Once, a man who was recently released from prison told his counselor how enraged he was that he just had his wallet stolen from him. This man was visibly angry as he described having $450 dollars in that stolen wallet; and to make things worse, he had a strong suspicion who stole it. He told the counselor that he was going to seek out the thief, get his money back, and kill him. The counselor did not flinch, judge, or panic when the man told him he would seek out and kill the thief. Instead, he asked the former prisoner how long he’d been incarcerated. “I was down for 8 years, and I just got out,” the man replied.
The counselor asked, “Did you like your time in prison?”
“What?” replied the man angrily.
"Did you like spending time in prison?" the counselor repeated in honestly inquisitive voice.
The man then stared angrily and directly into the counselor's eyes and asked, “Did you ever spend time in prison?”
“No,” said the counselor.
“I didn’t think so,” said the man angrily, and he looked away shaking his head in disgust.
The counselor prodded further, again, genuinely inquisitively, “Let me ask you: In all that time in prison, were there ever moments when you wanted to get out?”
The former inmate seemed to get even angrier at this question, “What’s wrong with you?” he asked. “Of course I wanted to get out! I wanted to get out every single day!”
Unfazed by this man’s anger, the counselor asked, “How badly did you want to get out?”
The man, now visibly more agitated and enraged, stared down the counselor intensely and said, “I wanted to get out every second of every day!”
And the counselor asked, “What would you have done to get out?”
And the man, still staring through the counselor, replied sharply, “Anything.”
“Anything?” asked the counselor, matching the man’s eye contact and in a firm voice of his own.
“I would have done anything!” said the former inmate, stepping aggressively toward the counselor.
The counselor looked piercingly but compassionately back into the eyes of the angry man without flinching and finally asked, “Would you have paid $450?”
The man stopped. He got it. He understood. The counselor's words moved through him. He realized that if he would have killed the man who stole his $450, he would have ended up in prison (this time probably for life), and while he was in prison, he would have “done anything to get out,” certainly including paying $450 - and his anger left. He thanked the counselor and walked away.
Now, this is a true story, and the client was mine, and because it’s a true story, you probably want to know the rest of what happened, so I’ll tell you. The man, the former inmate, he was calm enough after talking to me that he went home and went to sleep instead of seeking out the man he believed to be the thief who stole his money. In the morning when he awoke, he said a thankful prayer that he didn’t go after that man and end up in prison. In fact, he even imagined that he paid the amount that was stolen from him and was now free. He felt so good knowing that he resisted acting on impulse for the first time in such a long time, that he decided to make another good decision and clean his room as soon as he got out of bed. To his grateful surprise, not long into his picking up the pile of clothes off the floor of his room, he found his wallet - and the $450.
The question you can ask your clients is this: How much would you pay to undo impulsive decisions you've not yet made? Would you be willing to pay the price of self-control? In the safety of your counseling office, it's often helpful to play out your clients' most impulsive thoughts without the slightest bit of judgment. The more you can play out future scenarios, impulsive decisions, realistic consequences, and what your clients would be willing to do to go back and "undo" something that they haven't even technically done yet, the more you can expand their consciousness and move them from the impulsive, emotional center of their brain to the higher-level thinking center that will help them make more effective decisions. It's never too late to undo what hasn't yet been done.
My wife and I had reason to be on the “other side” of town last week, that part of the city where I lived my previous life with my previous wife. While my wife listened patiently to a story I had surely recounted many times, I do believe I caught the slightest hint of glaze slowly creeping its way over her eyes.
As we drove by an otherwise innocuous restaurant, I slowed down and replayed a scene in my mind’s eye that unfolded dramatically and indelibly over 30 years before in that very same spot. I wasn’t simply a novice therapist at the time, green around the gills, but one who was quickly and easily stymied into therapeutic paralysis during family sessions, particularly those that were contentious and loud, too closely paralleling the not-so-just-below-the-surface drama that pervaded my childhood.
