from someone else whose identity is different in some of those aspects. So, it's not a situation where you can say, oh well, all transgender people are X or Y. In fact,
I say all the time, when you've seen one transgender person, you've seen one transgender person
I say all the time, when you've seen one transgender person, you've seen one transgender person. That is part of the challenge in terms of training and education in clinical practice.

One of the things I hear often is, "Oh, well, you know, coming out as transgender, well, that's like coming out as gay." Well, no, it's not. Gender identity has to do with every aspect of who you are. To equate the transition of someone who is trans from maybe being perceived as one gender into being perceived in a different way, is not exactly the same as someone who may have been closeted as a gay person and then comes out as gay and is living more openly as gay. But that's a common thought for some people who are not very well versed in these issues. It’s disturbing to some trans people to be thought of as, "Oh, well, at one point in time, you're just kind of revealing something about yourself." It's a lot more complex than that!

Beyond Binaries

LR: This suggests that clinicians need to be aware of the developmental trajectory, not just of gender, but the convergence of multiple trajectories across the lifespan that include, but are not limited to, gender.
EA: Absolutely. In fact, as we know from the traditional field of developmental psychology, people develop in lots of different ways, and that development is very uneven for most individuals through childhood and adolescence, and even into young adulthood. So, we know that we can narrow in on various aspects of development. I say all the time that everybody has their own individual developmental pathway, and that where they are at any given point in time is simply that, and it's subject to change.

The other takeaway from the emerging knowledge about transgender issues is that gender identity is something that's very fluid. So, there isn't a single narrative that explains the course of development of all transgender people. In fact, people can come to an awareness of themselves very early, in early childhood, or later in adulthood. And there's a mixture of factors in any individual case that may be contributing to those differences.
LR: It seems therefore that one of the core skills for a clinician to master is to think intersectionally—to broaden their case conceptualization and treatment planning to include these multiple converging trajectories.
EA: Exactly right, which is what makes the work so interesting for those of us who are doing it now. The evaluation process involves parsing, where we look at certain aspects of the situation, traits and historical trends of an individual, and interweave these factors. And because of the highly individual nature of gender identity, we really must listen carefully to each person, no matter what their age is. We must listen to what they say about themselves because gender, as identified by an individual, is a deeply internal and personal thing and we cannot assume that we wholly understand, in a simple way, what is going on with somebody unless we spend some time focused on it.
LR: So, one of the skills that a clinician should have is being able to move past not only binary thinking regarding sexuality and gender, but beyond binary thinking about people in general.
EA: I say all the time,
there's nothing about human beings that's binary
there's nothing about human beings that's binary. If you think about psychology as a field that has attempted to study individual differences, there's really no characteristic that is simply binary–yes or no, this or that, black or white, on or off. We're not machines. We generally think about individual differences and the intensity of various traits when we think about personality. Even in medicine, we think about laboratory studies, growth charts and laboratory ranges for all kinds of characteristics. So, there's nothing binary about human beings. But thinking about that in terms of gender requires a fundamental reordering of how we bring together all the aspects of who a person is, and a recognition that they have been evolving and changing and developing, and they're going to continue to do so.
LR: I joke sometimes with my students by saying that there are two types of people in the world, those people who believe in binaries and those who don’t.
EA: I love that. That's really cute and apt.

Words Matter

LR: Therapists not particularly trained or experienced with transgender or transitioning clients may be unsure how to start, what language or personal pronouns to use, or even how to broach the subject. What advice would you give them?  
EA: This is a big challenge for all of us, even those of us who have more experience, because society has been changing rapidly. People are bringing to these discussions whatever they've known or learned or thought they knew, as well as what information is circulating now in the world, on the Internet and in professional circles. And we don’t all mean the same thing when we use the same words. I’ve seen this evolve in my career.

I was trained on DSM II which listed homosexuality as a sexual disorder. That came out in a revision of DSM II. But today's clinicians who have been trained more in DSM-IV and DSM-5 don't think about the fact that there are huge numbers of people who are still alive who were reared in an era when homosexuality was considered shameful and a psychological disorder. I had a patient years ago who was expelled from medical school because he was arrested in a gay bar for soliciting—and that’s in my lifetime.

So, the words that we use continue to evolve. An example is "gay." You know, "gay" used to be a slur, a pejorative word. It still is in some circles. But now we have the word "queer." People are using the word "queer" all the time but don't know what anybody else means by the word. So, if somebody comes in my office—and this is a tip for therapists—and starts using some of the words that have to do with gender and sexuality, I routinely will ask them, "Well, what do you mean by that word? What do you mean by queer? What do you mean by trans? What do you mean by gender? What do you mean by attraction?"
LR: So, letting the client lead in creating the definitions, and even helping them to make peace with a definition that best fits them at that point in their life…
EA:
Dr. Seuss wrote, "You are the you-est you can be. No one is more you-er than you."
Exactly, and I love to invoke my favorite philosopher, Dr. Seuss, who wrote, "You are the you-est you can be. No one is more you-er than you." You know, we really fundamentally have to accept that people define themselves. And people who have deep-seated psychiatric disorders may be defining themselves in ways that are not helpful and maybe even toxic, but we must start there. We have to start with what's going on with someone. And there is no more significant area to do this in than gender and gender identity.

