As I was driving home from a trip to the local hardware store I was channel-surfing until I heard a radio talk show physician say, "Today I am going to examine the ills of psychiatric medicines."
Now, that caught my attention. This was going to be my kind of entertainment. First, let me admit my own bias upfront. Although I worked with psychiatrists for years, I am not a huge fan of psychiatric medicinals. Yes, they can be helpful, but I don't believe they should be advertised day, night, and seemingly every minute in between. These brain drugs (as Dr. William Glasser, the father of reality therapy was fond of calling them) come with heaping doses of side effects.
Just listen to the conclusion of any television ad released by the pharmaceutical industry and you'll be saying "he got that right."
As I listened to the doc on the radio, who clearly had an alternative functional medicine slant, I must say she really did her homework. I mean she was seriously armed to the teeth with facts and figures. With every jab she took at the prescription drugs for mental health, she backed her allegations up with journal articles, studies, and meta-analysis data.
She boasted that she would be willing to debate any psychiatric or other medical doctor who was listening. Sadly, none called.
She covered it all. The horrific side effects of the drugs. The studies where prescriptions were useless or worse yet made the client more depressed or anxious. Then there was a discussion of how anti-depressants caused folks who were depressed to become suicidal; hence the so-called black box warnings on some of these wannabe miracle pills.
She explored research where safer alternative supplements won out. And, who could forget those random double blind experiments she rattled off where the placebo fared as well as the highly advertised meds.
This was so great. But the best part was yet to come. After the commercial break (which was not sponsored by a drug company . . . yes!) she was going to talk about superior interventions. I just knew this was where psychotherapy was going to walk away with the grand prize.
Sure enough, as soon as the commercial ended the good doctor began listing a host of things to help folks with emotional issues. Some of these included: yoga, meditation, massage, chiropractic interventions, exercise, tai chi, getting enough sleep, drinking adequate water, negative ion generators in the home and the car, helping someone else in need, herbal remedies, minerals such as lithium orotate, and on and on and on.
Since I was pulling into my garage as she was going over her seemingly endless list I sat patiently with the engine off waiting for the information about psychotherapy.
Certainly, all of her interventions had some merit, but I felt like popping a lithium orotate capsule chased by a hit of Prozac myself when I heard, "Okay, well that does it for this week's show. Next week I'm going help our listeners tackle blood sugar difficulties."
Blood sugar? Did she say, "blood sugar?" Yes Howard she said, "blood sugar." Quite frankly I was stunned. But I just knew my day would turn around.
Several hours later a friend who was going back to college after many years in the business world called to say he was writing a paper on happiness. The assignment dictated that he should use YouTube sources and therefore he wanted me to have a look at his video references.
After punching in key words related to happiness, he had videos put together by physical trainers, alternative health experts, inspirational speakers, business management types, a multi-level marketing (MLM) guru, and perhaps most interesting, a 16 year old who usually talks about make up strategies, but decided she needed to dedicate a video to emotional health. And to round out the field -- thank god for small favors -- a couple of research and social psychologists.
What about trained, licensed psychotherapists? I regret to say the psychotherapists were MIA. Or as they say in the baseball world: their bats were silent.
To be sure, neither of the aforementioned incidents included in my day from hell was very scientific. But it did make me wonder. Has the golden age of psychotherapy come and gone?
Indeed, this is a different time and a different place; a whole new era, if you will.
Have Ellis, Rogers, Wolpe, Satir, Erickson, and Frankl been replaced by a young woman who normally gives advice about shades of blush? I was just about to say "absolutely not," when a rather scary free association whispered, "Howard, don't be so sure."
Although there are hundreds of different psychotherapies, certain fundamental ideas are common to them all. Among these are the concepts of naming and renaming. I can illustrate these tactics with a literary example.
In Shakespeare’s Hamlet, a ghost claiming to be his dead father tells Hamlet he was murdered by his brother, the current King, and orders Hamlet to avenge his death. Hamlet delays, seeking more proof. The King sends Hamlet away to be secretly murdered. Hamlet foils the plot, decides the King is a villain, returns, and—after three hours dithering on stage—kills him. Scholars have long debated the reasons for Hamlet’s hesitancy and failure to act.
Some years ago, I took part in a trip to England guided by a Shakespeare scholar. After we had attended a performance of Hamlet, our tour group had a spirited discussion about whether Hamlet’s indecision could be explained by a diagnosis of clinical depression. Many of those present believed that it could. Didn’t he, in his famous to-be-or-not-to-be speech, contemplate suicide? The inhibition and helplessness of his dysthymia, they argued, would explain his inability to act on his ghost-father’s demand for revenge. I contended he was not depressed and here’s why...
1. In 1600, depression was called melancholia. Where we would say, “I’m depressed,” someone of that era would say, “I am melancholy.” So: was Hamlet melancholy?
Shakespeare’s Hamlet dates from around 1600 and his protagonist appears in Act I with all the trappings of melancholy: black clothing, sighing, tears, “the dejected haviour [behavior] of the visage.” The photo shows an actor in his Hamlet costume, with all the melancholic signs. The photo below shows an actor in his Hamlet costume, with all the melancholic signs.
But wait: the height of fashion among aristocratic men of that time period was to adopt a melancholic dress and demeanor. They wore dark clothing with open collars and unbuttoned robes or doublets, affecting a disheveled appearance and world-weary poses with sad expressions. (Perhaps in our own time those who dress in the Goth tradition make a similar fashion statement.) This “melancholic style” was considered a sign of great poetic feeling and intellectual depth, a stereotype with which Shakespeare’s audience would be very familiar. In short, Hamlet strikes a melancholic pose but his fashionable outfit doesn’t mean he’s depressed.
2. Hamlet is mourning his father’s recent death. In his 1917 paper, Mourning and Melancholia, Freud differentiates the two states: “In mourning, it is the world which has become poor and empty; in melancholia it is the ego itself.”
Hamlet is unequivocal about which state he experiences. For example:
In Act I, he observes, “How weary, stale, flat and unprofitable/ Seem to me all the uses of this world.”
And later (Act II), he says: "… it goes so heavily with my disposition that this goodly frame, the earth, seems to me a sterile promontory...”
Clearly, it is his world that is, as Freud said, “poor and empty,” and not Hamlet himself. He is contending with grief, not depression.
