Author Archives: jayEinhorn

Branding Therapists

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This article is reprinted from the winter, 2013, Illinois Psychologist, the newsletter of the Illinois Psychological Association.

A recent article in the New York Times Magazine focused on “branding” as the solution for underfilled therapy practices.  Posted online as “What Brand Is Your Therapist?” therapist Lori Gottlieb described her problem establishing her practice after completing her training, and the role of “branding consultants” in advising therapists on how gain traction in the marketplace (12-24-12 edition).   The article produced online reactions both at the Times website and also on the IPA listserve (where I’m always glad to see substantial dialog!).

I suppose that “branding,” understood in this case as putting a superficial tag on something much more complex in order to make it recognizable in a marketplace that devalues complexity, is a very old problem.

The Sufi teacher Idries Shah tells a modern version of an old story about a spiritual teacher who teaches mainly through stories, the meaning of which unfold over time, partly through the effort of each student and of the group of students as a whole, partly through receptive absorption, and partly through interaction with the teacher through conversations and experiences.  One particularly superficial student was unable to learn.  He tried to torture a meaning from the stories, and when he couldn’t he tried to trick the teacher into giving the key to unlock them; as if there was one.  Finally the teacher sent the hopeless student away.  Several years later, the former student returned to visit.  He had become successful in the world, arriving in a lavish new car, upholstered in priceless carpets, with a uniformed driver, wearing a bespoke suit and gold jewelry.  “I am glad to see that you’ve become successful in the world,” said the teacher.  “And have you given up trying to torture a meaning from the stories?”  “Oh yes,” said the student, “I teach them now.”

So the student was better at branding himself than the teacher was, although branding may not have been the teacher’s priority.

Psychologically, it makes sense to look at branding from a neurocognitive perspective. Our brains operate perceptually as pattern-matching stimulus recognizers and information organizers.  This both makes us very efficient at recognizing things once we’ve learned to, and also gives rise to the problems of stereotyping and prejudice, cognitive-affective functions that underlie much of brand-perception.

The Times article focuses on therapists branding themselves in order to be perceptible to potential clients, as if the problem is entirely on the consumer side.  But the culture of professional mental health itself is by no means immune from branding.  The DSM, with its division of mental illnesses into categories which are often artificially distinct–you can have an affective disorder or a personality disorder–acts as a kind of compendium of “brands” of mental illness.  The diagnostic job is done when the label is conferred, even if little or nothing is understood about the client’s personality, cognitive style, history, social network, or existence within the larger culture.

Psychotherapy, too, is permeated by “brand” thinking.  “What kind of therapist are you?”  “I’m CBT.”  “I’m psychodynamic.”  etc.  Yet we know that relational, interpersonal, dynamic, and cognitive factors are present in virtually all therapeutic work, and that the personality, personal history and personal style of the  therapist make a huge contribution to how each therapist actually goes about doing therapy.

So, to be human is to be susceptible to “brand” thinking.  And if America has evolved a particularly brand-conscious culture, that is the culture in which therapists who work here have to succeed, while maintaining our integrity and without letting the more complex and nuanced perception of the nature and treatment of psychological problems, which good psychotherapy depends on, be lost in the process.

“Read the Consitution”

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A Facebook buddy shared this photo of anti-Obama rally participants showing a sign:  “Obama, Read the Consitution.”  Of course, they think it means what they think it does, even if they can’t spell it.

The Constitution has been interpreted in various ways ever since it was written.  During the Civil War, both sides fought to defend the Constitution.  The doctrine of “original intent,” meaning that the Constitution should be interpreted in light of how the framers would have understood the issue at hand, is in vogue.  I am told that the majority in the U.S. Supreme Court favors the doctrine of “original intent,” including the Justice who would likely have been a slave had he been alive when the Constitution was written.

Ulysses S. Grant made this striking observation about the Constitution in his “Personal Memoirs of U.S. Grant and Selected Letters 1839-1865:”  I haven’t seen a better comment:

“The framers (of the constitution) were wise in their generation and wanted to do the very best possible to secure their own liberty and independence, and that also of their descendants to the latest days.  It is preposterous to suppose that the people of one generation can lay down the best and only rules of government for all who are to come after them, and under unforeseen contingencies.  At the time of the framing of our constitution the only physical forces that had been subdued and made to serve man and do his labor, were the currents in the streams and in the air we breathe.  Rude machines, propelled by water power, had been invented; sails to propel ships upon the waters had been set to catch the passing breeze–but the application of steam to propel vessels against both wind and current, and machinery to do all manner of work had not been thought of.  The instantaneous transmission of messages around the world by means of electricity would probably at that day have been attributed to witchcraft or a league with the Devil.  Immaterial circumstances had changed as greatly as material ones.  We could not and ought not to be rigidly bound by the rules laid down under circumstances so different for emergencies so utterly unanticipated.” p. 147

