A Facebook friend posted this poem by William Butler Yeats:
“Wine comes in at the mouth
And love comes in at the eye;
That’s all we shall know for truth
Before we grow old and die.
I lift the glass to my mouth,
I look at you and I sigh.”
Prompting my reply:
But Yeats, entranced by words and such
Forgot to mention holy touch
And wrapped up in what he can do
Forgot your reach belongs to you
This is a memo I prepared for parents of students, and students themselves, seeking accommodations for the SAT and ACT college entrance exams. It also applies to graduate level high-stakes exams such as the GRE, GMAT, MCAT, LSAT, etc. I revised it after hearing a presentation by the psychologist in charge of granting accommodations at the Educational Testing Service, which owns and manages the SAT, at the 2012 Learning Disability Association annual conference (at which I also presented, with colleague Jordi Kleiner, on LD/ADD evaluation).
As the SAT and ACT exams approach, parents, students, and therapists, sometimes wonder whether to request accommodations, such as for extra time taking the exam. It used to be the case that a therapist’s note stating that a student had a disability and needed extended time or other accommodations was sufficient, but that is no longer the case. SAT and ACT now require both substantial evidence of disability and evidence of both eligibility for, and use of, the specific accommodation(s) being requested, including:
1. An evaluation documenting both that a student has a disability and that the disability, in his or her specific case, impacts processing speed or effectiveness in reading, mathematics, or other cognitive or learning processes in such a way as to require extra time (or other accommodation). A copy of the report of evaluation has to be provided with the request for accommodation, not just be referred to by a therapist or other third party. It has to include detailed test results and supporting information (such as case history, behavioral observations and teacher and parent rating forms or interviews). It is not enough for an evaluator to say that a student has a condition, such as ADHD or anxiety disorder, and therefore needs extra time. The evaluation has to document that the disorder affects this particular student in such a way as to substantially affect the student’s information processing and test taking. “Document,” here, means not just saying that it does, but showing how it does, through empirical methods.
2. A history of the student actually having both been found eligible, in school, for the specific accommodations being requested, and having actually used those accommodations. This history should document a track record of accommodations going back several years–not weeks or months. It is not sufficient for the school to have found the student eligible for an accommodation which the student did not use.
There are several situations in which requests for extra time or other accommodations are unlikely to be granted by SAT or ACT:
•Parents asking us to request extra time, or other accommodations, on behalf of a student whose record does not contain the necessary supporting evidence referred to above.
•Therapists making the request on behalf of student patients, without the supporting evidence referred to above.
•Parents asking for extra time, or other accommodations, for students who have received them on an informal basis, that is, without an evaluation specifically calling for them based on a diagnosed disability, and without being provided as part of a formal educational plan for that student.
The date of the evaluation may make a difference to SAT or ACT. Generally, evaluations over three years old may be regarded as too old to be valid. First-time evaluations done shortly before the request for accommodations may be regarded as done solely or primarily for that purpose, rather than to elucidate the needs of the student for educational accommodations.
Another issue is timeliness of our receiving the documentation from parents/families in order to include them in our documentation to ACT or SAT. Note that evaluations and any supporting documents need to be on file at school within the time limit specified prior to the date of submission to ACT or SAT. Evaluations or other documents submitted after that date may not be included with the request for accommodations, or may be included without being integrated into our request.
Shame is emerging as one of the most important and overlooked emotions in mental and emotional suffering, both among psychotherapists and the public. Shame is both a form of mental and emotional pain, and a major obstacle to psychological healing. Psychological work on ourselves needs detachment, self-observation, and acknowledgement of what we are feeling; all of which shame prevents. Shame can evoke the grief of being utterly alone, unworthy and incapable of authentic relationship with others, and can also drive rage, as the pain is directed away from the self and externalized and projected out onto others.
But there is more to shame than meets the eye. Although shame tends to be labeled in therapeutic circles as a negative emotion, and in therapy it is often true that shame both creates emotional disorder and prevents therapeutic growth, I think we need to see shame in a larger context. All our emotions and reactions have been selected by evolution, so shame must have made an important contribution to human survival over the long trek of human history.
Shame is a way of getting people to behave in conformity with what a group needs, or thinks it needs. Group cohesion was (and is!) essential for human survival, and shame is a way of getting the individual to fit in. Shame is also a way of maintaining attachment to the group. If members act in ways that threaten the cohesion and survival of the group, they can be shamed into changing back into acceptable ways of behaving by being threatened with the loss of attachment. Institutions use shame to get members to conform. Parents use shame to get children to conform. People use shame to get each other to conform.
Now, there are two main problems with this. The first one is that conditions can change, so that the patterns of behavior and belief that groups have used to survive no longer are adaptive, but instead become counterproductive. But the group still goes on, shaming members into conformity. Those who defy the group norms have to deal with the attempts of the group to shame them. This applies to small groups like families, as well as to larger communities and groups.
The second problem is that groups that were formerly better organized and functioning may become deteriorated, corrupted, and dysfunctional. Authority figures who were effective leaders may decline morally or cognitively, or may be replaced by others who are more dangerously stupid and/or corrupt. The hierarchy may become mindless and insipid, and groups which had been adaptive and furthering of their members’ human needs instead become obstacles and problems. But the group, through its members, will still shame members who speak out into conformity; “If you don’t do it our way you are not one of us.” During the Vietnam War, protesters were admonished to “love it or leave it.”
The story of “The Emperor’s New Clothes” is an example of this. Although the emperor was naked, the courtiers and subjects all told him how magnificent his robe was; coerced by shame, and perhaps also the fear of consequences.