3. And then there is the seemingly suicidal rumination of the “to be or not to be” speech.
Here again, Hamlet’s thoughts are not those of someone struggling with the mental pain of true depression. Rather the soliloquy reflects his wish to be relieved of a heavy burden: what to do about the ghost’s demand for revenge.
He doesn’t speak directly about this dilemma. Instead, he generalizes about the many frustrations and indignities of life.:
“the slings and arrows of outrageous fortune” and
“the thousand natural shocks/ that flesh is heir to.”
Again, his focus is the world, not his inner mood. He rejects suicide as a solution to these afflictions because death is “The undiscovered country from whose bourn/ No traveler returns,” and the possibility of more dreadful troubles in the afterlife “makes cowards of us all.” No thanks, Hamlet concludes, I’ll stick with the problems I’ve got. A wise choice, not a melancholic decision.
But Hamlet is only a play, so whether the Prince is depressed or not really doesn’t matter. In psychotherapy, however, the incorrect identification of an affective state can create unnecessary problems. We sometimes encounter patients who confuse “depression” with a variety of other emotions. They may tell us:
“I’ve been depressed since my grandmother died.” (No, like in Hamlet, that’s grief.)
“My team lost in the playoffs. I’m really depressed!” (No, that’s unhappiness.)
“That tearjerker movie left me so depressed!” (No, that’s sadness.)
“I’m depressed because I didn’t get a raise.” (No, that’s disappointment.)
“I can’t afford a new cellphone. It’s really depressing.” (No, that’s frustration.)
Confronted with these misapprehensions, our first task is to help the patient accurately identify the dysphoric state. This correction not only allows us to focus our therapeutic effort on the appropriate target, it also helps the patient to better understand his or her own reactions. In the worst case, it avoids the temptation to consider an “antidepressant” as a helpful intervention. None of these mischaracterized emotional states would respond to a drug.
So, back to the idea of naming and renaming...
Merely naming a set of symptoms provides clarity and a focus of exploration. As above, naming Hamlet’s emotional distress as “grief” not only explains his mood; it allows us to better understand his later behavior. If he were in therapy with us, we might examine his ambivalence about his ghost-king father as a basis for his indecision or challenge his negative overgeneralization about the world’s “emptiness.”
Renaming is an intervention that helps define a therapeutic problem in a more accessible manner. If we renamed Hamlet’s “indecision” as his sense of justice—being right about his uncle’s crime must precede any possible revenge—we could help him resolve his dilemma with much less vacillation. The play would no longer be a masterpiece, but it would save years of unnecessary therapy.
Hard to believe, but it's been 22 years since I set up a small booth at The Evolution of Psychotherapy Conference in 1995 in Las Vegas, peddling my first videotape (yes, VHS) Existential-Humanistic Psychotherapy in Action featuring James Bugental, a teacher of mine who happened to be one of the presenters. At that time the Evolution folks (namely Jeff Zeig, director of the Milton H. Erickson Foundation, which puts on the conferences) was kind enough to contact the other faculty members, and ask them if they had any videotapes to sell, so I ended up having a small collection at my booth. Plus I managed to obtain some copies of my father’s video series on group psychotherapy. I ran an ad in the program, plain text, nothing fancy, which I recall started with this headline: “Yalom. Bugental. You’ve seen them here; now take them home.”
Honestly, I had no plans to start a business at all, I just wanted to sell some of the Bugental videos I had produced to make back my production costs. But we had an overwhelmingly positive response to our videos, and as is often the case, a business was inadvertently born.
Flash forward 22 years, and the Evolution of Psychotherapy Conference is still the event in our field. December’s conference had over 7000 attendees from over 50 countries. Initially every 5 years, then 4, and now the next one will be 3 years from now in 2020, it has been referred to as the Woodstock of Psychotherapy Conference, if you’re old enough to get that reference. Most of the presenters are….in fact sadly many of the granddaddies of the field (and a few of the grand dames) that presented at prior conferences are no longer with us (Rogers, Satir, Whitaker, Bowen, May, Haley, Ellis, Bugental, Lowen, Gendlin, and most recently Minuchin, just to name a few).
A couple of thoughts: The title of conference, The Evolution of Psychotherapy implies we are evolving as a field. Sometimes I wonder. Given the total lack of family therapists from the current crop (a striking contrast from the early Evolution conferences), this would add evidence to what we all know, which is that family therapy is in serious decline. Suddenly it’s all about the brain…but we wouldn’t have a brain without families, just for starters. And as the attachment folks like Sue Johnson point out, without close connections the brain surely wouldn’t do too well at all (think Harlow’s monkeys). Are we really evolving as a field, or are we just coming up with acronyms for new branded therapies?
There was a greater number of female speakers in this year’s conference than the first conference in 1985, although they were still the minority—although the attendees were overwhelmingly female—eyeballing it I’d say well over 80%. I’m not sure that’s an entirely positive development, and unfortunately I think partly reflects the economic challenges in our field—and now another example of women being overrepresented in lower paying professions (at least compared to other professions requiring comparable education and training). Although women are typically the nurturers in our society, we need men who are compassionate and empathic as healers as well. And as for minorities…I count two in the roster: Derald Wing Sue, and Patricia Arredondo, both of whom were there to speak on multicultural issues in therapy. It will be nice when one day therapists of color are there to speak on issues other than how to do therapy with people of color. I think this says much more about our field and society than this particular conference.
Jeff Zeig and his crew know how to put on a show like no one else in our field. The energy and excitement at Evolution conferences is contagious, and one leaves with feelings comparable to ending a stimulating voyage, or theater festival, or 17 course dinner (not that I’ve partaken): filled, stimulated, tired and rejuvenated at the same time. Looking forward to 2020. If you haven’t been to a previous Evolution conference, mark this on your calendars. Based on actuarial tables, I should be there again.
A family sent their abrasive son to a monastery to learn a better path. When he came home to visit them after having been there his first year, they asked him what he learned. The son replied frustratingly, “All I learned to do was breathe.”
He returned to the monastery, and five years later, when his family asked him what he learned, he looked disheartened as he shrugged his shoulders and said, “All I learned to do was breathe.” He went away and returned again after ten years, and this time he seemed defeated as the same question was posed and he gave the same answer.