 

At the Illinois Counseling Association 2012 Conference

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I’ve just completed the Illinois Counseling Association 2012 conference, in Springfield, Illinois, where I presented as well as attending.  Here are some highlights:

On Friday, 11/9, in Reclaiming the Future:  Preparing Disengaged Adolescents for Productive Lives After High School, Ginny Fenski-Mathers presented the alternative high school program where she counsels in Rich Township District 227 (Matteson).  Her program is for students who have “detached themselves from the traditional educational process,” by becoming “credit-deficient” (e.g., falling too far behind to graduate in traditional high school) or being “students who are in danger of leaving the educational setting before earning a high school diploma as a result of dropping out, being pushed out, or being ‘aged out’ of school.”  The primarily problem is that these students have become “disengaged.”  “Most of the students we work with lack a sense of belonging; they feel that they don’t belong anywhere.”

Disengaged students may be dealing with traumatic losses, such as critical illnesses in the family, homelessness, etc.  “Just about every student coming into our setting are dealing with grieving issues.”  Fenski-Mathers quoted grim statistics:  “80% of jobs require post-high school education, 82% of criminals are high school dropouts, including 59% of federal inmates.”

Family support can be key to helping disengaged students graduate, and parents must come in with their child “on day one” of the alternative program.  Student risk factors include academic (unidentified learning, behavior and/or emotional disorders, learning gaps for one reason or another), social-emotional (undeveloped social skills, unresolved grief, negative perception of the environment), home (poverty/homelessness, high family mobility, illness or abuse in family) and life (gang association, drug and alcohol use, pregnant/teen parent, or incarcerated) factors.

Fenski-Mathers’ program is an evening (4:00-8:00 PM) program housed in a high school, which provides self-paced computer instruction with teacher support in each classroom.  “Most teachers teach to the average, so classes don’t work as well for these kids.  Self-pacing with support is more user-friendly.  The computer provides visual and kinesthetic contact, and the teachers provide 1:1 support and auditory input.”  Each staff member “adopts” 5-6 seniors each year, to see them through, nudging them along and running social and program interference for them.

Fenski-Mathers’ colleague Josh Collier then spoke movingly about the need “to make them feel that they belong.”  Much of what we teach, he said, is “social skills and anger management.”  The perspective on anger is, “Anger is just unresolved hurt.”  “Many kids don’t even know what a healthy relationship looks like, “he said, so thye have to teach even that.

Fenski-Mathers has been with the program since its inception, 12 years ago, and her dedication (along with Collier’s) was apparent.  When twelve of her students voted after a voter preparation program at the alternative school, she felt, “…their ‘I voted’ stickers really said, ‘I belong’ to the community.”

In Reconceptualizing Adventure-Based Counseling:  Activities for Everyday School and Clinical Settings, Kimberly Hart and Charles Myers presented activities “beyond simply talking with clients and listening to others talk to you” for teaching and counseling.  The group did a number of “warm-up” type activities, designed to help members experience and discuss feelings rather than just talking about them.  Such exercises, which go back to the days of Encounter Groups (which I participated in as an undergraduate), can be helpful for “breaking the ice” and helping strangers (or people who know each other within very restricted roles) to feel a sense of human connection, and that happened very easily in this group of counselors and counseling students.  Beyond that, such exercises can be useful for opening doors into deeper feelings, attitudes and experiences of members, but those results are often difficult to harvest and integrate meaningfully into the group.  In some ways, the two sets of goals–establishing connection and digging deeper–can’t very effectively be done at the same time, it seems to me; although the warm-up goal can precede the dig-deeper one.

There were poster sessions on Friday and Saturday; I only got to Friday’s.  The poster I was most enthusiastic about featured the “Living Room” program, a mental health crisis respite program that is an alternative to the emergency room, presented by Courtney Emery of the Turning Point agency.  E.R. services are hugely expensive and, except for patients who really need inpatient admission then and there, not usually the most appropriate service for persons with mental health crises.  A program staffed with trained mental health counselors can both offer better care and reduce treatment costs.

I was invited to join a small party for dinner–in fact, participants in the Activities session earlier–and then chatted with several counselors after we returned for a “desert bar.”  There was a warm open-heartedness from so many people in this group of counselors, which was quite distinctive among conferences I’ve attended.

On Saturday, 11/10, in Why Can’t My Client Change his/her Financial Behavior, financial adviser Wallace Larson focused on an issue that I think is far too underrecognized as a source of distress, conflict and trauma:  personal economics.  “Through both nature and nurture we absorb messages about money,” he said, which “frequently…cause a dysfunctional relationship with money.  In couples work, “Money conflicts in relationship can evoke unfinished business, unconciously,” from a client’s past.  Experiences like growing up in a home where the refrigerator is empty at the end of the month because the money’s gone, or a home that becomes foreclosed, can exert a powerful influence on the developing child.  And, “T.V. shows images of homes which send messages about wht to spend on.”  Larson’s references to “financial infidelity” and “financial enabling” identified important categories of dysfunctional financial behavior.

