I often see people who've seen previous therapists. Some of them report positive experiences, and some report negative experiences. In either case, I often find that people don't give me a lot of details about their previous therapy. This is a problem, because it's important for me to know what worked and what didn't work in someone's previous therapy.
I have pondered if some persons think that if they talk at length about a previous therapist's failings, I will side with the previous therapist. This is not true, as I am well aware that many therapists are not good. In fact, I sometimes say to friends, "I wouldn't refer a cat to 80 percent of the people in my field." It's not a joke.
When I do hear complaints about previous therapists, the most common complaint is that the therapist talked about him/herself. Why does this happen? Probably for many reasons. One possibility is the decline in the popularity and influence of psychoanalysis and of psychoanalytic training. Although psychoanalysis has some limitations as a treatment, it does insist on the neutrality and relative anonymity of the therapist. Other schools of therapy don't necessarily encourage therapist self-disclosure, but they don't place as much of an emphasis on boundaries as psychoanalysis does. Unfortunately some less-than-competent therapists may assume that if their training didn't emphasize boundaries, it means boundaries aren't important.
I usually limit information on my personal life to answers to direct questions asked by patients, in cases where the information might be relevant--for example, if someone asks me "are you going away on vacation?" I will answer, as this could relate to the issue of whether I can be contacted in an emergency. Another example would be when a patient discusses a movie they've seen and wants to know if I have seen it. I've found that discussions about movies are often quite meaningful, as which characters patients identify with, or which ones remind them of their family members, can lead to interesting discussions.
Therapists should not talk about events in their personal lives or personal problems. I've heard two (!) stories about therapists who talked about their own upcoming weddings--I can't think of any way this could be appropriate and it could be damaging to the patient.
I've developed a hypothesis that some therapists talk about themselves because they are bored by their patients and don't feel a connection with them, and are hoping that if they talk about something they have "in common" with a patient it will help them feel more connected and less bored. This boredom usually represents a type of narcissism. Unfortunately, some people become therapists for the wrong reasons. Some people believe that as a therapist they will be super-important to their patients and will wield great influence over their patients' lives. Although this can happen, it's not a good reason for someone to become a therapist. People with narcissistic problems are often attracted to the field of therapy. These persons should not be therapists, but they are not screened out of graduate school programs.
Other personal problems of therapists that interfere with therapy include difficulties with the opposite gender or with cultural differences. I've heard stories about male clinicians who gave compliments to female patients on their clothing and make-up. It apparently didn't occur to these clinicians that this behavior might be seen as objectifying by their patients--the clinicians probably thought they were boosting the patient's self-esteem. I've also come across female therapists who can't work with male patients due to projections of anger or disgust that come from their own experiences with men. In conversations with therapists from other parts of the country, I've discovered that religious bigotry is not uncommon. It's hard for a bigoted therapist to practice in New York, but once in awhile I've come across a homophobic therapist here, or other types of issues.
The worst failings of other therapists that I have come across, however, are inaccurate assessments. Sometimes the end result of these errors is tragic. In the worst cases, there may be a preventable suicide. Fortunately I haven't heard very many of those stories.
Errors in assessment and diagnosis often stem from a belief that recognizing someone's severe pathology is tantamount to not liking them or not recognizing their strengths: Years ago, while working in a clinic, I worked with a paranoid schizophrenic whose previous therapist encouraged him to attend college. The vast majority of people with schizophrenia cannot complete college. The patient dropped out and was left with student loans he could not repay as well as a blow to his self-esteem. In another case, a therapist treating a family member of one of my patients didn't notice the woman's severe personality disorder and the extent of her pathological behaviors, which were affecting my patient. Many therapists have bought into society's stigma against mental illness, and this makes them believe that diagnosing a patient with a disabling condition is equivalent to condemning them or not liking them.
Being a therapist requires a sober view of humanity and its problems combined with a genuine interest in other people and their lives. Unfortunately, my field is filled with therapists who aren't really that interested in other people--especially those who are different from them--and others who confuse recognizing their patients' serious problems with not liking them. I keep a short list of other therapists to whom I can refer people when I can't treat them. I wish there were more people whose professional expertise and behavior I could trust.
Tuesday, May 12, 2015
Tuesday, April 14, 2015
Addiction: Truth and Myth
I spent the first several years of my clinical career working in substance abuse treatment programs. On the front page of my website, I note this fact and state that I "frequently work with persons in recovery." If only this were actually true! What has happened over the years is that the people who've come to see me for my addictions treatment experience are mostly not in recovery. Most have been people who are still abusing drugs and/or alcohol. But psychotherapy is not the best treatment for addictions, which is why I tried, in the language on my website, to suggest that I want to work with people who've already stopped using drugs/alcohol and are looking for relapse prevention and treatment for other emotional problems.
"Recovery" means that you have stopped abusing substances--you are now abstinent from the problematic substance and any other substance with a similar effect, and are engaged in a different lifestyle. What I have found consistently in the course of my career is that 90 percent of addicts/alcoholics need a 12-step program to remain in recovery. Sadly, most of the substance abusers who have come to my office, although they may verbally express an interest in going to a 12-step program, don't stick with it and thus they don't stop using drugs/alcohol.