This week I attended a presentation entitled: “Resilience to Shame: Getting to Authenticity,” by Deerfield social worker Margaret Moore (margaretmooremsw@aol.com/ 8473909145). Moore sees shame as interfering with our living fully and authentically, interfering with our ability to be fully present, and, preventing clients from making full use of therapy. She spoke of a case in which the client had completed therapy, apparently doing well, and then returned, years later, to work on another issue which she had never even brought up, because it was too shameful at the time.
Moore, who presented at the Gifted Center of the North Shore (as part of a series hosted by Gifted Center Director Noriko Martinez, 8473728134, nmartinez@giftedlearningcenter.org) referred to the work of Brene Brown on shame, vulnerability, and shame resilience. Brown has become a leading voice on this topic, with several TED talks, books, etc.
Some key points from Moore’s presentation handout:
• Shame is the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging. Women often experience shame when they are entangled in a web of layered, conflicting and competing social-community expectations. Men experience shame when they are ranked, or judged to be less than powerful and strong.
• Shame is different than guilt: “I am a mistake” (shame) vs. “I made a mistake” (guilt).
• Empathy is more than words. It takes work, to see the world as others do, to be non-judgmental, to understand another peson’s feelings, to communicate your understanding of that person’s feelings.
• People who demonstrate high levels of shame resilience share four elements in their lives: the ability to recognize and understand their shame triggers, high levels of critical awareness about their shame web, the willingness to reach out to others, and the ability to “speak shame,” (being able to talk about shameful feelings and situations).
• Shame is the biggest obstacle to authenticity, and living authentically is the “noble goal.”
I appreciated Moore’s focus on shame, and certainly see it as an obstacle to authenticity and therapeutic growth. Her presentation helped me become more aware of the pervasiveness of shame, both in society and in individuals, and to be more aware of it in my own self-work and my work with clients. But I think we miss something if we stop at shame and don’t look at what’s beneath it; which is the urgent need to attach to others. Our need to attach is so strong that we will split off or disown parts of ourselves to do it. When we are subject to disabling shame, we have already made a sort of transaction, trading integrity for acceptability—because we authentically needed to be accepted. The need to attach, to belong, etc., is as authentic as the parts of ourselves that we disown in order to achieve it; and often more powerful, which is why attachment wins out over integrity. Of course that contributes to splits in the personality, the understanding and healing of which psychodynamic therapy is all about.
Affective neuroscientist Jaak Panksepp and psychoanalytic therapist Lucy Biven, in their The Archaeology of Mind, describe the basic affective state of “panic/grief,” which is a “separation distress” system. When it is overwhelmed, “one experiences a deep psychic wound–an internal psychological experience of pain that has no obvious physical cause.” Spelling the system in capitals, Panksepp and Biven state, “The PANIC/GRIEF system helps facilitate positive social bonding…because social bonds alleviate this psychic pain…” This need is one we share with animals, and it is directly connected with the evolutionary need of individuals to survive as part of a group. “When people or animals are deprived of love and acceptance, when they are spurned and forced into lower echelons of a social hierarchy where they have few rights and fewer pleasures, this is often emotionally damaging” (p. 156). Thus, the child, or adult, in separation distress may bond with an adult, or a cult-like group or organization, to alleviate that distress, even at the cost of disowning authentic parts of the self. Better fragmented but attached than isolated, seems to be the emotional rule here.
Even though modern culture seems to value and encourage independence, in fact it cultivates intense conformity. Shame—the emotion of feeling extruded and excluded from the group, or key attachment figures–such as parents and high-status peers–is a key emotion by means of which conformity is established and maintained, through the manipulation of separation distress, which Panksepp and Biven call the PANIC/GRIEF system. Of course families, schools, peer groups, faith communities, as well as the larger society, all tend to work like this. And when so many groups that we must affiliate with are so deeply flawed, we have what I call the insanity of modern life (see, “How I See It”).
One of the ways therapy works is by providing an alternative relationship within which the client can establish attachment in ways which allow, recognize and appreciate parts or aspects of themselves that they’ve had to split off or disown as the price of forming earlier attachment relationships.
Here’s how I see it:
We live in a world of drastic change, for better and for worse. Over the millennia, centuries, decades, the pace of change has been accelerating. “Every generation throws a hero up the pop chart,” Paul Simon wrote, and a generation, in popular music, is now only about 5 years. That’s how long it takes for the music to change from one style to another. Most people throughout most of human history lived in relatively small villages or groups in which they knew everyone, and everyone knew them, from birth to death. Today, it’s a very different world.
How we understand ourselves and others, how we understand and communicate our needs and experiences, how we make and keep (or don’t keep) relationships, how we find our economic way in the world, how we understand the meaning of our lives and how we seek to achieve our purposes, are all profoundly influenced by this world, and by the cultures–of family, neighborhood, community, belief, economy, nation, and more–in which we’ve learned who’s who and what’s what. Every culture, too, celebrates some values and omits others, claims certain values and also undermines them. This becomes part of the fabric of who we are.
We are also creatures of our biology; members of our species, each with our own biological individuality, with our own temperament and disposition. As neuroscientist Gerald Edelman said, “Every brain is unique in the history of the universe.” To which I would add, “At every moment!”
Creativity, adaptability, compassion, love, the motivation to know and achieve; the instincts (not always well developed) for truth and justice; resilience, the ability to rebound, reinvent, start over; the ability to laugh at ourselves; and the potential to learn through awareness of ourselves, of others, and of life around us, are among the resources we can draw on. Being stuck in habit patterns of thinking, feeling, perceiving, reacting, believing what we’ve been told, trying to relate and communicate but not succeeding, trying to solve today’s problems, which we often don’t understand, with yesterday’s tools, which often weren’t even good enough yesterday; these are what bring us to the impasses in our lives for which we seek psychological help.