Then, many years had passed, and the young man now became a much older man, and at last, he reached enlightenment. When he was asked what he learned to become enlightened, he replied, “Finally, I learned to breathe.”
Our egos like to assure us that we “know.” “I know, I know,” we say, “I should meditate. I know it’s good for me….” But then we don’t. Talking about knowledge makes for interesting conversation, but practicing knowledge is wisdom. In 2018, we have enough evidence from the field of neuroscience to know that even five minutes of meditation a day for six weeks can create physiological changes in the brain. Meditation decreases activity in the default mode network (our constant inner chatter), it lowers blood pressure, and it helps our amygdalas send fewer false signals of danger that lead to anxiety, fear, and ultimately all-too-often, anger. In short, you know that daily meditation can significantly help you, so what’s stopping you from practicing it?
Many people tell me that they “don’t have the time,” and I certainly understand living a fast-paced life with a seemingly perpetually busy schedule; so I often tell people this: You might not have ten minutes a day, and maybe right now you’re convinced that you don’t even have five minutes to do it, but you cannot rationally come up with an reasonable excuse for not having two minutes to meditate a day. And people usually agree. I start people with two minutes a day, because 20,000 hours of clinical experience has taught me that when people start off with two minutes a day, two things happen: 1. They find that they can make the time, and 2. They eventually sit longer until it’s worth it to make five or ten minutes a priority in their everyday lives.
There are many different ways to meditate, but the most basic is to focus on your breath. I recommend people sit up, because I have seen evidence that sitting with a straight spine activates the reticular formation, which is the center of our brain’s ability to pay attention. Like the monk from the story above (and like mastering anything), learning to breathe takes effort, until it doesn’t. I teach people to sit up straight and to focus on their breath. I also recommend not trying to stop your thoughts, as trying to do so often becomes discouraging, since it’s not very realistic. Instead, I encourage people to become an observer of their thoughts—to watch their thoughts move by like watching a boat pass on a river. As the “boat carrying your thoughts” goes by, come back to your breath. A two-minute timer will likely go off sooner than you think. Eventually, so will with the five or ten minute one.
My experience has taught me that it’s foolish to wait until we’re anxious or angry to try to begin handling those tough emotions. Instead, if we can breathe with intentionality as often as possible throughout our day, as well as engage in actively having realistic self-talk, then our ability to handle things like anxiety and anger when they arise will become significantly better. You have all the tools you need to start meditating daily and practicing and role modeling the type of self-control and healthy habits for your clients that will help them see that you are living the example that you are presenting to them. After all, you already know how to breathe… or do you?
Recently, the American electorate has been treated to the awkward spectacle of mental health professionals proclaiming that President Donald Trump is mentally ill. These pundits have ignored the ethical standard against diagnosing someone you’ve never met, based only on public scrutiny, and have exhibited both grandiosity (they believe themselves saviors of the Republic) and lack of insight (they fail to recognize how their personal politics taint their judgment). They show an evident contempt for our democracy and the 60 million voters who chose Trump over his rivals. (Full disclosure: I didn’t vote for any of the listed candidates; instead, I wrote in my choice: George Washington.)
In a New York Times OpEd (1/12/18), Jeffrey A. Lieberman, Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, said:
… when psychiatrists engage in clinical name calling about the president’s mental status without adequate evidence and proper evaluation, they are damaging the credibility of the entire field. Psychiatry has had a checkered past: Witness its collusion in Nazi eugenics policies, Soviet political repression and the involuntary confinement in mental hospitals of dissidents and religious groups in the People’s Republic of China. More than any other medical specialty, psychiatry is vulnerable to being exploited for partisan political purposes.
Barack Obama may have impulsively criticized as racist a white police officer responding to a possible burglary at a black professor’s home but had to publicly apologize through the “beer at the White House” photo op. Although a minor episode, it raised the issue of racial animus with the first President of color.
Lyndon Johnson refused to end the Vietnam war because, he said, “I will not be the first U.S. President to lose a war.” Tens of thousands of Americans and perhaps hundreds of thousands of Vietnamese were subsequently injured or killed because of Johnson’s apparent pathological narcissism.
Hillary Clinton may have revealed her paranoia when she defended her husband, Bill, as the target of a “vast right-wing conspiracy.” Perhaps this earlier instance of a secretive, suspicious nature presaged her later use of the infamous private email server.
And speaking of Bill Clinton, does any President more clearly show sociopathy than him? Consider a few of many possible examples: his purported history as a sexual predator, his questionable connections to the Chinese People’s Liberation Army, and even his apparent theft of White House property at the end of his term.
All of these alleged signs of mental illness fall under the category of character traits, an even more ambiguous area of diagnosis. After all, everyone has a personality, and it is only a matter of degree whether any of our mannerisms interfere with daily function enough to be considered problematic. Successful people often have strong character traits that may help or hinder them. All of the politicians above, including Donald Trump, have lifelong histories of functioning at very high and effective levels. To call any of them mentally ill begs the question: what is mental illness?
Leaving aside the political contretemps, we must recognize how difficult it is to define mental illness. The DSM5 attempts to categorize various observations and behaviors into a useful taxonomy. These categories are described as “disorders” rather than illnesses and they are constantly reshuffled with additions and subtractions in each revised edition. For example, before 1974 homosexuality was a disorder and afterwards it was not. The current edition includes gender identity disorder (or “transsexualism”) for the first time. So, in this sense, mental illness is whatever a large committee says it is. This approach is useful for research and to facilitate communication among providers, but it isn’t science.
Adding to the difficulty is the observation that a behavior considered abnormal in one part of the world is accepted as normal elsewhere. In the United States, taking one’s own life is almost always considered a sign of mental illness. Yet the Hindu practice of sati in which a wife throws herself onto her husband’s funeral pyre still occurs today, and Islamic fundamentalists blow themselves up like the Japanese kamikaze pilots of World War II. These acts are considered, within their own cultures, as honorable, not “sick.” Suicidal behavior, then, can sometimes be an illness and other times not, depending on the cultural context. I could give many other examples, but the point is that human societies vary and there is no universal standard for mental illness. The only definition that covers all of it is: mental illness is a marked deviation from cultural expectation. Although accurate, this definition is so broad as to be almost meaningless, and it has little practical utility.