Gender Politics

LR: What if a client comes to you and doesn't broach the subject of sexuality or sexual identity or gender identity? What's the therapist's role? Is it their place to ask a pointed question? Or is it sort of a Rogerian thing, to just let the client be and go with wherever they are?
EA: As you infer, I see a lot of people who come to me because they are dealing with some of these issues that we're talking about today, but not always. I will sometimes see people who are straight who have anxiety or depression. In my long career as a psychologist I've treated people with many different conditions. I don’t assume anything about what someone wants to focus on. On my website, I have a section called "Permission to Be," where I write about my philosophy. If someone comes to me and says, "I'm coming to you because I think I'm trans, or because I am trans, or because I want to explore my gender expression and identity," then we're off to the races. By contrast some clients come to me and say, "Well, I know I'm trans. I don’t really need to deal with that. But I'm really depressed" So, it depends on the particulars of a client.

In terms of advice to other therapists, I would say, don’t assume that something having to do with sexuality or gender is a problem for someone. If it is obviously a problem and they're asking you to help them with it, help them. But if they are coming to see you for other reasons, their relationship with their gender and sexual identity doesn't necessarily require any intervention.

I want to say something else about this that I think is significant. Transsexuality, as it used to be called, was categorized as a sexual perversion, and was nested in the DSM in the section on fetishes-paraphilias. But now we're at a point where we are questioning whether it is true that everyone who has a different-than-heteronormative or cisgendered identity has a psychological problem at all. In fact, the current DSM lists "gender dysphoria" to describe those who are trans, basically. The International Classification of Diseases 11 (ICD-11) that's coming out from the WHO, will be using the term "gender incongruence," and they are taking this label out of the psychiatric section and putting it into the sexual health category.

For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity
There are several reports, including ones published by SAMHSA in 2015 and documents from the American Psychological Association concluding that differences in sexual orientation and gender identity are normal variations. There is no presumption of psychological disorder.

Interestingly, there is a task force on gender dysphoria constituted by the American Psychiatric Association. They are going to be looking at the disparity between the DSM, which does in effect pathologize trans identity, and the ICD. It is going to be a challenge to reconcile those differences. I predict that the APA will come into agreement or alignment with the rest of the world, which uses the ICD and not the DSM. For the first time, we’re going to see a dramatic shift in de-pathologizing transgender identity. And I, for one, am welcoming that change. 
LR: If a transgender client visits a therapist who's not particularly experienced in transgender issues, and presents with issues seemingly unrelated to gender such as anxiety, depression or even sexuality; is it a mistake for the therapist to assume that these other non-gender-related issues are the cause?
EA: I think assumptions of any kind about etiology are always suspect. I think we must examine our own biases and expectations. A co-occurring disorder is simply that. It may be a contributing factor to distress about gender identity. Gender dysphoria often is reflected in interpersonal conflict and anxiety, sometimes depression. But it isn't necessary to treat them separately. It also is a mistake to assume that they're related in some systematic way.
LR: Some argue that therapists need not have personal experiences similar to a client’s in order to be empathetic. How does that apply here?
EA: On the one hand, I think sometimes we take therapist-client matching a little too far. On listservs here in the Bay Area, requests for referrals to therapists usually list eight or ten characteristics that they're trying to match up. I think to myself, “whatever happened to general training and the recognition of one's competencies or limitations?” However, I also think that this is an area that one shouldn't enter cavalierly. There is a limit on the empathy that a cisgender person can have towards a transgender person. The level of complexity and the extent of personal transformation that happens when someone comes to terms with a trans identity and then embarks on a gender transition is so complete that it's hard to explain simply, and it's certainly hard to imagine.

I hear all the time lay and professional people alike, saying, "I don't understand how this person can be trans. I knew them before. There was no hint of an identity other than sex assigned at birth. I don’t understand." And I say all the time that it's not so important that you understand. What is important is that you accept that this is a deeply felt identity by this person. And if they are disclosing it to other people, they've probably been struggling with it for a long time. In fact, it's well established that, at least until now, transgender people in American society have suffered trauma and continue to suffer trauma, and some more than others. I believe that if you've been transgender for more than 15 minutes, you probably have complex trauma. And that's a joke. Thank you for laughing. Because nobody is transgender for 15 minutes or three weeks or a month. It's a long, long thing.

There's another controversy in that regard that is currently swirling. There's a term being thrown around, which is not a scientific term: rapid onset gender dysphoria. Have you heard that term?