Most abusers of alcohol and drugs who come to my office claim that they "know" they have a "problem." This may represent a change from the attitudes found before the 1970s. Before the 70s, most alcoholics and addicts lied about their problem and were frequently in denial about its severity. Celebrities in the late 70s started to come out of the closet with their addiction problems. Now it's become socially acceptable to admit you have a problem with drugs or alcohol. But most people who "admit" this fact still don't really want to change. This may not make sense to most people, not only because using drugs/alcohol in the face of death or other severe consequences doesn't seem logical, but also because the media promote the myth that people use drugs because they don't have access to treatment. Nothing could be further from the truth, as the 12-step program is free and available all over the country. In addition, most inpatient rehabs are desperately seeking patients and some have closed.
Why would someone continue to engage in addictive behaviors despite access to treatment? There are many possible reasons, some that are psychological and some that perhaps could be better described as philosophical or spiritual, depending on one's beliefs.
Some recovering addicts have told me that before they found the 12-step program, they simply thought that they were destined to be drug addicts--it was their identity and fate. When they heard, in 12-step meetings, the stories of people like themselves who had completely changed their lives, they realized they were wrong. They realized they could choose their fate. They also realized that they needed help from others to remain free of drugs and alcohol. This may seem paradoxical, but all humans need both a sense of autonomy and self-direction and also social support.
People with intractable addictions--those who go to 12-step meetings but still don't arrest their addiction--may be people who are too narcissistic to accept their dependency on other people. This makes them unable to use the 12-step program. Others can be persons who just don't see a meaning in life. Ordinary activities that give others' lives meaning, such as the sense of pride in working for a living and doing a job well, mutual interpersonal relationships, and greater causes or beliefs, are meaningless to them. Without a sense of meaning in life, it's hard to see a reason to stop drinking or doing drugs. All experienced substance abuse counselors know there is a percentage of the population who cannot be helped and who will not recover from addiction.
Initially in private practice, I thought I would screen out all active addicts, and instead insist that they first attend 12-step or an inpatient rehab, or both. I changed that position when I realized some of the addicts and alcoholics coming to my office had severe depression or anxiety that needed to be treated. I didn't think it was right to deny treatment to someone for one disorder because the person refused treatment for another. I can say that I did help some of these individuals, whose depression and anxiety did improve, even though they did not completely arrest their addiction(s). (The fact that these individuals did not stop using drugs or alcohol despite recovering from their anxiety and depression shows that a popular theory, the "self-medication theory," is wrong. The self-medication theory, believed by many psychotherapists, holds that drug and alcohol abusers are simply self-medicating depression and anxiety and will stop their behavior if they take medication and go to psychotherapy. If this were really true, addiction would not be the vast social problem that it is). Recently, I've come to realize that active alcoholics and addicts present liability concerns for my practice. Therefore, I've decided to go back to my original position of requiring that addicts/alcoholics be in recovery before I will agree to see them.
"Recovery" means that you have stopped abusing substances--you are now abstinent from the problematic substance and any other substance with a similar effect, and are engaged in a different lifestyle. What I have found consistently in the course of my career is that 90 percent of addicts/alcoholics need a 12-step program to remain in recovery. Sadly, most of the substance abusers who have come to my office, although they may verbally express an interest in going to a 12-step program, don't stick with it and thus they don't stop using drugs/alcohol.
Most abusers of alcohol and drugs who come to my office claim that they "know" they have a "problem." This may represent a change from the attitudes found before the 1970s. Before the 70s, most alcoholics and addicts lied about their problem and were frequently in denial about its severity. Celebrities in the late 70s started to come out of the closet with their addiction problems. Now it's become socially acceptable to admit you have a problem with drugs or alcohol. But most people who "admit" this fact still don't really want to change. This may not make sense to most people, not only because using drugs/alcohol in the face of death or other severe consequences doesn't seem logical, but also because the media promote the myth that people use drugs because they don't have access to treatment. Nothing could be further from the truth, as the 12-step program is free and available all over the country. In addition, most inpatient rehabs are desperately seeking patients and some have closed.
Why would someone continue to engage in addictive behaviors despite access to treatment? There are many possible reasons, some that are psychological and some that perhaps could be better described as philosophical or spiritual, depending on one's beliefs.
Some recovering addicts have told me that before they found the 12-step program, they simply thought that they were destined to be drug addicts--it was their identity and fate. When they heard, in 12-step meetings, the stories of people like themselves who had completely changed their lives, they realized they were wrong. They realized they could choose their fate. They also realized that they needed help from others to remain free of drugs and alcohol. This may seem paradoxical, but all humans need both a sense of autonomy and self-direction and also social support.
People with intractable addictions--those who go to 12-step meetings but still don't arrest their addiction--may be people who are too narcissistic to accept their dependency on other people. This makes them unable to use the 12-step program. Others can be persons who just don't see a meaning in life. Ordinary activities that give others' lives meaning, such as the sense of pride in working for a living and doing a job well, mutual interpersonal relationships, and greater causes or beliefs, are meaningless to them. Without a sense of meaning in life, it's hard to see a reason to stop drinking or doing drugs. All experienced substance abuse counselors know there is a percentage of the population who cannot be helped and who will not recover from addiction.
