Psychologist At Large

Present and Past

2012-01-03T21:00:00.001-06:00

A client and I, in therapeutic discussion, came up with a phrase that condenses much therapeutic wisdom, almost like a mathematical formula:

"We can't live in the past, even though the past lives in us."

Can You Recommend A Book by Idries Shah?

2011-12-08T12:22:00.010-06:00

A colleague, appreciating a comment which I'd posted to a listserve discussion, which included a couple of quotes by Idries Shah, asked me to recommend a book of Shah's for her to read. Here's my reply:

Here's a very brief overview of Shah's writing that might indicate a title you might like to look into.

Shah wrote over 30 books, and the styles vary. He also wrote over a period of thirty years or so, so sometimes his writing might reflect changes in readership, with the later books perhaps written partly for a readership familiar with the earlier books. Which is not to say that the earlier ones aren't full of value; "The Sufis," for example, was his first Sufi book, in 1964 I think, and I am not alone in finding new content whenever I return to it. It lays out a sort of patchwork background of Sufi thought and action over the past thousand years or so, and if you are looking for a historical context, you might find it here. Another earlier book that has some context about Sufism is "The Way of the Sufi," which contains examples of stories, meditation themes, comments from the masters, sort of a representative cross-section of classical Sufi thought. At the same time, it isn't an A through Z genre or catalog; each book stands on its own, so a reader could start anywhere.

"Learning How To Learn: Psychology and Spirituality in the Sufi Way," is based on lectures Shah gave in New York and California (in 1974, as I recall), as is "A Perfumed Scorpion." "Seeker After Truth" came in 1982. "The Commanding Self," and "Knowing How to Know" are later works, and they are all very rich in psychologically and spiritually relevant content, in which the interaction of traditional Sufi attitudes and perspectives and contemporary Western psychological and sociocultural perspectives and behavior are more up front, at least to me. Shah was a great storyteller, and these books, in style, go back and forth between stories and discursive discussion.

The Sufis are preeminent cultivators of stories--Shah coined the term, "Teaching Stories" for a particular genre of tales--seeing story and metaphor as reflecting both reality and processes of thought and perception in ways that logic, analysis, etc., can't. It's not that logic and analysis are discarded, but they have a subordinate role to perception. This makes sense because we have to perceive the context of a situation before we can analyze or measure parts of it. Sufis see our perceptual capacities as capable of being provoked and evolved through various experiences, in which stories can play a part. At the same time, they emphasize the importance of having one's feet on the ground, as it were, in being well integrated into ordinary life.

Shah published several collections of stories without narrative, and little or no commentary, such as Tales of the Dervishes (an early collection of classical tales) and The Magic Monastery (a later one, including modern tales of his own). "Thinkers of the East" and "Wisdom of the Idiots" are others; "Dermis Probe" contains an award-winning script based on Rumi's "Elephant in the Dark" story, and has brief comments in an appendix. "Caravan of Dreams" is another kind of cross-section, containing travel writing, stories, table talk, and more.

Adding to the richness of Shah's work and the complexity of recommending a first book, there are several volumes of stories about Mulla Nasrudin, the wise-fool figure whose antics reflect mental processes, a sort of psychological mirror. Some Nasrudin fans like him right away, for others he's an acquired taste. There's a chapter on Nasrudin in The Sufis which provides context. Canadian storyteller Aubrey Davis posts Nasrudin stories on Facebook, and you can "friend" Nasrudin and receive occasional stories to your facebook screen,at http://www.facebook.com/mulla.nasrudin1/.

So, there's a brief overview of some of Shah's work. If you want an introduction with background and context, "The Sufis" is a good place to start. "Way of the Sufi" provides a sort of cross-section of classical Sufi thought. If you prefer a more psychologically oriented presentation, "Learning How To Learn" might provide that; although there's a lot of psychological and social-behavioral insight throughout Shah's work. If you'd like to start just with stories, you might try "Tales of the Dervishes," "Thinkers of the East," "Wisdom of the Idiots," or "The Magic Monastery." If you'd like a later work, starting at the end of his writing career so to speak, "Knowing How to Know," is his last.

Shah's books are not much on the bookstore shelf these days, although you can often find one or two, and you could try your luck with whatever might be in your local bookstore. Amazon and Barnes and Noble carry selections online. More complete catalogs are available in USA through ISHK Book Service, http://ishk.com/books/books_shah_catalog.html/, and also from Octagon Press in London http://www.octagonpress.com/index.htm/.

My colleague replied:

Hello Jay,

What a delightful answer, thank you for spending the time to give me such full information on Idries Shah. I have long been interested in storytelling and so love the tales of Nasrudin. I am also attuned to the mystical traditions in all cultures and would like to read more about Sufi thought. So, I will choose from each genre.

I have a favorite bookseller online, because they use part of their profits to support world literacy: BetterWorldbooks.com and they have 14 of Shah's books in stock.

Thank you!

Inspiration and the Creative Spark: at the 2011 Conference of the Institute for Cultural Research, London, Part 2

2011-10-15T22:00:00.001-05:00

Sunday’s program began with an experiential exercise in creative perception by the teacher, facilitator, engineer, businessman, artist and musician David Kayrouz (http://www.creativepathways.co.nz/).

Perception, Kayrouz said, is both cognitive and affective. Essentially, it is about How do you know. He quoted St. John of the Cross: “To know everything: Does anyone know the end of that? Know nothing.” Kayrouz continued, “Knowing is a way of not knowing because when we ‘know,’ we stop learning.” Similarly, he prefers the verb “knowing” to “knowledge.”

From the stage, Kayrouz held out two pictures, one to his left and one to his right. One was called “old rat,” the other, “old man,” both were quite similar. Then he projected a powerpoint image on the screen and asked the audience what it was. Those on his left said it was an “old rat,” while those on his right said it was an “old man.” Our perceptions of the picture had been shaped by our prior experience.

“We perceive color affectively but read cognitively,” he continued. He showed a slide of a list of color names, in which the letters of each color name were in a different color than the word name of the color, and asked an attendee to say the colors in which the names were written rather than reading the names. The reader had a hard time with that.

Kayrouz then showed a slide of an indeterminate abstract sort, which reminded me of a Rorschach ink blot, and and asked us to write what we saw. Then he rotated it 1/4 and asked us to look and write again, then he rotated it again. Next he asked us to form small groups and discuss what we’d seen. The members of my group found ourselves seeing more in the slide when we looked together and had the benefit of each other’s perceptions, and this turned out to be the experience of other groups as well. This emphasized, Kayrouz said, that creativity is often a group phenomenon, and that the image of the lone creator coming up with great ideas is more myth than reality.

Returning to his theme of contrasting cognitive and affective perceptual processes, Kayrouz said, “Cognitive perception has rules and judgment, affective perception has no rules and suspended judgment. Cognitive perception works with proven results, affective perception involves experiment and play.” Kayrouz showed a slide of a Venn diagram with cognitive and affective circles, and an area of overlap. “Imagination is where the cognitive and affective overlap.”

Kayrouz had one of the shortest session times, just 15 minutes in the program and somewhat longer actually, but he packed a lot of experience and meaning into a short time!

Our next presenter was Simon Elmes, Creative Director of BBC Radio’s Documentaries Unit, associated with such superb projects as “A History of the World in 100 Objects,” in collaboration with the British Museum. His presentation considered creativity at the BBC within two contexts:

• That of a public broadcast organization which identifies creativity as its professional lifeblood, and

•That of a public broadcast organization which is constantly challenged to maintain and improve programming quality in spite of reductions in resources, including personnel

“In some ways, inspiration to order” is his job.

Elmes contrasted ongoing creativity with mission statements and vision statements, which “tend to ring a bit hollow.” Creativity is the lived experience.

“The creative spark doesn’t come from a focus group,” he said. The inspiration for “A History of the World in 100 Objects,” for example, emerged from “a confluence of ideas at the British Museum” during a meeting of British Museum and BBC staff. “Afterward, several people said it was their idea.” In fact it was a creative collaboration between a number of highly professional people.

After giving the audience an exercise in coming up with ideas (“wind tunneling”), Elmes said, about his job and group at BBC: “New ways of seeing things is what we’re trying to do all the time. This applies not only to programming but also to the H.R. (Human Resources) department. B.B.C. as an organization has to be imaginative when we’re making photocopies as well as making programs.”

Elmes repeatedly returned to the theme of the need to live creatively on a day to day basis. “Words like creativity and community can take on a shibboleth value.”

Exercises can be part of the process of creativity. “There are hundreds of names for creative techniques, which unhook the creative part of the brain from the routine perceptive part of the brain.”

Contrasting creativity with genius, Elmes reflected on the great novelist Flaubert, who wrote slowly and complained of being “dazed, bogged, in a swamp of despair” as he struggled with his novel. “Today’s BBC can’t move at that pace,” Elmes commented. “We are working against an incredibly fast-moving and creative environment. All sorts of organizations have to be creative from top to bottom.” When substantial cuts were announced at B.B.C., it was with the slogan: “Deliver Quality First.”

The history of the B.B.C.’s commitment to creativity included a 2-3 year period of deeply studying creativity, which included sending a number of leaders within the organization to creativity training organizations such as the Stanford Research Institute, Creative Problem Solving Institute, IDEO, and WhatIf. This led to a group of trained and eager creative leaders within the B.B.C., but “A few evangelists who have seen the (creative) light are no substitute for senior management buy-in.” Fortunately, support for creativity throughout the organization came from B.B.C. Director General Mark Thompson.

This led to the emergence of “a creative network” of people who work “on a voluntary basis, under the radar and across silos--such as the News, Radio, TV, and Online parts of the B.B.C. “This involves people working creatively with parts of the B.B.C. they don’t know about.”

Elmes discussed some of the pitfalls of what can be mistaken to be creative processes. “When you work with a focus group what you often end up with is what you are already familiar with.” “Brainstorming s often not very well applied,” especially when participants are allowed to interject negative judgments on others‘ ideas (or their own). “Discipline in creative idea generation is absolutely basic. In brainstorming you mustn’t stop ideas, even if they are rubbish,” because a rubbish idea might lead to a better one. “If someone is being negative, you say, with a smile, ‘No negativity.’” Thus, improperly trained coaches could undermine the methods they are using. Creativity involves “the freeing up of the mind in a disciplined way.”

Asked about basing new B.B.C. programs on successful programs on other channels, Elmes said, “We innovate, we don’t clone.”

Writer Kamila Shamsie spoke next about “Finding the Novel Inside the Image.” “What does it mean for a writer to work within a discipline without formulae? How do you piece together a structure as intricate as a novel if your guiding notion is, ‘don’t do it the way you did it before?’

Like Susan Aldrich yesterday, Shamsie emphasized the importance of unplanned happenings in the creative process. In addition to the need for “some sort of structure and thought,” there have to be “some moments of serendipity...I haven’t met a writer who hasn’t been fantastically surprised because something (unexpected) happens” to the novel as it is emerging. “There’s a kind of wildness that happens when you are writing that’s essential, that’s unconscious, you don’t know what you’re interested in.”

Discussing the process of starting to write her most recent novel, “Burnt Shadows”, about the Nagasaki bomb, she said, “It was just one of those things that takes residence in your mind. There are some images, you know, they’re not going to go away. I tried very hard not to write this book.” Committing to a novel is no small matter since “The novel has to be something I’m willing to be obsessed with for two or three years.”

Although she intended to create a short opening to her book which featured the bombing of Nagasaki (most of the book takes place later on), Shamsie had to accomplish it through a nonlinear route. “I couldn’t have done a short opening on day 1.” Instead, she had to do the 80-90 page version, then reduce it to about 25 pages.