Families in Transition

LR: No. Is that like acute stress disorder affecting gender?
EA: It's a term made up by parents who are concerned that their teenage children are asserting a trans identity from out of the blue. They are worried that there's some kind of social contagion going on with teenagers where it's cool to be trans. More kids are trans than ever before, and they wonder if maybe they catch it from each other. But
I can assure you, transgender identity is not something one catches. It's not infectious
I can assure you, transgender identity is not something one catches. It's not infectious.
LR: Toilet seats and door knobs won't do it?
EA: Nope, won't do it at all. Even sexual contact between two consenting adults will not affect someone with a transgender identity. But this term has been thrown around. And one of the key issues is that teenagers, as they always have, talk with each other about things that they don’t talk with their parents about. And so they're exploring this with each other. And now we have the Internet, so they're going online and finding out all kinds of stuff, and they have friends online, and so forth. They explore for a while, and they get affirmed by their peers, and they draw their own conclusions, and then maybe they tell their parents, "I think I'm trans." The parents are, in some cases, surprised. In many cases, they're not, because there were indications earlier in the life of this child. But for those who are totally surprised, they think this is a recent phenomenon. But in reality, probably it has been percolating with this child for a while, and finally they come forward.

One of the issues for us in evaluating kids, though, is to be cautious about offering medical interventions—you know, puberty blockers or hormones, certainly surgery—until we're pretty satisfied that this really is an enduring identity of this person, and that it's the right thing, it's affirming of them, and it's medical necessary. I work at the Child and Adolescent Gender Clinic at UCSF and we see kids and their families, all ages, young children, preschool children to older teenagers and young adults. And as I was saying earlier in our conversation today, there's no one narrative, there's no one pathway that explains everybody. So, we have to be cautious where there isn't an obvious track record of development of a gender different than the assigned sex. But it doesn't necessarily rule out the legitimacy of it. It may mean that we'll have to have a longer period of observation than with some other kids, where it's quite obvious to everybody that this is a trans kid.
LR: I wonder if there's a correlation in the literature between children with rapid onset transgender disorder and parental unawareness disorder?
EA: Yeah, that's a good one. Certain parents, as you were implying by your very cute comment, find it harder to accept the reality of a child whose identity is very different than what they expect. They may have somewhat rigid views of sex and gender, and they may subscribe to the dominant gender schema of binary, and they may be, as you say, unaware of the fact that gay and trans people have been around throughout human history.
LR: How can therapists help parents enter the conversation once the kid or teen begins talking about it, even though it may have been evolving for years?
EA: Some of the basic principles that have peppered our conversation so far are relevant here, and that is, as a therapist, try to avoid bringing your own bias into the situation or the conversation. Try to maintain an open mind and be focused around listening carefully to the various people. Everyone in the family—no matter what kind of family, if it's a traditional heterosexual couple with kids or whether it's any one of the many versions of "modern family"—is coming at this from a different perspective. The
older people are coming at it having grown up in an era that was less open and less aware of some of these issues
older people are coming at it having grown up in an era that was less open and less aware of some of these issues. Kids may be bringing their own perspective, which could be quite spontaneous and quite free and quite direct. And so we need to listen to each other.

The word that's often bandied around and disregarded is "transition." A trans person goes through a transition of sorts to bring their life and even their body into consistency with their identity. Everybody gets that. But everyone else around that person is also going through a transition, and it's very uneven. Some resist it, some embrace it, and some are more troubled by it than others. Literally, I've had parents of teenagers cry in the consulting room, saying, "I thought I had a daughter, and I guess I have a son, but now I'm grieving the loss of my daughter." Or the other way around, "I thought I had a son, and now I know I have a daughter, but I'm grieving the loss of my son." These are very personal and poignant moments when someone is really trying to come to terms with the reality of what's going on. It's a very tender time and we have to be kind to each other about what we're going through. 
LR: Everyone is in transition and may have been struggling to come out of their own mental closets in acknowledging and embracing that their child or their teen has been struggling for so long.
EA: Every family is different. There are some themes that are common and that are often shared, but the nuance can be so subtle and important. I had a trans teenager in my consulting room last night, and we were talking about the resistance of their mother to their identity and the struggles that this teenager has had for years with a mother who has not found it easy to accept her child on the child's terms. It was really quite a pivotal moment in my work with this young person in that they disclosed for the first time the extent of verbal abuse that their mother had given to them throughout the years. And the child's efforts to cope with this meant that they kind of shut down and are currently afraid of going forward with transition, because they’re worried that their mother is going to say, "I can't accept this," and that their father would side with the mother. And my client is saying to me, "I'm worried they're going to kick me out. They're going to kick me out of the house."
LR: So, these kids are sometimes put in the position of bearing the burden of holding the family together or reducing conflict by remaining silent? You must be so skilled as a therapist to address this once you open yourself up to the systemic and contextual nature of it.
EA: It's a challenging thing. But in the case of this young person, critical. I have to address the dynamics between the parents and between the parents and this teenager because they’re really hurting.

Complicating Issues

LR: You were just talking about transitioning, so I'm wondering if there are different clinical needs for clients who are in surgical transition as opposed to those who, for whatever reason—health, finance or choice—can't or don’t pursue surgical transition?
EA: Each of the phases of the transition has its own set of challenges. One of the things that I'm impressed with by those who get surgery is that the characteristics of the person are all-important. So, if they're healthy, have realistic expectations and a good surgeon, they have a good result and there are no consequences. That's one process. Another might be someone who has health issues, who might be a little more likely to have some kind of untoward consequence of a surgical procedure and are then frustrated afterward because their recovery is a little choppy, and maybe the result isn't exactly what they had hoped.