Sometimes the stresses of our lives produce symptoms like anxiety, depression, unstable moods we can’t regulate, inability to relax and enjoy life, all the categories of the DSM-5. Eating disorders, sleeping disorders, thought disorders (psychotic episodes), addictions of various kinds, all kinds of mental suffering and misery, can result. In many cases, we can learn to improve or resolve these disorders with our own mental resources and the process of therapy, without necessarily needing medication. In other cases, medication can be an important part of getting better; sometimes until the crisis has passed and we can take over on our own, sometimes on a long-term basis.
Each person is unique, each situation needs to be understood in its own terms, and there is no such thing as a one-size-fits-all therapy. Or therapist.
Conversation, relationship, and psychological skills training are what I have to offer. It can mean a lot to have our experience understood by our therapist, as we come to understand it ourselves. That can lift depression, inspire hope, and bring a sense of direction. Increasing awareness of self and seeing others more as they are can supports better, wiser choices, more likely to meet our needs. The therapeutic conversation, with its micro focus on the individual’s self and life, takes place in the context of the bigger picture of humanity.
Therapy can be fulfilling, healing, even humorous, but it’s not always easy. My song, “I Must Be Getting Better ‘Cause I Think I’m Getting Worse,” refers to part of the process of getting “back in touch” with oneself.
In all this, there is something that calls or pulls us to “reach up,” in our individual lives, in the context of the vast human journey of which we are a tiny part. It has to do with being honest, with how we treat ourselves and others, and being of service. We may call it nature, evolution, divinity, whatever; all our names and definitions are hit-and-miss. But to some extent our psychological health depends on how well we can be in harmony with it.
(This column is Dr. Einhorn’s article in the current Cappstone, the newsletter of the Chicago Association for Psychoanalytic Psychology. Dr. Einhorn is Chair of the Advocating Psychotherapy project at CAPP. To arrange for a presentation about psychotherapy, contact Dr. Einhorn through the website contact link.)
In this time of the prevalence of a one-dimensional medical model of mental suffering and treatment, and the increasing marginalization of psychotherapy as health care reorganizes under intense economic pressures, a colleague has advanced, and perhaps also hindered, the cause of advocating psychotherapy, in a recent column in the New York Times (9-29-13). Op-Ed contributor Brandan A. Gaudano, clinical psychologist at Brown University, writing on “Psychotherapy’s Image Problem,” begins by pointing out that “In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent,” despite the fact that “a recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.” “As well they should,” he continues, “…Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.” (entire article at: http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?emc=eta1&_r=1&/)
Dr. Gaudano attributes “the gap between what people might prefer and benefit from, and what they get,” to the fact that “psychotherapy has an image problem.” And what is that problem? “Primary care physicians, insurers, policy makers, the public and even many therapists are unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries–industries that, not incidentally, also have the money to aggressively market and lobby for those practices.”
So far so good. We heartily agree with Dr. Gaudano’s comments, which are entirely in harmony with the perspective of CAPP’s Advocating Psychotherapy project. But when it comes to identifying what constitutes effectiveness in psychotherapy, Dr. Gaudano is beating the drum of randomized controlled trials. “For patients with the most common conditions, like depression and anxiety, empirically supported psycho- therapies–that is, those shown to be safe and effective in randomized controlled trials–are indeed the best treatments of first choice.” Referring to a recent survey that he completed with his colleague Ivan W. Miller, for the November edition of Clinical Psychology Review, Dr. Gaudano states that “It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).”
“Psychotherapy’s problems come as much from within as from without,” Dr. Gaudano states. “Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which–like some old-fashioned Freudian therapies–should be abandoned.”
Here, I am afraid that some of Dr. Gaudano’s comments tend to muddy the waters about what psychotherapy is and how it can be of value, at the same time that he’s trying to clear them up. For example:
•The use of randomized controlled trials (RCT) as the “gold standard” of outcome study is misleading. RCT requires the standardization of patients into relatively pure diagnostic groups (depression, anxiety, etc., with careful pre-screening to have as close as possible to “pure” diagnostic groups) and therapies into methods defined by techniques (cognitive-behavioral, interpersonal, etc.), overlooking the individuality of patients, therapists, and patient-therapist pairs. Such clarity, simplicity and replicability are not found in the real world, in which patients are usually quite complex, therapists have to adapt whatever methods they are using accordingly, and the interaction between patient complexity and therapist adaptability often has more to do with outcome than diagnosis or treatment method per se.
•The largest contributor to outcome in therapy is quality of relationship between client and therapist (as Jonathan Shedler described in his overview of studies, “The Efficacy of Psychodynamic Psychotherapy,” in American Psychologist (Feb-Mar. 2010). This is not to dismiss the importance of methods and techniques, or the value of a well-stocked toolbag for therapists with more than a narrow specialization. But the methods and techniques are applied within a relational context, which has as much to do with their efficacy as technical skill per se.
•The practice of treating psychodynamic, cognitive, interpersonal, etc., interventions as if they are separate is misleading. I’ve never seen any successful therapy in which unconscious factors in the patient weren’t elicited and transformed, in which the patient didn’t learn to think and perceive differently, and in which the interpersonal life of the patient wasn’t in some ways altered for the better through interaction with the therapist.
•A key mistake, often repeated in the history of modern psychology, has been to reduce our understanding of human behavior and experience to the currently available scientifically accepted methods. “Science” does not mean “whatever we can study with RCT.”
•While it’s good to see psychodynamic therapy included in the winner’s circle of empirically proven methods, the emphasis on short-term therapy overlooks the need of many patients for longer-term work. Symptoms may be resistant to treatment, and can change into a focus on underlying existential issues as therapy proceeds; all of which can take a lot longer than 20 weeks.
