Rear View Mirror

The temperature had jumped from -2F to +52, and a couple of feet of snow were rapidly melting as I drove through puddles and mist on Saturday morning errands.  A glance in the rear view mirror showed that the rear window was completely fogged, so I turned on the rear window defroster.  My car has a heavy duty rear window defroster, so I was surprised when nothing happened after a few minutes.  I wondered if the defroster was broken, or if the fog was on the outside of the window rather than the inside (although shouldn't the defroster clear that too?).  I opened the front windows a bit; perhaps air flow might clear the rear window.  Then I saw a clearing view out of a corner of the rear window.  But that was puzzling, because the clarity should have spread out from the defroster strips.  What was happening?

Then, as I looked in the rear view mirror and saw the clarity in the rear window spread, I realized that the fog wasn't on the rear window at all; it was on the rear view mirror with which I had been looking at the rear window.  

Surely, this is a "teachable moment!"

The shift of perspective--when I realized that what I took to be one situation, a befogged rear window, was really another, a befogged rear view mirror--shows brain at work in an unusually clear way.  Our perception of reality is in fact an interpretive construction that is part of the work of the brain.  The "Aha!" moment was the recognition of a shift in perception; this can often happen in humor, too.  This experience was especially valuable because it duplicates, in a low key and inconsequential way, what can happen in very much more consequential situations.  

There's a famous Welsh tale about Gelert, the faithful hound.  Prince Llewelyn heard the dog snarling in his infant son's nursery, rushed in to find the dog covered in blood and the infant nowhere in sight, and drew his sword and killed Gelert...only to discover, when he looked around again, his infant son alive and well in a corner of the room, surrounded by the remains of a wolf which had attacked it, and which Gelert the loyal hound had attacked and killed, saving the baby.  The same theme shows up in a Sufi story about a soldier who returns home after many years to see his wife walking hand in hand with a younger man.  He resolves to kill them for infidelity, but pauses, recalling the advice about pausing before acting impulsively that he'd begrudgingly purchased from a Sufi teacher years before.  Then he overhears his wife say, "We'll go to the harbor again tomorrow, my son, to see if your father has returned."  The story, as told by Idries Shah, has more context:  the soldier, many years before, paid the Sufi for a couple of pieces of progressively more expensive advice and then balked at the third, which would have saved him many years of suffering and deprivation.  So there's a theme about the value of advice here too, and whether we perceive the value, and more.  (I can't recall the book that story is in, and will be grateful to a reader who can tell me!)  

This theme--at its most basic, that things are not necessarily as they seem to be, and that perceptual mistakes can be very consequential when we commit ourselves to action--turns up so often in stories from different cultures and traditions that it must be part of the human inheritance of literature that shows us how the mind works. But that inheritance of literature itself is subject to befogging over time, as the folkloric elements come to predominate over the psychological and instructional ones.  Like my rear view mirror, the psychological content within the literature becomes befogged periodically and needs to be clarified if it is to become available again.    

Another insight has to do with how we understand ourselves and our lives.  Each of us has a narrative about who we are and where we have come from that is central to our sense of identity.  It provides us with some measure of inner stability and cohesion as we go about our lives, often buffeted by the impacts of events.  We look back, even as we go forward, and our understanding of where we have come from shapes our perception of where we are.  Sharing that narrative with others is part of becoming closer with them, and sharing particularly private episodes of our narrative is a sign of increasing trust and intimacy.  Yet the narrative, which we weave as we go forward in our lives, often incorporates perceptual mistakes, which can come from a number of factors:  lack of information, wrong information, mistaken beliefs, allegiances that shape what we see and how we see it.  

A large part of psychotherapy, at least as I and my psychodynamically oriented colleagues do it, is about understanding the patient's current situation and challenges in the context of the developmental history that has brought her to this point.  In order to do that, we have to reflect together on the patient's narrative of who she is and how she came to be who she is.  And in that process of mutual reflection on her (or his) narrative, we often discover the psychological equivalent of "fog on the rear view mirror."  Psychotherapy, then, when it works as it should, is to some extent the equivalent of "opening the windows so the fresh air can clear the fog."    