In everyday practice, we rely on those who seek our help to define their own mental disability. Behaviors others might consider abnormal can be acceptable to an individual. Some live with phobias by restructuring their lives to avoid anxiety triggers. Others may accept low-level chronic depression as normal, as in the old blues song, “been down so long it looks like up to me.” Narcissistic, dependent and even antisocial personality traits may be tolerable unless they lead to significant interpersonal or societal dysfunction. People who come to a psychotherapist usually can tell us what they consider “abnormal,” and maybe that’s all the definition we need.
Nowhere is privacy more important than in the mental health field. We psychotherapists have always insisted on the highest standard of confidentiality for our patients. We want to be more protective than HIPPA and outdo the CIA in insisting on need-to-know. Even without the absolute protection the law gives attorney-client relationships, we resist whenever possible any intrusions from courts and from government investigators.
This effort has become even more important as privacy has disappeared from our society. People seem increasingly willing, even eager, to open their lives to public scrutiny through social media and other manifestations of the digital revolution. Texting, sexting, tweeting, personal blogging, online forums, and other displays of private, personal information are all too common, even when the consequences are employment problems, public shaming and legal jeopardy. Whether it’s loss of a job or a promotion, or revenge porn, or evidence in a criminal trial, the lesson never seems to be learned. If people want to be foolish in their personal lives, however, it’s their right to do so.
But nowadays many of us lose our privacy even when we want to protect it. Involuntary loss of privacy is increasingly prevalent as massive examples of hacking and the theft of personal information and identities destroys the attempt to keep private data private. Already, tens of millions of online medical records have fallen prey to malicious hackings. In our field, patients are routinely forced by third party payers to surrender their personal health data or lose their insurance coverage.
And now, a new and growing threat to the privacy of mental health information is the Electronic Health Record (EHR). With the government making the EHR a legal requirement, imposing fines for non-compliance and threatening to withhold reimbursement, the EHR is no longer a choice for many and soon might be universal. Even apparently benign uses of this data can lead to unauthorized disclosure when the EHR is shared with other providers, whether they be for medical, legal or justifiable mental health purposes. Once the information is out of our hands, we can no longer apply our standards to its release. The EHR represents a clear and present danger, but, unfortunately, it is also a legal document and cannot be entirely avoided.
The only remedy to this growing menace is to limit what we put into the EHR to the absolute necessary minimum. Examples are legally required data, such as the date of service, the next scheduled meeting, and any specific advice or prescribed treatment. We should also include any perceived risks, such as suicidal intent, and, most important, what steps we plan to take to mitigate them. Add perhaps any communications from other providers or significant sources of external information. In short, we are legally required to preserve any data that forms the basis for patient care.
We may also need to include the diagnosis, although that piece of data is the most problematic. Psychiatric diagnoses are simply observations that have been codified to facilitate communication and allow research comparisons. Nothing, however, embodies the stigma attached to mental illness more than a diagnostic label. In the EHR, available to all providers within the system and, through third party records, to anyone who ever provides care to that individual, it is likely to prejudice others against our patients and clients. Because it can bias the attitude of other caretakers, it may result in skewed, limited or even injurious treatment in the future. Where possible, we might use a brief description rather than a formal diagnosis. If that’s not feasible, then at least we can choose the least negative label available.
All the rest of what we’d like to memorialize—process notes, observations, plans, speculations and other insights—should be kept in a separate, non-digital record. Here is where paper is the best option. Paper can’t be hacked, won’t leave our control unless we want it to, and can be thoroughly and completely destroyed. No computer technician can retrieve the data from paper the way deleted material can be retrieved from a digital source. Paper can’t be squirreled away forever in a “cloud” server.
In our paper-based patient file—that only we ourselves will ever see—we can record anything that does not directly relate to patient care and that we would never want to release. After treatment ends, we can shred (or burn) the patient’s paper file and be confident we have protected both the patient’s privacy and our own standard of care.
The impetus for this blog originated many years ago when I stopped at an all-night book store late one evening and walked away with a copy of Jay Haley's book, Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, MD. That night I could hardly sleep as I read well into the wee hours of the morning. I knew that Dr. Erickson was doing something new, exciting, and creatively different than the rest of us. I couldn't wait until the next morning to ask one of my graduate professors about this master of psychotherapeutic intervention.
As I shared my reading experience with my professor, he laughed and shook his head from left to right. He then cut me off as I was speaking. "Howard stop, listen, those eight psychosocial stages he talks about are totally useless when performing psychotherapy. Trust me, I've been doing counseling for years. Please don't waste another minute of your time on that useless stuff."
I came away with two important conclusions. One, my professor clearly had no clue who Milton H. Erickson was, and wrongly believed I was talking about Erik Erikson. And two, for the sake of my GPA, I sure as hell wasn't going to point out his ignorance, nor would I share his thoughts with my Human Growth and Development course professor who thought the sun rises and sets around Erik Erikson's stages!
In this brief blog, I am going to do a reality check and attempt to separate fact from fiction regarding this larger-than-life figure in the history of our field. Using 12 key questions I am going to touch base with the living person who knew Milton H. Erickson better than anybody on the planet—his daughter, Betty Alice Erickson. And, yes, she's a card-carrying published therapist who has conducted workshops around the world on Ericksonian therapy. She also served as co-editor with Bradford Keeney, Ph.D., for the book, Milton H. Erickson, M.D.: An American Healer, and she co-authored the text Hope and Resiliency: Psychotherapeutic Techniques of Milton H. Erickson, M.D. with Dan Short, Ph.D., and Roxanna Erickson Klein, RN, Ph.D., as well as contributing chapters and forewords for numerous books.
Howard Rosenthal: Think back to when you were ten years old or so. If you had to describe your father in a few sentences what was he like as a parent? Was he strict, permissive, or supportive?
Betty Alice Erickson: He was a typical father. He was too strict and not strict enough. We were allowed quite some freedom if we had demonstrated we could manage it. He stressed and valued hard work greatly. We always knew we were loved and he was interested in us and was proud of us.
HR: So when you were having a problem or down in the dumps how would your father generally respond?