Initially in private practice, I thought I would screen out all active addicts, and instead insist that they first attend 12-step or an inpatient rehab, or both. I changed that position when I realized some of the addicts and alcoholics coming to my office had severe depression or anxiety that needed to be treated. I didn't think it was right to deny treatment to someone for one disorder because the person refused treatment for another. I can say that I did help some of these individuals, whose depression and anxiety did improve, even though they did not completely arrest their addiction(s). (The fact that these individuals did not stop using drugs or alcohol despite recovering from their anxiety and depression shows that a popular theory, the "self-medication theory," is wrong. The self-medication theory, believed by many psychotherapists, holds that drug and alcohol abusers are simply self-medicating depression and anxiety and will stop their behavior if they take medication and go to psychotherapy. If this were really true, addiction would not be the vast social problem that it is). Recently, I've come to realize that active alcoholics and addicts present liability concerns for my practice. Therefore, I've decided to go back to my original position of requiring that addicts/alcoholics be in recovery before I will agree to see them.
Thursday, April 2, 2015
Evaluating Risks Part 2
I decided my last post needed a follow-up. In the last post, I discussed how employers can conduct psychological screening that could help them identify potentially suicidal and homicidal employees. For jobs that give people the power to endanger the public, I believe such screening is necessary. I noted that I discovered, through reading recent media reports, that airlines don't usually conduct such screening on pilots, which is incredible considering that pilots have the lives of hundreds of people under their power. However, it has occurred to me, after reading additional media reports, that some people may misinterpret employment-based psychological screening as something that keeps individuals from getting the mental health care that they need. The "argument" I've been reading is that people won't obtain mental health care if they think it will lead to loss of employment.
The Americans with Disabilities Act, passed in 1990, forbids discrimination based on disability, under most circumstances. Businesses have to show that employing a person with a disability would impose an unreasonable burden in order to be able to "discriminate" against such applicants or employees.This law means that you can't be fired for a mental health problem or even a substance abuse problem unless it makes you unable to do your job even with treatment and reasonable accommodation. Therefore, if you need to take a month off work to go to a treatment center, your job has to allow you to do so. If you need to leave early one day a week to see a therapist, your job has to allow you to do so.
If, on the other hand, despite your treatment you continue to do drugs and this impairs your work performance or causes disruption to other employees or clients, or creates a hazard, you can be fired. If you come to work late every day because you're too depressed to get out of bed, because you either refused treatment or treatment simply did not work, you can be fired. I believe the ADA is a fair law that has worked well. Someone who is too disabled to work qualifies for federal disability payments but most people with disabilities can work if they receive treatment.
Duty to Warn
Therapists in the US have to abide by something popularly known as "Duty to Warn." If we have a patient who threatens to harm someone else or whose illness puts the public at risk, we are required to break confidentiality to take action to prevent the loss of life or injury to another person. I had to do a "Duty to Warn" some years ago when a psychotic patient came to my office with a plan to kill a relative. In addition, he showed me a recipe for making bombs. I sent him to the emergency room and I also called the police in his relative's town. These are the requirements under "Duty to Warn." Even though I believed the patient was unlikely to act out his homicidal ideas, it didn't matter because it was possible that he would. The hospital re-evaluated him and, if I remember correctly, changed his medication. The patient didn't lose his job (he was a doorman) and no one was killed. (There was no evidence the patient had constructed a bomb or that he was actually planning on doing so). The hospital agreed to continue his treatment on an outpatient basis as it was too much for someone in private practice such as myself.
A colleague of mine years ago had a patient who was a motorman on the subway. The patient had severe panic attacks. My colleague did a Duty to Warn because panic attacks can occur without warning and can be disabling, and the patient was responsible for the lives of hundreds of people on the subway. I don't recall what the end result of this was, but I imagine it was something similar to what happened with my patient: The patient probably took a leave of absence, went on medication and then went back to work if his treatment was effective. In my opinion he should have been monitored by the MTA afterward to make sure he was complying with his treatment. I don't know whether this happened, however.
There are some people who are too sick to be able to safely work at jobs in which they hold the lives of others under their power. Most people who fall into this category are substance abusers, and only a small percentage are people with other clinical problems. Most people with mental health problems are effectively treated and can do most jobs. However, our societies do need ways to screen out people with intractable problems from jobs in which they can put the public at risk.
The Americans with Disabilities Act, passed in 1990, forbids discrimination based on disability, under most circumstances. Businesses have to show that employing a person with a disability would impose an unreasonable burden in order to be able to "discriminate" against such applicants or employees.This law means that you can't be fired for a mental health problem or even a substance abuse problem unless it makes you unable to do your job even with treatment and reasonable accommodation. Therefore, if you need to take a month off work to go to a treatment center, your job has to allow you to do so. If you need to leave early one day a week to see a therapist, your job has to allow you to do so.
If, on the other hand, despite your treatment you continue to do drugs and this impairs your work performance or causes disruption to other employees or clients, or creates a hazard, you can be fired. If you come to work late every day because you're too depressed to get out of bed, because you either refused treatment or treatment simply did not work, you can be fired. I believe the ADA is a fair law that has worked well. Someone who is too disabled to work qualifies for federal disability payments but most people with disabilities can work if they receive treatment.