  

This brings us to two reasons that prevent people from coming in for therapy when they need it, and that prevent them from benefitting once they've begun.  First, they don't understand, at a deep enough level to make a difference, that part of their problems in living comes not from what has happened to them per se but from how they have perceived what has happened to them.  Helping people to understand this at a deep enough level to make a difference is a very important goal of therapy.  The second reason is that they are so attached to their narrative of who they are and how they became that way that they have confused it with their own innermost self, so they can't step aside from it to do the reconstruction necessary to bring their narratives more into alignment with reality.  Our innermost self, as psychiatrist Arthur Deikman points out in The Observing Self, is awareness; and with awareness, we can revise, re-view, reconstruct our narratives about who we are and where we have come from.  

We just have to have a clearer rear view mirror to look into.    

"Safe As Houses:" A Psychoeconomic Reflection

There's a relationship between economics and psychology.  A lot of human behavior often has an economic motivation, although it's often concealed, sometimes from the person doing the behaving.  I address that in a question in the Q and A archive on my website, www.psychatlarge.com, where I see psychoeconomic issues figuring powerfully, if without acknowledgement, in the marital issues of a questioner.  Similarly, a lot of economics looks to me like a branch of psychology, because it's about human nature, what people believe and how we behave.  

The current economic crisis is a psychoeconomic case study worth our reflection, because I think we are looking at a case of the removal of trust from human relationships, and the elevation of greed in the absence of context to a dominant position in our national economic life.  For these two psychoeconomic dynamics, we are paying the price. 

There is a spectrum of trust in economic relationships. 

Let's think about credit, which is at the center of this crisis.  If I ask you for a loan, and you give it to me at a rate of interest that I can pay, you can accept, and we can agree on, we have a relationship in that loan.  You have evaluated my ability to repay.  I want to keep my reputation as credit-worthy.  We will both have probably assessed the risk that I might not be able to pay back the note, and found it worth taking.  Probably I will pay you back.  If I can't you can live with it.  Maybe I put something up for collateral.     

Now, if we think about a traditional home mortgage, a bank is making a significant multi-year commitment to a borrower who promises to pay back the note, and in whom the bank has a reasonable basis for trusting that he will.  We are moving up the spectrum of trust from person-to-person relationship to person-to-institution relationships.  But it is still between the borrower and the lender, for the duration of the loan.  It is a relationship of trust that is direct and effectively interpersonal, albeit at one remove.  Having made the loan, the bank still carries it.  Someone, or some group, at the bank decided to make that loan, and they are probably going to be around.  Their own reputation among their colleagues at the bank depends in part on the performance of that loan.  The well being of all the depositors and investors in the bank even depends, in some small way, on the performance of that loan.  There is a long-term relationship among the people involved in that loan.  

Then we have Fannie and Freddie, buying mortgages from banks in order to stimulate the mortgage market.  It seems to have been an idea that worked, for many years, as long as banks made loans for sale to federal agencies by the same standards that they would apply if they had to hold the mortgages themselves.  The relationship of trust between borrower and lender was effectively maintained, albeit at another remove when it was passed onto the federal agency.  It became part of the relationship between the federal agencies and the banks that made mortgages.  The line of financial relationship was longer, it was extended, but it hadn't snapped.  It remained intact.  

The bubble in the mortgage market removed that financial relationship between borrower and lender, because lenders could sell mortgages for quick profit immediately after closing the deal, and borrowers could apply for mortgages that they couldn't repay with the expectation that they could always refinance later, when their homes would be even more valuable. Under such circumstances, the incentive in the mortgage market was just to make and sell as many mortgages as one could.  There was no longer a relationship of trust; it was gone.  In it's place was greed:  the greed of unqualified home buyers to purchase homes they couldn't really afford, and the greed of the mortgage seller for a quick profit.  

Now we come to the interesting term "securitization."  This involves bundling mortgages together into financial investment instruments purchased by investors and insured against default by insurers such as AIG.  The economic rationale in bundling mortgages into securities was that most mortgages would be repaid even though some would fail, and the majority of successful notes would compensate for the small minority of failures within the security.  This worked well as long as the original mortgages were based on relationships of trust.  It was based on expected ratios of home mortgage payoff to failure that were typical of mortgages made in the traditional, fixed rate, long-term, more or less interpersonal way.  But such ratio estimates did not apply to the new short-term adjustable make-and-flip mortgages which were comprising an increasingly large proportion of the mortgage market.  Similarly, the security insurer (such as AIG) made its insurance against default on the basis of an expected rate of failure that characterized securities with much more fundamental validity than these new instruments.  My impression is that default insurance hardly ever had to be paid, because the instruments rarely defaulted; they were, as the saying goes, "safe as houses."  This expectation was seemingly borne out by the bestowing of triple A rating on the securitized mortgage instruments.  This is another example of greed for gain in the absence of relationships of trust; with the statistics involved in bundling the mortgages together, and a belief--astonishing in financial professionals--that the values of housing stock would always move upward without correction, substituting for relationships of trust in the mortgages themselves.  