Shamsie read extracts, from others work and her own, to demonstrate the relationship between experience, linguistic imagery, creativity, and inspiration. I didn’t make notes from those readings, but came across this in her 2005 novel, “Broken Verses,” the last one of her novels left on the book table when I bought it. The voice belongs to Aasmaani, the 31 y.o. Pakistani woman who is at the center of this story. We find her musing about the many roles of her mother, an activist on behalf of politically charged women’s issues whose disappearance when Aasmaani was 17 has defined her life:

“I entered my flat and locked the door behind me. Here, in my mind, were so many different images of my mother. My mother at twenty-three in a white kurta, lapis lazuli at her wrist. My mother at twenty-six, unable to resist an ex-lover in a grey shawl. My mother at twenty-seven, carrying me into prison. My mother at thirty-four, rallying women together. My mother at thirty-five, running after the Poet to Columbia, leaving the women and me behind. My mother at thirty-eight, her body covered in bruises from a policeman’s lathi, preparing to go out and lead another demonstration. My mother at forty, still dancing to old Donna Summers records. My mother at forty-one, allowing her grief over the Poet to consume her. My mother at forty-two, worse than she had been the year before. My mother at forty-three, gone.
“What connected all the women in these images–the activist, the lover, the mother, the mourner, the dancer, the deserter? What allowed a single ‘version’ to arise from such variedness? There was a word for it: character. That imaginary tyrant. We pretend we all have one, and that it is something to be relied upon, something knowable and true, even when it oppresses and constrains us. When someone behaves ‘out of character’ we frown a little, a voice inside us whispering something that makes us uneasy, but then our brows clear. We’ve found a way to reinterpret the action as being in character. Or we say we were wrong about the person’s character to begin with, and now, magically, our memory is able to furnish us with clues which would have revealed as much had we but picked up on them earlier...we don’t dare consider that the internal voice which makes us uneasy is a voice that whispers: there is no such thing as fixed character, there is only our need to join the dots into a single picture...
“...The joke of it, of course, is that we ourselves become slaves to the stories of our own character. Our invented narratives of self determine our actions and reactions...Character...is the self-fulfilling prophesy that guides our lives...And all around us, people are reinforcing our notions by telling us, directly and in their treatment of us, who we are, what we believe in. At what point does character-playing become habit, something for which we are grateful because it allows us to go through the world with the ease that comes from being predictable to ourselves, even if that predictability takes the form of neurosis, hysteria, depression? And at what point does that habit turn darkly into addiction...”

Shamsie’s writing suggests that our beliefs about what we’re like both liberate and limit our creativity, and that allowing inspiration to occur and creativity to work its way along implies that we discover ourselves and others in new ways.

Creativity trainer and improvisational actor Greg Fraley gave the final presentation, of the “Mash-Up” method. “Most great ideas tend to be made of mash-ups,” by which he means, roughly, throwing ideas and experiences together and shaking them up to see what comes out. He praised Sunni Brown’s TED talk on doodling (http://www.youtube.com/watch?v=7fx0QcHyrFk) and then led us in experiential “Mash-Up,” in which we doodled, danced to music, and free-associated about some situation that we were thinking about.

Some participants found it easier going than others. One participant, thinking about how to lose weight, came up with the idea of carrying the food he’d need with him for the day. Fraley pointed out that about half the people find forced associations, which is what his mash-up exercise was, easy, and half find it difficult.

The final event on Sunday was the Panel, on which several presenters took questions in writing from the audience, read by Saira Shah.

One presenter--I didn’t note whom--in response to a question about metaphor, said that “metaphor is a way of communicating experience without being so descriptive as to require the listener or reader to re-live it.”

In response to a question about how to make a better environment, Kamila said, “Stop asking a question like that, and just sit down and do it...You find that space, you make that space.” She quoted someone (again I didn’t not whom) on the importance of will compared to talent and originality, in achieving results.

Simon said, “It’s not so much having an idea as spotting an idea as it goes by. You need to take your will and say, I will spot that idea.”

David said, “Experiments with two groups of equal talent, one of which believes they are creative...you know the outcome.”

Simon added, “Ideas cost nothing. People say we can’t afford creativity, but ideas cost nothing.”

Responding to a question about whether there was something in society that stifles creativity, Kamila commented, “There’s something about the incredible response to the death of Steve Jobs, (who was) both very creative and a billionaire.”

Greg added, “Educational systems reward having the one right answer and not the ten possible answers.”

David said, “Even trees are creative.” Saira replied, “Perhaps not consciously creative.”

In a response to a question (which I had submitted) about the effects of creativity in the financial system as they contributed to the global economic crisis, Greg observed that, “One definition of creativity is novelty that’s useful. Some of the new financial instruments that made a lot of money for a few people are creative but not innovative.”

Kamila commented, “There was a lot of imagination on the part of governments.”
David said, “What we want is creativity that’s good for everyone. We need a moral and ethical process integrated with it.”

Kamila observed: “The human imagination is not moral. The atom bomb is an act of creativity in a certain sense.” She referred to the play‘“Copenhagen,” by Michael Frayn, in which physicists Niels Bohr and Werner Heisenberg are in conversation, Bohr asks Heisenberg why he did not do the maths to create the bomb, and Heisenberg says, “Because I didn’t really want to create the bomb.” “An idea can have a life of its own,” she observed, and want to be realized, regardless of its morality.

Greg said that “Creativity comes from very near the soul. When it is negative it comes from a corrupted soul.” Kamila replied, “Beyond a certain point I don’t know that you can stop yourself. You walk down that path far enough, it’s going to happen. Your brain fools itself.”

David recalled a dream of Kamila’s that she had described in her talk, in which she wept at the epicenter of the Nagasaki bomb, where her character died, emphasizing the role of empathy in creativity.

In reply to a follow-up question about whether creativity was always a good thing, Simon said, “Yes, if you’re not creative you’re on a stalled elevator.”

The diversity of backgrounds, interests, personalities and professions of the presenters, as well as the diversity among the audience, made for a great conference; it was good “brain food,” and I expect I’ll be digesting it for some time to come.

Inspiration and the Creative Spark: At the 2011 Conference of the Institute for Cultural Research, London, Part 1

2011-10-13T08:19:00.003-05:00

On October 8 and 9 I attended the 2011 conference of the Institute for Cultural Research, London, entitled “Inspiration and the Creative Spark.” This year’s conference brought together presenters from the worlds of neuroscience, psychology, visual art, fiction writing, corporate leadership, myth and legend, and creativity training, to approach the subject from many different perspectives. So the conference itself was both a source of inspiration and sparks for creativity!

Neuroscientist Adam Zeman, author of Consciousness: a user’s guide, and A Portrait of the Brain, Professor of Neurology at the Penninsula Medical School in Exeter, and former Chairman of the British Neuropsychiatry Association, started the conference on Saturday morning with a look at creativity and brain function.

He addressed three typical misunderstandings about creativity and brain:

•The assumption that culture and biology are separate. They are not: culture influences the brain and the brain influences culture.

•The assumption that the brain is passive. It is not: the brain is continuously active. Even at rest it consumes the largest share of oxygen taken in by the body of any organ, about 20-25%, and that percentage goes up some, but not a great deal, when it is actively focused on a task.

•The assumption that imagination and creativity are rare. In fact, Zeman sees the brain as spontaneously, and more or less continuously, imaginative and creative, even while just doing the ordinary chores of life.

Zeman presented what he called the “Ski-D-y” model of creativity, consisting of three parts:

•Skill: what the brain has learned how to do through its interaction with culture, and it’s ability to continue to extend and modify that learning
•Detachment: the ability to step aside from what one is doing to take another look at both what one is trying to do and how one is trying to do it, in order to adapt, modify and improve both understanding of task and approach to it
•Spontaneity: the ability of the brain to suddenly find new connections within itself and responses to its environment, following the development of skill and a period of detachment (which could be of any duration)

Within the brain, “learning depends on modifying the numbers and strength of synapses.” Each of the one billion neurons in the brain have between 1,000 and 10,000 synapses, so there’s a huge potential for learning.

Digging deeper into his Ski-D-y model, Zeman considered “Skill” in four aspects:

•Language: the unique (as far as we know) ability of the human brain to construct complex and detailed systems of language to communicate knowledge of various kinds

•Learning: all those neurons in the brain creating new synaptic interconnections

•Theory of Mind: the interpersonal skill of creating implicit models of how other people are thinking and experiencing, including how they are experiencing us as we experience them

•Mirror Neurons: there’s a lot of scientific buzz about these recently discovered neurons that become active both when we do activities and when we watch other people doing activities. By including them within his “skill” category, Zeman seemed to be saying that mirror neurons both provide us with a biological model of how we can understand other people, and that we can learn to improve our understanding of other people as a fundamental skill that is associated with creativity and inspiration

Zeman next dug deeper into “Detachment:”

Crucially, detachment “allows us to choose how we want our minds to be engaged,” and is largely associated with the executive functions of the frontal lobes.

The capacity of imagination means that “We have acquired the ability to run our brains offline.”

Turning to a deeper consideration of “Spontaneity,” Zeman emphasized the brain’s continuous spontaneous activity:

The brain at rest uses about 20-25% of the body’s oxygen. When engaged it only increases that utilization by a percent or two. “So the resting brain is very active.”

There are networks of brain regions that are active even at rest, associated with seeing, hearing, moving, and also theory of mind and moral decision-making. Thus, even when we are not actively perceiving, brain regions associated with perception are active. Even when we are not actively interacting with others, brain regions associated with theory of mind (or social-emotional perception) are active. Even when we are not actively making moral decisions, regions of the brain involved in moral decision-making are active.

“When we dream, areas of the brain involved in memory and emotion are very active but parts of the brain associated with logic and laying down memories are not.”

Perception itself “involves ceaseless spontaneous background (activity) in the brain.”

Zeman emphasized the growing role of the brain in pre-human to human evolution. “Over the last three million years, body weight has remained fairly equal but brain volume increased substantially.” He showed a slide indicating increase in brain volume over Australopithecus, Homo Habilis, Homo Erectus, and Homo Sapiens. This evolution has produced a brain which is “intrinsically spontaneous, creative and imaginative.”

Drawing an analogy between the broad sweep of biological evolution and the particularities of human culture, Zeman commented that, “Biology, like human life, shows a tension between rule making and rule breaking. DNA passes on but occasionally mutates.”

Drawing another connection between culture and brain, Zeman noted that “The pressure of culture creates an evolutionary pressure to improve culture. Enriched environments make the brain grow.”

In reply to a question, Zeman commented on the “creative explosion” that has been dated to around 30,000 years ago; more or less at the time that cave paintings and artistic artifacts have been dated to. “The record may be misleading us, because there may have been creativity whose objects have been lost” prior to that time.

I asked Zeman a version of the question that has been at the core of my own interest and career in psychology: If the brain is so continuously spontaneous, creative and active, how is it that so many people live their way into cul-de-sacs, dead ends, which so much of my work as a clinical psychologist is about helping people find their way out of? In reply, Zeman returned to his theme of “rule making and rule breaking: “Rule making itself has to be learned,” and we can learn our way into a cul-de sac, so to speak, rather than refining the learning process and attitude toward learning. “Brain chemistry affects that as depression, which is associated with (excessive) self-criticism, (and) mitigates against creativity.”

Reflecting on Zeman’s answer, it occurred to me that a great deal of the work of Idries Shah, founder of the Institute for Cultural Research (in 1965), was about helping us to “learn how to learn,” to develop an attitude about learning that prevented cul-de-sacs, or at least supported early recognition of them in order to remain psychologically free, and what I might call metacognitively supple. Furthermore, the teaching stories that Shah collected, revised and wrote provide us with a way to recognize the presence of patterns in our lives and cultures, and prepare our minds for new learning.