Larson has a website and newsletter, at www.EssentialFinancialStrategies.com/.

In When a Soldier Comes Home:  Reviving the Relationship with Family and Society, Renee Saltzman and Lynette Sanchez introduced the way soldiers are taught to think about themselves as they enter military life; which includes the fact that only Army soldiers are “soldiers;” Marines and “Marines,” Navy are “Seamen,” and Airforce are “Airmen.”

Among the challenges facing soldiers (used generically) upon return are “New Self versus Old Self;” the soldier has become, in some ways, a different person as a result of his or her deployment.  And so, of course, have the spouses, children, friends, and family members whom the soldier left behind and now returns to.  There are “existential issues” having to do with the significance of ordinary life compared with the urgent intensity of life-and-death during deployment.  “Unemployment and homelessness” may plague returning soldiers, and “predatory higher education recruitment,” focusing on their G.I. benefits, is a specific problem.  (One Marine, who had suffered a brain injury and was signed up by a higher education recruiter after returning home, couldn’t remember the courses he’d signed up for.)  Excerpts from a poignant video of a Marine discussing the experience of coming home after 4 years in Iraq were played.  “We were told what to do in the Marine Corp, and have to be a self-starter outside,” he observed  But, the Marine continued, most soldiers don’t want any training when they are done with their service, they just want to come home.  “A lot of guys think they’re OK (but) they’re really not OK.”

Kashunda McGriff presented A Relational Cultural Approach to Working with Undocumented Students.  She emphasized the “Fear of getting caught, deported, sent to a country where they don’t know anyone,” that can plague undocumented students who came here as young children, or perhaps were born here to undocumented immigrant parents.  Such children may feel that they belong neither to the U.S.A. nor to the country of origin of their parents.  Their inability to visit family members back home, including for significant events, contributes to their sense of isolation and lack of belongingness.  Their parents may have suffered from pre-migration trauma, and may feel guilt about leaving relatives behind.  “Immigration enforcement has changed a lot since 9/11,” McGriff emphasized.  Students “may be responsible for speaking for the family, for parents who may be unable to speak English.”

In Relational Cultural Therapy, healing and change are seen as coming from the relationship between therapist and client, in which the therapist helps clients feel connected by respecting and accepting their experience.  The approach is egalitarian and sees chronic disconnection from society as often due to oppressive power relationships.  The theory originated at Wellesley College, where it was founded in feminist theory, though it has evolved to be more inclusive, McGriff said.  She offered a quote from one of the founders, Jean Baker Miller, “All forms of oppression encourage people to enlist in their own enslavement.”  McGriff’s demeanor was warm, respectful, inviting, welcoming; she’s a counselor anyone would want to be accepted by and would open up to.  But I could see how another practitioner might be more strident and overtly ideological.

I spent most of the period before my presentation reviewing it, but was able to arrive in Eric Dutt’s session on Living a Purpose-Driven Life:  A Critical Overview of Cultural Motifs and their Impact in time to hear Dutt, who is from India, give an example of how people from different cultures may experience the same thing.  Dutt considered drone strikes from an Eastern and Western point of view.  From the Western point of view, such strikes are carefully managed, as warfare goes, and the deaths of innocents, or “collateral damage,” are regarded as minimal and worth the military and security goals of the operation.  From the Eastern point of view, however, the scales of value are reversed, such that the killing of innocents is seen as so terrible that it outweighs the value of killing and discouraging militant terrorists.  This was quite an eye-opener for me, and I asked Dutt, after the formal session ended, how he would explain such terrorist acts as suicide bombings, which of course kill many innocent people.  “Those are done by ideological groups,” he explained, not people grounded in the basic values of their culture.

Then I presented my program, A Model for Incorporating Spirituality in Clinical Practice.  My goals were to:  1. present a model of spirituality that makes psychological sense and is neurocognitively and traditionally informed; 2. to consider the model’s contribution to our understanding of how psychotherapy works (since the method of therapy is more powerful than the ability of any extant theory to explain it, imho); 3. to discuss how the model can be incorporated in clinical practice; and 4. to provide some time for participants to try putting it into practice.  My presentation introduced spirituality as a necessary topic in clinical practice; differentiated spirituality from religion, and considered emerging trends in an expanded view of cognition.  These included neuroscientist Roger Sperry’s view of how consciousness can self-organize the “top-down reorganization” of mind, psychologist Robert Ornstein’s “Multimind” concept of the inner life, and the “Observing Self” concept of psychiatrist Arthur Deikman.