Duty to Warn
Therapists in the US have to abide by something popularly known as "Duty to Warn." If we have a patient who threatens to harm someone else or whose illness puts the public at risk, we are required to break confidentiality to take action to prevent the loss of life or injury to another person. I had to do a "Duty to Warn" some years ago when a psychotic patient came to my office with a plan to kill a relative. In addition, he showed me a recipe for making bombs. I sent him to the emergency room and I also called the police in his relative's town. These are the requirements under "Duty to Warn." Even though I believed the patient was unlikely to act out his homicidal ideas, it didn't matter because it was possible that he would. The hospital re-evaluated him and, if I remember correctly, changed his medication. The patient didn't lose his job (he was a doorman) and no one was killed. (There was no evidence the patient had constructed a bomb or that he was actually planning on doing so). The hospital agreed to continue his treatment on an outpatient basis as it was too much for someone in private practice such as myself.
A colleague of mine years ago had a patient who was a motorman on the subway. The patient had severe panic attacks. My colleague did a Duty to Warn because panic attacks can occur without warning and can be disabling, and the patient was responsible for the lives of hundreds of people on the subway. I don't recall what the end result of this was, but I imagine it was something similar to what happened with my patient: The patient probably took a leave of absence, went on medication and then went back to work if his treatment was effective. In my opinion he should have been monitored by the MTA afterward to make sure he was complying with his treatment. I don't know whether this happened, however.
There are some people who are too sick to be able to safely work at jobs in which they hold the lives of others under their power. Most people who fall into this category are substance abusers, and only a small percentage are people with other clinical problems. Most people with mental health problems are effectively treated and can do most jobs. However, our societies do need ways to screen out people with intractable problems from jobs in which they can put the public at risk.
Friday, March 27, 2015
Evaluating Risks
Yet again, a suicidal/homicidal person causes a tragedy. In this case, the person flew a plane into a mountain. As usual, media reports are full of quotes that make no sense. Authorities quoted in The New York Times report that the pilot, Andreas Lubitz, was "100 percent flightworthy" (obviously he wasn't) and that they are pondering "whether" it was a suicide or homicide (don't the facts speak for themselves?). Many laypeople may assume it's impossible to determine whether or not someone is homicidal or suicidal, if the person decides to lie. This is only partly true.
Most people who truly want to commit suicide or a homicide will lie about it if asked directly, because they want to succeed in their plans. But that doesn't mean organizations can't screen out persons with serious pathology.
Psychological testing is a simple and accurate way to screen for serious pathology. I don't do psychological testing, but I have read many psychological test reports. Some were done on patients I was seeing and in a couple of cases, I participated in appeal evaluations for NYPD and Dept. of Corrections applicants, which allowed me to read the test results performed by the NYPD and Corrections psychologists. What I have found is that these tests are accurate. In the clinical cases, they weren't that helpful, because if you're someone's therapist and you're competent, the results of their standardized psychological tests should come as no surprise. In the cases of the appeal evaluations, although I felt sympathy for the rejected applicants, the results that I and the other professionals performing the appeal evaluations came up with were similar to the NYPD and Corrections evaluations' results (if you're wondering about how someone can pass the NYPD psychological tests and still murder someone by strangling them to death, I don't have a good answer. One possibility is an incompetent examiner).
One common psychological test, the MMPI (Minnesota Multiphasic Personality Inventory) has a built-in "lie scale" that determines the level of truthfulness of someone's responses. One would think that any applicant for a sensitive job with a high score on the "lie scale" would be rejected. One hopes that this is true, anyway.
Another well-known and occasionally ridiculed test is the Rorshach inkblot test. Although results from Rorschach tests don't diagnose particular illnesses, they give clues that could guide an examiner or clinician to ask further questions.
People don't become homicidal or suicidal overnight. There are many psychological problems that create risks for future homicidal or suicidal behavior. These include not only depression, but also impulsivity, sociopathy, and narcissism. I don't know how Lufthansa pilots are screened and can't comment on whether I think Lufthansa is doing the right tests. What I do know is that personality remains more or less consistent during adult life and that there are many types of psychological tests and interviews that can reveal the types of problems that indicate a risk for future suicidal or homicidal behavior.
UPDATE 3/29: I just found out, through reading The New York Tiimes, that most airlines don't conduct any psychological testing on pilots or prospective pilots. This is incredible.
Most people who truly want to commit suicide or a homicide will lie about it if asked directly, because they want to succeed in their plans. But that doesn't mean organizations can't screen out persons with serious pathology.
Psychological testing is a simple and accurate way to screen for serious pathology. I don't do psychological testing, but I have read many psychological test reports. Some were done on patients I was seeing and in a couple of cases, I participated in appeal evaluations for NYPD and Dept. of Corrections applicants, which allowed me to read the test results performed by the NYPD and Corrections psychologists. What I have found is that these tests are accurate. In the clinical cases, they weren't that helpful, because if you're someone's therapist and you're competent, the results of their standardized psychological tests should come as no surprise. In the cases of the appeal evaluations, although I felt sympathy for the rejected applicants, the results that I and the other professionals performing the appeal evaluations came up with were similar to the NYPD and Corrections evaluations' results (if you're wondering about how someone can pass the NYPD psychological tests and still murder someone by strangling them to death, I don't have a good answer. One possibility is an incompetent examiner).
One common psychological test, the MMPI (Minnesota Multiphasic Personality Inventory) has a built-in "lie scale" that determines the level of truthfulness of someone's responses. One would think that any applicant for a sensitive job with a high score on the "lie scale" would be rejected. One hopes that this is true, anyway.
Another well-known and occasionally ridiculed test is the Rorshach inkblot test. Although results from Rorschach tests don't diagnose particular illnesses, they give clues that could guide an examiner or clinician to ask further questions.