So the psychoeconomic line from an economy based on relationships and trust to an economy based on greed without relationship or trust was crossed when the relationship between borrower and lender was effectively nullified.  The borrower no longer had an obligation to pay off the note as made,, based on the assumption that housing value would continue to increase and new mortgages at favorable terms would always be available whenever the note came due.  The lender no longer had an obligation to hold the note for the loan, because it would be instantly flipped into a securitized bundle.  When houses and mortgages could be bought and flipped, there was no foundation of relationships and trust to support the economy any longer, and it wasn't a matter of whether the system would collapse, but of how long it could keep going until it did.     

Another dynamic of greed fueling the bubble was the existence of large amounts of investor wealth, both in the U.S..A. and internationally, looking for opportunities for high rates of return.  With the bestowal of triple A rating, and in the presence of default insurance, the elements of an economic "perfect storm" all came together.  

Reflecting on the unrealistic thinking that went into creating this mess, I'm reminded of the story of Mulla Nasrudin, the Sufi wise-fool star of hundreds of jokes and tales, who was observed by his friend one day, pouring yogurt into a lake.  When his friend asked him what he was doing, Nasrudin said, "I'm making yogurt."  "But you can't make yogurt that way, Nasrudin!" exclaimed his friend.  "Yes," replied Nasrudin, "but just suppose it takes!"  (See, "The Exploits of the Incomparable Mulla Nasrudin and The Subtleties of the Inimitable Mulla Nasrudin," a double book, by Idries Shah, available at I.S.H.K. Book Service,  http://www.ishkbooks.com/books/EXSM1.html.)

    

 

    

Inappropriate Stimulant Use for Misdiagnosed A.D.H.D. Can Contribute to Psychosis

A very bright young man whose evaluation I recently completed sent me information that he'd found, on psychiatryonline, that he thought might be useful for others, so I'm posting it here.  (His encouragement to write a blog contributed to my beginning this one.)  He had suffered a psychotic episode in college after using stimulants for A.D.H.D.; though stimulants were not the only factor contributing to the psychotic episode in his case.  My evaluation indicated that his attention problems were part of his cognitive learning style, a kind of nonverbal learning disorder, and not really due to A.D.H.D.  The stimulants had only helped him as they would help anyone who took them, and his dependence on them contributed toward tipping him into a psychotic episode that he is still working his way out of.  Here's what he sent:   

"This case has some similarities to my situation."

"Stimulant use to treat attention deficit disorder and stimulant misuse to aid studying has dramatically increased in recent years among college students.  A phenomenon we have observed is the use of stimulants during the schizophreniaprodrome for presumed attention deficit disorder or attentional difficulties in the absence of any childhood attention deficit disorder.  The following case typifies this presentation, which we have seen several times over the past 2 years in our First Episode and Early Psychosis Program.

"Mr. A," a 20 year old man, with normal childhood development and no behavioral or academic problems, graduated high school with honors despite regular marijuana use.  During his sophomore year, he suddenly found it difficult to concentrate and demonstrated difficulty keeping up with his course work.  these difficulties prompted him to try a friend's prescription stimulant Adderall, which he found effective and continued to use it intermittently without a prescription for "cramming."  Several months after starting Adderall, he became acutely psychotic after smoking phencyclidine-laced cannabis at a party.  He required a lengthy hospitalization but was eventually stabilized and treated with aripiprazole 10mg/daily.  His request for stimulants "to concentrate better" was resisted, and after 6 months of treatment with aripiprazole, he made a full symptomatic and functional recovery without any objective or subjective residual psychotic or cognitive symptoms.  His provisional diagnosis of schizophrenia was confirmed when he had a psychotic relapse 3 months after discontinuing his maintenance antipsychotic aripiprazole following 1 year of treatment. (italics added to identify case presentation)

The prodrome of schizophrenia is characterized by nonspecific symptoms that include cognitive problems, often characterized by patients as "difficulties concentrating."  The construct of "basic symptoms" attempts to capture these nonpsychotic, subjective cognitive problems that begin during the prodrome and might presage the onset of psychosis.  Two basic symptoms that would lead to a complaint of "difficulties concentrating" are thought interference (the intrusion of often banal thoughts) and disturbances of receptive language (problems with the meaning of words).  Both are of particular interest because of their potential as specific predictors of schizophrenia.  