Artist Susan Aldworth was our next presenter. Misdiagnosed with a possible brain lesion around Christmas of 1999, and hospitalized for diagnostic tests, the experience of watching her brain imaged on a screen while she was experiencing herself in real time was a life-changing and career-changing event for her, as exemplified in this etching from her website (http://www.susanaldworth.com/), “Apoptosis 1 (2007).” (I was unable to paste the etching into the blog, but it's worth seeing, along with her other work, on her website).

“I’m a very cerebral artist,” she said, “I think about my work,” but that doesn’t mean that it can be described in words. Aldrich is “interested in celebrating the mystery of brain and consciousness and bringing it out of the labs.”

Aldworth, who also has a degree in philosophy, showed a short film, “Going Native,” and then discussed the brain, science, philosophy, and the human condition, as muse to the artist.

• “The Brain as Muse:” After being discharged from hospital, Aldrich contacted the physician who had worked with her and asked if she could work with him, which led to her spending a day a week watching brain angiograms from behind a screen in the consulting room (with the patients’ permission, of course). Susan read from her diary about waking up in the operating room with her own monitor, watching an image of her brain in action created from a camera in a catheter which had been inserted in an artery in her groin and threaded into her brain.

• “Science as Muse:” Aldworth uses “quasi-scientific images” in her art, for example, “Birth of a Thought.” “We use brain-scans culturally as a kind of sign-post to the person.” She has created art based on the brain images of an epileptic patient, with eyes looking out, back at the viewer. These images had a very discernible and powerful effect on the audience. It was as if the person depicted in the image was both having a seizure and looking out from that experience at the view, simultaneously. Replying to an attendee’s comment about the power of that image, Aldrich commented that the eyes are associated with selfhood.

• “Philosophy as Muse:” Aldworth described the work of two physicians--I didn’t get their names--who weighed terminally ill patients just before and just after death, each of whom found a difference of about 21 grams. “A materialistic shorthand for the soul?”

• “Human Condition as Muse:” Aldworth works with people with Alzheimers, and has a work entitled: “Dissolution.”

Discussing creativity from her perspective as an artist, Aldworth said, “For an artist, creativity comes from being curious and interested. I do my research and then comes the hard work. For an artist, the accidents that happen on the etching plate” can make a profound contribution to the work.

“There’s a huge history to anatomists and artists working together. Before the 20th century, there were very few representations of the brain. Now there are many brilliant artists” working with brain images.

Aldworth received enthusiastic response from the audience when she talked about the deadening of inspiration in school. “In art school, assessment of students and ticking off boxes is killing creativity and inspiration. We have to look to what we’re doing as our culture.” Another attendee commented: “I trained as a teacher and decided not to go into it because it seems to me that we’re preparing sausages rather than human beings.” Aldrich replied, “It’s not done out of maliciousness, it’s done to raise standards, but the overadministration (ends up stifling inspiration and creativity in the name of higher standards).”

I had purchased the book, “Scribing the Soul,” containing essays by a neuropsychologist, an artist/writer, and a curator, around Aldworth’s images. Chatting in a small group afterward, I had mentioned the importance of constructive nagging, and Aldrich inscribed the book, “To my dear Naggers.”

Lunch was enlivened by conversation with attendees with diverse backgrounds, at a little cafe not far from the School of Oriental and African Studies at the University of London, where the conference was held.

After lunch Ilona Roth, Senior Lecturer in Psychology in the Department of Life Sciences at the Open University, and an expert on Autistic Spectrum Disorders, spoke about “Strange Imagination: Insights from Autism.” (I also purchased her book, “The Autism Spectrum in the 21st Century.”)

“Consideration of creativity in people on the autistic spectrum challenges ideas of what creativity is,” Roth said. The autistic spectrum diagnosis is based on:

• Communication difficulties, verbal and nonverbal

• Social interaction difficulties

• The appearance of such difficulties before the age of 36 months

However, “shadow autistic traits,” autistic-like traits which do not rise to the level that would support a diagnosis, can show up early in life and then recede.

Roth showed several slides of drawings of outstanding artistic talent by autistic children. “Artistic talent in autistic children seems to show fully formed right away, rather than going through a developmental process,” she observed. She compared examples of Andy Warhol’s “realistic” art to those of autistic children, and noted that Warhol “seemed to have some autistic traits,” such as liking to talk to people on the phone rather than in person, even if they were close nearby.

“Some preliminary impressions suggest that the brains of people on the autistic spectrum may be more richly wired within local areas but less well wired between areas,” Roth said, which may make for “better attention to detail rther than cognitive flexibility.”

Elizabeth Archibald, Professor of Medieval Literature in the Department of English at the University of Bristol, gave the final presentation on Saturday, on “The Birth of Romance: Creativity and Inspiration in the Twelfth Century.” Archibald noted that there was a sudden flourishing of creativity in twelfth century Europe, in which Lone Ranger knights travelled out in search of adventure and love, featuring women who were suddenly depicted in a new role, as able to choose their knight, sometimes even before or outside of the bonds of marriage, as in some versions of the tale of Arthur, Guinevere and Lancelot. During the question portion of her presentation, Archibald commented that the sudden burst of romance narratives in about the twelfth century might be partially attributable to the sudden increase in need for literacy, following the Norman conquest and the establishment of new administrative processes and controls, in a new language.

This concludes my notes from Saturday’s program. My notes from Sunday’s program will follow.

Hypnosis As A Form of Therapy

2011-09-05T12:07:00.002-05:00

“Brian” asks:

“What are your thoughts about hypnosis as a form of therapy? I’m considering seeking out a therapist who specializes in this to help me with some personal stress and issues at home.”

Dr. Einhorn replies:

Thanks for your question, Brian. I think hypnosis can be a very useful part of therapy, but I don’t use it as a form of therapy by itself. I do include it as a part of therapy for some clients, along with talk therapy, which is my main method.

I'll just say a few things about hypnosis and how I use it in my practice. Trance is a natural state which occurs spontaneously, as we can see in animals as well as people, and in children as well as adults. It’s interesting that, for something so important, there’s no universally, or even generally, agreed definition of hypnosis. For purposes of this discussion, I’ll define it as a state of trance involving the partial and temporary suspension of executive functions and a restriction of attention focus to a primary stimulus in the context of a collaborative relationship whose purpose is the healing or improving of the patient or client. Relaxation training is usually a part of hypnosis. Deep relaxation can be an end in itself, or there can be an additional focus on therapeutic work in trance, called hypnotherapy. In hypnotherapy, we can access the unconscious in some respects more directly than in conscious conversation. In fact, we go in and out of trance in ordinary psychotherapy conversation without noticing it. Hypnotherapy is a way of using trance in therapy in a very focused way.

Deep relaxation, usually involving somatic or body awareness and/or guided imagery, is a great stress reducer and health improver, physically and mentally. Practicing deep relaxation for 15 minutes every day or even every other day can have a 24/7 stress reduction benefit. Deep relaxation can help a number of medical conditions, including hypertension and irritable bowel syndrome, as well as reducing anxiety and panic. Deep relaxation supports immune function in general, probably through helping to stabilize mood and generating healing neurochemicals such as endorphins. It's not a magic cure or a one-time one; you have to practice to get good at it, and keep practicing to continue to benefit from it. While it can take shorter or longer periods for different people to learn to relax deeply, once we learne how we can usually put ourselves into a more deeply relaxed state in a few seconds or minutes, depending on how upset or distracted we are when we begin.

Hypnotherapy takes trance into the work of psychodynamic psychotherapy. “Psychodynamic” is another one of those words that means different things to different people. I’m using it here to mean therapy that acknowledges the importance of unconscious processes and works with unconscious as well as conscious mental processes, such as thoughts, feelings, impressions, perceptions, associations, etc. The trance state allows a certain degree of direct access to unconscious process, which can sometimes help identity issues and impasses (an impasse is a place where we’re stuck, we can’t pass through it) in the person’s life or therapy. Those “issues and impasses” can sometimes be partly resolved in hypnotherapy, although more often they are worked through in the talk therapy that follows. Sometimes that working through can be done in a relatively short time, sometimes it takes a longer time. I want to emphasize that because hypnosis has a reputation as a quick fix, but it is not usually one, in my experience, and that is not how I use it.

So, hypnosis can add value to therapy, but I use it as a part of overall therapy and not as a stand alone method. Incidentally, I did write a song to help people relax and go to sleep using hypnotic imagery on my new CD. The CD is "The Elephant In The Dark" (which will soon be available on www.elephantinthedark.com) and the song is "Deeper and Deeper." I recommend that people listen to it four times through, which will be about 16 minutes; and of course not when they are driving or doing anything that they have to be alert for, only when it's safe to relax deeply and even go to sleep.

Logical Nonsense

2011-07-18T23:47:00.003-05:00

Words can lose their meaning, and when they do, utterance becomes nonsense, even it it seems logical.

This example of logical nonsense was reported by Peter S. Latham, J.D., and Patricia H. Latham, J.D., in Newsbriefs, the newsletter of the Learning Disabilities Association of America (November-December, 2009, Volume 44, No. 5).

A child with learning and attention disorders in a public school district had been described by his teachers as having trouble paying attention in class and completing his assignments. His problems got worse in high school and his mother asked the school district for a psychological evaluation. School psychologists evaluated the child and concluded that he did not qualify for special education services, in an evaluation which was subsequently found to be legally inadequate. The child’s parents sought private professional evaluation which resulted in a formal diagnosis of ADHD and several forms of learning disability. The private specialist recommended placement in a structured, residential learning environment, and his parents enrolled him in a private academy serving children with special needs.

His parents notified the school district of the private placement and sought a due process hearing to require the school district to pay for it. The hearing resulted in the determination that the school district had not offered an appropriate education and confirmed that the private school placement was appropriate, so the school district had to pay for it.

The school district sought judicial review in U.S. District Court, on the basis--here is the logical nonsense--that the child’s parents were barred from reimbursement for his private special education placement because he had not previously received special education services. Of course, the reason why he had not received special education services was because the school's psychologists had found him ineligible on the basis of an inadequate assessment.

The U. S. District Court, unable to discern between logic and nonsense, agreed with the school district’s reasoning. The parents appealed that ruling to Circuit Court which, restoring sense, reversed on the grounds that eligibility for private special education wasn’t conditional on having first received special education in the public schools. The school district appealed to the state Supreme Court, which upheld the Circuit Court's finding for the parents. So sense won out in the end, this time at least.

D. L. Pendlebury, commenting on the depth of language that he could not include in his translation of sections of the Afghan Sufi poet Hakim Sanai's "The Walled Garden of Truth" (published by Octagon, London), reflects on the way "the hypnotic power of linear verbal communication" underlies the loss of meaning in speech in Western societies. "We are effectively anesthetized to words; and perhaps precisely for that very reason we have been more enslaved by them than any other culture in history..." (p. 62)

I can't help wondering whether the school district's attorneys and administrators really believed their nonsense or whether they felt that they had to come up with something and that was the best they could do. And I can't help wondering whether the U. S. District Court judge who held for the school district really believed the school district's nonsense, or whether he (or she) knew it was nonsense but felt compelled to support the school district for some other reasons.

A lot of psychotherapy is about restoring sense to language from which sense has become separated.

Client Comments

2011-06-30T11:44:00.005-05:00

Among some old files I found a group of notes I’d written of comments that various clients had made, which had impressed me as particularly insightful or pithy, and which I'd written down after asking for, and receiving, permission to quote anonymously:

•“You think, because you’re brought up with a set of rules, that you have a set of values.”

•A client, describing early family history, said: “They were practicing Catholicism at the expense of Christianity.”

•“Her way of healing old wounds is to open them up and play with them.”

•“I’m so open-minded--but with gates.”

•"It's the unquiet spirit that breaks down the body."

•A client said, “You have to think through what you want to do and what goal you want to achieve.” I said, “Let’s do some of that now. What do you want to do, and what goal would you like to achieve?” She said, “That’s a loaded question.”