•Dr. Gaudano’s assertion that empirically supported therapies are superior to medication still takes place within the medical model, in which mental and emotional disorders are disconnected from the facts and experiences of people’s lives. “Safe and effective” are statistical abstractions within this model. In practice, what is safe and effective for one person may not be for another; thus the lengthy caveats about problems with safety and/or effectiveness in medication advertisements.
As to “psychotherapy’s image problems,” psychoanalytic authorities and institutions have certainly contributed to them, but so have proponents of “empirically validated” treatments. In fact, just about every form of treatment in the field of psychotherapy has been heavily influenced by gifted authoritarian empire-builders and their followers, resulting in a mine field of claims and counterclaims, in which conviction based on reductionist thinking at the expense of wider truth, together with contemptuous dismissal of alternative paradigms, is the currency of the realm. There is no “one size fits all” therapy, or therapist, or method of determining efficacy.
This mine field is the main “image problem” of psychotherapy. The basic method of therapy, in which two people meet to discuss, and try to understand and resolve or improve on, the mental, emotional, and relational problems of one of them, during which they form a particular kind of working relationship which evolves if the work goes well enough–and each of those relationships is unique–continues to be more powerful than the ability of any theoretical model to explain.
Neuroscientific advances will contribute to our understanding of what’s happening in psychotherapy. Neuropsychologist Elkhonon Goldberg, in his The New Executive Brain, states that “even relatively brief but sustained cognitive activity is capable of affecting brain morphology and is detectable in neuroanatomically specific ways” (p. 239). Goldberg is talking about kinds of learning such as new languages or music, but the application to therapy is clear. All this work between patient and therapist, when effective, cultivates salutary brain changes in the patient; and perhaps also, to a lesser extent, in the therapist. Research in this area is already proceeding, although the methods and conceptual frameworks remain relatively crude. Such research, when it reaches maturity, has the potential to reformulate how we understand schools and methods of therapy.
In wider perspective, we can see that therapy and medication, mental and emotional disorders, have all evolved within our society, where rhetoric and practice in politics, education, economics, medicine, the military, religion, government, and business, are characterized by misleading oversimplifications, dogma and ritual mistaken for knowledge and truth, turf wars, cult-like processes, and successive fads; each claiming superiority until it, too, is debunked. And the people, including professionals as well as consumers in each field, tend to be blind to the process itself, caught up in the cycle of fads, one after another. Why should psychotherapy be any different?
What’s needed, across the board, is better information and better informed consumers and practitioners. Now that’s a long-term process; it will probably take more than 20 weeks. But contributing toward it, in whatever ways we can, is the goal of our little Advocating Psychotherapy project here at CAPP.
On Saturday, September 21, Dr. Robert Galatzer-Levy gave the keynote address at a conference entitled “The Essential Other: Generativity, Resilience, and Narrative, A Conference Honoring the Life and Work of Bertram Cohler, Ph.D.” The name is a mouthful, but the conference delivered plenty of nutrition–cheers to conference organizer (and panel presenter) Dr. Christine Kieffer and host (and panel presenter), at Francis Parker School, Dr. Daniel Frank.
Dr. Galatzer-Levy, a psychoanalyst and teacher, had been a long-time colleague and friend of Bert Cohler’s, who died in May of 2012. They had written a book together, entitled “The Essential Other,” published in 1994, thus the title of the conference. Dr. Galatzer-Levy gave the keynote address.
“Why,” he asked, “are people important to each other?” Aristotle’s answer, because man is a political and social animal, is circular. Freud’s “beautiful theory” is that people have drives which can only be satisfied by others; for example, the infant’s need for food and the more mature person’s need for sex. Renee Spitz found that the infant’s needs go beyond merely being taken care of physically. Heinz Kohut noticed that people have an experience of living that is disorganized, so people need “selfobjects” (difficult word) who provide functions like the mother who soothes and calms the child. This experience with the mother, and/or with other selfobjects, including the therapist, is the precursor to the child’s later experience to organize itself. Self = the experience of being in the world. Objects = other people, the focus of drives.
In the late 1980s, Galatzer-Levy and Cohler were very recent grads of the Psychoanalytic Institute and students of Kohut. The then current psychoanalytic concepts didn’t capture the aliveness of being in the world, in relationships with other people and institutions. For Freud, development ends with adolescence, more or less, with the ego and superego in place. Galatzer-Levy and Cohler weren’t satisfied with that and wanted to develop a theory that development continued across the life course. “We were driven by the wish not to be dead at 50.” Their collaboration on “The Essential Other” was easy and productive.
Other people are best conceptualized not as abstractions but as concrete expressions of bodily alive relatedness with someone doing something. The experience of other people combines these things. Cohler and Galatzer-Levy “didn’t have an abstract relationship, we wrote together, did things together.” The idea of the essential other combines the vigorous activeness of actual people with the need for others to meet our needs.
Galatzer-Levy criticized the idea that development means that one moves from dependence to independence. There is, instead, “a shift from a very narrow focus of dependence to an ever wider spectrum of essential life and functioning.” Llinear developmental sequences fit neatly on charts–oral, anal, etc.–but life is not a sequential unfolding, and pathology is not a deviation from that sequence. “Life is continuing transformation across the life course. The only thing abnormal is stasis.”
Theresa Benedict noticed that development is a mutual experience in which there is a change in the caretaker by virtue of the process of caretaking, a mutuality. Cohler would say, to freshman at the University of Chicago, when he was teaching Freud’s “Interpretation of Dreams,” “We are all equal before the text.” The benefits of teaching, of caretaking, go in both directions. Memories can serve “essential other” functions, entities can be present in a way despite the fact that they are not physically present, even no longer here, as is the case for Galatzer-Levy with his friend and collaborated, Bert Cohler.