College students who present for treatment with self-diagnosed "pseudo-attention deficit disorder" should be asked about misuse of stimulants and followed closely, since a small percentage will be in the early phases of schizophrenia.  Although the impact of stimulants on the course of schizophrenia is not known, sensitization has been described with stimulants, raising the possibility that stimulant use is a risk factor for some cases of schizophrenia."

http://ajp.psychiatryonline.org/cgi/content/full/163/11/2019.

This observation, from psychiatryonline, indicates both that some attention problems that look like attention deficit might be early indications of schizophrenia, and that misuse of stimulants, especially together with use of hallucinogenic (or other recreational) drugs, might conduce toward psychosis in certain individuals.  

This information is important to consider in light of the widespread practice of prescribing stimulants for individuals with attention problems without either taking a detailed and fairly thorough case history, or having the opportunity to review the results of psychological testing that might indicate the presence of cognitive patterns that explain the attention problems in other ways than as a result of hyperactivity.  In my evaluations, I typically spend an hour or more taking a case history from a patient--sometimes several hours over parts of several sessions--and an hour and a half taking a developmental case history from the parents if they are available; and that's not including perhaps 10 or more hours of testing.  The current standard of practice for prescription of stimulants is a single medical interview, often not even lasting an hour.   

While we don't have any test that will objectively confirm the existence of attention deficit disorder, a fairly thorough case history and the results of a fairly comprehensive battery of psychological tests can provide a much more informed basis for clinical judgment. 

It's important to remember that stimulants will help most people to concentrate better at first, so the fact that a patient reporting attention problems concentrates better after beginning stimulant treatment by no means indicates that the problem was attention deficit disorder.  Stimulants are in demand on college campuses for exactly that reason, especially at exam time.  It has long been known that stimulant abuse is associated with an increase in paranoid symptoms, especially when used on a long term basis, and more recently stimulants have been observed to exacerbate bipolar symptoms in patients who had hypomanic or cyclic tendencies before beginning the stimulant.  Now we see that stimulant abuse may also be associated with  psychosis.  

This doesn't mean that stimulants aren't very useful, even sometimes necessary, for patients with the kind of attention disorders for which they can really make a great deal of difference.  It means that the prescription of stimulants for attention disorder should follow a much more detailed and thorough assessment than is current in general practice.  

I hope that my former evaluatee's research, part of his path of recovery on his own personal journey, will help others to avoid this particular pitfall of medication misuse.  I know he hopes for that as well.

Review of "Hanging By A Twig: Understanding and Counseling Adults With Learning Disabilities and A.D.D.," by Carol Wren and Jay Einhorn

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 and 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 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)

Religion, Spirituality, and Mental Health: A Study Group

This is a description of a study group which I've facilitated a couple of sections of.  I expect to be convening another section in 2009, and persons who might be interested in participating are invited to contact me.  I'm also available to speak, consult, and lead workshops on this topic.

Research and experience show that religion and spirituality can make a potentially positive contribution to our mental health.  They help us form the networks and communities that provide cohesiveness in our lives, provide explanatory frameworks to make sense of events, encourage resilience in the face of challenge and change, and, in spiritual or transpersonal experience, connect us directly with the meaning of life, transcending the boundaries between the individual, the community, and humanity as a whole.  But religion and so-called spiritual experience have also done a lot of harm.  Religious and supposedly spiritual organizations and institutions can become self-serving, coercive and abusive, undermining healthy communities and mental health, encouraging beliefs and behaviors that are dangerous to self and others, and even giving rise to terrorism.  This study group will assemble psychotherapists, pastoral counselors, and others who are interested in these topics to consider the relationship between religion, spirituality and mental health.  

The study group will meet for six sessions, once a month.