•Speaking with a client on the autistic spectrum, I said, “I’m trying to teach you that there’s something more to relationships than self-preoccupation and manners.” The client replied, “I don’t agree.”

•A client said, "I know that I've always felt like a dunce in my family. I just never said it out loud." I said, "Congratulations," for saying it out loud. "What difference does that make?" asked the client.

•Palpably describing what psychodynamic therapists call "dissociation," a client described coping with a mother's harangues: "I'd sit tight, put on a face, and not be there."

•A former client who returned to see me, commented: "Gee, the last time I saw you, you had a little more brown in your hair. What'd you do, eat something grey?"

Coaching and Psychotherapy

2011-06-11T18:40:00.002-05:00

A colleague asked how I understand the difference between coaching and psychotherapy, and how I use Skype. Here's my reply:

Dear .......

Sorry for not being able to reply sooner to your question about services I offer to coaching clients, where I draw the line between coaching and psychotherapy, and where Skype fits in.

I offer coaching services to clients who want to improve their personal and professional effectiveness in areas where I can add value. That includes the human relations side of supervision, leadership in organizations, and the learning styles and outcomes side of education. Clients consult with me around career issues, to help them reflect on their careers and see if they might want to modify or change them, as well as for help with job searches. Clients may seek coaching for evaluating and improving their relationship skills, whether personally (with a spouse or partner) or professionally (with a supervisor and/or colleagues). Parents may wish to improve their parenting skills. In the organizational consulting side of my practice, I've learned something about helping people to develop attitudes and skills for having difficult conversations more effectively, and sometimes people come for that. Some clients come for help in understanding their learning styles and how to learn more effectively given their particular cognitive and personality styles. Relaxation training can be a part of coaching, where the client can benefit from it as a health enhancement rather than as a treatment for a diagnosable mental disorder.

Where I draw the line is between these kinds of mentoring/coaching/consulting/counseling (in the sense of providing counsel) activities and psychotherapy as a treatment for a mental illness. Therapy patients qualify for a DSM-IV diagnosis of a mental disorder, and psychotherapy is a treatment for that and has a procedure code on the bill or receipt which patients submit to third party payers.

Sometimes a coaching client is actually in psychotherapy already with another therapist, to which coaching can be complementary, but the foci are different and neither coaching nor therapy replaces the other. In coaching mode, I've said things like, "This is what I advise you to do in order to take the next step toward achieving your goal. If you have a problem doing it, you should talk to your psychotherapist about it." And, while it isn't always the case, my coaching clients often come at less than weekly intervals; semimonthly (EOW), monthly or at even longer intervals, and usually that's fine with me, but I've declined to work with potential psychotherapy patients who weren't available for the session frequency that I felt was appropriate to the presentation and intensity of their symptoms.

About Skype: My current practice is to offer psychotherapy in my office, and only to add remote methods (Skype, telephone) if the person moves out of the area (or, on occasion, is too ill to come to the office) after getting a good start to the therapeutic relationship in person. That's because there are intuitive aspects of the therapeutic relationship that require personal presence; at least as I understand and practice psychotherapy. So I don't offer psychotherapy, in the sense of a treatment for a mental disorder, remotely from the beginning. I do offer coaching, consultation and counsel from the beginning via Skype or telephone. .

I hope that helps.

Best,
Jay

Fat, Muscle and Bone

2011-05-01T14:14:00.001-05:00

(originally published in the spring, 2011, Illinois Psychologist, the newsletter of the Illinois Psychological Association)

In the early 1980s I was teaching organizational psychology at The Management Center of Aurora University, where my students were mostly first-level through mid-level supervisors and managers from companies and organizations along the Fox River valley. It was the era of leveraged buyouts, and one student spoke simply and eloquently about the effects of multiple takeovers on his company. “The first time we were purchased it was good for us. The new ownership got rid of fat, and we became lean and efficient. The second time we were bought, the reductions and layoffs imposed by the new owners to pay off the debt of the acquisition cut into muscle. Now we’ve been bought again, and this time they’re cutting into bone.”

A decade or so later I was in private practice, on the panel of an insurance company. A parent called me about an adolescent, an early high school student in severe crisis. The adolescent--let’s call him “Jack”--turned out to have an agitated depression with psychotic features. The insurance company’s treatment authorizer, a social worker, was supportive of intensive outpatient treatment as an alternative to hospitalization. Working collaboratively with Jack’s psychiatrist, who prescribed a combination of antipsychotic and antidepressant medications, I began seeing him three times a week in individual and family therapy. Treatment worked, Jack gradually improved, and it became possible over time to discontinue antipsychotic medication and reduce therapy frequency to twice weekly, then to once, over a period of about a year and a half.

Jack began his senior year relatively stable, on once weekly, mostly individual, therapy and 80 mg. of antidepressant medication. I submitted a treatment plan, which Jack, his parent, and his psychiatrist all supported, to continue weekly therapy throughout his senior year with the goal of eventually discontinuing antidepressant medication. By that time a psychologist had become Jack’s treatment authorizer for the insurance company, and he disallowed continuing therapy; explaining that, since Jack was stable on medication, further therapy was not indicated. The fact that weekly therapy was contributing to Jack’s stability wasn’t noted by that psychologist, who was content to leave the patient on antidepressant medications and call treatment complete. What was therapeutic muscle and bone, to me, to the patient, to his parent, and to his psychiatrist, was fat to the psychologist working for the insurance company.

I resigned from that insurance company’s panel, negotiated a fee with Jack’s parent, and successfully completed the treatment plan. At the time I was on the affiliate staff of a hospital where a psychiatrist consulted for the insurance company, and I asked him why the company’s policy had changed so much over the course of a few years. “The company’s been bought twice since you starting treating that patient,” he told me, and it had acquired a lot of debt to pay off. “It’s all about the bottom line, now.”

Most psychologists who provide therapy do so as sole practitioners, in small groups, or in small community agencies. The insurance and managed care companies that provide or manage third party payment, on the other hand, are usually very large organizations with substantial needs to manage costs in order to pay down debt associated with purchase or other expenditures, and reward owners or shareholders for their investments. So when a psychologist-practitioner speaks with a psychologist (or other mental health professional) working for an insurance or managed care company about authorizing psychotherapy, there can be quite a difference of perspective when it comes to perceptions about what is fat, what is muscle, and what is bone, when it comes to patient needs and treatment.

Because of this and similar experiences, addressing the gap between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations has been a goal of mine since becoming a Council member a couple of years ago. I am currently facilitating an ad hoc committee of Council members drafting an aspirational statement regarding the relationship between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care companies, for presentation to the Council. Surely the foundations of such a relationship include mutual acknowledgement that the patient’s best interests is a core value shared by both providers and payers, and also acknowledgement that we are all stakeholders, as taxpayers and insurance rate-payers, in a system in which we all want to provide necessary services to people who need them in an economically viable way. Let’s see if there’s a middle ground where psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations can meet collegially, when we discuss the fat, muscle and bone of psychotherapy.

Marital Therapy and Infidelity

2011-04-10T16:46:00.008-05:00

On April 9, 2011, I gave a presentation on marital therapy of infidelity, as part of a series of presentations on couples therapy sponsored by the Illinois Psychological Association. A presentation by Carol Cradock, Ph.D., on counseling couples who are in the process of divorcing, preceded mine. Northwestern University Medill School of Journalism student Helen Adamopoulos was there and wrote an article on our presentations. I've copied the text here. You can access the article itself, with a great picture of Carol in action, at:

http://news.medill.northwestern.edu/chicago/news.aspx?id=184617

Here's the text:

Therapists learn how to counsel couples on divorce, cheating
BY HELEN ADAMOPOULOS
APRIL 08, 2011

Dr. Jay Einhorn scanned the small classroom, where about 30 psychologists and therapists sat watching him.

“It would be fun to ask for a show of hands,” he said with a grin. “How many people have been unfaithful?”

The room erupted with laughter as people glanced around at each other. No one raised his or her hand.

Although no one in that classroom was willing to admit it, Einhorn said most people have probably been affected by infidelity in some way, whether they have been unfaithful themselves, been cheated on or known about someone else’s affair.

He spoke Friday morning about approaching infidelity from a therapist’s perspective as part of a workshop series on couples counseling hosted by the Illinois Psychological Association. The workshop was the fourth in a series of six sessions the association is holding on the second Friday of each month through June at the Chicago School of Professional Psychology.

Einhorn, a consulting psychologist at Roycemore School in Evanston and an independent practitioner, said there aren’t reliable statistics on the instance of infidelity, but it is evidently a common problem.

“We can estimate that many if not most divorces have to do with infidelity,” he said.

Einhorn said therapists should consider the couple’s developmental history (did they grow up in a family where infidelity was common?) as well as evaluating the relationship according to a concept called the “identity union.” The identity union refers to how the couple view themselves as one entity, rather than two separate people. They view their union as something unique and special.

“That’s what the infidelity hurts most,” Einhorn said.

Whether the couple can stay together depends on reconstructing the identity union. This cannot take place if there is ongoing infidelity, physical violence or ongoing verbal and emotional attacks, he said. The betrayed or “hurt” partner needs to realize that the couple’s former identity union was partly an illusion; the relationship wasn’t what the betrayed spouse thought it was. If the hurt partner can come to terms with that, there is a better chance of healing the marriage, Einhorn said.

In turn, the unfaithful partner should examine how the identity union wasn’t meeting his or her needs. Integrating those needs into the framework of the marriage is a key part of couples therapy, he said.

If a couple decides they can’t or don’t want to salvage their relationship, therapists can employ strategies to try to minimize the personal damage for both people. Chicago psychologist Dr. Carroll Cradock, who has worked extensively with couples in the process of separating, also spoke at the workshop about improving divorce outcomes.

“Divorce is a life transition, one of life’s most difficult transitions,” Cradock said.

She compared the process to “trying to steer a boat across Lake Michigan during a storm.” However, therapists can guide couples and their children through those dangerous waters.

Cradock staged a mock therapy session to demonstrate how to deal with a separating couple. First, she showed a clip from “The Squid and the Whale,” a movie centering on a family dealing with divorce. Then two workshop participants pretended to be the parents from the film, while Cradock counseled them.

She asked them what they wanted for their family, such as both parents maintaining strong attachments with their children. Cradock said that she would also speak to the children alone to find out what they wanted, and then combine that with the parents’ wishes to form a family mission statement.

“It’s a road map for them,” she said.

Rita Guertin, a therapist at Alexian Brothers Behavioral Health Hospital in Hoffman Estates, said she found the workshop useful and engaging.

“I liked doing this little vignette here,” she said of Cradock’s role-playing exercise. “I’m a really visual person.”

Guertin said she was attending the entire workshop series because she wants to open her own practice one day and needs to learn about working with couples first. Clinicians can earn a maximum of 39 continuing education credits (6.5 each day) by participating in the series.

For more information on the workshop series, visit www.illinoispsychology.org.

Diagnosing Attention Deficit Disorder

2011-04-02T06:36:00.002-05:00

Several colleagues on a listserve asked questions or made comments about diagnosing attention deficit disorder, which moved me to write this reply.

When we look at diagnosing attention deficit disorder, it’s important to remember that there are three moving targets.

The first moving target is our knowledge of attention and how attention works in the brain, which is not simple. The frontal lobes are largely involved in deciding what to focus on, maintaining focus, inhibiting distractions, monitoring appropriateness of focus, evaluating effectiveness of focus, and transitioning to a new focus when that is appropriate, within a huge constant stream of perceptual and sub-perceptual inputs from both the world around us and from within our own bodies. (See Elkhonon Goldberg, “The New Executive Brain.”) Our knowledge of what the frontal lobes do and how to evaluate frontal lobe dysfunction is relatively recent and constantly growing.