In this model, spirituality is understood as a natural potential for self-transcendence in which the individual connects with some source of higher values and/or experience in the process of self-observation in a way that can have a top-down reorganizing potential in personality and behavior.  Therapy provides many micro-experiences of self-transcendence, usually not noticed for what they are, while the client reflects on her or his internal life, and these micro-experiences cumulatively support increases in consciousness leading to top-down reorganization.

The model doesn’t advocate any particular form of therapy, but sees this kind of micro-self-transcendence (which, far from being an emotional or ecstatic experience, is so small and seemingly mundate that it is easy to overlook) as existing in most or all forms of therapy that are effective.  Therapists who are aware of it can induce it more mindfully.

I had planned to sing a few songs as part of today’s presentation, but had a bad cold and could barely talk, let alone sing; but I played parts of a couple of songs from my laptop.  As always, I left the program thinking about how I could have improved it; less lecture and more time for experiential practice would have been a better mix, I felt.  But participants had good comments, were interested enough to ask me to post the current version of my slideshow (rather than the one I’d sent in earlier and subsequently modified), and the break-out practice sessions, in which participants alternated serving as therapists, clients, and observers, hummed with energy and seemed, in some cases, to get quite deep quite quickly.  A participant said she’d be including some of my slides in her teaching, which I approved of as long as my work was given with attribution to me, and the same participant delighted me with the comment that she’d entered this session, the last of the conference, feeling so tired that she was worried about driving safely home, but after our session she was so full of energy and ideas that she’d was certain she’d be fine.

How We Disregard What We Know

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How is it that we can act in disregard of what we know?  It must be one manifestation of what psychologist Robert Ornstein calls, “Multimind” (http://ishkbooks.com/books/MULT3.html/).

A stark example of acting in disregard of what one knows comes from “Plan of Attack,” journalist Bob Woodward’s 2004 book about how the U.S.A got into the Iraq war.  Woodward describes a memo which then Secretary of Defense Donald Rumsfeld prepared for then president George W. Bush, early in the tenure of the new administration.

“Two months into the job,” Woodward writes, “Rumsfeld drafted a three page memo called, ‘Guidelines for Consideration When Committing U.S. Forces.’  He took the fourth revision to the president and went over it in detail.  It was a series of questions to be addressed:  ‘Is a proposed action truly necessary?’  ‘Is the proposed action achievable?’  ‘Is it worth it?’

“Rumsfeld argued for being clear-eyed,” Woodward continues.  “One passage foreshadowed problems to come:  ‘In fashioning a clear statement of the underpinning for the action, avoid arguments of convenience.  They can be useful at the outset to gain support, but they will be deadly later.’  He also had written:  ‘U.S. leadership must be brutally honest with itself, the Congress, the public and coalition partners.’  And he added, “It is a great deal easier to get into something than it is to get out of it!'”

Despite this knowledge, U. S. forces were committed in Iraq with no other plan than to decapitate the Iraqi government, in the expectation that the U.S.A. would get in and out easily.  The invasion was justified with the convenient argument of WMD–notwithstanding the preponderance of evidence to the contrary.

Between the writing of the memo and the Iraq war, the nation had been attacked, and the neocon culture had become ascendent in Washington, D.C..  Surely there are reasons why we disregard our knowledge.  Social psychology has accumulated an impressive record of experiments in which people act in disregard of what they know, and leaders are no more immune to such influences than anyone else.

Humanity has to learn this lesson, of being mindful of what we know, over and over.  At the individual level, the lesson is learned and re-learned, one person at a time, in each of our lives.  I’ve often referred to my office as the “room of reflection,” where my clients often reflect on how they’ve disregarded what they know, as they work on being truer to themselves.  It makes neuroscientific sense to suppose that such work consists of improving, and growing better connections between, the perceptive, affective (emotional) and executive modules and neural networks of the brain.

Client’s Observation

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Sometimes a client makes an observation in a therapy session that is so profound and eloquent that I am moved to write it down and, with permission, share it.  Here is such a comment:

“It really can’t be overstated, how much we carry from childhood, of being hurt, abandoned.  And the resulting kind of adaptations, adjustments we make to survive, when we’re so broken.  It just feels so old, it never ceases to surprise me how present that feeling of old pain is, or old loss, or old sadness.  I feel better today, but still I feel the loss as a child.  I suppose we never really completely lose that, do we, that sense, except through embracing the child, of course, and caring for it, respecting it, offering consideration and space and voice to that child, like any normal child…In some ways those original patterns remain, and we simply build new patterns around them or through them.  Which is kind of a cool thought, because as we evolve through, we can refer to those old patterns as we help others.  What a nice gift…It is a wonderful experience, reencountering the gift of transcendence.  It’s very cool.”