Galatzer-Levy emphasized the importance of friendship, “about which psychoanalytic theory has little to say.” Kids who are happy have friends who matter a great deal to them. Most people, asked who the most important people in their lives are, will include their friends. Galatzer-Levy recommended Huckleberry Finn as a study in friendship, in which Huck Finn and Tom Sawyer were essential others to each other, as their dialog moves both boys forward.
In addition to “essential other” relationships between people, there is the relationship of the individual with institutions. Cohler’s relationships with the University of Chicago “played a central role in his psychological life,” beginning as a patient/student at the Orthogenic School. “The University of Chicago’s values were his own,” including “close reading of text,” and within the University framework Cohler taught classes of freshman “year after year.”
Noting that “The Essential Other” is 20 (or so) years old now, Galatzer-Levy considered what changes he and Cohler might make were they to do a revised edition today. “The work of developing coherent narratives is a lot of the process of psychoanalytic work (and) the editing of narratives is a large part of psychoanalytic work.” Another difference: “We described a 1:1 relationship between individuals, and between individuals and institutions.” But today’s models for analyzing networks provide a richer way to see the individual’s role within a network.
Galatzer-Levy noted that fractals provide another way of looking at people. “Fractal structure separates the inside from the outside in a complicated way, you can’t specify what’s inside and what’s outside. The fractal vision of boundaries doesn’t fit with the issues of one person interacting with another as analysts usually think of it. The boundaries (between inside and outside) are much richer.”
I very much appreciated and enjoyed the clarity of Dr. Galatzer-Levy’s overview of a stream of psychoanalytic thought beginning with Freud and going through Kohut, with significant contributions from others. His jump from Aristotle to Freud did overlook a few significant developments in understanding human nature between the one and the other, but, as Doris Lessing pointed out, this is typical of the Western academic tradition. I was delighted to hear Galatzer-Levy consider the implications of fractals for understanding, or at least modeling, metaphors of human behavior, since I’m interested in the question of whether fractal math can complement the math of probabilities and the normal curve upon which all of psychometrics (the math underlying psychological testing), and most if not all of science, is currently based. I was especially impressed with the concept of “the essential other” in our understanding of human nature and development through relationship. Certainly therapists become “essential others” for clients or patients, when the therapy is working. The concept of “the essential other” is also powerful in relationships between individuals and persons no longer physically present, and with institutions.
I’m thrilled that my song, “I Got A Brain,” is featured by Dr. Virginia Campbell on the hallmark 100th edition of her great Brain Science Podcast, of which I am a fan. The program begins with a few lines from the song, and concludes with the entire song in the final 2:25. In between is a great interview with Alvero Fernandez on brain fitness and some feedback from listeners expressing their gratitude for the nearly seven years in which Dr. Campbell has been creating the Brain Science Podcast. The BSP website is www.brainsciencepodcast.com/, and the 100th episode is at:
http://ec.libsyn.com/p/7/c/9/7c943f28babea572/100-BSP-BrainFitness.mp3?d13a76d516d9dec20c3d276ce028ed5089ab1ce3dae902ea1d01cf8033d6c05992d4&c_id=6035218
Last month I gave a presentation on “Incorporating Spirituality In Clinical Practice” to the therapists at the Lakeview Center for Psychotherapy, in Chicago, and this week I’ll be presenting on “Top-Down, Bottom-Up, and Reciprocal: A Brain-Based Model Of How Psychotherapy Works,” to therapists and guest colleagues at the Gifted Learning Center ~ North Shore, in Skokie.
These presentations at local programs remind me of house concerts, where the artist performs in a host’s living room for a small audience. There’s much more possibility for interaction, supporting a fuller and more complex experience, compared to a concert performance, or a professional presentation at a conference; unless it’s a small break-out program at which I’m presenting to a relatively small group, as I did at the Illinois Counseling Association last year.
I’m looking forward to it!
By Jay Einhorn, © 2013
We all need to be able to have difficult conversations effectively, and there are attitudes and skills that can help us do that. Here’s a summary I wrote, with a pitch at the end for consulting and training work.
Executive Summary
Communication fads come and go, but difficult conversations are here to stay, so information that helps us to have them more productively is welcome. The books, “Difficult Conversations,” and “Crucial Conversations” describe a number of ideas, attitudes and skills to help. I’m using key ideas, mainly from “Difficult Conversations,” in my consultation and therapy, and recommend the book. “Crucial Conversations” looks at the same territory in a somewhat different way, with one very important difference. I introduce ideas from both books, together with information from other sources, in my consultation, training and therapy.
Learning a concept doesn’t necessarily mean knowing it deeply enough to apply it, and there’s a tendency to revert to old habits and “them and us” attitudes in actual situations. So, in addition to presenting the information, I recommend supporting depth learning through experiential methods, including discussion of cases, role playing, and ongoing focus on the issue through a focus on pre- and post- difficult conversation work.
We All Have Difficult Conversations
Communication fads come and go–there’s a new one every few years in the worlds of human relations, education and organizational training–but difficult conversations have always been with us, and always will be. As a student of human nature, a therapist, diagnostician, consulting psychologist, administrator, and–of course–as a person living in this world, I have been in and around many difficult conversations!
Four impressions have become clear:
1. Many difficult conversations that go badly don’t need to be had at all. They occur because of a misunderstanding that could have been cleared up through simple inquiry, or because people acted on feelings and assumptions that they should have taken time and effort to understand and manage rather than “letting them out the door” prematurely.