The group will read and discuss two books:  "Spirituality and Mental Health Care:  Rediscovering a 'Forgotten' Dimension," by John Swinton, and "Them and Us:  Cult Thinking and the Terrorist Threat," by Arthur Deikman; other readings may be announced.  An approximately equal balance of discussion of readings and cases will be encouraged.

The study group is co-sponsored by the Chicago Association for Psychoanalytic Psychology and the Learning Resource Alliance.  The study group facilitator will be Jay Einhorn, Ph.D., Chair of Peer Study Groups for the Chicago Association for Psychoanalytic Psychology (www.cappchicago.org), and President of the Learning Resource Alliance (www.learningresourcealliance.com).  Dr. Einhorn is a psychologist in private practice in Evanston, with a long-term interest in this topic.  For further information, contact Dr. Einhorn at 847.212.3259, or jay@psychatlarge.com.

Reflections, Ruminations and Rants

"Guarantee"

I am grateful to Geoff Nunberg (http://people,ischool.berkeley.edu/~nunberg/), the linguist on Terry Gross' "Fresh Air," for pointing out how words can be used in a way contrary to their original meaning.  Most "guarantees," for example, are actually predominantly "limitations of liability."

Words and Reality

I'm calling my telephone service to ask why this month's bill is larger than last month's, when my usage was the same.  The first thing the automated announcement tells me is, "We value your time."  Then it goes on to waste my time with a bunch of advertising and irrelevant announcements, eventually taking me through a series of steps, then putting me on hold again until I can finally speak with an account representative.

What counts more, the words--"We value your time"--or the reality?

"Only One Book"

Spanish writer Arturo Perez-Reverte (http://www.perez-reverte.com), in his novel, "Purity of Blood," (http://www.amazon.com/Purity-Blood-Arturo-Perez-Reverte) tells a story from the perspective of the 13 year old Inigo Balboa, ward of Captian Diego Alatriste.  Following a disastrous attempt, with Alatriste, to resuce a young woman from a convent which is also a prison and cult, Inigo is captured by the Inquisition.  He is beaten and tortured, and witnesses worse done to others, inflicted by those who believe they are obeying the highest authority (sound familiar?).  Commenting on this episode later in his life, Inigo reflects:

Later, with time,, I learned that although all men are capable of good and evil, the worst among them are those who, when they commit evil, do so by shielding themselves in the authority of others, in their subordination, or in the excuse of following orders.  And even worse are those who believe they are justified by their God.  Because in the secret dungeons of Toledo, nearly at the cost of my life, I learned that there is nothing more despicable or more dangerous than the malevolent individual who goes to sleep every night with a clear conscience.  That is true evil.  Especially when paired with ignorance, superstition, stupidity, or power, all of which often travel together.

And worst of all is the person who acts as exegete of The Word--whether it be from the Talmud, the Bible, the Koran, or any other book already written or yet to come.  I am not fond of giving advice--no one can pound opinions into another's head--but here is a piece that costs you nothing:  Never trust a man who reads only one book.

"Intention Invention"

I’ve recently been recommending a book entitled “Difficult Conversations: How to Discuss What Matters Most,” by Douglas Stone, Bruce Patton and Sheila Heen, of the Harvard Negotiation Project (http://www.amazon.com/Difficult-Conversations-Discuss-what-Matters). It’s an excellent source of information about how difficult conversations can go bad and how we can approach them to help them turn out more constructively. One of the ideas in “Difficult Conversations” that I find very useful is, “intention invention.” By “intention invention,” the authors mean that we make up reasons why we think someone we’re having a conflict with is doing whatever they’re doing, when we don’t really know why they’re doing it at all.

Here’s an example: Johnny, a fifth grader, isn’t doing his homework and is falling behind in class. His teacher thinks that his parents don’t care about his homework, or how he is doing in school. His parents think that his teacher doesn’t like Johnny and doesn’t understand how to make a relationship with him so he’ll want to do her assignments. In fact, neither the teacher nor the parents know what the others’ intentions are, and they are just making up their ideas about each other.

“Intention invention” is a great phrase, because it combines several complex ideas into one that is readily understandable at an everyday level. In fact, you don’t need to know any more about it than that, to use it. If you are in a conflict discussion with someone who accuses you of bad motivation, you don't have to accept it, but can say that their impression of why you're doing it doesn't fit how you actually feel, and "reframe" the conversation (another key idea in "Difficult Conversations") back to the issue under discussion. And, if you start to impose bad motivation on the other person, you can catch yourself at it, let it go, and get back to the conversation. But I can’t help but be interested in the implications for what "intention invention" means about our mental functioning.