The second moving target is the definition and description of attention disorders. Society itself is changing, including norms and expectations about how children and adults should behave. Styles of attention that would have been normal throughout most of human history, when children would have been running around the woods, helping around the house or in the fields, or apprenticing in some craft or business, become disorders when children and adults spend most of their time in schools or offices, seated rather than moving and focusing on abstract tasks. And professional culture is continuously modifying its concepts about what qualifies as attention disorder; DSM V is in preparation, for example.

The third moving target is the experience of the diagnostician. If we say, for example, that physicians and psychologists typically diagnose attention disorders, that places the focus on how physicians as such and psychologists as such make diagnoses. However, a closer look at how actual physicians and actual psychologists go about diagnosing attention deficit disorders shows large discrepancies not only between groups but also within them. Much of the training, in fact, is obtained on the job, and experience matters.

It is usually psychologists or physicians who make the diagnosis. Physicians usually make the diagnosis based on a clinical interview, and psychologists usually make the diagnosis based on interview(s) and testing. Both physicians and psychologists may ask third parties (often parents, teachers, spouses, sometimes supervisors, siblings or significant others) for input, either in interviews or by completing rating forms. Among physicians, pediatricians, psychiatrists, and neurologists are the usual diagnosticians, although any physician can legally make the diagnosis. Among psychologists, clinical psychologists and neuropsychologists are the usual diagnosticians, although school psychologists are increasingly making the diagnosis, especially those in private practice.

Because attention is so complex, there are a number of different ways in which it can be disordered, all of which require some compensatory strategies to manage behaviorally, and not all of which respond equally well to medication. What might be called the “classical” hyperactive type of attention disorder, the impulsive, distractible, hyperenergetic presentation, often shows the paradoxical response of slowing down when stimulants are administered. This paradoxical response has been explained by psychologist Russell Barkley’s theory of inhibitory undersupply. The structures in what’s usually called the limbic system send arousing signals to the upper parts of the frontal lobes, which select which signals to attend to and which ones to inhibit, which they accomplish through inhibitory tracts signaling downward. Barclay’s theory is that the inhibitory tracts from the frontal lobes to the limbic system structures are undersupplied with modulating and/or transmitting neurochemicals (probably especially dopamine) in hyperactive people, so they don’t work very well. When stimulant is administered to hyperactive people, his theory goes, it is selectively channeled to the neurochemically undersupplied inhibitory tracts, which creates the paradoxical effect of a hyperactive person being slowed down by taking a stimulant. For that reason, I call stimulants for classically hyperactive people, “brake fluid.” (Elkhonon Goldberg includes limbic structures as part of the lower frontal lobes, in which case we’d be talking about intra-lobe communications, which doesn’t really alter Barclay’s model, just how we talk about it.)

The diagnosis for people within what might be called this original paradigm of hyperactive attention disorder was relatively straightforward. Observation of the child in school, or a good case history supported by observations of parents and teachers, was sufficient to establish the pattern. Some hyperactive kids are obviously hyper in the doctor’s office, others can keep it together for one or several interviews, but the case history, supported by corroborating observations from school and home (or work, in an adult), was sufficient. So an experienced physician or psychologist, doing an office interview, usually with supporting evidence from parents, teachers, etc., can make this diagnosis quite well for the “standard model” of hyperactive patient, as long as there aren’t any significant rule-outs. (The diagnostician may have received the referral from a therapist who already suspects hyperactivity and can supply more background information to support the diagnosis.) But that’s where things can get complicated.

The more we learn about frontal lobe functioning and attention, and the more clinical observations we accumulate as the diagnosis becomes more common, the more obvious it becomes that this original hyperactive syndrome is only one of a wide range of possible issues with attention with which patients present. For example, people with nonverbal learning disorders, in which the relational functions usually associated with the right cerebral hemisphere, and especially the right frontal lobe, are deficient (often accompanied by a substantial discrepancy between higher verbal scores a lower nonverbal scores across a number of tests), often appear disorganized, unable to select and maintain appropriate task focus, distractible, etc., and so they present a behavioral picture very much like that of many hyperactive people; but they are not classically hyperactive, and they do not respond to stimulants by slowing down. People with sequential processing deficiencies (who may or may not have the opposite test score pattern, with higher nonverbal than verbal scores) may have difficulty perceiving information that comes in a series or sequence (as most language does), and have difficulty organizing and following through a multi-step process. Stimulants affect people with such cognitive styles as these like they affect most people; that is, by general arousal. Sometimes that helps--for the same reasons that stimulants can help high school and college students without attention disorders to cram for final exams--but they can also just stimulate the entire system, thus increasing distractibility and disorganization. And issues of stimulant dependence may be of more concern with this population than with the hyperactive folks for whom stimulants act like brake fluid. Although it used to be boys who were mainly found to be hyperactive, as professional awareness of non-hyperactive inattention as a form of attention deficit increases, more girls and women are found to have forms of attention disorder that are not of the classically hyperactive kind and do not respond to stimulants in the paradoxical, efficacious way.

And the picture gets even more complicated by other cognitive information processing styles that can be mistaken for primary attention disorders. For example, some people have a deficiency in processing language which they hear, an auditory language processing disorder, even though their sensory hearing is normal and they are fluent in speaking. This can be due to central auditory processing disorder, which has to be diagnosed by an audiologist who knows how to do it; but there are speech and language tests that can indicate its presence, if the evaluator has learned about it. Some people who seem to have an attention disorder because they don’t retain what they read actually retain better when they read aloud, or use a reading method such as SQ3R to support memory and comprehension. Their disorder is with language processing, a kind of dyslexia, rather than with attention per se; though the child may look inattentive in class or the adult in the office. Some people have limited processing speed--they may have lots of intelligence, but need to learn at a slower pace than most of their peers, although they can learn a great deal if they have the time. Some people have limited processing capacity, their cognitive “house” is like an igloo that can only admit a small amount of information at a time, even though the interior may be quite large. Some people have deficiencies at making new learning automatic (which probably involves circuits extending from the frontal lobes into the cerebellum). Any of these people, in a clinical interview, can look as if they have a primary attention disorder.

It’s not only learning and language disorders that can sometimes look like attention disorders; so can emotional and personality disorders. If someone is anxious, depressed, subject to powerful mood swings, or has a self-defeating personality tendency or disorder of one sort or another, that can show up as underachievement, difficulty focusing, disorganization, etc.; in other words, it can look, on superficial review, like a primary attention disorder. I once evaluated a physician, a very bright person indeed, for ADD/ADHD, and found that he had a writing disorder (a specific learning disability) and a complex personality structure (emerging out of his personal history) that led to undermining himself at key points in his life, but not an attention disorder.

Complicating matters still further, learning and/or language and/or emotional and/or personality disorders can present together in the same person. Patients with attention deficit disorders often present with comorbidities, which just means other clinically significant conditions. I’ve seen estimates ranging from 20% to 50% of persons with attention disorders having significant comorbidities.

That brings us to testing. While there is no test for attention disorder per se (despite the fact that some tests are labeled as tests of attention), testing can paint a picture of a person’s cognitive style, can rule in or out learning disabilities such as verbal or nonverbal disorders that can be mistaken for attention disorders, and can also look more closely at emotional and personality functioning than can be done in a routine clinical interview. The comprehensiveness and extent of testing and interviewing varies a lot among practitioners. I typically conduct a long and structured initial interview, followed up with subsequent interviews of the patient during testing, and supporting interviews with parents and teachers (or spouses, with adult patients), as well as administering neuropsychological, psychoeducational (usually reading, writing, and arithmetic, to which I add expressive and receptive spoken language, which strictly speaking are in the speech and language testing domain), and personality/emotional testing, over the course of which I get to watch how the person applies himself or herself to interviewing and responding to a variety of testing challenges. This is a fairly comprehensive approach, but it obviously involves considerably more time and expense than a single clinical interview. A full evaluation typically involves 10-20 hours of testing and interviewing, after which there’s the work of integrating the test results and preparing a report that puts the test results together with the case history, and behavioral and supporting observations, gives a diagnostic impression and recommendations. A typical report of evaluation runs to 15-20 pages, only a couple of which are boilerplate; most consist of narrative and test scores.

So the issue of diagnosing attention disorders is far from a simple one. Diagnosticians need to learn about different kinds of attention disorders and other learning and emotional conditions that can look like attention disorders. For the patient, as is usually the case with any complex condition, each person and each family has to find his, her or their own way within the educational and health care systems, and will hopefully find the doctor or team which will be able to help them understand their cognitive and personal styles, for better and worse, and find their way to achieve their goals.

The Importance of Attitude

2011-03-20T12:11:00.002-05:00

New knowledge about brain function supports an old-fashioned idea: Our attitude has a lot to do with our ability to learn from experience.

It turns out that how our brains operate when we make a mistake depends a lot on our attitude about ourselves and our mistakes. If we have the attitude that mistakes are inevitable and we can learn from them, the frontal areas of the cerebral cortex, the seat of executive functions, seem to be doing most of the work. This is the area that underlies sequential and relational thinking, and recognition of new patterns in information, so it’s obviously well suited to learning. But if we have the attitude that we should be right and not make mistakes, if we feel ashamed at having made a mistake and beat up on ourselves, then the more central parts of the brain that are involved in emotion become more active, at the expense of the frontal lobes. Our brains generate a neurochemical flood of negative emotion, and our learning efficiency decreases rather than increases. You can’t learn much when you’re flooded with shame and self-contempt.

This research, which was done on learning tasks like those involved in school, turns out to be very relevant for psychotherapy and coaching also. When I am talking with therapy patients or coaching clients about their decisions and behavior, in situations in which they could have been more realistic, more caring and more effective, their attitude toward their mistakes makes all the difference. Of course, nobody is happy to have made a mistake, but the people whose attitude is, “OK, I’ve made a mistake, I regret it, and now I’ll learn from it, with your help,” tend to learn more and faster. The people whose attitude is, “If I made such a mistake, then I’m such a hopeless loser,” or “I’m so ashamed of myself I can’t stand myself,” basically shut down their learning processes, because we can’t learn anything when we are in that state. Then I have to try to help them get out of that state and into a learning one.

People who have a genuine and deep sense of a higher truth, whether they think of that in spiritual or natural terms, tend to have an easier time of getting into a learning attitude. Maybe that’s because being in relationship with a truth that’s higher than we are tends to make us humble, and it’s easier to learn from a position of genuine humility. So we can see that humility is not an end in itself so much as a means of getting somewhere. If you need to learn, and you’re not too self-important, you will learn.

Paradoxically, self-abasement, which is often confused with real humility, emerges from an elevated sense of self-importance. This is what psychiatrist Arthur Deikman refers to as the arrogance of self-contempt. Both too much self-esteem and too much self-abasement emerge from an overvaluing of the importance of self within the personality, and both interfere with learning.

New York Times columnist David Brooks has written a new book emphasizing the importance of the mostly unconscious attitudes and relational skills to individual and group success: “The Social Animal: The Hidden Sources of Love, Character and Achievement.” He talks about it during his book launch at the New York Public Library on a video available through fora.tv: http://fora.tv/2011/03/07/David_Brooks_The_Hidden_Sources_of_Love_and_Character#fullprogram

Freud and Columbus

2011-01-23T23:47:00.002-06:00

There are a lot of similarities between Freud and Columbus. Both were great and bold explorers who discovered new worlds; Freud the unconscious and Columbus the “New World.” Neither man understood what he had found, both were mistaken about most of the details (Freud’s unconscious was mostly a figment of his fertile imagination, Columbus thought he’d landed in India). Both discovered realms which had actually been discovered by others previously, but of which they and their European cultures were ignorant. Both left their epochal discoveries to posterity, which has had to sort out what’s really there from what was incorrectly imagined to be there. Both are worshiped as heros and reviled as evildoers, perhaps more than they are understood as brilliant, bold and limited men in the context of their times.