2. Many difficult conversations that must be had are avoided, because the people who need to initiate and manage them don’t know how to. The result is that bad consequences are allowed to happen because no one is dealing with a problem that needs to be dealt with.
3. When difficult conversations are necessary, there are attitudes and skills that can help them to go better. Potential damage can be avoided or minimized, and relationships preserved and even improved. The participants in the conversation can learn things they need to learn. Such conversations can even be healing.
4. When difficult conversations happen without the necessary attitudes and skill, they can be counterproductive. Relationships can be damaged, people can be hurt–there can be “too much heat and not enough light,” in one of my favorite phrases–necessary learning won’t happen, and the consequences can be injurious to the people having them and their families, organizations, communities, and societies.
The book “Difficult Conversations,” by Douglas Stone, Bruce Patton, and Sheila Heen, of the Harvard Negotiation Project, takes an in-depth look at how difficult conversations can go wrong, and describes a set of ideas, attitudes and skills to support having the necessary difficult conversations of life more effectively and productively (http://www.amazon.com/Difficult-Conversations-Discuss-what-Matters). I’ve found it useful in my work in individual and couples therapy and organizational consultation and training.
Some Key Ideas From “Difficult Conversations”
1. Shift from a Conflict Conversation to a “Learning Conversation”
The purpose of applying “Difficult Conversations” methods is to move difficult conversations from being antagonistic or adversarial conversations, in which people are attacking and defending or trying to achieve goals through power or manipulation, to being learning conversations in which both parties are listening to one another as well as saying what they need to say.
2. The “Three Conversations:”
A key idea in “Difficult Conversations: is that every difficult conversation is really three conversations:
1. The “What Happened” conversation, consisting of “3 stories,”
2. The “Feelings” conversation, and
3. The “Identity” conversation.
3. What Happened: The Three Stories
There are three stories about “what happened” in every difficult conversation: each party’s story or narrative of events, and the “third story.” The “third story” is the story which might be told by an impartial third party, such as a mediator, which includes elements of each party’s story without casting any blame.
For example, in a school situation, a parent and teacher might need to have a difficult conversation about a child’s failure to complete his homework.
Let’s say that Johnny, a fifth grader, has stopped handing in his homework and is falling behind in class. The teacher’s story is that she is sending homework home with Johnny but his parents are not following through to make sure that he does it. Johnny’s parents both have demanding jobs and the teacher thinks that they are just too drained when they get home to have the energy to do the difficult work of making Johnny do homework, especially if he doesn’t want to do it. She also thinks Johnny’s parents might feel guilty about spending so much time away from home at work, so they might be overly permissive and allow him to avoid homework.
Johnny’s parents’ story, on the other hand, is that Johnny is being bullied by a bunch of kids at school, and he’s hurt, sad and angry about it, so he doesn’t want to even think about school once he’s out of there. So that’s why they think Johnny isn’t doing his homework. And they think his teacher is either accepting other students bullying him as normal behavior and letting it happen, or else that she is just too careless to even notice that it’s happening.
The “third story” is that Johnny is not doing his homework and falling behind in school, so now his teacher and parents need to look at this together to try to understand why he’s falling behind and see how they can work together to help him get back on track.
The “Difficult Conversations” authors suggest starting a difficult conversation with the “third story.” Johnny’s teacher might do that at the beginning of her meeting with his parents, to start the conversation on a good foundation that she can “reframe” back to if the conversation is in danger of becoming undermined or blown up as it progresses.
4. The “Feelings Conversation”
According to “Difficult Conversations,” every difficult conversation is powered by feelings, which are often not acknowledged. It can be very important to acknowledge these feelings without letting them undermine the conversation. For example, Johnny’s parents may feel angry about Johnny’s being bullied at school, helpless to do anything about it, and let down by his teacher. His teacher may feel let down by Johnny’s parents, and unfairly blamed. It’s important for both parties to acknowledge and respect one another’s feelings, while not letting them derail the conversation. If someone becomes too upset, taking a time out and returning to the conversation in a few minutes, or even rescheduling it to another day, can help to keep it on track.
5. “Reframing”
Reframing is one of the most important “Difficult Conversations” skills. If Johnny’s parents accuse his teacher of not caring about him, she could allow the conversation to get blown off course, by reacting defensively or counterattacking, or she could reframe the conversation by interpreting their comment as an expression of their concern, emphasizing that she is concerned too–that’s why she called the meeting–and getting the conversation back on track.
6. The “Identity Conversation”
The “identity conversation” could be described as the stake that each person’s ego or self has in their personal or professional role in the conversation. For example, if Johnny’s parents accuse his teacher of not caring about Johnny, they are attacking her identity as a teacher. If she then gets stuck in defending herself–”of course I care about him, I’ve been a teaching for a dozen years and I care about every one of my students!”–or gets too upset to remember her agenda for the meeting and keep managing her role as facilitator, the conversation is likely to become useless or counterproductive. And of course the same thing could happen if she counterattacks Johnny’s parents with: “If you cared about him you’d make sure he got his homework done!”
7. Reframe From Blame to Contribution
The “Difficult Conversations” authors regard the establishment of blame as not a useful strategy. Instead, they assert, it’s more useful to think in terms of the relative contribution of each party. In our example, it doesn’t really help anyone for Johnny’s parents blame his teacher or his teacher to blames his parents. But if, as a result of the difficult conversation, Johnny’s parents and teacher can have a learning conversation, the teacher might realize that she’s contributed to the problem by not being aware that Johnny was feeling picked on, and his parents might realize that they’ve contributed by not taking a firmer position with Johnny about doing his homework regardless of how he felt about his day at school.