On Loneliness: Notes from the March, 2012 Chicago Assn. for Psychoanalytic Psychology Conference

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The Chicago Association for Psychoanalytic Psychology’s 2012 annual conference was on the theme of “Loneliness:  An Interdisciplinary Exploration,” and I have written up my notes here, which may be of interest.  They are only my personal notes, and are neither intended to reflect a comprehensive review of the presentations nor fact-checked. The speakers were:

• John Cacioppo, Ph.D., at the University of Chicago, where he is Tiffany and Margaret Blake Distinguished Service Professor; Director of the Center for Cognitive Neuroscience, and Director of the Social Neuroscience Laboratory; presenting on: “Loneliness:  Human Nature and the Need for Social Connection.”

•Molly Witten, Ph.D., faculty member at the Erikson Institute, Chicago, and the Chicago Institute for Psychoanalysis, gave a case study presentation on: “Relational Mis-Attunement in Infancy and One Path Into and Out of Loneliness.”

•Ann-Louise Silver, M.D., faculty member at the Washington Center for Psychoanalysis, who’s presentation was entitled: “The Interrelationship of Our Patients’ and Our Own Loneliness.”

Dr. Cacioppo got the conference off to a great start with a well informed and (at least for cognitive neuroscience nerds and therapists, of which I am both) very catchy presentation on the cognitive and social neuroscience of loneliness.

“It’s your ability to have grandchildren that determines whether your genes make it into the gene pool,” he said.  What differentiates us from other animals is how much we learn socially.  Research has focused too much on the individual and not enough on the group and the individual’s relationship to the group.  “What it means to be an adult in a social species is to be the one on whom others can depend.”  To which I would add, to be able to depend on others.  “The pain and dysphoria of social isolation evolved as an aversive biological signal to support social connection, as well as vigilance for predator threat.”

Over five different studies, more socially integrated people have longer lifespans.  The hypothesis has been that other people encourage us to live a healthier lifestyle, so people with others around them will tend to live longer.  But Dr. Cacioppo disputed that hypothesis, noting that “All social animals either die early or show pathology when isolated.  The fruit fly that dies in the absence of company doesn’t die because other fruit flies don’t encourage it to exercise…Loneliness is a predictor of mortality regardless of exercise, so that nails the coffin of the ‘social connection encourages exercise’ hypothesis.”

Emotional loneliness is characterized by:

•lack of companionship

•feeling left out

•feeling isolated from others

•being unhappy about being so withdrawn

Dr. Cacioppo consults with the military, and noted that people, especially men, underestimate their own loneliness.  A military leader told him, “Loneliness is not a word we use.”

People who are socially connected are giving when with others and take individual time for solitude as needed.  Marriage is health protective if it is a positive connection, negative if the individual feels trapped.

Dr. Cacioppo used chronic pain as an analogy with loneliness.  “Loneliness is the social pain that connects the person socially.  Acute social pain motivates us to reconnect with others.”  Loneliness can be factored into two kinds.  “Social loneliness” involves feelings of relational connection, and a predictor for social loneliness is the number of personal contacts the person has had over the past two weeks.  The second kind of loneliness involves a kind of social or collective connection, for which the number of group associations a person has is a predictor.  The relational area is a little more important for women, and the collective area is a little more important for men, Dr. Cacioppo said.

Loneliness is not necessarily about how many people one knows.  “People can be around others and still feel lonely, or have one significant relationship and feel close.”  Loneliness seems to be about 50% genetic and 50% environmental.

Children are sent to time out because they are acting selfishly.  A more effective time-out is in the presence of others, rather than sending children to their room with toys.

Neurocognitivelly, the lonelier you feel the less activation of the tempero-parietal region bilaterally, which is involved in “theory of mind.”  Lonely young adults rate hassles as more severe than socially connected adults rate the same hassles.  The anteroventral striatum lights up at scenes of beauty (like a butterfly) and social connection (like a baby smiling), and lights up more in socially connected people than in lonely ones.  Social and physical pain overlap in the brain; acetaminophen and opiates both lessen the pain of loneliness.

There are significant differences between lonely and non-lonely people in factors of social support, shyness, social skills, anger, anxiety, self-esteem, fear of negative evaluation by others, optimism, positive mood, and negative mood.  Interestingly, the effect size of the differences is just as large between the same people when hypnotized to feel lonely or not lonely, in research at Stanford.

Lonely people have a different pattern of genes turned on and off compared to non-lonely people.  Feeling lonely changes the oldesst cells in the immune system.  Isolation increases immune arousal.  Loneliness also affects sleep:  the lonelier they were, the more microawakenings each night and the less beneficial the sleep that subjects experienced.  Lonely adults take more sleep medications.

An AARP study found that 35% of people are lonely.  The prevalence of loneliness seems to be increasing, as is the proportion of people living alone.