People don't become homicidal or suicidal overnight. There are many psychological problems that create risks for future homicidal or suicidal behavior. These include not only depression, but also impulsivity, sociopathy, and narcissism. I don't know how Lufthansa pilots are screened and can't comment on whether I think Lufthansa is doing the right tests. What I do know is that personality remains more or less consistent during adult life and that there are many types of psychological tests and interviews that can reveal the types of problems that indicate a risk for future suicidal or homicidal behavior.
UPDATE 3/29: I just found out, through reading The New York Tiimes, that most airlines don't conduct any psychological testing on pilots or prospective pilots. This is incredible.
Sunday, March 15, 2015
Know Who You're Talking To
Recently, I was invited to join a few "Closed" or "Secret" Facebook groups. They looked like fun, so I accepted. Within a few days I had left all the groups. One reason was that they cluttered my Facebook feed with posts from people I don't know. But another reason was that I realized they were neither "Closed" nor "Secret." Anyone could easily take a screen shot of a conversation in the supposedly "Secret" group and post it anywhere and everywhere on the internet. I thought about an old adage, "if you wouldn't be comfortable seeing something on the front page of The New York Times, don't put it in writing."
Of course, today, many people put almost every communication in writing, via text messaging or email. This is a mistake. I find that many people don't know their friends as well as they think they do. Of course, voicemail is also recorded, but it isn't as easily transmissible.
The best way to communicate is in person. Not only is it confidential, but it allows for the nuances of tone and body language. People also feel more free to insult, abuse and harass people when they don't have to face them. The more you communicate virtually instead of in-person, the more you're likely to expose yourself to the type of cowardly and abusive people who like to harass people online, where they can usually hide behind anonymity or at least not have to face their victim. The New York Times recently published a long feature on people whose lives were ruined by Twitter:
http://www.nytimes.com/2015/02/15/magazine/how-one-stupid-tweet-ruined-justine-saccos-life.html
I've been a professional writer, which puts me at an advantage compared to most people in terms of writing for the public. One of the rules of writing is to know your audience. I think that one of the mistakes Justine Sacco--one of the individuals profiled by the Times--made was to assume that her Twitter followers were people like her. She made a joke that was a type of ironic self-parody. It apparently didn't occur to her that people who understand ironic self-parody are those who have higher-than-average intellectual capacity. There's a reason why most newspapers are written on a reading comprehension level of 10th grade or below.
Many of us live in bubble worlds, in which we associate with co-workers, friends and relatives who work in similar types of occupations, have similar educational/intellectual abilities and similar values. If you don't associate with a wide variety of people, it's easy to forget, or to never learn, that other people aren't like you. They may be stupid, they may lack a sense of humor, and they may be malicious. Today people are "friending" people on Facebook and "following" people on Twitter whom they do not know. Facebook requires people to use their real names (although many find ways around this rule) which means anything you write is attached to you. Twitter has a special risk created by the fact it uses short sentences or sentence fragments as a form of communication. Not only are these easily misunderstood, but this type of communication attracts many followers who can't understand or don't have the interest in following a complex argument. They prefer reading tweets to newspaper op-eds or blog posts such as this one, because 145 character tweets don't strain the brain. Do you really want to be "followed" by such people?
I've read some comments (on the internet!) that people should "own" what they say, because, they said it. This point of view is naive. Anything that is said can be misunderstood, taken out of context, or otherwise twisted. There's a reason why the police "Miranda" warning states "ANYTHING you say can, and will, be held against you." The New York Times' profile is a perfect example--ironic self-parody was interpreted as racism.
I have a private Facebook profile, but more importantly, I limit what I say and post there and keep my "friends" list to less than 100 people. If you are using Facebook for business networking, you should have a "page" rather than a "profile" for that purpose. Don't confuse the two. Business and friendship don't always mix. If you want a forum to talk to people you don't know and say whatever you think, join a message board where you can post under a pseudonym. And still be careful what you say.
Of course, today, many people put almost every communication in writing, via text messaging or email. This is a mistake. I find that many people don't know their friends as well as they think they do. Of course, voicemail is also recorded, but it isn't as easily transmissible.
The best way to communicate is in person. Not only is it confidential, but it allows for the nuances of tone and body language. People also feel more free to insult, abuse and harass people when they don't have to face them. The more you communicate virtually instead of in-person, the more you're likely to expose yourself to the type of cowardly and abusive people who like to harass people online, where they can usually hide behind anonymity or at least not have to face their victim. The New York Times recently published a long feature on people whose lives were ruined by Twitter:
http://www.nytimes.com/2015/02/15/magazine/how-one-stupid-tweet-ruined-justine-saccos-life.html
I've been a professional writer, which puts me at an advantage compared to most people in terms of writing for the public. One of the rules of writing is to know your audience. I think that one of the mistakes Justine Sacco--one of the individuals profiled by the Times--made was to assume that her Twitter followers were people like her. She made a joke that was a type of ironic self-parody. It apparently didn't occur to her that people who understand ironic self-parody are those who have higher-than-average intellectual capacity. There's a reason why most newspapers are written on a reading comprehension level of 10th grade or below.