The differences between people are clear. Historically, surgery has been largely confined to adults 18 and over. But more and more, the trans kids that we're working with whose identity is clear at a young age and who have been on puberty blockers and cross-sex hormones as young teenagers, are getting surgery in their teenage years. This is, of course, with the full consent of their parents when everyone agrees that it's medically indicated.
These kids are being given a gift that someone in that situation a generation ago would never have had
These kids are being given a gift that someone in that situation a generation ago would never have had, which is to avoid some of the life experience in the gender they don’t want, and some of the physical changes in their body that they're not completely comfortable with. They're able to move ahead with their physical transition in such a way that by the time they're in middle to late teenage years, they're fully embodied as the person they see themselves to be and the gender that they assert. From that point on, all their experience is in that gender. So, they go to college and the people at college only know them that way. They've done their name and legal gender change, and so forth. That's a whole interesting set of patients.

By contrast, you also have people who are married, have children, have started a career or are deep into a career, and then they come to terms with who they are, and they transition. And I'm thinking of two people I’m currently working with who were assigned as male at birth. They are in their 30s and 40s, married with children, going ahead with the transition and all the complications that you would expect based on having to deal with the reaction of the spouse, the children and the people in their professional world. It's a whole different set of issues.

The Psychologist’s Role

LR: More and more, psychologists are being called on by doctors who are working with patients contemplating anything from gastric bypass surgery to—I don't know if I'm using the right word—gender reassignment?
EA: Currently, gender confirmation surgery.
LR: Thanks. These psychologists are being called on to perform evaluations to provide physicians with concrete validation that this person is psychologically ready for surgery. Do you have any recommendations for these psychologists?
EA: There are guidelines for this, we call such reports "letters of support." They're really what you and I would consider evaluation reports. They are a review of this person, their history, any co-occurring issues, and their life circumstances. In addition, as we would agree, a necessary part of this is essentially the informed consent, you know, to talk through what is going to happen with this surgery by a skilled surgeon who is well trained and experienced with this procedure. And then, does the person really understand the risks and the benefits of this surgical procedure? And what are their expectations of what it's going to be like for them after they have this surgery? I was referring to that earlier today as we were talking about how realistic the person’s expectations are about surgery.

Most people who think about gender confirmation surgery have done extensive research on it. So, I find that—maybe it's a selection bias—the people who come to me are those who are a little more sophisticated. But I must satisfy myself that they've gone through that process, and that they've asked and had answered all the questions that they have, and that they've thought through whatever the likely consequences are, and they've considered the possible unexpected consequences. And if they have, if we've done all of that, and if there isn't an outstanding psychological issue or an acute psychiatric problem, then I'm inclined to write the letter and say, yes, I recommend that this is medically necessary for this patient.

Surgeons do require such letters still, at least according to the standard of practice. There is an organization called WPATH, that has standards of care, currently in its seventh edition. These are standards of care for medical and psychological service to trans people. The 8th edition is currently under preparation. And just like everything else that we're talking about today, things are moving in the direction of de-pathologizing. The question in the future will be, "What is the purpose of the evaluation? Is it to screen for any contraindications? Is it to satisfy the psychologist and the surgeon that this person is a good candidate for this surgery?” Those are open questions as far as I'm concerned. But I do believe that because of the wide-sweeping consequences of a gender transition—and if you add into it gender surgery which is irreversible—that performing these evaluations requires serious skill and should not be done lightly.  
LR: Therapists and clinicians want to render the most competent services in a way that is correct, ethical and moral. So, it's not just laying a quick MMPI on someone and saying, "Yeah, ready to cut."
EA: Exactly.

Closing Thoughts

LR: What should therapists be wary of within themselves when working with clients who are either contemplating surgery or thinking and feeling deeply about gender identity?
EA: I have been doing a lot of thinking in the last few years about our whole paradigm of transference and countertransference, and how that might need to be adjusted for work with transgender people., I myself am transgender. I ask myself all the time, "Do I bring any bias to my work with an individual client or patient?" I try not to, of course. But, in a slightly different way, I know that some people come to see me not only because I'm a qualified psychologist, but because I'm trans. They want to know about me and will ask me personal questions which is historically seen as being out of bounds. And I wonder, how is that related to transference or not?
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them.
My inclination is that if client questions are not too deeply personal—nobody asks me about my sex life—I will answer them. These include questions like, "What is it like to go through hormone changes? What happens in the surgery?" And I will selectively tell them a little bit about me, because it does reassure them. It's kind of like, "Oh, yeah, she went through this, so I can do that too."