It seems to me that there are at least three rather complicated ideas underlying “intention invention:”

1. The idea of “attribution,” which, in cognitive psychology, means why we think someone is doing something and the relationship between that and how we feel about them. For example, if I’m driving my car and am stopped at a stop sign, waiting for a teenager to cross the street, and he’s walking very slowly while talking on his cellphone, completely oblivious of the drivers who are waiting for him to get across, I might get annoyed if I think he’s a narcissistic, spoiled, entitled brat without an ounce of awareness of what’s going on around him or concern about how his behavior is affecting others. However, if I happen to know that his mother had surgery last week for a brain tumor, and expect that he’s probably numb and in shock from that, I might be grateful that he has people to talk with, for support or just ordinary relationship in the midst of his crisis, and not be annoyed at all. In either case, he’s doing the same thing, but how I react to it depends on why I think he’s doing it. That’s attribution.

2. The idea of “projective identification” in psychoanalytic psychology. This is a very complicated idea, and something of a moving target in that different analytic writers have used it to refer to somewhat different behaviors. My teacher on this subject, psychiatrist Harold Balikov, described it as the way we react to another person because of what we feel they’re thinking about us, when we are, in fact, projecting that onto them in the first place.

Here’s an example from therapy: a client feels that his therapist doesn’t want to hear him talking about his dissatisfaction with his marriage. When he was a child, his mother was unwilling to listen to his feelings or needs. She wanted him to be conventional, successful, and happy, and whenever he wasn’t she responded with ridicule and scolding. Then he’d suppress his dissatisfaction and unhappiness and put on a happy face in order to bond with his mother, who had a strong personality and was the most powerful person in his life for many years. The client doesn’t say, “I feel like I need to project a conventional, successful and happy image to my therapist, even though that doesn’t reflect how I really feel.” Neither does he say, “I’m reluctant to talk about my marital problems with my therapist because of the way my mother treated me when I was growing up.” He says, “I know you don’t want me to talk about how unhappy I am in my marriage.” That’s projective identification.

3. Multiple motivation: The “Difficult Conversation” authors emphasize that most of what we do has multiple motivational sources. In the example of Johnny and his teacher and parents, Johnny may be falling behind in his homework because he’s being picked on by other kids, and because he feels the teacher doesn’t like him, and because he finds the work difficult, and because he'd rather have fun after school than do homework, and because he can get his parents to let him get away with it, and because he feels more special and influential in his family when he does. His teacher and parents have similar multiple motivations contributing to their own perceptions, feelings, and attributions. So it’s generally a mistake to think that someone we’re in a conflict with is doing something for only one reason, and that we know what it is. Equally, we ourselves are not usually motivated by a single value or goal; we are just as subject to multiple motivations as anyone else. In fact, we are almost always operating on the basis of a mixture of motivations.

So, in a difficult conversation, the important issue is not why we think the other person is doing what she’s doing, but what the consequences are. In our example about Johnny, the key issue is that he isn’t doing his homework and is falling behind. If his parents and teachers get into an argument about each other’s motivations (Parent: “Why don’t you care about my son?” Teacher: “Why don’t you care about your son?”), it won’t help solve the problem. They need to face the fact that Johnny isn’t doing his homework and is falling behind, and start finding ways to work together to help him get back on track.

(Note: A longer article about “Difficult Conversations” and other methods of having the necessary difficult conversations of life with less damage and more benefit will be posted shortly on by website, “Psychologist At Large,” www.psychatlarge.com.)

Two Questions, One Answer

The two questions discussed below illustrate several important ideas. One is that different questions can reflect similar themes, which become apparent when they are considered side-by-side. Another is that people may come into therapy or consultation wishing to hold onto something that they may have, in fact, already lost. Yet another is that people may come into therapy hoping to change someone else, when their focus really needs to be on themselves.

So, here are a couple of questions that were submitted through my web page, “Psychologist At Large,” (www.psychatlarge.com). The women who sent these questions are suffering, and my heart goes out to them. Yet the main cause of their suffering, from a psychological point of view, seems to me to be that they are unconsciously clinging to narratives about their relationships that have already been disconfirmed by events; specifically, the behavior of their respective boyfriends.