Many of us live in bubble worlds, in which we associate with co-workers, friends and relatives who work in similar types of occupations, have similar educational/intellectual abilities and similar values. If you don't associate with a wide variety of people, it's easy to forget, or to never learn, that other people aren't like you. They may be stupid, they may lack a sense of humor, and they may be malicious. Today people are "friending" people on Facebook and "following" people on Twitter whom they do not know. Facebook requires people to use their real names (although many find ways around this rule) which means anything you write is attached to you. Twitter has a special risk created by the fact it uses short sentences or sentence fragments as a form of communication. Not only are these easily misunderstood, but this type of communication attracts many followers who can't understand or don't have the interest in following a complex argument. They prefer reading tweets to newspaper op-eds or blog posts such as this one, because 145 character tweets don't strain the brain. Do you really want to be "followed" by such people?
I've read some comments (on the internet!) that people should "own" what they say, because, they said it. This point of view is naive. Anything that is said can be misunderstood, taken out of context, or otherwise twisted. There's a reason why the police "Miranda" warning states "ANYTHING you say can, and will, be held against you." The New York Times' profile is a perfect example--ironic self-parody was interpreted as racism.
I have a private Facebook profile, but more importantly, I limit what I say and post there and keep my "friends" list to less than 100 people. If you are using Facebook for business networking, you should have a "page" rather than a "profile" for that purpose. Don't confuse the two. Business and friendship don't always mix. If you want a forum to talk to people you don't know and say whatever you think, join a message board where you can post under a pseudonym. And still be careful what you say.
Tuesday, February 17, 2015
Can Therapy Help You Find A Marital Partner?
Not infrequently, someone comes to my office complaining that they can't find a mate. Usually the person is a woman, but sometimes a man. Typically, the person also complains of anxiety or depression. What I have found is that when someone's anxiety and depression are alleviated, barriers to dating and finding the "One" often go away. People who are depressed or riddled with anxiety aren't attractive to most people. They can be difficult to be around. Depression also saps energy and self-confidence, which are necessary to tough it out in the New York dating scene.
Several patients I've worked with found marital partners while they were in therapy. I am convinced that in most cases, it was the alleviation of the person's depression or anxiety that was the key to helping them find a mate. In some cases, looking at reasons why the person had chosen dysfunctional mates in the past also played a role in helping the patient find someone.
Coming to therapy for no other reason than wanting to find a mate may not work. I recall a patient, who I'll call Patient X, who came to my office with the complaint that her friends were getting married and she wasn't, and she felt left out. She didn't mention any other complaints. I had the sense in our first session that she might be depressed, and that there might be other issues she wasn't voicing. I decided that although I'm not a match-making service and can't find someone a husband, the patient would benefit from therapy. In retrospect, I never should have agreed to work with this person. I should have listened more closely to what she said in our first meeting. What I mean is that the patient never said that there was anything wrong with her.
Like most therapists, I want to help everybody. I am also trained to listen for what people aren't saying and to look for unconscious motivations. When I see someone in front of me who shows evidence of a clinical problem that I am trained to treat, I want to help that person. But every course of therapy is based on a "contract." This is the verbal agreement between patient and therapist about what they're going to work on. It isn't usually written out, but just discussed in the first session. Sometimes, patients only voice that they want to feel better, or that they feel "stuck" in their lives, which usually means that they are having difficulty with motivation or making decisions. Regardless, as long as the patient admits that there is something wrong with them and asks for help, they can usually be helped. But if the patient frames the problem as something in the outside world, I can't help them, because I can't change the world.
Patient X stayed for a few months and I thought we were working on some real issues. Then one day I received an email from her telling me she was dropping out of therapy with me. She implied in the email that I didn't agree with her quest for a high-status mate and therefore, we weren't on the same page. I am sure that I never stated such a thing, although it was true that I was somewhat puzzled by her criticisms about men she dated. The mistake I made, however, was in not telling her in the first session, "if you have no other issues you want to work on besides lack of a husband, I can't help you."
It occurred to me that the patient's inability or unwillingness to talk in person with me about what she perceived as a conflict between us was probably related to her problem finding an intimate relationship. Relationships all involve conflict and require discussion and negotiation. If you can't do this with a therapist, it's unlikely you'll be able to manage a more demanding type of relationship. This illustrates a sad paradox of psychotherapy: Many people want help with relationships, but therapy itself involves a relationship with the therapist. Often people enact with the therapist the same behaviors and patterns they experience in their relationships with other people. This can be useful if the patient is willing to discuss and examine the behavior. These discussions can lead to insights.
In short, therapy can help you find a marital partner, it you admit that you might have a problem or two and if you are willing to engage in an honest discussion with the therapist about what these problems are.
Several patients I've worked with found marital partners while they were in therapy. I am convinced that in most cases, it was the alleviation of the person's depression or anxiety that was the key to helping them find a mate. In some cases, looking at reasons why the person had chosen dysfunctional mates in the past also played a role in helping the patient find someone.
Coming to therapy for no other reason than wanting to find a mate may not work. I recall a patient, who I'll call Patient X, who came to my office with the complaint that her friends were getting married and she wasn't, and she felt left out. She didn't mention any other complaints. I had the sense in our first session that she might be depressed, and that there might be other issues she wasn't voicing. I decided that although I'm not a match-making service and can't find someone a husband, the patient would benefit from therapy. In retrospect, I never should have agreed to work with this person. I should have listened more closely to what she said in our first meeting. What I mean is that the patient never said that there was anything wrong with her.