The particular family I was working with at the time consisted of a mother, stepfather, father, stepmother and two children from the original marriage.The mother and father had divorced several years before they got to me, and if they had attempted therapeutic intervention at the time, it was surely not evident and the wounds from that original bond had not even remotely begun to heal.
I often felt sad, powerless and wordless in those sessions, which my supervisor suggested I expand to include all members of the family. Had I been more experienced, I could have more adeptly navigated that brutal emotional terrain. And had my supervisor had even the slightest sense of how to move beyond simple structural realignment of parental hierarchies, I could have more effectively guided these desperate people in their re-integrative work. And perhaps, had I been more forthcoming with my supervisor about the immense internal struggle I experienced with that family and how it triggered my own childhood insecurities and rage, I may have been more effective in helping them move forward in their lives. And maybe, just maybe, a traumatic and traumatizing event would have been avoided.
The long and painful short of the story is that I received a call from the stepfather from his hospital bed and listened in horror as he told me how he had been shot that morning by the father… in front of the children.
Flash forward to the present and that very same restaurant parking lot in which I now sat with my wife, once again retelling the story of how years before, on that side of town, in that very spot, the drama of what would eventuate in my own divorce played out.
I had just discovered that my first wife was having an affair with the law partner of my best friend. Drugs were involved, as were all-night binges, secrets, lies and betrayal; you know, the usual. I had followed my wife one night to that very parking lot and soon found myself in a made for-television imbroglio, fitting for the reality show “Cheaters.” At the height of that blazing row, a car pulled up, the drive slowly rolled down his window, and said “how you doing Dr. Rubin… need any help with your marriage?” It was, you guessed it, the father from the warring family who had been shot the week before by his connubial replacement.
The rock singer, Meatloaf has a song “Objects in the Rearview Mirror May Appear Closer Than They Are” in which he recounts painful memories of childhood abuse, stinging him still and dragging him back. In that moment in the parking lot I was transported back the state of emotional pain and therapeutic impotence that working with that family had triggered in me at the time. And that feeling lingers still, although not as painfully and poignantly, thanks to subsequent (good) supervision, personal psychotherapy and the wisdom to know and feel the difference between past and present when working with couples and families, particularly when countertransference comes a knocking.
These days, it is hard to flip through the television or cable channel listings or search movie offerings without being bombarded by ads, coming attractions or trailers for something or other superhero. These men, women, earthlings, aliens and everything in between are everywhere; flying in and out of our consciousness, challenging us to be bigger, better and stronger. They are in many ways role models for strength, morality, virtuosity and humanity, while also being poster children for weakness, vulnerability and fragility… heroes with feet of clay.
As a matter of “fact,” superheroes, despite their unflagging heroism and unwavering commitment to the greater good, are typically misunderstood, marginalized and often persecuted by those they seek to protect. Superheroes notoriously come from broken homes, have complex and conflicted family of origin relationships or have suffered immeasurable childhood traumas. They are lonely, self-doubting and tormented figures, shadowy reflections of our own frailties and fallibilities.
The brutal childhood loss of Bruce Wayne’s parents, Superman’s dislocation from his home planet Krypton, the Thing’s exposure to mutagenic radiation and Wonder Woman’s quest to find her place among humanity are but a few metaphors for the struggles that are common to all of us, whether or not we change the course of mighty rivers, bend steel in our bare hands or save entire civilizations.
Yet somehow, superheroes seem to wake up every morning, pull on their boots and spandex, ready to face the challenges of the day, just like you and me. But as it turns out, they manage to find strength, meaning, and identity in the very same ways that we mere mortals do; by aligning themselves with others such as in the X-Men, Avengers and Justice League. They seek comfort in relationships, continually and painfully look inward for a deeper sense of self understanding and self-acceptance, and when these methods fail, turn to psychotherapy. Yes, superheroes go to psychotherapy!