BAE: This sort of goes back to the last question. Daddy was very clear that we were responsible for what was rightfully ours. If we had a problem, for instance, we would go to the home office door and stand. He was always working on something. He would finish his thought, and motion us to come in. Then we would shut the door, if we wanted, and sit down. He would then set his pencil down and from that moment he was totally attentive and helpful. When we had what we had come in for, he would pick up his pencil and say, "Anything else?" And that was it. I think this was a very valuable teaching. If you want something, you must ask or at least seek it. Then you get help or needed information or better understanding. But it is your job to ask for what you want.
HR: Were you aware that he was a master therapist at a very young age and did that influence your decision to become a helper yourself?
BAE: I am not sure any kid is really interested in their parent's work—unless they're participating in it. We used to read whatever he wrote, especially for the American Society of Clinical Hypnosis Journal, but only to see if he mentioned our names. As for me, I was a high-school teacher and gradually shifted into troubled adolescents—I even ran a self-contained school for the Department of Defense overseas, long before there were special programs for this. Later, I got tired of the increasing paperwork schools were requiring, so I figured out what I really liked—teaching and seeing people change and grow. I went back to school and became a licensed therapist and then a licensed supervisor. I have been lucky to have taught countless workshops all over the world—and I have never ceased to be humbled and amazed at how important and influential and truly "genius-y" Dad was.
HR: In our field we always think of Milton H. Erickson as being a larger than life hero, but did he have any heroes growing up or when he entered into the psychotherapy field? Was there anybody who was a role model to him?
BAE: I think Daddy carved his own pathway from the very beginning, and never varied from that. But he always made it clear he admired and respected honest, productive people who were open to learn more.
HR: A lot of the textbooks imply that your father developed his keen sense of perception due to his health challenges in his childhood. Do you buy that position or do you think something else was going on?
BAE: Daddy spent a year bedfast, paralyzed with polio, and had lots of time to think. He used to practice listening to people walk up to the house, trying to figure out—male or female, how old, who it was. Then when conversation began in another room, he would figure out if it were a social visit, if someone wanted a favor, who would be the first to directly address that. He never stopped practicing those type of skills. He began to move by practicing remembering how it felt to move his thumb and fingers together . . . and practicing that memory over and over until he actually saw a movement. He took off from there, with enormous dedication and even greater hard work.
He had always keen visions of where he wanted to go in his life. With therapy, he did the same—what does the patient productively want? He was a farm boy, and would look at the "lay of the land," just as a farmer does to see if he can plant a productive crop. Then he would think about what he, and the patient, had to do to help get the best outcome. People call it speaking the other person's language; but it's more complex than that.
In other words, he figured out where he wanted to be before he tried to get there.
HR: Just like a child growing up wants to become the next Babe Ruth or Serena Williams, as therapists many of us still want to be Milton H. Erickson. Is that even possible or did he have special talents that the average helper could not ever hope to possess? For example, a therapist who saw your Dad performing therapy once told me it blew his mind. He said your father was such an adept helper it was like he possessed psychic powers or telepathy. What was the main thing that separated him from the average, everyday therapist working in a private practice or agency setting?
BAE: Daddy definitely did not have psychic powers, and it annoyed him when people asked him that. But more to the point of your question, he believed people were too infinitely varied to be classified in any theory—certainly the kind of clients we usually see. He never forgot to listen to the patient and hear what he was really saying, which is another skill which he constantly honed. The more I practice, the more I recognize clients always tell you what they want, maybe clumsily, maybe hidden, but if you're interested and really listen without thinking about you, or how it fits in the theory you're constructing (or using), you hear it. That's one thing. Another is he truly cared about his patients. He was unafraid to tell them things about him—to share certain things about himself. Today that's often seen as a "violation of boundaries." I was once chastised by a supervisor because my client, a professional astrologer, asked my birth date and I told her. My supervisor said it was inappropriate sharing of personal information. Nonsense! That's merely human beings connecting. That human connection is absolutely vital to good therapy, to a good relationship.
Last but far from least, he genuinely liked his patients. He recognized they had made the best of what they knew how to do, and they wanted to make themselves better—even if they phrased it that they wanted someone else to do something.
You can't convey these kinds of connection unless you, the therapist, can genuinely offer yourself. It's a hard skill to teach because when you connect, you become vulnerable and many people don't like to be vulnerable. They mis-define it as opening yourself to personal rejection. But it's not.
HR: As a therapist who used a lot of hypnosis myself I can't help asking: How does Ericksonian hypnosis differ from the garden variety practiced by nearly everybody else in the field?
BAE: Michael Yapko once told me that Dad re-defined hypnosis. It isn't what someone "does to someone else"—it is a co-created relationship between two people. Most of his students understand and teach that. However, people who don't understand his work are often not real comfortable with a non-rigid pattern of hypnosis. Daddy also relied on a conversational trance, which is so so easy to create and has most of the attributes of a formal trance even though it is far more flexible. A true Ericksonian knows his unconscious and the subject's unconscious are integral parts of all trance states. Even more structured ones, as in pain management, have to be crafted with the subject in mind.
HR: Did the textbook authors like Haley, Bandler, Grinder, Rossi and others get it right? I say that because I've have heard you hint in the past that some of the literature and workshops weren't quite accurate and might have misrepresented what Dr. Erickson was doing.
BAE: Some of the them "get it"—many, many do not. When people try to make Daddy's work a 1,2, and then a 3 and 4 . . .it is not Dad's usual type of work. First, Dad's work expands available options. Word choices are extremely important because most words carry many meanings. It can be very direct, but it is also very indirect. It looks at the whole picture as well as specifics within that bigger landscape. The problem is the client's, the solution has to be the client's.
Our skill as a therapist lies in creating the best, truthful, and most attractive options. With an expanded field of those options, most clients do the right thing for them. Most-- clearly not all. Then you have to do, say, offer things differently.
HR: When you read about Milton H. Erickson you get the feeling he could treat almost anybody of any age, with virtually any problem. Today there seems to be a push for specialization . . . you know, a therapist has to be a specialist in suicide prevention to help suicidal kids, or an expert in eating disorders is required to help an adult who is bulimic etc. What would your father think about this model? Is it limited and would he think it is inaccurate?