Like most therapists, I want to help everybody. I am also trained to listen for what people aren't saying and to look for unconscious motivations. When I see someone in front of me who shows evidence of a clinical problem that I am trained to treat, I want to help that person. But every course of therapy is based on a "contract." This is the verbal agreement between patient and therapist about what they're going to work on. It isn't usually written out, but just discussed in the first session. Sometimes, patients only voice that they want to feel better, or that they feel "stuck" in their lives, which usually means that they are having difficulty with motivation or making decisions. Regardless, as long as the patient admits that there is something wrong with them and asks for help, they can usually be helped. But if the patient frames the problem as something in the outside world, I can't help them, because I can't change the world.
Patient X stayed for a few months and I thought we were working on some real issues. Then one day I received an email from her telling me she was dropping out of therapy with me. She implied in the email that I didn't agree with her quest for a high-status mate and therefore, we weren't on the same page. I am sure that I never stated such a thing, although it was true that I was somewhat puzzled by her criticisms about men she dated. The mistake I made, however, was in not telling her in the first session, "if you have no other issues you want to work on besides lack of a husband, I can't help you."
It occurred to me that the patient's inability or unwillingness to talk in person with me about what she perceived as a conflict between us was probably related to her problem finding an intimate relationship. Relationships all involve conflict and require discussion and negotiation. If you can't do this with a therapist, it's unlikely you'll be able to manage a more demanding type of relationship. This illustrates a sad paradox of psychotherapy: Many people want help with relationships, but therapy itself involves a relationship with the therapist. Often people enact with the therapist the same behaviors and patterns they experience in their relationships with other people. This can be useful if the patient is willing to discuss and examine the behavior. These discussions can lead to insights.
In short, therapy can help you find a marital partner, it you admit that you might have a problem or two and if you are willing to engage in an honest discussion with the therapist about what these problems are.
Wednesday, January 28, 2015
Do Therapists Give Advice?
A couple of years ago, I and some other therapists were debating whether or not we should give advice to patients. Traditionally, advice-giving has been frowned upon in the field of psychotherapy. Psychotherapy is supposed to be a treatment process to help people to grow emotionally--to understand themselves, to become aware of unconscious thoughts or suppressed emotions, to build a sense of self and to increase mastery over both feelings and behaviors. The giving of advice was seen as potentially undermining the patient's autonomy and sense of self. The reason I and the other therapists were pondering this tradition was because many of us were working with young adult patients who did not seem to have anyone in their lives from whom to ask for advice. Ultimately we reached a consensus that we often had to give advice, because no one else was advising our patients, who often were in the position of having to make important life decisions.
There are many pitfalls in giving advice, the most obvious one being that you could be wrong. When I give advice to patients I usually start by saying "in my experience." I also advise people to seek out advice from other professionals, such as attorneys or accountants, if they need legal or financial counseling that I'm not qualified to give.
Sometimes patients ask me bluntly what they should "do." In most circumstances, I don't tell people what to do. It's important to learn how to make decisions. Usually, I just help people evaluate their choices and offer what information and insight into their situations that I might have.
It's easier to be a therapist who never gives an opinion, because this means fewer opportunities for disagreement with a patient. Sometimes patients will drop out of therapy if the therapist doesn't nod in agreement with all of their decisions. In my opinion, it is better to risk losing some patients than to allow someone to leave my office on the verge of making a bad, perhaps life-altering decision, without hearing some information that might suggest they give the decision more thought. Here is an example of such a situation:
A young woman who was seeing me for problems with anxiety mentioned to me that she was planning on entering the same type of graduate program I had completed 20 years earlier. She told me she planned to take out $40,000 in loans for this program. I informed her that her starting salary would probably be $40,000 and since she already was paying loans for her undergraduate degree, the total would be quite a lot of money for someone making a fairly low salary. The patient looked at me quizzically and told me that the financial aid office had told her it was ok to take out loans up to one's expected annual salary. It hadn't occurred to the patient that the financial aid office had a vested interest in getting people to enroll in the university and pay however they could. (I find many patients, and people in general, do not evaluate the sources of the information they receive and their possible bias). The cost of the type of graduate program I attended is approximately four times what it was when I was a student, and entry level salaries haven't even doubled. I suggested to the patient she think about a different degree that would allow her to make more money in the short term but also allow her to pursue a career in the mental health field. The patient never came back for another session. Did she drop out of therapy because I suggested her plan wasn't the best idea? It really doesn't matter, because I could not in good conscience allow a young person to leave my office thinking a lifetime of debt for a degree that isn't worth what it used to be was a good idea.
When I work with patients who are a little bit older--in their 30s and 40s--I not uncommonly find that their lives have been severely disrupted by bad choices. I often wonder if they discussed their choices at the time with anyone and what that person or people said. Sometimes I ask this question. Here are a few of the disastrous situations I have encountered. I found myself thinking, in each of these cases, that I wished I had seen the person earlier in life and given them some advice:
1. A middle-aged woman came to me with complaints of dissatisfaction and irritability. She had a job she didn't like and some family and marital conflict. When I explored her history, I discovered she had made a couple of fatal career decisions some years previously--decisions to turn down great job offers. She turned down the job offers for the sake of a relationship with a man. Then she discovered marriage isn't a solution to life's problems. If I had been the woman's therapist earlier in her life, I would have advised her to think of the long-term consequences of giving up what might be one-time career opportunities. I might have also asked her to ponder why her boyfriend would want his future wife to derail her career in order to be in closer proximity to him and what this might indicate for their future relationship.