Some of the questions therapists can ask themselves could include, “What are you bringing to that discussion with someone? Do you really have empathy for what they're going through? Do you have a bias? Have you examined your perspective about this?” I think the therapeutic pitfalls are to assume that someone is too young to decide, to assume that someone is neglecting their family responsibilities if they transition and they're married with a family, to assume that someone is not going to be able to have sex if they change their body. There are a lot of potential assumptions, and we just have to be careful not to hold them because we have a bias.
LR: So, the same general concerns about countertransference, self-disclosure, presumptions and biases, but a little bit more finely tuned to the needs of clients who are in transition.
EA: I am concerned that therapists who are relatively inexperienced in this area may have a hard time parsing the co-occurring disorders. And so they might think, "Okay, we can't go ahead with hormones or anything else, or certainly not transition, until we deal with your depression. And we've got to cure all your psychological problems before I feel comfortable encouraging you to go ahead." That is, in my judgment, a mistake, and often kind of a rookie mistake. I think the literature on co-occurring disorders suggests that there are many situations where we treat concurrently, not consecutively. To pretend that we can separate aspects of a human being and treat one part and ignore the other or set aside the other for a while doesn't work very well in this area.
LR: We can’t surgically remove pieces of pathology, revealing the true issues—it is simplistic and naïve.
EA: Here's the challenge! We have inadequate empirical bases for a lot of the things that we're doing. We're doing what we're doing based on the data we do have. This includes longitudinal information we have about patients, comparing and contrasting patients who do well and patients who don’t do as well, and bringing into our work in this area what we know about other clinical challenges. If we waited until we had long-term treatment outcome studies on all these things, there would be a lot of people who would struggle.

As you know, the rate of suicidal ideation and suicide attempts is very high in trans people. So, we're going to lose a lot of people if we deny treatment to trans people until we have what the rigorous scientists consider to be adequate empirical justification for what we're doing. There is a five-year research study going on at UCSF, one of four sites for a multi-site NIH study of transgender kids and the first of its kind. But that's a five-year study. The research is looking at both medical and psychological factors having to do with how kids do when they go on puberty blockers and how kids do when they go on cross-sex hormones. And in five to ten years, we'll have some data that will help illuminate what we're doing.

Hopefully it's going to confirm what we think we know about best practices with kids. We're one of the more advanced centers in terms of embracing what we call the gender affirmative model. We're very interested in affirming kids and their gender, and not putting roadblocks in their way to living authentically. We work hard to reach consensus about the truth about any individual kid, and then a consensus about what we know about this kid and what we are going to do. We ask important questions including, “What's the timing of various things? Are we holding off on things for specific reasons?” It's a very individual matter with both kids and older patients and it’s about crafting a plan for the gender journey heading towards transition. It is about trying to responsibly approach each of the potential decisions and make the best decision that we can at the time based on what we know for each patient. And that is, I think, a sound approach, but it isn't necessarily justified by empirical findings.

Gender identity isn't something that easily lends itself to measurement. Earlier, you invoked the Minnesota Multiphasic Personality Inventory (MMPI). I was at the University of Minnesota for a number of years, and I interpreted thousands of MMPIs. I don't know that we're going to ever have, at least in my career, any kind of test for who's trans and who isn't, or what level of trans-ness exists, and, oh, this means that they should proceed at this kind of pace in terms of decisions regarding medical supports for identity. 
LR: You're a transgender woman. How has your own personal journey prepared you to work as a therapist? No easy question, right?
EA: Like most of us who have been psychologists or therapists for a long time, every chapter in our lives does inform who we are and gives us insight into how life is for other people. I emphatically believe that I could not do what I do without incorporating some of what I've learned about myself and the world.
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society
I will tell you that it is amazing to have lived as a man in society and now live as a woman in society. Sometimes I joke with other women and say, “I’m on our team now, and I get it. I get what it's like to be treated differently by men.” I had another interview recently in which I was “mansplained” many times. It's really hilarious when I get mansplained.

The subtlety of what I've experienced is not lost on me or some of my clients in that I know what the experiential aspects of this are, exquisitely! And although I didn't keep a careful journal of what I went through, I remember many aspects of it very, very clearly. I sometimes bring this subjective understanding into my work. I'm sure you could appreciate this. Sometimes, when my clients or patients are really struggling, I lean in, and say, "You know, I really do understand what you're going through, and I want to help you." And they realize that I'm being honest and direct about it, and it means something to them.

I'll tell you one other little anecdote which is kind of special for me. When I see trans kids at the UCSF clinic, I'll say to them, "Do you know any other trans kids?" Sometimes they shake their head, and say, "No, I don't know any other transgender kids." I'll then say, "Well, do you know any other transgender adults?" They'll shake their head, and say, "No, I don’t know any other transgender adults." I look at them and say, "Well, honey, you can't say that anymore, because I'm trans." Their eyes get big, their jaws drop. Sometimes they gasp, sometimes they break into a big smile. And it's such a sweet, special moment for me. Sometimes the parents are not surprised and other times they say, "Really?" And then they say to their child, "See, honey, you can be a doctor. You can have a good life." And I feel, in that moment, like this is a gift to me, to be there with that child.
LR: A gift to you, indeed. I was reading a book by Fred Rogers who quoted someone something along the lines of, "You're not just your age; you're every age you've ever been." And that makes me think of what you just said. You're not just your gender; you're every gender you've ever been.
EA: Yep!

The Value of Evidence-Based Treatment That Fails

Posted on by Psychotherapy.net Team

In CBT I Trust

I became a psychotherapist because I wanted to help people feel better. I’m sure all therapists share that motivation. In my master’s program, I learned about cognitive behavioral therapy (CBT), and that no other type of therapy had as much research evidence to support it. I was drawn to its promise of rapid relief from suffering.