Infidelity and Marital Therapy

2010-12-29T15:53:00.003-06:00

(This article ran in the Winter, 2010, Cappstone, the newsletter of the Chicago Assn. for Psychoanalytic Psychology.)

Keith Richards is the co-founder and lead guitarist of the Rolling Stones. Early in his rollicking autobiography, "Life," he tells a story of music, marriage and infidelity from the life of his grandparents, Gus and Emma, during World War II, when they had several children and London was under air attack.

“Why was my grandmother long-suffering? Apart from being in various states of pregnancy for twenty-three years? Gus’s great delight was to play violin while Emma played piano. But during the war she caught him bonking an ARP warden in a blackout, caught him up to the usual. On the piano too. Even worse. And she never played piano for him again. That was the price...” (p.44).

This anecdote--which I found laugh-out-loud funny when I first read it--though a female colleague to whom I read it was not at all amused, for some reason--gives us a lot of psychological meaning to unpack. Gus and Emma are married, and Gus is sexually unfaithful, not for the first or last time. Gus’ infidelities are somehow external to his commitment to his marriage, in his own mind. Emma remains with him--accepting, at some level, that Gus’s view of commitment is different from hers--but she expresses her own hurt, anger, and integrity, by refusing to play piano with Gus, ever again. The ARP (Air Raid Precautions) warden is somehow less than a complete person in this narrative, identified only by her gender and job title.

Marriage and infidelity are among the most ubiquitous human behaviors, expressing the powerful conflicting evolutionary drives of monogamous and multiple mating. The U.S. Centers for Disease Control reports a 2009 marriage rate of 6.8 per 1000 population, and a divorce rate exactly half that, at 3.4 per 1000 population (http://www.cdc.gov/nchs/fastats/divorce.htm). Reliable metrics on infidelity seem impossible to find, but it’s a good guess that many of the marriages that end in divorce, and some that don’t, experience infidelity. Certainly, many couples in marital therapy present infidelity among their critical issues.

Typically, the infidelity will have different meanings for each partner, and working through those meanings for the “unfaithful” partner and the “hurt” partner--as Janis Abrahms Spring labels them, in After The Affair--is a big part of marital therapy. Infidelity often reflects problems in the marital relationship, as well as issues that each spouse brings to it. Spouses often enter into marriage with some reservations, usually not expressed and often at least partly unconscious. The romantic power of early intimacy will, sooner or later, need to be supplemented by conscious work on intimacy, including communication, values, and conflict resolution. But that often doesn’t happen, and intimacy can become complacency without anyone realizing it. Then unexpressed and/or unconscious needs and drives can make themselves known; living as we do in a Darwinian world in which there are interesting and attractive people in our various networks, with whom “one thing can lead to another.”

I’ve often been impressed by how lightly and unthinkingly unfaithful spouses allowed themselves to live their way into adulterous relationships, as if infidelity were somehow not likely to have a huge and potentially life-changing impact on everyone involved. Perhaps our society’s lack of appreciation of the deeper levels of commitment and relationship in marriage, together with its preoccupation with the superficialities of sexuality and mating, partly acculturates and partly hypnotizes us into expecting that casual sexual intimacy can be indulged with little consequence. By the time I hear about it, of course, the couple is in marriage therapy, things are desperate, and the future of their marriage--and often, their family--is in the balance. Or it may be one of the three parties--the unfaithful spouse, the hurt spouse, or the extramarital sexual partner--in individual therapy with a broken, or at least very badly bruised, heart.

The term “bonking,” which Keith Richards uses to describe his grandfather Gus’ relationship with the ARP warden, indicates a view of sexual intimacy as more or less impersonal and inconsequential. From a certain purely logical perspective, as long as pregnancy and sexually transmitted diseases were prevented, there would be no reason for anyone not to “bonk” away. The catch, of course--which entirely disqualifies such mechanistic logic--is that the natural human instinct and need for attachment often gets involved in sexual intimacy. The yearning for attachment is often an unconscious factor in unfaithful spouses living their way into infidelities, and it is always a risk, even when a sexual pair gets together for “just a good time.”

Biological anthropologist Helen Fisher has researched three phases in loving attachment, each mediated through a different primary neurochemical. The first phase is primarily sexual, mediated primarily through testosterone, in both men and women. This leads to a romantic phase, mediated primarily through dopamine, which in turn leads to a bonding phase, mediated primarily through oxytocin. Oxytocin is stimulated by orgasm, and orgasm, as Desmond Morris tells us in Intimate Behavior, is stimulated by loving sexual intimacy. So one thing can certainly lead to another, even if that’s not what the unfaithful spouse, or even the extramarital partner, intended.

Morris is aware of the deep attachment in a genuine love relationship: “To say that ‘marriage is a partnership,‘ as is so often done, is to insult it, and to completely misunderstand the true nature of a bond of love...” Morris‘ human ethological review of the “typical sequence” of steps of intimacy is illuminating: “eye to body...eye to eye...voice to voice...hand to hand...arm to shoulder...arm to waist...mouth to mouth...hand to head... hand to body...mouth to breast...hand to genitals...genitals to genitals...twelve typical stages in the pair-formation process...Each stage will have served to have tightened the bond of attachment a little more...” (p 72-78). Of course, there are personal and cultural variations on this typical pattern, but the work of Morris and Fisher can help us to see how “one thing can lead to another.”

So “bonking” can lead to potentially life-changing consequences, pretty quickly and quite unexpectedly, because of the potential of sexual intimacy to create powerful attachment, even if unintended.

Sometimes these attachments persist unconsciously long after the relationship is over. I’ve treated clients whose unconscious attachment to lovers long since out of their lives has interfered with their ability to form successful new attachments ever since. These clients were still, unconsciously, holding their former lovers close, even though they consciously had relinquished them entirely. Sometimes new partners were unconsciously selected in part because they did not threaten the special place in the client’s heart of the closely held former (and still, unconsciously, current) beloved.

Every marriage is unique, and so is every infidelity, although patterns do tend to emerge. Like Gus, the unfaithful partner may commit infidelity with no intent to harm the marriage, and like Emma, the hurt partner may remain in the marriage even while deeply, and perhaps permanently, hurt. Sometimes the extramarital partner hardly seems to exist at all--like the ARP warden in grandpa Gus’ story--while at other times the extramarital partner is a very real person. Infidelity can be a reaching out for love and erotic connection that has been too long missing from the marriage, or an avoidance of issues in the relationship that the unfaithful and/or hurt partner have been needing to step up to. It can express self-efficacy, a determination to be true to oneself and not allow oneself be mistreated or neglected beyond a certain point, while not intending to end the marriage, or it can instantiate some sort of deficiency in self-awareness, integrity, and capacity for relationship. If unfaithful partners can’t find the intimacy they need in their marriages, it might be because they aren’t looking in the right way--perhaps because they lack the self-awareness and/or a skill set to know how to reach out to the other person around certain issues. There is an anthropological piece to some of the work of marital therapy, because American society and typical family life leave a lot out in cultivating self-knowledge and relational skills. Conflicts of values, which may derive from religion or personal philosophy, may need to be unpacked and explored. Some marriages were created with major issues left unaddressed--sort of like the way slavery was ignored when the United States of America was founded--which can emerge later on, turbulently. Perhaps either or both spouses have stopped paying attention, are taking the marriage for granted, or are distracted by issues of career, self, other family members, or health. Often, a partner’s infidelity can be a wake-up call to both spouses, and a springboard to the revitalization of the marriage. Sometimes it’s a symptom of a marriage whose romance, whatever it may have been, has run its course; a marriage whose love has expired and is essentially dead on arrival in the therapist’s office. Sometimes unfaithful spouses meet their “true” partners through infidelity. Infidelity can be self-fulfilling, self-defeating, or both; like marriage. A marriage reflects the dynamics of the individual spouses and their relationship, and some of those dynamics have more potential for regeneration and longevity than others. Whatever the background, infidelity raises the question of whether a couple can rise to the occasion and regenerate their relationship together. That is where the marital therapist meets them.

Marital therapy takes place within a network of relationships; like individual therapy does, but exponentially multiplied. There is the relationship between the therapist and the couple, the relationship between the therapist and the hurt spouse, the relationship between the therapist and the unfaithful spouse, and the relationship between the spouses; all of which are going on simultaneously in the therapeutic process. If the couple has children, there is the relationship of each spouse with each child, the relationship with each spouse and the children as a sibship, the relationship of the couple as a couple with each child, and the relationship of the couple with the children as a sibship. And, in addition to the relationship between each spouse and her or his immediate family, there is the relationship of each spouse with their in-laws, individually and collectively, and the relationship of the couple, as a couple, with both sets of parents, and perhaps grandparents. Often there are also relationships between each spouse and the other spouse’s friends and/or professional colleagues. Sometimes either or both spouses are in individual therapy, in which case I recommend that the therapists consult, occasionally or as needed, which means that the clients have to authorize that. The web of networks gets pretty complex.

And, of course, each member of the couple brings her and his own complexity to the therapy. Tendencies or habits of perception and interpretation of oneself and the intimate other that spouses bring to their marriages may need to be identified and “unpacked” in order for fresh perceptions and new possibilities of understanding, perception and relationship to occur. Sometimes the therapist has to work “bottom up,” connecting directly with the emotion in one or both spouses and “thin-slicing” it, as Sue Johnson says, to make it more accessible for therapeutic work. Sometimes the therapist works in a more “top down” way, teaching the couple about their communications and interactions, as John Gottman does, or making psychodynamic interpretations, which can be about the individuals and about the couple. Of course, there is a good deal of overlap among these various approaches, which are not, in practice, as separate as they are described here.

“Life,” Harold Balikov used to say, “is not user-friendly,” and co-creating a healthy marriage isn’t easy. A cartoon by Steve Kelly, originally in the New Orleans Times-Picayune, reprinted in The New York Times, shows a middle aged couple seated on their living room couch. The husband is reading a large document entitled: “Study: MARRIAGE OBSOLETE?” and says, “Well, I, for one, enjoy being in a committed, monotonous relationship.” “Monogamous,” his wife says. (11/28/10, Week in Review, p 2)

As I write this, I’m looking forward to doing two presentations on infidelity in marital therapy. The first will be a consideration of psychodynamic aspects of working with infidelity in marital therapy for CAPP, planned for Friday, March 11th, 2011, from 2:30--4:00 PM, in Evanston. For further information, visit the CAPP website at www.cappchicago.org, or contact me at jay@psychatlarge.com or 847.212.3259. The second presentation will be part of the Clinical Treatment of Couples series presented by the Illinois Psychological Association. That entire program takes place over six daylong workshops at the Chicago School of Professional Psychology, 325 N. Wells, Chicago, and my presentation will be one of four workshops on April 8th. For further information, visit the IPA website at www.illinoispsychology.org/.

Jay Einhorn is Chair of Peer Study Groups for CAPP and a Council member of the Illinois Psychological Assn. ©Jay Einhorn, 2010

Keith Richard's "Life"

2010-12-16T23:09:00.017-06:00

I’ve just read Keith Richards’ “Life,” with great enjoyment. Richards is the co-founder, co-leader, and lead guitarist of the Rolling Stones, and author or co-author of many of their songs. Notwithstanding the outrageousness of his life, the addictions and extreme partying--and there is a great deal of that in "Life"--Richards emerges as an unexpectedly dependable and reflective person, and I find myself resonating with his insights into friendship and leadership. In addition to being a rollicking good read across one of the definitive lives of our times, “Life” offers some key insights into human nature, as well as delightful observations about characters he’s come across.