8. Avoid “Intention Invention”
By “intention invention,” the authors mean that we make up reasons about why we think someone we’re in a conflict with is doing whatever they’re doing, when in fact we don’t really know why they’re doing it.
“Intention Invention” reminds me of two rather complicated ideas, which I’ll mention without going into in depth: “attribution” in cognitive psychology, and “projective identification” in psychoanalytic psychology. I’ve described how these ideas relate to intention invention in my blog, http://psychatlarge.blogspot.com/.
The “Difficult Conversation” authors emphasize that most of what we do has multiple motivational sources. In our school example, Johnny may be falling behind in his homework partly because he’s being picked on, partly because he feels the teacher doesn’t like him, partly because he finds the work difficult and would rather avoid it, partly because there are more enjoyable activities for him to do after school, and partly because he can get his parents to let him; which then makes him feel special and able to control the events in his life, at least at home. His teacher and parents will have similar multiple motivations contributing to their own perceptions, feelings, and attributions. So it’s generally a mistake to think that someone we’re in a conflict with is doing whatever they’re doing for only one reason,; or that we ourselves are. We are almost always operating on the basis of a mixture of motivations.
“Intention invention” is a modern version of the old saying, “Give a dog a bad name and hang it.”
9. Authentic Listening
Authentic listening is a key skill in any difficult conversation. Everyone knows that you’re supposed to listen, but people often just go through the motions of listening, and sooner or later the other person usually gets this.
The Difficult Conversations authors don’t assume equal motivation on the part of both parties at the beginning of the conversation. Whichever party is taking the responsibility to facilitate the difficult conversation has to be ready to authentically listen to what the other party has to say. The purpose of listening is not to defeat the other person in argument, or manipulate them, or wear them out. I would say that authentic listening leads to existential engagement, and that often makes a difference in difficult conversations, because people often know intuitively when someone is, or isn’t, really engaging with them.
“Crucial Conversations” and Truth
Another book that provides insight, attitudes and skills for having difficult conversations effectively is “Crucial Conversations: Tools for Talking When the Stakes Are High,” by Kerry Patterson, Joseph Grenny, Ron McMillan, and Al Switzler (http://www.amazon.com/Crucial-Conversations-Tools-Talking-Stakes). “Crucial Conversations” provides ideas such as “Speaking Persuasively, Not Abrasively” and “Making It Safe” in a conversation, and many others, covering much of the same territory as “Difficult Conversations,” in another way. But one key difference between “Crucial Conversations” and “Difficult Conversations” is in the attitude toward truth.
“Difficult Conversations,” holds that each person has their own truth, but there isn’t necessarily an objective truth per se. “Crucial Conversations,” on the other hand, both sees objective truth as existing in situations, and even sees the goal of conversational skill as to be able to speak the truth about a situation effectively, in a way that doesn’t attack or repel the other person(s) in the conversation, and in a way that they can hear. So, in “Difficult Conversations,” there’s my truth, and your truth, and we have to work it out. In “Crucial Conversations,” there’s the truth, and we have to be able to acknowledge it together.
I believe that there is an objective truth in all situations, but that it’s more important to some difficult conversations than others to acknowledge it explicitly. A related issue is how much truth needs to be acknowledged in a difficult conversation in order for progress to be made. There is, after all, always more truth than we can perceive or absorb at any given time. This has led me to coin the phrase, “the minimum necessary truth.” That means that, in any situation, there is a minimum necessary truth which must be acknowledged by all parties if things are to be made better.
“Them and Us:” Arthur Deikman
Psychiatrist Arthur Deikman (www.Deikman.com) makes an important contribution in his book, “Them and Us: Cult Thinking and the Terrorist Threat” (http://www.amazon.com/Them-Us-Thinking-Terrorist-Threat). Deikman discusses the effect of propaganda and how cult-like thinking can foster the illusion of debate of issues rather than genuine consideration. “In most conflict situations, disagreements are based on differences in interpretation and in the priorities given to different values, but these differences are seldom stated, and, lacking that clarification, we absorb highly selective information, are swayed to one side or the other, but end up no wiser…opposing propagandas do not assist the democratic process but produce partisans, each with the mind-set of a cult member…” It’s easy to see how the same attitudes undermine the necessary difficult conversations of life, when the participants try to win (however they define that) rather than have an actual conversation.
Deikman indicates four areas that can usefully be clarified in the discussion of a controversial problem:
“1. The key data. (Are they disputed?)
2. Interpretations of the data.
3. Value conflicts. (Reason for giving one value priority over the other?)
4. Error indicators. (What events or facts would indicate to each side that their belief or strategy should be changed?)”
Clearly these ideas, and the attitudes underlying them, can usefully be included in many difficult conversations.
Application: From Passive to Active Understanding
The attitudes and skills for having difficult conversations more successfully are not easy for most of us to acquire and use. We generally don’t learn them through our professional education, or even our moral, religious, or spiritual education. Doing difficult conversations well requires an enormous amount of cognitive executive functioning–that is, staying on task, not taking criticisms and attacks too personally, continually monitoring the conversation and reframing as necessary.
Psychologists distinguish between different forms of learning, such as semantic and procedural. It’s one thing to know the key ideas about how to have difficult conversations more effectively so that one can define them or answer multiple choice questions about them. It’s entirely another thing to know them deeply enough to apply them in actual situations. In my work with individuals, couples and groups, I’ve often found that people who seem to understand them pretty well when I discuss them, or present them in lecture and Powerpoint, often revert instantly to a “them and us” attitude when applying them in discussion of cases or role playing exercises.