Oxytocin, the neurochemical associated with emotional bonding, decreased the perceived threat in picures, and loneliness decreased with both the amount of and sensitivity to oxytocin.  Lonely people may perceive threats and react to others as if they are threatening, which drives the perceptions and responses of others toward them.

Denmark has declared loneliness to be a national problem.

Later on, in panel comments, Dr. Cacioppo observed that “The brain has 5% of the body’s weight but uses 20% of the oxygen” that we breathe.  He also observed that “consciousness is a small part” of mind, most of which functions implicitly, even if in ways that were once learned consciously.

More information on Dr. Cacioppo’s work is at:  http://psychology.uchicago.edu/people/faculty/cacioppo/jtcreprints/ch09.pdf

Dr. Witten then presented a case study of a child whom I’ll call:  “David”

Dr. Witten’s presentation changed the focus from the general and researched to the individual and clinical, but was no less fascinating and informative.  The subject was the relationship between “David,” who was nearly 10 months old when he and his parents came to see Dr. Witten, and his parents.  David’s one-minute and five-minute Apgar scores were 7 and 7, and he had low motor tone and couldn’t suck, so he’d fall asleep when nursing.  His mother had a history of depression and of having been the daughter of a mother who was so depressed that she ended up mothering her own mother, in some ways.  When David was six months old, his parents found a dula who gave him a preemie nipple and then he could suck, but by then he’d become “prickly.”  At nearly ten months, David would become upset and then “shut down his sensory-motor functioning by limiting what he would allow himself to take in and inhibiting how he would allow himself to relate,” a response which Dr. Witten saw as a kind of dissociation.

Luckily, David’s parents had consented to videotaping sessions and to their use in professional education, and Dr. Witten played tapes from an early family therapy session, and from one much later; I didn’t note the dates, but recall it being about a year and a half later.  I didn’t take detailed notes on the clinical presentation–partly because I was so busy watching and listening and partly because it’s easier to take notes on a research-based presentation like Dr. Cacioppo’s than a clinical one, especially when there’s a videotape.  My notes indicate that David’s mother (and father) were challenged in establishing a healthy reciprocal relationship with their new infant because of their own histories.  “The baby becomes the (projective screen) on which those images (of parent history) are played out,” Dr. Witten said. She quoted Andre Green:  “We carry within us the totality of our past, not as memories but as organizers (italics added).”

In her family therapy work with David’s parents and David, Dr. Witten helped his parents learn to engage with David rather than disengaging from him when he disengaged from them.  A videotape clip of a session later session, when David was walking and talking, showed a much more engaged family unit.

Dr. Witten’s psychoanalytic background made it possible for her to focus on two important processes which are acknowledged in psychoanalytic culture, but only emerging in neurocognitive culture:  dissociation and a kind of implicit organizing memory that analyst Christopher Bollas called the “unthought known;” which workers in the neurocognitive domain might think of as an implicit affective-perceptual-attributional memory.  This raises the question, “What kind of memory, neurobiologically, is not ‘remembered’ consciously but organizes perceptions and responses?”

In the final Question-and-Answer session, Dr. Witten commented, “Being a therapist means having a higher than average capacity to ‘be with’ someone else.  It’s not ‘mirroring,’” in the sense of just reflecting back to clients what they have said.  “To ‘be with’ is to be a witness to someone else’s experience.”

Ann-Louise Silver, M.D.:  Frieda Fromm-Reichmann & Therapy with Psychotic Patients

Dr. Silver’s presentation focused on the life and work of Frieda Fromm-Reichmann, one of the pioneers of psychotherapy, and the importance of doing therapy with psychotic patients, as Fromm-Reichmann did, rather than consigning the treatment of psychosis entirely to medication, as is so often done today.  Her presentation was highly informative–I didn’t know that the William Alanson White Institute, a rebellious psychoanalytic training program in New York where several of my teachers were trained, was started by therapists working in Washington, D.C., among whom was Fromm-Reichmann–but didn’t really address the topic of the interrelationship of patients’ and therapists’ loneliness.  Yet Dr. Silver’s humanity was clearly shown throughout her presentation.  “We need to wean ourselves from a professional dependency on the DSM,” she said, “thinking of loneliness as a depression.  One person (the client) comes with suffering, and you’re forming a team until the person doesn’t need you anymore.”

In all, it was a really valuable conference.  Thanks to CAPP, and President Bernadette Berardi-Coletta, Ph.D., for conceiving and organizing it.  (I’m a member of CAPP and Chair of Peer Study Groups.)