As it turns out, quite a few superheroes have turned to the therapeutic couch when all else and all others have failed them. Bruce Banner, a.k.a. the Hulk turned to fictitious neuromuscular psychiatrist Angela Lipscomb to help integrate his deeply fractured personality. Oliver Queen, a.k.a. Green Arrow sought solace from Dr. Edmond Cathcart to resolve painful inner conflicts, and Peter Parker, a.k.a. the Spiderman who is tormented by intrusive memories and the pull to his dark side (Venom), turned to Dr. Ashley Kafka so that he might vanquish his inner demons.
Interestingly, the psychotherapists who come to the rescue of these tormented superheroes struggle in many of the same ways that real-life psychotherapists often do. Dr. Frederick Wertham Blink, so-called “superhero shrink,” struggles to raise his own tormented teenage daughter, psychiatrist Leonard Samson wrestles with his own existential angst as he simultaneously struggles to render therapeutic assistance to the various heroes of the X-Factor, and Dr. Edmond Cathcart must somehow decompress from the challenging work of healing others just to muster the energy to leave his office at the end of the day.
Clearly then, superheroes are far more than two-dimensional fantasy heroes who model impossible standards for us to achieve. They are, despite alien origin, profound trauma and inevitable estrangement, very much human, and as such like the rest of us in need of connection, meaning and inner peace. So, they turn to psychotherapy. And in turn, their psychotherapists are often quite realistically portrayed in the comic-book world as caring, committed and loyal helpers, who also like the rest of us try to find a balance between our lives in and out of the office, within our own skins and in our own real-life relationships…all the while battling self-doubt, seemingly insurmountable odds and forces beyond our control. In other words, just like the rest of us therapists out there in the real world struggling to give it our best shot.
On my way to the airport recently my Lyft driver asked my wife and me what we do for a living, so I told him that we produce training videos for mental health professionals. Sometimes that’s a conversation stopper; people say something like “oh, interesting….” and the banter trails off. But he didn’t miss a beat and told me he had seen a psychologist for three sessions, but the therapist said very little, and he stopped going. I thought to myself, “oh no, another client with a sub-optimal experience with a too-passive therapist.” Although he was quite chatty, I didn’t feel we had enough “Lyft alliance” for me to inquire about the reason for his consultation, but he then relayed a related story.
He told me he had experienced a severe snake phobia, so much so that he couldn’t even look at a picture of a snake. He also had a fear of being alone (join the club, I thought). One day he was with a friend in a touristy area, and spotted a man with a large snake around his neck, offering the general public the privilege of sporting his snake in a photo pose for a mere $5. Before his pre-frontal cortex was able to chart out a course on Google maps to his Broca’s area to articulate that this wasn’t a business proposition he was interested in, his friend snatched the snake and put it around his neck, and snapped a few photos.
Somehow this quick action threw a monkey wrench into his previously established phobic narrative, and he found himself touching the snake and liking the experience. Voila, phobia cured in a few seconds for only $5!
This reminded me of an interview I did a few years ago with the legendary Albert Bandura at Stanford, where he relayed to me his studies using systematic densensitization to quickly and effectively cure snake phobics. When I first heard about this, I thought “so what?”—I’d been in private practice for many years, treated hundreds of clients, and didn’t recall a single one complaining of a snake phobia, or any other phobia for that matter. But Bandura explained that the folks in his study were in some cases really handicapped by their phobia, for example: plumbers who were afraid to crawl under a house because of their fear. And so eliminating the fear really did have profound ripple effects in their lives.
Such was the case with the unnamed Lyft driver. He told us that this instant success at curing his snake phobia gave him confidence in other matters. He realized that the fear was all in his head, and that suddenly other fears lost their potency. His fear of being alone, for example: he realized it’s not such a terrible thing. This gave him the courage to walk away from a lousy relationship with his girlfriend, and he reported being happily single.
I’m not much a behaviorist, but examples such as this further convince me that it’s just plain silly to limit your “interventions” to whatever school or orientation you align yourself with. I know, I know…others will argue that fidelity to a specific model is important. I respectfully disagree. Success breeds success. If our Lyft driver can conquer one fear and this has ripple effects throughout his life, more power to him. He got great treatment for 5 bucks!
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.
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