Surely, there are different levels or ways of knowing, and it’s part of human nature that we know information that we don’t apply. One of my favorite teaching stories is about Ibrahim Ben Adhem, a prince who, like the Buddha, left his royal home to seek knowledge. As he was walking down the road he came across a stone on which was written: “Turn me over and read.” Turning the stone over, Ben Adhem read: “Why do you seek more knowledge when you pay no heed to what you already know?” (Retold by Idries Shah in his Caravan of Dreams, within the narrative, “Encounter At A Hermitage.” See listing at http://www.ishkbooks.com/books/books_shah_catalog.html)
There are multiple levels of depth to that story! We often find, as we look back on our mistakes, that we knew better than to do whatever we did. We may have had some sort of inkling that we failed to heed at the time, or maybe there was a principle that we ignored because we wanted to see the situation in some other way than it really was. In psychotherapy and consultation, I often contribute more by helping my clients clarify and apply what they already know, than by introducing new information; though some new information may be necessary to help them understand and use what they already know, like the “stone,” and some effort, like “turning it over.”
Emphasizing the difference between different kinds of learning, British educational psychologist Lawrence Stenhouse, in his, “Introduction to Curriculum Research and Development,” distinguished between “information,” by which he meant what we know passively (for example what we can define on a multiple choice test) and “knowledge,” by which he meant understanding that we can apply in situations in which the correct response can’t be pre-specified. (http://www.amazon.com/Introduction-Curriculum-Research-Development-Stenhouse). American psychologist Robert Ornstein, in his “Mindreal” (http://www.ishkbooks.com/books/MRB.html), refers to his research on both halves of the brain in discussing how the left hemisphere is more involved in understanding words as such, but the right hemisphere is more involved in interpreting what they really mean.
This is why experiential learning is so important when it comes to learning difficult conversation skills (and many other relationship skills!). Discussion of actual case situations, and role playing of actual and simulated situations helps to bring home the meaning of attitudes and skills for difficult conversations. Even participants who just watch can potentially benefit from watching others actually engaged, as cats who watched other cats learn a maze were able to learn it more quickly later than cats who hadn’t.
Accordingly, there are several ways that I’ve been involved in helping people to learn skills for having difficult conversations more effectively:
1. An information presentation of basic ideas, attitudes and skills for having difficult conversations more successfully. This happens on a discussion basis in individual and couples therapy, and is supported by Powerpoint and handouts in group training.
2. Consultation reviewing case studies involving discussion of actual difficult conversations.
3. Experiential learning through role playing.
4. Ongoing consultation and training, including pre-planning before difficult conversations and debriefing afterward, extending over a series of consultations.
5. Actual involvement as a consultant-participant-facilitator in difficult conversations, optimally also including pre-planning and debriefing.
Even with training, we all learn in our own way and at our own pace, and sometimes we have to have experiences after training for the training we’ve received to actually make sense. But we’re all going to be involved in difficult conversations, so it’s important that we learn attitudes and skills that support having them more effectively. Knowing and using a more productive approach can make a great deal of difference, again and again.
(note: I want to emphasize that I haven’t met the authors of “Difficult Conversations,” haven’t received training from them or their colleagues, and am not an “official vendor” of “Difficult Conversations” training. I’ve been interested in helping people develop attitudes and skills for having difficult conversations and resolving conflicts more successfully for a long time, and “Difficult Conversations” is a valuable resource, as are the other sources mentioned.)
I’ve been in practice long enough to remember when very few students applied for extra time on the SAT/ACT college entrance exams, or the GRE, LSAT, and MCATS graduate exams, or professional board exams, and all that was needed was a doctor’s note that the student needed extra time due to a certain condition. That was when parents and adult students thought it was stigmatizing to be labeled with a disability. Parents often resisted allowing it even when school staff thought the child should be evaluated to receive accommodations, including extra time for exams.
Then parents and adult students began to realize that having extra time on high stakes tests could confer a competitive advantage, and there was a trickle, then a flood, of parents seeking diagnoses for their children, and adult students seeking diagnoses for themselves. This coincided with the widespread recognition of ADHD and related attention disorders, and resulted in a flood of applications to SAT, ACT, GRE, LSAT and MCATS for extra time. Many of these applications were based on attention disorders which were diagnosed for the first time just as the student was approaching the high-stakes exam, and were supported by flimsy or shoddy evaluations.
The result was that the test organizations pushed back with a series of guidelines for eligibility, based on the student’s having a history of needing and receiving accommodations in school before applying for accommodations for the high stakes test, including:
• Learning or attention disorders diagnosed earlier in life, preferably supported by subsequent re-evaluations (generally at 3-year intervals)
•Diagnosis based on evaluations including case histories and standardized measures, tending to be more thorough rather than less
• A history of accommodations having been provided by the school(s) the student attended
• A history of the student actually using the accommodations that were available
This policy favors early evaluation and accommodations in order to develop a track record by the time the application for accommodations on the high stakes test is made. Students who have managed to get by despite learning or attention disorders, and who are evaluated and diagnosed for the first time in high school or college or professional school, especially just prior to the high-stakes exam, are unlikely to be found eligible for extra time. High school and college special education staff have learned to be suspicious of claims for accommodation from newly diagnosed students.
The result is that there are fewer students qualifying for extra time on the basis of inadequate diagnosis and documentation, but also that some students who really should qualify can’t. This is unfortunate because, at any point along the educational path, students who have been able to keep up so far despite their learning or attention issues may find themselves no longer able to do so.
Unfortunately, the emphasis on high-stakes tests often leads parents and older students to think about evaluation just as a way to qualify for extra time, a gatekeeping event, rather than as a method of clarifying the learning styles and issues of students so that they can know themselves better and learn more effectively.