Anxiety and Trust: A Key Emotional Relationship. Part I

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During the 1970’s I began to hear about “the age of anxiety.”  Anxiety disorders have emerged as leading causes of mental and emotional distress today, and are one of the leading motivators for people to seek therapy and medication, as well as being one of the main causes of abuse of alcohol and drugs.  Anxiety plays a substantial role in eating disorders, cutting and other forms of self-harm, compulsive disorders, and contributes to overeating and the complications of obesity, such as diabetes.  Anxiety contributes to disorders that have a psychosomatic aspect, including cardiac and gastrointestinal disorders.  And anxiety underlies a widespread behavior pattern that doesn’t really have a clinical name but has to do with either underperforming, as a way of avoiding the risk of failure or the challenges of success, or overperforming, as a way of trying to extend one’s control over life.

But where does all this anxiety come from?  I think that there is a key relationship between anxiety and trust.  We have an excess of anxiety, in my opinion, because have a deficiency of trust.  This is the first of two columns in which I’ll explore that relationship.

As I often say, it’s no accident that psychotherapy evolved just as Europe was running up to the huge transformations of the first Great War, which led to the redrawing of the global political and socioeconomic map.  Psychotherapy, an attempt at a rational approach to understanding unconscious process and healing unconscious rifts, was born more or less at the ending of the great Austro-Hungarian, Ottoman, and Russian empires, with repercussions that are still being felt today, in Europe, the Middle East, Central Asia, and Africa.  World War II, a continuation of the first, facilitated the end of the French and English empires, and, reaching to the Far East, led to revolutionary upheavals in the Japanese and Chinese empires, and elsewhere.

Social, political and economic upheaval has affected virtually every family, in ways that are bred into the “DNA,” the behavioral and emotional memes, of family cultures down the generations.  To this instability and insecurity are added the vast changes brought about by technological innovations in industry, agriculture, economics, medicine, and communications, which we can see expressed in the culture and even the language of the “new generation” that emerges among adolescents every 5 years or so.

A key result of all this change and transformation has been the loss of trust in the stability of how things are and how things are done; how we communicate, relate, make a living, what we can expect and take for granted.  During most of human history, people lived in times when conditions were quite stable, and even the dangers of life were familiar.  Things didn’t change much over the generations, let alone during the course of a single lifetime.  Indeed, I’m told that, during most of human history, most people lived their entire lives in groups of 30-50 people, to most or all of whom they were related.  Those days are gone, for nearly everyone on the planet; although the search for new “tribes” is one of the motivators, and sources of anxiety, in modern life.

It is not only empires that were swept away in the abrupt, tumultuous, often bloody transformations of recent history, but the role and authority of institutions upon which populations depended for stability, including the religious, academic, legal, political, and cultural institutions which where the adhesives that glued the old order together.  The resulting psychological challenge of modern life is that we have to learn to trust change rather than stability, which is very hard to do.  In order to trust change, we need to understand it better, and to have the roots of our stability anchored in values, relationships and experiences that are deeper than those which are changing.

A key psychoanalytic insight is that the self can dissociate or split into different parts, which may not recognize, or be “unconscious” of one another.  It’s also possible to think about a model of mind that is inherently multiple, as in the “Multimind” model described by psychologist Robert Ornstein (http://www.ishkbooks.com/books/MULT3.html), and Human Givens therapist Pat Williams (http://www.humangivens.com/publications/publications/Which-you-are-you-CD.html).  In this model, different “selves” come into prominence at different times, rather like actors on a stage; except the director may be absent, and the troupe may be working from an old and fragmentary script.  (By the way, it seems to me that the difference between “psychoanalytic” and “psychodynamic” concepts is that  psychoanalytic ones postulate a single self that has split, in various ways and for various reasons depending on which analytic theory you buy, while “psychodynamic” concepts can include that as well as multiple self and multiple levels-of-consciousness models of mind.)

Now, here’s where all this comes together.  Anxiety is one reason for the evolution of psychotherapy during these revolutionary planetary changes, and anxiety is related to the untrustworthiness of the key institutions upon which we depend for stability and meaning in our lives.  It may be that there is a natural process of fragmentation of self, and need for subsequent reunification of self, that is just part of the human condition; the ancient stories certainly indicate that.  However, the conditions of modern life encourage fragmentation, without giving much guidance about how to achieve the subsequent unification.  It seems to me that that’s where finding the roots of value deep within ourselves, in our relationships with one another and with humanity as a whole, at a deeper level than such transient institutions as government, temple, school, court, etc. can provide, becomes a key part of healing our inner fragmentation and resolving our anxiety.