I sought out a doctoral program where I could receive specialized training in CBT for depression and anxiety. During my training, I saw firsthand how a few weeks of treatment could lead to big improvements in symptoms—not for everyone, but for many.

As an assistant professor I joined a leading center for the treatment of PTSD and OCD, and I witnessed the power of CBT to reopen lives that had been completely subverted by these conditions. When I found that cognitive and behavioral techniques weren’t always effective, I sought training in mindfulness and acceptance-based approaches. I wanted to be equipped to help everyone who came to me. Just as when I began this journey, I wanted to be a healer.

Later, I added CBT for insomnia so I could treat the frequent sleeping problems I encountered in my work. I began writing about the power of CBT to relieve suffering, first on my blog, then through a co-authored account of recovery from OCD, and then in two self-directed books on CBT techniques. I developed a blog and a podcast under a label that captures cognitive, behavioral and mindfulness-based approaches: “Think Act Be.” I was fully immersed in the evidence-based model, and I continued to be inspired by the successes I witnessed.

And yet I often remembered best the people I couldn’t help—the ones who came to me for a few sessions, or for many months, and never experienced lasting progress. They seemed to feel just as depressed, just as anxious, just as gripped by constant worries or obsessions as they did on the day I first met them. Some felt worse. My inability to help them weighed on me as I felt I’d let them down. Sometimes, when they left my office in obvious emotional pain, I cried at my desk.

Another Form of Healing

My work with Evan comes to mind (details changed to protect his identity). Evan was in his fifties and had been dealing with anxiety, depression, and obsessional thinking for his entire adult life. I introduced the standard CBT and mindfulness-based strategies, which Evan struggled to use. He experienced some relief from the meditations I led him in, but otherwise continued to have debilitatingly severe anxiety and depression. I could have blamed his lack of progress on his infrequent practice between sessions, but I didn’t believe that was the whole story, or even most of it. Whatever the reason, I couldn’t help him find relief.

And yet Evan often expressed his gratitude for everything I did for him. Like what?, I often wondered to myself. On one occasion when he thanked me “for everything,” I told him I wished I could do more to take away his pain. He expressed how much relief he found in our meetings, and particularly in the meditations I led him in and which he diligently recorded for listening between our sessions. “And you listen to me,” he said, “and you don’t give up on me. And I can tell sometimes when we’re talking that you’re feeling what I feel. And that’s huge.”

Many other names and faces stand out from over the years, people whose symptoms I seemed unable to touch. No one ever yelled at me or demanded that I do more to help them. Some expressed frustration at their continued suffering, occasionally directed at me, but most were entirely gracious, even grateful despite our lack of progress. Some even referred their friends or family members to me. It took me several years to realize that some of the deepest work I’ve done as a therapist has been with individuals whose symptoms didn’t improve.

This realization didn’t come until a few years ago as I sat with my friend Jim at his kitchen table. Jim had been battling an aggressive form of cancer for two years and had just learned it had returned. I didn’t realize as we sat there that it was the last time I would see him; Jim died two months later.

What surprised me in our final conversation was the gratitude Jim expressed for his treatment team. I expected he would be disappointed in them; after all, he was receiving the most state-of-the-art cancer treatment in the world, and yet it hadn’t kept his cancer away. I could imagine being bitter if I were in his shoes, and not at all happy to have to return for treatment.

Quite the contrary, Jim described how grateful he was for the care he’d received over the past two years. He noted that his medical team had extended his life, giving him time to put his things in order. He had been given more time with his family than he would have had without treatment. He was dying, and yet he was thankful to those who had done all they could to help him.

And more than the cutting edge care they provided, Jim seemed to appreciate that they cared. Jim wasn’t treated as a cancer case, or a research trial number. He was a complete human being, with a family, with hopes and fears, and likely a foreshortened future. The professionals with whom he worked provided compassionate care right until the end.

When I went through my own debilitating illness—much less severe than Jim’s, I learned what it meant to receive compassionate care. By my count, I saw 13 specialists over a 4-year period, and none of them was able to completely resolve my health problems. And yet most of them provided another form of healing—not of the body and mind, but perhaps of the spirit. I would leave their offices feeling a little less alone, a bit less afraid.

A True Presence

When I was in my late thirties, I was diagnosed with open-angle glaucoma. My optometrist who detected it reassured me that I wasn’t “guaranteed to lose my vision,” but the prospect of going blind hadn’t occurred to me until his reassurance. I didn’t ever want to not be able to see my kids.

The ophthalmologist I was referred to treated me with two rounds of laser surgery in each eye. The first involved boring a hole in the iris, making a tiny second pupil to decrease the dangerously high pressure inside the eye that could destroy the optic nerve. The second was meant to dissolve the blockage in the eye’s drainage ducts, allowing the pressure to return to normal. Unless it wouldn’t!