Let’s look at the questions:

Georgia: “How can I make him see...”

Georgia writes:

Hi, I have been with my boyfriend for almost 3 years now and we have known each other for almost 8 years. When we started going out together it was because we realized that we loved each other and want to build a future together and all this time we were looking elsewhere when we are right next to each other.

Things were doing great until about 2 years ago, when he started being distant, I had then found out that he was spending time with another girl, and we fought about it until he gave up on that girl. When we talked about it, he told me that he did that because she would listen to him and not stress him out. So I acknowledged my mistakes and tried to be better for him.

About 6 months ago, I don't know why, he makes me feel like a yo-yo, always rethinking us. I don't know if it's because he his seeing that he will become successful (music) or because he has vengeance towards me, all I have been doing lately is run after him and try to show him that I changed.

What I have noticed about him is that he is always stressed around me, but when he is with others he is always happy. Even when I am calm and relaxed he will turn things around to get me heated up. He doesn't want to talk to me because he says I will do something that will stress him. How can I show him that I just want to spend some good time with him when he closes the door before even seeing who's there or at least what they're trying to do.

I know that he also had a tough childhood, his mother left his father for his best friend and his father is always backtalking them, while the mom is imposing his stepdad on him. She even told me she thinks that all the hatred he has towards her, he channels it towards me, and I noticed recently that he became very close to his sister, but at that same time he gives me affection less and less as if he takes it from me and gives it to his sister instead.

How can I make him see that he is seeing me negatively even when I'm being positive and how to help him stop please?

Catherine: “Oh no, not again!”

Catherine writes:

I am 50 yrs. old; my boyfriend is 53. We have both been in long relationships, including marriage. We have been together for seven years and only see each other weekends due to the distance (appr. 1 hour) and work schedule. He is the most wonderful, giving, handsome man I had ever been with. We always tell each other that "you are the One". Sometimes he goes into a deep depression in which he has to be alone for about one week. I don't call him or bother him. I accept this. This past week I had gone away with a friend for about four days. I called him at home and said how much I missed him and loved him. I also said that I wish we could walk this beautiful beach together, etc. He called that night to tell me that I really have to NOT miss him and NOT call him so much. Of course, I was hurt. Bill is a private man who likes to do things by himself, which I understand. I like to be around people and have lots of fun. He goes to bed at 7:30 p.m. and does not like to go anywhere except to a cottage once a year with myself and my dog. That is okay. He encourages me to go with my friends.

I had just come back from a four-day weekend with a friend, as I noted above. He called and told me that he wanted to end the relationship. I was so stunned that I could not speak. He said that I call him too much and that I should have never called his father to see if he was there to talk to him. Believe me, I am NOT a clingy person - just someone who likes to give her boyfriend a nice message saying that I missed him. I said that I thought he loved me, and he said that he did love me very much but that he really liked to be alone. After much crying on my part, he agreed to see how things would go and still see me.

I called his older sister hysterically crying, and she said, "Oh no, not again". Apparently, he has done this with other women - it is a pattern. He dates for a number of years, then breaks up with them claiming he wants to be by himself. We concluded that he may be bipolar. She said she had so many hopes for us and thought that would be the end of this pattern. She was happy that we were making long-term plans together and that our relationship is the best one he had ever had. I told her that he does not like to go away with me but that he encourages me to go with my friends. She claimed that that is the start of his pulling away, slowly. I had never put two and two together.

He is on Paxil and has been for a long time. He gets in his "funks" where he is not "right" for about one week - usually in the winter. I am used to that, but he tells me that it has nothing to do with me, and he eventually gets over it

He just now called me to ask how I was doing with my cold. (I've had a bad cough for about one week) I said okay and asked him about his earlier call, but he would not talk about it. I have no idea what to do. I am scared because I am sure this will happen again, but maybe the next time it will be for good. It also seems that while I will be hurting, he will not be. I can't understand it. He loves me, I am "the one", making plans to move south and retire with me, etc. He is a wonderful man all around, but this is so shocking. I don't want to start over and want to stay with him, but does that mean I cannot express any feelings I have or be afraid to, in fear that it will be too much for him?