The old institutions are not entirely irrelevant, of course.  They continue to provide a kind of social stichting-together function.  In addition, each institution contains, within itself, traditions of access to deeper and higher values.  Religions, beyond their role of  organizing populations and telling people what to do and believe, included access to spirituality through esoteric and mystical affiliates.  Academic institutions, beyond requiring rote learning and preparing students for roles in society, included access to the deeper questions of the meaning of life, especially through philosophy and the humanities (science, a late-comer, is still getting oriented there).  Legal institutions, beyond maintaining laws, enshrined devotion to justice, and sometimes exemplified it.  Government, in addition to administration, aspires to uplift the well-being of all.  Even today, people who feel they can trust their social institutions seem to have less anxiety than others.  But sooner or later something happens to undermine their trust, so they do have to deal with being unanchored in life, one way or another.  The commitment to the fundamental values of spirituality, meaning, and justice, along with their discernment, seems to have diminished in the practice of religion, education, and law–everywhere, as far as I can tell from what I see around me and glean from newspapers and other media.  The result has been that, at a time of great change, when people are in greatest need of connection with perennial human values, the institutions upon which societies have relied to maintain and transmit those values have been less and less up to the job.  There are individual justices, reporters, ministers, teachers, administrators, who exemplify highest values, and some organizations do a better job than others of instilling them into the culture.  But the institutions, on the whole, are a pretty sorry lot, measured against higher values.  They neither embody nor represent such core values, and as a result people are unable to trust them; and, often, one another.

So we can’t trust our social institutions to be what they are supposed to be, and when we ourselves are part of those institutions, we often have to conform, to go along and get along, or else stand against the tide and perhaps get swept away.  The resurgence of fundamentalism in religion, and the fundamentalist variant of strict constructionism in legal and judicial practice, seem to me to reflect the misguided attempt to return to the times when the institutions of religion and law were more closely connected to spirituality and justice, respectively.  However, that’s like focusing on the utensils we ate with years ago, because we are hungry now.  As to education for meaning in life, our academic institutions seem to have pretty much given up on it, except for those which go in for brainwashing, and the odd teachers and schools here and there who persist in trying to help students connect with themes of meaning in life, albeit against the tide of rote learning for high stakes testing, indoctrination in social beliefs, and education for vocational preparation.  The attempt by departments of education across the country to develop a common core curriculum (see my post of April 16th, 2012), is an attempt to establish fundamentals in education, but it focuses on behavioral objectives that can be measured, so it must, of necessity, omit the crucial dimension of meaning of life and connection with the real core values of experience.  And so, in the midst of our busy lives, we are adrift.

As a psychotherapist, I find that issues of spirituality, meaning and justice in life (expressed through family and other personal relationships, as well as relationships with teachers, employers and other institutions) often underlie anxiety, although that is not something you will find in the professional literature, such as the DSM-IV (http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders).  As the great psychologist Abraham Maslow pointed out, when these issues are identified and clients are able to make progress by establishing or reestablishing their connections with their own spirituality, sense of meaning, and love of justice (what Maslow called the “being-values”), anxiety tends to diminish.  But that is not taught in our therapist training programs today either, since it can’t be reduced to a measurable behavioral objective.

 

Review of “Hanging By A Twig: Understanding and Counseling Adults with Learning Disabilities and ADD,” by Carol Wren, with Psychotherapeutic Commentary by Jay Einhorn

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(Reviewed by Delores S. Doherty, MD, FRCPC, St. John’s Newfoundland, in the Journal of the Canadian Academy of Child and Adolescent Psychiatry, 2006, 15, 95-6)

This book could not have come into my experience at a better time.  My patients are growing up, and lo and behold, they are still disabled!

Hanging by a Twig is the way one disabled adult described her life, i.e., just hanging on and always precariously.  Mary’s story is told in chapter 2, intermingled with information on the historical context of our current understanding of learning disabilities, learning styles, cognitive strengths and weaknesses.  Each chapter in this book is built around the story of an adult with specific learning issues.  Carol Wren moves us through the stated purpose of the chapter while Jay Einhorn gives us a psychotherapeutic commentary on the issues described.  Together they take us through development of self, coherence of self, adult skill set, self-esteem, addiction, and other co-morbidities, looking at the issue and its impact on the individual.

The pervasive nature of these impairments of cognition on the overall functioning of the individual becomes very evident as we read these real life stories.  In addition, the challenges for doing therapy with these people, who are intrinsically at heightened risk for personality distortions, jumps from the pages.  The authors make clear the need to help these adults understand their own strengths and limitations.  Then they are better able to make informed choices in regard to further education and career, to seek appropriate supports for themselves, and to begin to consider the impact of their disabilities might make on personal relationships.

As a group involved with children and adolescents, I believe that we also have an obligation to attempt to help our adult colleagues understand that these individuals suffer.

This book is a resource that we can recommend with enthusiasm.  It is well written and provides clear descriptions of a number of possible scenarios as well as suggestions for management.  I will be encouraging those I know who counsel adults with residual developmental concerns to read and learn from Hanging by a Twig.  I have already recommended it to our local chapter of the Learning Disabilities Association.  It is an excellent resource and an enjoyable reading experience.

(published by Norton and Co., New York, 2000)