I learned through my own research that these procedures are effective in about seventy-five percent of patients. Thankfully, mine were successful and my pressures have been in a healthy range for the past few years. But I was struck by the failure rate of this treatment, given how directly it seems to target the root of the problem. Examples like this one abound across medical specialties; whatever the medication or procedure, the success rate of evidence-based interventions is significantly less than one hundred percent.

In light of the limitations of modern medicine, we shouldn’t be surprised at our limits as therapists. And yet many of us are quick to assign blame when a client isn’t showing obvious improvement. Often, we’ll blame the client, assuming there must be personality pathology or that they “don’t want to get better.” We may assume the symptoms bring secondary gain. We might prefer to believe that the treatment is effective, but the client just isn’t ready for change. These factors may be present, but they also have the convenient effect of letting us off the hook. It’s not us, it’s them.

The danger that I found in my own reaction to ineffective treatment was running ahead of the client, as it were, and trying to pull them along. This tendency showed up in things like assigning homework that I knew they weren’t going to complete, so at least I could feel like I was “doing something.” My conscience could be clear. Except it wasn’t, because I knew on a deep level that I wasn’t meeting the person where they were. They needed me to walk alongside them, to sit down with them when they sat to rest. They needed my true presence.

Our presence is what matters most. Otherwise, we would dispense therapy techniques from vending machines, or in fortune cookies. Even self-guided CBT books are written with a personal and encouraging tone. It’s crucial to feel that the guidance is coming not only from someone who is supposedly an authority, but from someone who wants the best for us, who’s in it with us. The relationship with an author matters.

Lessons Learned

I suspect I’m not alone in finding that my eagerness to help is actually unhelpful at times. For example, when Rick told me he felt like his life “hadn’t even been a prelude to anything,” I immediately jumped into cognitive therapist mode. My knee-jerk assumption was that this belief was exaggerated; after all, Rick had done many things in his life–graduated at the top of his high school and college classes, worked abroad, completed law school.

“Is that true?” I asked with skepticism. Immediately I knew I’d missed the mark. Rick wasn’t asking me to change his mind, especially not before he felt I’d really heard him. The truth was that his life hadn’t turned out the way he’d imagined. He’d come close to getting married twice, but never tied the knot, and he never had children. And despite his intelligence and education, his major struggles with anxiety and depression had left him unable to work since a year after he got his law degree. His life consisted mostly of tending to his garden, reading the news, and occasionally seeing a friend.

While I may have been on the lookout for distorted cognitions, on an unconscious emotional level I was motivated to look away from the deep pain expressed in Rick’s statement. It would have been much easier if I could have fixed his thinking and taken away his unhappiness. “See! It’s not that bad,” I wanted to say. But maybe it was. And the life Rick had lived wasn’t a problem I could solve.

As a therapist, I have come to appreciate the importance of remaining with and tolerating my discomfort and feelings of inadequacy, if I am going to serve as a full human being to those I treat. I must make peace with what I can’t change. Otherwise, I run the risk of compelling my clients to fight on two fronts, as they must contend not only with their suffering but with my expectations that there must be a solution.

All of this probably seems patently obvious to many therapists, perhaps especially those from a more psychodynamic background. Maybe my tendencies are specific to CBT, or to me. I do suspect CBT fosters some of the expectation about taking away symptoms, but I imagine some form of that expectation lives in all of us in the healing professions.

Sometimes life-changing work gets done while the symptoms are unchanged. For some that might mean connecting with the strength they have to meet their challenges. Others may discover the life that’s possible even through ongoing struggles. Still others will have their experience validated after a lifetime of being told what they felt wasn’t real or will simply feel less alone.

A Broader Lens

Hopefully it goes without saying that I still want to help people reduce their symptoms, and I want to offer each person all the tools that might be useful. Accepting the limits of my abilities and the value of our presence doesn’t mean I must stop trying to reduce suffering in any way I can. It’s also not a way to settle for less than optimal outcomes for my clients. And it certainly doesn’t mean that I have secret insights into what my clients really came to treatment for and that MY job is somehow to get them there.

I still want everyone I treat to experience less anxiety, better sleep, fewer OCD compulsions, or whatever else they came to me for. I provide referrals when I don’t feel that I have the expertise a person needs. At the same time, I’m trying to use a broader lens through which I see a person’s experience. As physician Rachel Naomi Remen suggests, there is a difference between fixing and healing. This stance isn’t a cop out, as I used to believe—a way to make myself feel better about my lack of skill. Rather, it’s a recognition of the reality that there is pain I cannot take away, and that “treatment success” is a bigger concept than can be easily captured in data from a randomized clinical trial, or from a well-validated self-report measure.

Therapy is as complex as any human relationship, with effects that potentially penetrate much more deeply than the apparent symptoms. The best we can do for anyone is to provide compassionate care until the end, whether that means a triumphant recovery, ruinous tragedy or the wide expanse in between.

I’ve also come to recognize that the end of our time together is not the end of the person’s road to healing. For some the time we spend together will be transformational, while for others there will be no obvious effect. For many others, the work we do together will plant seeds that grow only later, well after therapy has ended. It’s easy for me now to recognize the hubris in believing that the evidence-based therapy I offered was the person’s last hope. Now I know that I’m only ever part of a longer journey.  