I am thinking about seeing a therapist to better understand him, but is that the right step?

Dr. Einhorn replies:

Looked at from a distance, and simplified, these questions have similar structures, something like this:

“I had a relationship and believed that it was great. Then it turned out that my partner was not who I thought he was, and our relationship was not what I thought it was. I understand I have to make some changes. What can I do to keep my relationship the way I want to believe it is?”

The truth, of course, seems to be that neither woman has the relationship that she once believed she did. Even when their relationships seemed so great, both Georgia and Catherine’s relationships contained the seeds of later conflicts, challenges, and disillusionments. Both Georgia’s and Catherine’s boyfriends gave them cues that things were not entirely what they seemed. If Georgia and Catherine acknowledge that they didn’t recognize what was happening then, they will be able to look at what’s really happening now. Such acknowledgment leads to psychological freedom; the freedom to be their real selves, in their real lives, today. But there is a cost: they’ll have to revise their impressions about their relationships. They’ll have to take another look at who their boyfriends are, what they are offering of themselves in relationship, and whether that's really what Georgia and Catherine want after all. In the process, they’ll have to take another look at who they themselves were, how they chose to conduct themselves, how they tried to protect themselves, what they chose to notice and ignore, what they chose to believe, as their relationships formed and evolved.

The brain is a maker of stories, a weaver of narratives that give form to events and explanation to experience. And no story is more powerful than that of the meeting of two soul-mates. But the brain is a better maker of stories than it is an adapter of them. We cling, often largely unconsciously, to the stories that tell us who we are and orient us in our lives. It is in our lack of readiness to adapt our stories based on the facts of events and experience that so many of our mistaken decisions and judgments, and the suffering they lead to, are rooted.

If I were in a therapeutic or consultative relationship with Georgia and Catherine, I would proceed from three fundamental perspectives. The first is that the human brain is capable of the “top-down reorganization of life,” as Roger Sperry said (www.rogersperry.info). That means that, even though we learn as we go forward through experience, like any animal that learns, the human brain is unique, as far as we know, in it’s ability look in, look back, and reorganize; to detach, review experience, and make sense out of it in a new way. I would want to help them review these relationships so that they could understand them more realistically. The second fundamental perspective is that of unconscious process. And there are two parts of that. The first part is the stories they told themselves about what was happening early in their relationships, and later. The second part is the cues that they received which told them that their stories were not accurate enough, and in need of revision; cues which they more or less disregarded.

It gets more complicated, there are more levels. Their stories themselves come from different sources. Some of those sources might be stories they’ve absorbed from their culture, with internal themes that are too simplistic to be real. Their stories could have been influenced by patterns of relationship in their families of origin and other situations whose structure they absorbed while growing up. There might be aspects of their formative situations in which a kind of unconscious but deliberate intention not to recognize something that was happening was absorbed.

“The brain is a creature of habit,” as I often say, and the problems that bring people into therapy or consultation are often repeating earlier patterns.

The third fundamental perspective is that work on oneself, of the right kind, in the right way, brings about changes in the brain and mind of the person doing it. The process of self-observation, and of putting words and images to thoughts, feelings and attitudes that haven’t yet been expressed, creates a change in the brain that is doing that work. What psychiatrist Arthur Deikman calls the observing self (http://www.deikman.com/observingself.html) becomes more consciously a part of the mental life of the person. And with greater self-awareness comes the possibility of being more honest with oneself; honest about what one is really giving and getting, and what one needs. Which, in turn, leads to more awareness of what our real choices in a situation are.

It may be that either Georgia or Catherine, or both, can do something to save their relationships. If they can, it will be at the cost of seeing their boyfriends, and themselves, more realistically. If they can’t, they can still learn the lessons and avoid repeating their mistakes. But it will take some self-searching. It’s possible that, after awhile, couples therapy might help either or both couple(s), but it seems unlikely that it’s the best place to start, since neither man seems ready to work on himself to try to preserve and enhance his relationship. Neither seems ready to detach and look at his own narratives. And, in a way, neither do Georgia and Catherine really seem ready to look at themselves; they’re both asking me to advise them about how to keep their relationships as they’d like to think about them. But Georgia and Catherine seem to care more--after all, they took the trouble to write--and perhaps that will bring either or both of them into a place where they are ready to look at themselves, as part of the process of trying to understand and save their relationships.