BAE: I don't know what Daddy would think. I know he totally believed that AA was an excellent resource for alcoholics, and he referred people there regularly, as do I. But I think he would think that this mini-specialization ignores that we all have experience with some level of most problems. There are some issues which probably do require specially trained people like a protocol for dealing with severe PTSD for recent trauma. But I know he thought problems are problems. We can probably help most people --while remembering to remember our own limitations.
HR: What would your Dad say about the emphasis on big Pharma today? It is nearly impossible to watch a television show or pick up a magazine without seeing an ad for some sort of psychiatric prescription medicine.
BAE: He definitely knew sometimes people need meds for mental health. After all, he worked at the Colorado State Institution for the Criminally Insane for his medical residency—long before psychotropic drugs existed. We older children also grew up living in state mental institutions where he worked early on—even we knew there are people who genuinely need something more than talk-therapy. But Big Pharma for everything?—the only truism about medication is that they have side effects which I think is sometimes forgotten.
With that aside, how are we going to learn to deal with life, which is often not to our liking, if we only know how to medicate our discomfort, our pain away? We forget pain can be a wonderful teacher. Even little kids quickly learn that if you touch a hot stove, you'll have pain.
HR: Okay, tell us something about your Dad we don't know that might surprise us.
BAE: There has been so much written about him that I really don't know except trivial things like he loved limburger cheese which is the most terrible smelling cheese in the world and has to be kept in the refrigerator where it stinks up everything. Or, he contributed anecdotes for years to a "humor/human-interest" column in the Detroit Daily Newspaper under the name of Eric the Badger. He loved puns and, what all we kids considered, stupid jokes and riddles. And kept a little notebook so he wouldn't forget them, which I now have.
HR: Eric the Badger. Wow, I'll need to check that out. Okay, I know you carved out 10 life rules from your Daddy's teachings. 1. Life is hard work. 2. Life is unfair. 3. Life is filled with pain. 4. Everything ends. 5. Every choice costs. 6. The law of averages is usually correct—that's why it's called the law of averages. 7. Change is the only constant. 8. It is what's in our head and heart that really matters. 9. What we receive in life depends on merit—and good or bad luck—or a combination. 10. Life was made for Amateurs. If you had to single out one rule that has been the most important in your own life what would it be and why?
BAE: That is genuinely hard. The one my clients usually hate is #9—but it, like the others, is true. Dot.com millionaires worked genuinely hard, but had they been born five years earlier or later, they wouldn't have had such success. I guess the best for me is #7. Change is the only constant. This is miserable—it'll change. This is wonderful? Savor and love it because it too will change.
HR: Betty Alice, this has been great. Thanks for sharing these gems of wisdom.
BAE: Thank you! You've made me think and organize my thoughts as well as have even more appreciation for my good fortune in life.
My mom died recently after struggling with dementia and severe rheumatoid arthritis for many, many years. I moved to the Bay Area from the East Coast in the year 2000 to be closer to her, as I thought she might not have much time left, and 17 years later, on a sunny spring morning shortly after my 43rd birthday, she died as I lay in a liminal half-sleep between the 3rd and 4th round of my snooze alarm. I woke to a series of texts from her very dear Armenian-American caretaker at her assisted living facility:
Mrs Linda’s blood pressure dropped
significantly this morning, called
hospice to monitor her
I’m sorry to let you know, Mrs Linda
Passed away :(
What?! While I slept? Over text?! I wandered frantically around my apartment for a minute, or ten, searching for my mother’s gone-ness, eyes open wide, unblinking.
I had waited and prepared for this moment, had even started praying, tentatively and awkwardly, that she be released from her incontinent, bed-bound, arthritic limbs and atrophied mind, and yet: How could she just die like that? I was going to go visit her in two weeks for her 78th birthday. I should have gone sooner. I should have gone sooner.
Much of that day was spent a few inches outside of my body as I negotiated with the mortuary, made calls to friends and family, and repeated the phrase “My mom died,” each time a dissociated succession of syllables. My friends knew of her long struggle, my long struggle, and said things like, “You must have mixed feelings.” I did not have mixed feelings. I was devastated.
This was Friday. I went back to seeing clients Monday, and didn’t tell anyone that my mother had died. Eleven years earlier, when my father died after a struggle with Alzheimer’s, I had also gone right back to seeing clients at my practicum in graduate school, but because I had canceled sessions for two weeks while he was dying, I told them why I had been away. This time there was no dying—just death—and not many details to attend to after. My mom’s sickness had been long, her personality alienating, her plight sad; by the time she died there were no friends left, no one with whom to gather for a funeral.
Not having skipped a day of work, I decided I would only share my loss if it arose organically with a client. It didn’t. I felt protective of them. How hard would it be to talk about themselves, whatever they were working on at the moment, once they found out my mom had just died? Plus, I was still kind of numb—would I come across like a zombie with no remorse? Would I be able to reassure them that I was in fact OK and that I was just where I wanted to be? I imagined what a drag it would be to go to my therapist, prepped to talk about the week’s pathos, only to find out her mom had died. I would feel like a self-involved jerk diving into my own preoccupations in the face of her loss, and would feel like a jerk talking about how I felt like a jerk talking about my own preoccupations. No, I didn’t want anyone to bear my burden. That’s not why they come to therapy, after all.
The opaque sense of unreality that arose in the weeks after she died—my palette of sensations muted like a blue twilight after the sun disappears—was almost comforting. “Perhaps this won’t be that hard,” I thought. After all, she’d been deteriorating, and then dying, almost forever. Losing her had been a slow and steady stream of small infirmities and indignities rather than a flash flood, the erosion of her essential being an accumulation of griefs I hoped would inoculate me against the crushing pain I had suffered after my father died.
But I didn’t know how to both bear my burden and not burden clients. I wanted to be doing therapy—I felt present and alive with my clients—but after a few weeks it felt like the vessel in my heart where I hold people’s pain, their stories, had no more room in it. I hadn’t entirely understood that place in my body until it stopped working, and it was alarming. Because I wasn’t experiencing paroxysms of grief, weeping uncontrollably at random intervals, I mistook myself for “not really grieving.” This was compounded by the fact that my mom was in many ways a “not-good-enough” mom—her mental and physical illnesses had compromised her ability to mother long ago, but I thought I had “dealt” with that grief already, damnit. So what was this parched-solar-plexus feeling?
Ah…It was my grief.
You see, I loved her madly. Still do.