Richards’ was always about the music, and his relationship with the fans is about maintaining the quality of the music at all stages of the process: writing, recording, performing. Notwithstanding all the craziness--the sex, drugs, and rock-n-roll--his commitment to the integrity of the music, and to providing musical and entertainment value for fans, is extraordinary. It is through that commitment that he helped form and maintain the huge musical, entertainment and business entity know as the Rolling Stones. And he has appreciated and collaborated with some of the greats in the music business, known and unknown.

Richards is unrepentant about his dependency on drugs, drinking, and assistants to fetch drugs for him and look after him, which have been cited as objections by some colleagues and friends to whom I've mentioned my appreciation of his autobiography. Speaking with Andrew Marr, in an interview posted on YouTube, Richards commented on the relationship between drug use and fame. "In its own weird way, that's how heroin, all this stuff, helped me, because it kept my feet in the gutter, not just on the ground. Fame is probably a bigger killer than drugs in my game..." http://www.youtube.com/watch?v=HjNCEhVmLxo/. One of the things that I find interesting about Richards is that he coped at all with the huge fame that he experienced as a young man; when, for example, after a Stones concert filled with hysterical female fans, the janitor commented that it must have been a good concert because there wasn't a dry seat in the house. This level of fame stopped the Beatles from touring and killed Elvis Presley, but Richards has managed to ride the wave, damaged but still himself, and with a very good memory for what happened; "episodic memory," as psychologists call it. In addition to his career success, he seems to have a successful second marriage, close family relationships, and a number of significant long-term as well as new friendships. It's because Richards cares so much and so consistently about music and relationships that his journey through sex, drugs, and rock-n-roll is so interesting.

He was a natural leader, who says that, if he’d gone into the army, “I’d probably be a general by now. There’s no way to stop a primate. If I’m in, I’m in. When they got me in the (boy) scouts, I was a patrol leader in three months. I clearly like to run guys about... I like to motivate guys, and that’s what came in handy with the Stones... It’s not a matter of cracking the whip, it’s a matter of just sticking around and doing it, so they know you’re in there, leading from the front and not from behind.”

Richards connects his outrageous partying to changes in states of consciousness. “Some of my most outrageous nights I can only believe actually happened because of corroborating evidence. No wonder I’m famous for partying! The ultimate party, if it’s any good, you can’t remember it... It’s very hard to explain all that excessive partying. You didn’t say, OK, we’re going to have a party tonight. It just happened. It was a search for oblivion, I suppose, though not intentionally... I can improvise when I’m unconscious. This is one of my amazing tricks, apparently. I try and stay in contact with the Keith Richards I know. But I do know there’s another one that lurks, occasionally, about. Some of the best stories about me relate to when I’m not actually there, or at least not consciously so...”

Here's a one-liner that I think will be around for a long time: “It’s impossible not to end up being a parody of what you thought you were.”

Having lived in Jamaica and hung out and played with Rastafarians, Richards places Rastafarianism in a cultural context. “Rastafarianism was a religion, but it was a smoker’s religion. Their principle was, ‘ignore their world,‘ live without society. Of course they didn’t or couldn’t--Rastafarianism is a forlorn hope. But at the same time it’s such a beautiful forlorn hope. When the grid and the iron and the bars closed in on societies everywhere, and they got tighter and tighter, the Rastafarians loosened themselves from it. These guys just figured out their little way of being spiritual about it and at the same time not joining in. They would not accept intimidation. Even if they had to die. And some of them did. They refused to work within the economic system. They’re not going to work for Babylon; they’re not going to work for the government. For them that was being taken into slavery. They just wanted to have their space. If you get into their theology, you can get a little lost. ‘We’re the lost tribe of Judah.‘ OK, anything you say. But why this bunch of black Jamaicans consider themselves to be Jewish is a question. There was a spare tribe that had to be filled and that one would do. I have the feeling it was like that. And then they found a spare deity in the unreal medieval figure of Haile Selassie, with all his biblical titles. The Lion of Judah, Selassie, I. If there was a clap of thunder and lightning, “Jah!” everybody got up, “Give thanks and praises.” It was a sign that God was working. They knew their Bible back to front--they could quote phrase after phrase of the Old Testament. I loved their fire about it, because whatever the religious ins and outs, they were living on the edge. All they had was their pride. And what they were engaged in was not, in the end, religion. It was one last stand against Babylon...What really turned me on is there’s no you and me, there’s just I and I. So you’ve broken down the difference between who you are and who I am. We could never talk, but I and I can talk. We are one. Beautiful.”

Richards has some pithy observations about cultural events and people. Here's Richards referring to Ken Kesey in the context of remembering founding Stones member Brian Jones, who later drowned in his own swimming pool. Taking LSD “made Brian feel like he was one of an elite. Like the Acid Test...Brian saw it as a sort of Congressional Medal of Honor. And then he’d come on like, 'You wouldn’t know, man. I’ve been tripping...' It was the typical drug thing, that they think they’re somebody special. It’s the head club. You’d meet people who’d say, “Are you a head?” as if it conferred some special status. People who were stoned on something you hadn’t taken. Their elitism was total bullshit. Ken Kesey’s got a lot to answer for.”

On the emergence of the punk bands, Richards notes “a certain sense of renewal” in the Stones when they felt “we’ve got to out-punk the punks. Because they can’t play, and we can. All they can do is be punks... I love every band that comes along. That’s why I’m here, to encourage guys to play and get bands together. But when they’re not playing anything, they’re just spitting on people, now come on, we can do better than that.”

About pop art: “I liked the energy that was going into it rather than necessarily everything that was being done--that feeling in the air that anything was possible. Otherwise, the stunning overblown pretentiousness of the art world made my skin crawl cold turkey, and I wasn’t even using the stuff."

About Allen Ginsberg: "Allen Ginsberg was staying at Mick’s place in London once, and I spent an evening listening to the old gasbag pontificating on everything. It was the period when Ginsberg sat around playing concertina badly and making ommmm sounds, pretending he was oblivious to his socialite surroundings.”

Richards' instinct for co-creating friendships that combine his intensive love of music, musical enterprise, and enjoyment of life--the latter of which does seem to have meant different things at different times--is on view throughout "Life." He comments: “Most guys I know are assholes, I have some great asshole friends, but that’s not the point. Friendship has got nothing to do with that. It’s can you hang, can you talk about this without any feeling of distance between you? Friendship is a diminishing of distance between people. That’s what friendship is, and to me it’s one of the most important things in the world...”

"Thank You For Counseling!"

2010-11-30T21:27:00.001-06:00

I was delighted when a counseling/coaching client told me his wife's Thanksgiving prayer: "Thank you for my husband, thank you for my children, thank you for counseling!"

:-)

A Mother Wonders

2010-11-20T23:33:00.003-06:00

A colleague asks:

A therapist, writing on a listserve for therapists, asks for suggestions on behalf of a client whose concerns about her 3 year old son have to do with what she describes as social/behavioral issues. This mother wonders about some unusual behaviors in her son, including that he often doesn’t seem to perceive or respond to body language. He often doesn’t look at his mother in the eyes, sometimes walks with his head cocked and, when walking, often doesn’t look up and around to make sure that he won’t run into things. In addition, he often doesn’t smile at people who smile at him, holds his hands in unusual positions, and likes to walk in circles and spin. Her pediatrician seems inclined to disregard her concerns.

Dr. Einhorn replies:

Your client does well to notice her son’s behaviors. There aren’t really any tests to determine whether a 3 year old with these behavioral signs does or doesn’t have a diagnosable issue. A professional who is experienced in working with children, particularly those on the autistic spectrum, might be able to identify some signs or tendencies in that direction, if they are present. If issues were identified, the interventions would be social: helping the family encourage more socially responsive behavior in this child, helping them to communicate more effectively with him (if that’s an issue), helping him to self-regulate more effectively, finding a preschool program where these interventions could be implemented to some degree.

Pediatricians often disregard subtle behavioral signs in children which are of concern to parents, and they are usually right to do so; most of the time, parents are overly concerned and/or the kids grow out of whatever behaviors their parents are concerned about. However, in my work with children with learning disorders, it has often been the case that pediatricians dismissed signs that parents, usually mothers, identified early on that actually turned out to be of real concern as the child grew up and did not grow out of them.

A behavioral assessment of the child would involve meeting with his parents first, then observing him at home and perhaps elsewhere (playgrounds, preschool if he goes to one, etc.). A psychologist with experience in working with children on the autistic spectrum, and their families, could provide this. Occupational therapists who are experienced in working with children on developmental delays and on the autistic spectrum can also contribute to the evaluation and treatment as well.

Two Couples

2010-10-19T15:10:00.005-05:00

("Two Couples" was printed in the fall, 2010 "Illinois Psychologist," the newsletter of the Illinois Psychological Association)

As the year anniversary of their marital therapy approached, the couple and I reviewed how far they’d come. At the beginning, it wasn’t at all certain that one spouse, acutely suicidal, would survive the year, or that their severely troubled marriage would. Neither the suicidal spouse nor the troubled marriage is safe for certain, but both are much better now.

During the year, I have at various times accepted, supported, and challenged the narrative of self and history presented by each or both spouses. I have used “bottom-up” emotion-focused therapy (learned from Sue Johnson), behavioral interventions, and “top-down” psychodynamic interpretations. One spouse had to go through what seemed like a volcano of rage and pain, sometimes abusing the other spouse, and I had to simultaneously endorse the feelings and experiences that led to that state while helping to stop the abuse and leading that spouse toward a higher level of self-integration. I have offered understanding and support for the other spouse’s distancing and disengagement while challenging that spouse to take steps of risk toward being more authentically available. I have, at various times, included in our talk therapy, or supplemented it, with mindfulness, hypnotherapy, spiritual counseling, humor and metaphor. I have consulted with each partner’s individual therapist.

This couple came to me after having seen a marital therapist on their insurance plan who thought she could fix them in twelve sessions, or something like that. The suicidal partner had been seen by an individual therapist working on the same lines. One of the first things I had to do was find an individual therapist for that partner who would allow that partner’s feelings and experience to actually enter the room.

This couple are not even bothering to submit their marital therapy bills to their insurance company. And if I had been asked, on a pre-authorization, to submit a treatment plan describing how I planned to work with them over a finite number of sessions, I don’t see how I could have done it.

Another couple is brand new to me and marital therapy. Brought to the brink of divorce by an infidelity, they are emotionally all over the place. The betrayed partner started a recent session by forcefully asserting that the marriage was over, and ended it by almost whispering that marital repair was the goal. The unfaithful partner, full of guilt and remorse, is challenged to make sense out of behavior that was more lived than reflected on when it was happening. Both partners, full of pain, have to understand their own contributions to what happened, even as they revise their individual and shared narratives of their marriage. Both yearn for stability which neither is able to commit to, right now, and I have to help them accept that uncertainty as they work through the issues that have suddenly become the most important in their lives.

This couple does intend to use their insurance, and I will be asked to complete a treatment plan. How about if I say: “I will empathize with each partner in such a way as to understand that partner’s experience of their relationship and the impact of the other partner’s behavior on them, and convey that in intensive conversation with both partners together in such a way as to help them integrate these perspectives into their conscious reconstruction of their relationship, supporting them in the meanwhile through a period of intensive uncertainty while encouraging each partner to discover and acknowledge what is authentically his or her truest wish for their relationship.”

What do you think the insurance company will make of that?

Coaching Versus Therapy

2010-09-20T12:27:00.002-05:00

(posted on a listserve for psychotherapists, as a contribution to a discussion about the differences between coaching and therapy):

As I've read, with interest, the dialog about coaching vs. therapy, it seems to me that the distinction, at least in my practice, has to do with the coach-client and therapist-client contract. I don't mean a written contract, but the mutual understanding about what we're doing and why.