2. A man who was seeing me lost his $300,000 a year job and was forced to live off of unemployment compensation and savings. He had acquired student loans in the sum of six figures. I discovered that he didn't really like his career and only entered it for the money. Unfortunately, most people who enter careers only for the money aren't very successful in those careers. If I had been his therapist years earlier, I would have encouraged him to do something he liked and to choose a university and/or graduate program he could afford.
3. A woman who worked in a prestigious field complained of constant anxiety. She was wracked with anxiety because her job involved making life-or-death decisions and she did not have a decisive personality. I found out she had accrued more than $100,000 in student loans and it wasn't feasible for her to switch careers because her job was one of the few that would allow her to pay off these loans. In addition, she was no longer young. If I had been her therapist years earlier, I would have helped her explore whether her personality and talents fit the career she thought she wanted. I strongly believed she chose her career because it seemed prestigious, not because she really wanted to do it. Her family may have played a role in her decision to choose this ill-fitting career.
My experience with patients has taught me that helping patients explore life choices can be an important part of therapy. Sometimes it may be necessary to give advice, in one form or another.
There are many pitfalls in giving advice, the most obvious one being that you could be wrong. When I give advice to patients I usually start by saying "in my experience." I also advise people to seek out advice from other professionals, such as attorneys or accountants, if they need legal or financial counseling that I'm not qualified to give.
Sometimes patients ask me bluntly what they should "do." In most circumstances, I don't tell people what to do. It's important to learn how to make decisions. Usually, I just help people evaluate their choices and offer what information and insight into their situations that I might have.
It's easier to be a therapist who never gives an opinion, because this means fewer opportunities for disagreement with a patient. Sometimes patients will drop out of therapy if the therapist doesn't nod in agreement with all of their decisions. In my opinion, it is better to risk losing some patients than to allow someone to leave my office on the verge of making a bad, perhaps life-altering decision, without hearing some information that might suggest they give the decision more thought. Here is an example of such a situation:
A young woman who was seeing me for problems with anxiety mentioned to me that she was planning on entering the same type of graduate program I had completed 20 years earlier. She told me she planned to take out $40,000 in loans for this program. I informed her that her starting salary would probably be $40,000 and since she already was paying loans for her undergraduate degree, the total would be quite a lot of money for someone making a fairly low salary. The patient looked at me quizzically and told me that the financial aid office had told her it was ok to take out loans up to one's expected annual salary. It hadn't occurred to the patient that the financial aid office had a vested interest in getting people to enroll in the university and pay however they could. (I find many patients, and people in general, do not evaluate the sources of the information they receive and their possible bias). The cost of the type of graduate program I attended is approximately four times what it was when I was a student, and entry level salaries haven't even doubled. I suggested to the patient she think about a different degree that would allow her to make more money in the short term but also allow her to pursue a career in the mental health field. The patient never came back for another session. Did she drop out of therapy because I suggested her plan wasn't the best idea? It really doesn't matter, because I could not in good conscience allow a young person to leave my office thinking a lifetime of debt for a degree that isn't worth what it used to be was a good idea.
When I work with patients who are a little bit older--in their 30s and 40s--I not uncommonly find that their lives have been severely disrupted by bad choices. I often wonder if they discussed their choices at the time with anyone and what that person or people said. Sometimes I ask this question. Here are a few of the disastrous situations I have encountered. I found myself thinking, in each of these cases, that I wished I had seen the person earlier in life and given them some advice:
1. A middle-aged woman came to me with complaints of dissatisfaction and irritability. She had a job she didn't like and some family and marital conflict. When I explored her history, I discovered she had made a couple of fatal career decisions some years previously--decisions to turn down great job offers. She turned down the job offers for the sake of a relationship with a man. Then she discovered marriage isn't a solution to life's problems. If I had been the woman's therapist earlier in her life, I would have advised her to think of the long-term consequences of giving up what might be one-time career opportunities. I might have also asked her to ponder why her boyfriend would want his future wife to derail her career in order to be in closer proximity to him and what this might indicate for their future relationship.
2. A man who was seeing me lost his $300,000 a year job and was forced to live off of unemployment compensation and savings. He had acquired student loans in the sum of six figures. I discovered that he didn't really like his career and only entered it for the money. Unfortunately, most people who enter careers only for the money aren't very successful in those careers. If I had been his therapist years earlier, I would have encouraged him to do something he liked and to choose a university and/or graduate program he could afford.
3. A woman who worked in a prestigious field complained of constant anxiety. She was wracked with anxiety because her job involved making life-or-death decisions and she did not have a decisive personality. I found out she had accrued more than $100,000 in student loans and it wasn't feasible for her to switch careers because her job was one of the few that would allow her to pay off these loans. In addition, she was no longer young. If I had been her therapist years earlier, I would have helped her explore whether her personality and talents fit the career she thought she wanted. I strongly believed she chose her career because it seemed prestigious, not because she really wanted to do it. Her family may have played a role in her decision to choose this ill-fitting career.
My experience with patients has taught me that helping patients explore life choices can be an important part of therapy. Sometimes it may be necessary to give advice, in one form or another.
Subscribe to:
Posts (Atom)