I took the week off from work in an effort to bring some space and consciousness to my grieving. I slept, read, wrote in my journal, saw beloved friends, exercised, booked an extra therapy session, got a massage. It was awful. Anxious, listless, unmoored from my routines, I spent the week berating myself for not doing a better job at grieving. I felt it was up to me to figure out an appropriate ritual to mark her death, but the idea overwhelmed me. What would I say? Who would I want to bear witness? Inside or outside? What spiritual tradition to draw from? My dad was Jewish. She was a blend of everything and nothing, but a spiritual person. Where would I release her ashes? It was too much to figure out; I was tired. I stuck her ashes in the closet near, but not directly next to, my father. They hated each other. Was it OK for them to be in the same closet? I watched a video about cremation and decided it was.
The capacity to be wise and spacious around others’ pain, the sense of tenderhearted compassion that comes so readily through me in my role as a therapist, often tricks me into thinking I don’t need help with my own struggles. But I don’t have me the way that my clients do. I have my own therapist and she, in turn, doesn’t have herself the way that I have her. We cannot be our own therapists. Therapist-Me is also an orphan right now, struggling to make sense of death, of having no parents, of the freeing and terrifying reality of being on my own—generationally-speaking—for the rest of my time here on earth. No amount of “self-care,” parenting of my inner child, and guided meditations makes Therapist-Me available to myself.
Despite years of training in the mental health field and working with people as they struggle with death, I’m struck by what a strange land grief is for me. I’ve heard many therapists say that their own grief has brought a richness and depth to their work with clients, and I think that is true for me too, but not in a particularly tangible way. What I am most aware of is how nurturing working with clients is to me right now. It is the only place where I am fully present, and being present is a tender relief as I navigate the complexity of loss in my own life.
How have your experiences of grief impacted your work as a therapist? What has helped you? What has not? I would love to know. Feel free to send me an email at: Deborah@psychotherapy.net.
When I gear up to read a blog I invariably have the same thought: Tell me something I don't know.
In this blog I am going to fulfill that promise for my readers since I have never encountered a psychotherapist or addiction counselor who knows what I am about to share. (If you are the one in a million exception, please accept my apology.) So make yourself comfortable and let's get this party started.
Let's begin with something you do know. In the summer of 1935 Bill W (aka Bill Wilson) and Dr. Bob (actually Dr. Bob Smith, birth name Robert Holbrook) conducted the first Alcoholics Anonymous or AA group. Since this initial meeting AA has helped more individuals than any group on record.
Make no mistake about it. Bill Wilson loved AA and he believed in it with every fiber in his body. But two key factors prohibited this from being the end of the story. First, although AA helped Bill W deal with his alcoholism, it did nothing to curb his anxiety and depression. Second, as powerful as AA was it didn't work for everybody.
Now fast forward from 1935 to the year 1960. Bill Wilson decided to attend a parapsychology conference in New York City. It was there that the famed British Writer and AA supporter, Aldous Huxley, introduced Wilson to two esteemed psychiatrists, Abram Hoffer and Humphrey Osmond.
These psychiatrists shared with Wilson a promising new treatment for alcoholics and schizophrenics dubbed vitamin B3 or niacin therapy. He was fascinated by their research.
Wilson began ingesting a bomber's load of the nutrient, 3 grams daily, only to report that his lifelong battle with depression and anxiety lifted in just 14 days! Is that amazing or what? I mean, seriously, it sounds like something right out of an infomercial airing at 2 AM after the one for Tony Robbins' self-improvement materials. Here was an ordinary over-the -counter vitamin that when ingested in the proper dosage was a fast acting remedy for alcoholism, depression, anxiety, and schizophrenia. And, as a side effect it helped lower the so-called bad cholesterol.
Wilson took immediate action and prescribed his miracle like intervention to AA friends who were described as educated. Others were said to be celebrities. According to Wilson, the results were nothing short of amazing.
Wilson was brimming with enthusiasm and forged on to share his knowledge with the doctors of AA. These were physicians who were alcoholics and therefore attending AA groups. But here is where the gauntlet began to fall and nothing was ever quite powerful enough to reverse the pattern.
The International Organization of AA, despite the fact that the members were appointed by Bill W, and he considered them friends, were not happy campers. Wilson, as they pointed out, was not a licensed physician and thus had no business extolling the virtues of vitamin therapy.
Bill Wilson spent the last eleven years of his life spreading the word about vitamin B3 therapy as a treatment option or supplement to AA groups. Wilson tried to rally the troops by creating three powerful booklets over the years to AA physicians, but it fell on deaf ears.
So who killed vitamin B3 or niacin therapy? Why was AA embraced by millions, while B3 niacin therapy never made it out of the starting blocks?
Certainly, I don't pretend to have the answer. Scores of reasons could be cited, but here are a few that just seem to make sense. Also keep in mind that nearly everybody is a great Monday morning quarterback. Had I been in Bill W's shoes at the time I might have done exactly what he did.
Who killed vitamin B 3 niacin therapy?
The niacin flush. Unlike the tiny amount of B3 included in a typical multiple vitamin supplement, in order to import a clinical impact, the dose of niacin (also known as nicotinic acid) generally has to be high enough to induce a flush replete with itching and profound warmth. The effect is so pronounced that individuals taking niacin often mistake these symptoms for a heart attack or stroke and end up in the ER or an acute care facility. In all fairness, a very small percentage of the population finds the experience pleasurable.
AA traditions. Tradition six suggests AA won't endorse, finance, or lend the AA name to any outside enterprise or facility. Tradition ten suggests that AA has no opinions on outside issues, hence AA cannot become involved in a public controversy.
The American Psychiatric Association. In 1973 the organization revealed they could not duplicate Dr. Hoffer's data and therefore could not promote niacin therapy. Rumors surfaced that large doses of niacin caused liver problems. Hoffer, who boasted he took more B3 than anybody on the planet, remained healthy until he passed away at age 91. He denied all claims that niacin was responsible for liver difficulties and went as far as to say it promoted longevity. Before he passed away he discovered a Canadian woman named Mary MacIsaac who took massive doses of B3 for 42 years. She practiced cross country skiing at age 110 and lived until age 112! Okay, I think I'll have what she was taking. Yes, it's clearly N=1 data, but I think it's safe to say that most supercentenarians don't spend the better part of the day on a ski slope.