What Am I Going to Do with all This Stuff?

Posted on by Psychotherapy.net Team

“I’ve always had trouble throwing things away. Magazines, newspapers, old clothes. What if I need them one day? I don’t want to risk throwing something out that might be valuable. The large piles of stuff in our house keep growing so it’s difficult to move around and sit or eat together as a family.”

“My husband is upset and embarrassed, and we get into horrible fights. I’m scared when he threatens to leave me. My children won’t invite friends over, and I feel guilty that the clutter makes them cry. But I get so anxious when I try to throw anything away. I don’t know what’s wrong with me, and I don’t know what to do.”

These statements are typical of clients with whom I have worked who suffer from what the DSM-5 calls Hoarding Disorder (300.5), a variant of Obsessive-Compulsive Disorder. Hoarding is a disorder that may be present on its own or as a symptom of another disorder. The other disorders most often associated with hoarding are obsessive-compulsive personality disorder (OCPD), obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and depression. Less frequently hoarding may also be associated with an eating disorder, pica (eating non-food materials), Prader-Willi syndrome (a genetic disorder), psychosis or dementia.

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These clients have extreme difficulty parting with common everyday objects such as magazines, newspapers, used cups, household supplies, foodstuffs and various forms of waste material. They may also compulsively acquire and then accumulate other items and commodities including clothing, mechanical parts, toiletries, CDs, DVDs and toys. There really is no limit, and each hoarder and the objects they hoard are unique.
Hoarding is not the same as collecting, as collectors tend to look for specific items and often organize and display them in well-maintained settings. Collectors also express a sense of pride about their possessions, enthusiastically talk about them, feel satisfied when adding to their collection(s), and can budget their time and money.

Individuals with hoarding disorder often experience severe distress at the thought of getting rid of their possessions. This results in their homes filling with clutter that disrupts their and others’ ability to use and, when severe, navigate living and working spaces. Individuals may engage in hoarding behavior for sentimental reasons. They not only feel, but deeply and intractably believe, that an item is unique, irreplaceable, or serves as a reminder of a cherished memory. Others attribute their hoarding behavior to instrumental reasons, clinging to the belief that one day these items will be useful. The psychological and physical burdens of hoarding may lead to unhealthy and dangerous living conditions, as hoarders are often reluctant to allow people into their homes to clear safe paths, remove contaminated or dirty items or to fix broken heating systems and appliances. Unlivable conditions such as these can lead to divorce, eviction, or loss of child custody.

Hoarding typically develops over the course of many years, sometimes beginning at a very young age and continuing throughout an individual’s life. Generally, in individuals living alone, the hoarding tends to develop more quickly and intensely than for those living with others. However, significant time must generally pass before the hoarder’s condition becomes very severe and impairing. It is the secretive and insidiously progressive exacerbation of the disorder that prevents those on the outside from immediately recognizing the hoarder’s issues and symptoms, and from facilitating the required intervention for the hoarder.

My work in hoarding arose through my interest in OCD, when a man once came to see me, reporting extreme concern for his children who didn’t have a bed to sleep on as the home was in disarray. The father was prominent in the community and was therefore expected to regularly invite guests to his home, which he was never able to do. Meeting the children was terribly sad as I learned firsthand about their isolation and the conditions in which they were living. My heart truly went out to the children and my memories of those interactions drove my future desire to treat and research hoarding. Upon meeting the wife who was the hoarder, it was evident that she was very socially presentable and an active member of the community. If you had met her outside of her home without knowledge of her home’s condition and clutter, you would’ve had no indication that she was a hoarder. This is very typical of most hoarders, and sadly perpetuates the hoarder’s resistance to treatment.

Many hoarders ultimately agree to seek therapy in order to avoid eviction or other negative consequences. When clinical intervention has been facilitated, which is often coordinated by those in the life of the hoarder, cognitive-behavioral therapy (CBT) has been demonstrated to have good efficacy. In such cases, it may be appropriate for the therapist to first specifically focus on helping the patient achieve greater insight into their personal situation, symptom severity, and necessity for change. Successful treatment is much more likely to be achieved and continued when the patient maintains awareness in these areas, and seriously engages in their intervention work.

Hoarders who are not determined to develop and exercise coping skills often don’t sufficiently engage in treatment to the point where they achieve long-lasting and sustainable progress, rendering them vulnerable to resuming their hoarding behavior. When CBT protocol intervention is appropriate, it focuses on four domains: information processing, emotional attachment to possessions, beliefs about possessions, and behavioral avoidance. The therapist will perform techniques such as cognitive restructuring and exposure therapy in order to challenge the patient’s beliefs about maintaining their possessions and the strong sentimental value placed on the hoarded belongings. Furthermore, the therapist will engage the patient in talking about commonly avoided and experienced situations related to hoarding that are intended to provoke anxiety, while allowing for the development of more adaptive coping techniques.

It is long and hard work to help the hoarder emotionally and cognitively disabuse themselves of their attachment to the things with which they’ve surrounded themselves, but quite rewarding to all impacted when the symptoms relent, and the stuff recedes from their lives.