Morbid fears related to the practice of orthomolecular psychiatry. Orthomolecular psychiatry (I'll pause while you Google it), a term coined by two time Nobel Prize recipient, Dr. Linus Pauling in 1968, is basically individualized mega-vitamin/nutrient therapy. B3 or niacin therapy fit neatly into this treatment category. The idea that patients might be diagnosing themselves and then heading for the nearest pharmacy or health food store to buy niacin on a BOGO sale just didn't sit well with mainstream psychiatrists. To be sure, the pharmaceutical companies marketing psychiatric medicinals were not overly thrilled either.
Forget the doctors of AA, Bill Wilson should have taken his message to the masses. I am thoroughly convinced that Bill W pitched his ideas to the wrong population. In my humble opinion if he had penned a self-help book on the topic B3 niacin therapy might well have become a household word. This was the 1960s and early 1970s for gosh sakes and titles like I'm O.K.—You're O.K., How to be Your Own Best Friend, and Born to Win were shaping American culture, not to mention the landscape of mental health.
Today, vestiges of niacin treatment live on in the minds of longevity seekers, the alternative health movement, and nutritionally minded cardiologists hell bent on shaving another silly little point off your LDL cholesterol score using straight niacin or a modern slow release version which may or may not eliminate flushing.
Had Bill W been successful in his mission to incorporate vitamin B3 niacin therapy into AA the entire face of addiction and mental health treatment might have looked very different today.
The story goes that before Bill Wilson passed away he was asked what he would like to be remembered for in the history books. Much to the chagrin of experts and those who have benefited from 12-step groups he chose niacin therapy over AA. Who knew?
Often when I “terminate” with a client (what a horrendous term for the conclusion of a meaningful human encounter) I let them know that I don’t see therapy as some kind of permanent cure to the concerns that brought them in to see me. At best it offers some meaningful relief, and some expanded awareness and resources that they may draw on when they inevitably face future challenges.
I usually tell them I’d be happy to be of help in the future, whether seeing them again, or referring them to a colleague, often adding that I’d be delighted to hear from them with any update on how things are going for them. 95% of the time I never hear back, but of course certain clients run through my mind at various time. I may walk by a building that a client had done the architectural plans for. Or I am riding my bike, and I remember their joy in a bike tour they once took in New Mexico. Or a client springs into my mind for no apparent reason at all, and I wonder whether their marriage—that I had some role shepherding them into—gave them the love and sense of safety they craved.
And then there are those clients that I mark down on my inner scorecard as failures. Yes, I might have given them some support, maybe I helped marginally change the trajectory of their lives, but I felt that somehow I just couldn’t help them break through to achieve the types of changes that they desired—or I desired for them. How were they doing? Were they still as depressed as when we parted ways? Or worse…had they given up entirely? Committed suicide?
I notice that I hesitate before I type the word “suicide” as if somehow that reflects poorly on me that I’d even have this worry. Why the hesitation? Is it that I should be omnipotent, and never have clients, or even former clients that might commit suicide? Or is it that I shouldn’t admit that clients occupy my thoughts even years after I stop seeing them? Has the pernicious concept of therapeutic “neutrality”—one that we thought started and ended with psychoanalysis—become so rooted in our profession that we carry it with us without awareness? As if it’s wrong to care about our clients as actual human beings, as individuals!
There is one specific client that I do worry about from time to time—yes, worry whether he did decide to put an end to his tormented life—but I was somewhat reassured recently when I ran into a colleague at a conference whom I had entirely forgotten was the original referral source. She knew the client personally, and related to me that he was still alive, although still very much struggling day to day, but that she was grateful for the help I provided her friend. Given my feeling of failure with him, I was pleasantly surprised that my efforts were appreciated.
Just a few days ago I got an email out of the blue from a client I’ll call Penelope whom I saw several years ago. She said she just wanted to say hi, thank me for the help I had provided, and let me know that things were going well for her. She was a classical musician who was starting to achieve some success in her highly competitive field, and for the first time in a stable relationship.
I recall that the course of therapy was not an easy one—for the client, as well as for me. We all have our own tricks of the trade, some we like to think of as our own, or at least ones we’ve customized to fit our own personality. I like to work in the “here-and-now” when I can, drawing attention to how the two of us are engaging, with the idea that this will shed light on the client’s interpersonal relationships. Of course this is not a proprietary technique—I learned a great deal about this from my father—but I like to think that I have achieved some mastery in this.
In this case it failed repeatedly: Every time I asked Penelope how she was feeling towards me, she bristled, got angry, and didn’t see how this was relevant to her issues. I recall various responses on my part. One time I made an impassioned plea, relating her difficulty in trusting me to problems she was experiencing with a friend or co-worker. Or I would try to push back, again in the here-and-now, saying something like “I really sense that when I ask you how you feel towards me, it hits some sort of nerve for you. Can you tell me what is triggered?” Again, this got nowhere fast. Finally, I took this prized technique and stuffed it back in my toolbox where it belonged. Was that a failure? Or a brilliant realization that there is no one-size-fits-all in this work?
My memory is a bit hazy, but I recall we worked on and off for a year or so. I don't remember exactly how things ended, but it certainly wasn't one of those Hollywood therapy endings where her neurotic puzzle was solved, and I was left with a warm glow that I had performed my craft with precision. So thank you Penelope for being one of the 5% who let me know what has happened in your life. I go on faith that most of those I work with have some lasting benefits from our work, but it’s sure nice to hear it from you.
* * * * *
That was going to be the end of my musings, so I sent this piece to Penelope to make sure she felt comfortable with me publishing this (even though identifying details are changed). She wrote the following:
“I think that even though it made me pretty mad when you asked me how I was feeling towards you, I realize now that I was mad because that’s what I needed to work on. It took me a few more years to not get mad when people asked me stuff like that, but once I got more comfortable having conversations like that it was a lot easier for me to have close relationships.”
Wow! If I had known at the time that my apparent misfires would ultimately yield results, it would certainly have reduced my anxiety during the therapy. Would that have made me a better therapist? Perhaps not. Uncertainty is inherent to the process, and something we need to learn to live with. But how heartwarming it is to know now that my efforts with Penelope planted some seeds that are now blooming.
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