Some of my coaching clients are in therapy when they come for coaching, so I can say things like, "This is what you need to do to take a step toward achieving your goal. If you have feelings that interfere with your taking this step, you can talk with your therapist about them." Other coaching clients have come for help making a career change, or for doing what they're doing better--for example, improving employee selection and retention procedures, improving relationships with colleagues at work, or coping with a difficult supervisor. The coaching contract is action-oriented, goal-focused, and not about a mental health or emotional problem. Feelings are a part of it but not the main part, and if they begin to become the main part, that begins to look like therapy to me. The action agenda can certainly be modified to take emotional issues into account; for example, a very anxious client who wants help with job-seeking skills, including modifying her expressions of anxiety in job interviews, may need to move more slowly than an executive with a successful career history now ready for a job change. If I help her learn to relax, it's so she can pass a job interview; not primarily to help her be less anxious 24/7, although it may have that effect.

Now, I don't know about the overlap between the kind of coaching I'm describing and the "life coaching" I've seen advertised on the web--"You, too, can become a life coach, get rich, help everybody..."--which is much more like the old-fashioned mix of self-improvement and hucksterism that is so quintessentially American. I suppose that the people who are really better at life coaching will eventually develop referral networks based on their competence, like therapists--or any other professionals--tend to do; and "caveat emptor" will be the rule for clients. For that matter, to the extent that "life coaching" really is about improving one's life in general, I'm not sure that mental health professionals, as a group, have the advantage over any other professional group on being prepared to be good at that.

When Is Therapy Done?

2010-09-12T11:40:00.003-05:00

(This article printed in the Fall, 2010, Cappstone, the newsletter of the Chicago Assn. for Psychoanalytic Psychology)

Susan C asks: “When is therapy done?”

One of the most important contributions of psychoanalytic psychology is the perspective that each person, and each client-therapist dyad, is unique. Susan has asked a general question, rather like one might ask a medical question: “When is antibiotic treatment done?,” or an educational question, “When is a course of study done?,” or even a plumbing question, “When will the furnace be installed?” If we are talking about people in therapy, we have to rephrase the question, to something like, “When is who’s therapy done, with whom?”

Generally speaking, people come into therapy with a acute problems which tend to improve after awhile, often within several months. Along with that improvement comes the perception that the client is vulnerable to react to certain stressors in certain ways; such vulnerability and reactions having contributed to the acute problem in the first place. Some people feel, once the acute problem has been relieved, that therapy has done its work, and that’s one way of looking at it. Others feel that it’s important to continue to work on the underlying vulnerabilities so that the problem is less likely to repeat itself. Here are a couple of cases that illustrate the situation of therapy that could be approaching completion, or could go on substantially longer.

An elementary school child who has developed some OCD type symptoms in response to various stresses is making good progress, and has become substantially freer of compulsive behaviors that used to complicate eating and bathing. He doesn’t especially like the idea of being in therapy, and he hopes that by checking off the list of ways in which he’s being compulsive, he’ll be able to stop. That’s alright by me; if the desire to be done with therapy provides the motivation to resolve his compulsive behaviors, then I can work with that. His mother, however, is concerned about his vulnerability to the stresses that he’ll encounter as he enters a new grade in school, and becomes a year older among his peers. She thinks he ought to use therapy to become socially more adept and personally more resilient. That makes sense to me, too, since his history demonstrates that he is vulnerable to developing OCD symptoms under stress. So he has a rationale for stopping soon, his mother has a rationale for continuing, and I can support both rationales.

Another client is a bright high school senior with a learning disability and family stress issues, both affecting his self-concept and self-esteem, which came to a head in a suicidal episode that brought him into therapy. In mainly individual therapy, with some family sessions, he’s worked on a number of difficult issues. He is doing much better, is no longer at substantial risk for suicidal behavior, and is on track to begin college this fall. However, his reactions to his learning issues and family stresses are still problematic, if no longer life-threatening, and significant gaps in his understand about himself and others make him vulnerable to getting into very stressful situations that he may have difficulty finding his way out of. These vulnerabilities put him at risk if some combination of stressors--such as he’s likely to encounter when he starts college--occur simultaneously and interact to become more intense. Again, there’s a rationale for stopping, and also for continuing.

When I’ve been on the receiving side of therapeutic conversation, it’s been pretty clear whether it’s helpful or not. If my therapist or consultant is trustworthy, listens carefully, and helps me to understand how I’ve been perceiving and reacting to various situations and how I could do better, that’s adding value to my life. When therapy or consultation is no longer making much difference in my quality of life, I can use my time and money in other ways.

Of course, therapy or consultation is an economic relationship, partly. Like any other service, it is selected and paid for because it is deemed to be of sufficient value, and ended when it’s value priority decreases relative to other priorities. This holds true whether the payor is the client, an insurance company, a not-for-profit agency, or the government.

Another client is an adult with a pervasive developmental disorder who came into therapy with a serious depression. On a scale of 1 to 10, where 1 is totally depressed and 10 totally happy, he rated himself a 2 or a 3. Several months later, he rates himself a 5 or 6. He’s dealt with some issues and his social life has improved. He still has issues, and could usefully work on them, but he’s also lost his job. His mother is supporting his therapy but anticipates a time when she may have to support his basic living expenses. Is therapy done or should it continue?

One thing that therapy should not do is cultivate dependency. The therapeutic dyad should be engaged around issues of importance in the client’s life, in ways that sustain and enrich her life, in a way that a careful observer, who can take the time to learn the details of the client’s life and needs, and to see how her therapy is working, ought to be able to recognize. There should always be that imaginary “third person” in the therapy room, someone who only has the client’s best interests at heart and in mind, who will know whether this particular therapeutic experience is adding value to the client. Maybe we can call her the Therapy Angel.

So, the response to Susan C’s question is, “What would the Therapy Angel say?” Clear-eyed and loving-hearted, she’d (or he’d, EOE) know when therapy’s done. And would know that “done” means different things for different people. For one person, “done” means the presenting acute symptoms have abated. For another, “done” means, beyond resolving acute symptoms, that the client has become a wiser and more resilient person. For another, “done” means that the client has benefitted more or less as much as possible from this particular therapeutic dyad. For another, “done” means that therapy, as an economic priority, has decreased compared with other economic priorities.

One last word about economics, though. I’ve found that therapy can often help people economically, either by helping them to maintain employment or earning power that otherwise might be compromised by psychological stress and dysfunction, or by helping them to recognize and take advantage of new opportunities in life--including business or professional life--and partnering. As one of my teachers used to say, “When therapy is working, it is very good value!”

Canned Training

2010-09-03T09:02:00.003-05:00

An executive coaching client asked my opinion on a certain brand of management training seminars. I replied:

I'm not familiar with these particular seminars. My attitude about canned training is that, in general, most of it doesn't apply to specific needs, but if you take an idea or two away from a seminar that you can plug into your work back at the ranch, that's probably pretty good. There can be a problem with being told to work in ways that actually won't work in your particular organizational milieu, market niche, or for your personality. So there's a sorting out responsibility that one has to do for oneself. Looking at the seminar descriptions, I found myself put off by what seem to me to be hyperbole in the titles and short descriptions, but then I became more interested when I looked into the details. I'm generally wary of hyperbole, and wonder how much of that will get into the presentations themselves, as a kind of hypnotic suggestion or propaganda wavelength. It's possible to leave training seminars feeling like one has been handed a jewel, but then find, afterward, that one's hand is really empty after all!

So, the bottom line is, yes, do go, bringing both your notebook and your skepticism with you, and be prepared to have to work, after the seminar is over, at sorting out what was potentially valuable from what wasn't. I'll look forward to hearing about it, and maybe that's where I'll be able to provide some value for you, in the sorting out process.

Stenhouse on Curriculum

2010-08-19T22:20:00.003-05:00

As the new school year begins, I picked up my old copy of "An Introduction to Curriculum Research and Development," by the Scottish educational thinker and teacher Lawrence Stenhouse (1975), and found some good old thoughts about curriculum.

Stenhouse saw curriculum as both what a school (or teacher) intends to do, and what it actually does. He takes it as given that there will always be a gap between intent and delivery, so understanding a given curriculum requires awareness of both what we're setting out to do and what we're actually doing. He thought teachers should be studying this, both on their own and together.

Stenhouse saw curriculum as composed of three broad domains:
-- content (information to be learned, which you can pre-specify and test with a multiple choice test),
--skills (recognizing letters and words, writing a three-paragraph essay, solving mathematical problems, which you can also pre-specify),
--knowledge (using what you've learned to solve problems or meet challenges in some unexpected way that can't be fully prespecified; an essay question at it's best, a scientific, artistic or community project).

He thought that educational thinking and theory often fell short by confusing content and skills, which can be prespecified, with knowledge, which cannot. He saw the teacher as being at the center of education, contrary to the trend to see teachers as deliverers of pre-packaged curricula.

35 years after his "Introduction to Curriculum Research and Development," Stenhouse's thinking holds up very well indeed. The only substantial addition that I'd suggest is about the way teaching methods relate to the more recent knowledge about learning and the brain; for example, strategies designed to engage the left and right hemisphere, frontal lobes and attention, and the domain of social-emotional learning (individual and group strategies, etc.).

In these times, when education is so often about making sure that children can simply read and define words, do math, or pass pre-specified tests at such and such a level, Stenhouse can help us to remember that there are domains of education that connect with potentialities of human nature that lie far beyond these meager models of what learning and knowledge are about.

Latent Tension

2010-08-04T18:46:00.008-05:00

"Dorothy" comments: "My dad came to visit and we had a pretty good time, but there was all this latent tension that he never noticed."

Dr. Einhorn comments: The implications that there is latent tension sometimes and not others, or that when there is latent tension we usually discuss it, are interesting, because they don't seem to reflect reality very well. It seems to me that there's always latent tension, or almost always, and we are always mostly ignoring it. Our lives and relationships are always moving, changing, bumping into one another, influencing each other. We are all--individuals, families, relationship networks of various kinds--part of this vast Darwinian humanity that is evolving, with huge fits and starts (wars, economic bubbles and crashes, dislocations of various kinds) into a planetary culture. Think of all the kinds of tension there are: status/authority, closeness/intimacy, economic, sexual, religious/spiritual (though I wonder if there can be real conflict once we are actually in the realm of the spiritual), etc. Not to mention the "latent tensions" within our own minds, between various impulses, urges, thoughts, feelings, values, allegiances, states, etc. These "latent tensions: are always going on; it's part of the environment that we live in. The questions that interest me are, which parts of the latent tensions going on at any particular time and in any particular relationships do we want to give attention to, and how do we want to do that. And, of course, that brings in the questions of how perceptive we are, how honest we are, and how much we are prepared to risk in being honest.

A lot of therapeutic work focuses on latent tension in the life of the client. It can also usefully focus on latent tensions in the relationship between client and therapist, if the therapist can use that skillfully and the client can enter into that level of dialog about their relationship.

A lot of art is about expressing the interaction between latent tensions in some way, especially (it seems to me) poetry and poetic musical lyrics, and storytelling in its various forms (novels, plays, etc.). Music itself is a way of creating harmony out of elements that are in a tension relationship, both in the music that is played and also in the instruments that make it. I remember the guitar being described as something that can hardly exist because all of its elements are in a state of tension with one another, the wood trying to collapse, the strings trying reduce their stretch tension. And of course that's what makes the beauty of the sound, when the tensions are just right and a harmony is created.

Rumi talks about the way that things apparently opposed can be working together, as in the handclap being created by the apparent "opposition" of the two hands, which we might see as the "tension between" them. The movement of the two hands through the air might seem "latent" in slo-mo, until they met one another and produced the clap.

It generally takes a lot of self-work to be able to talk about the latent tensions in any relationship, because the ability doesn't come naturally. You have to start the conversation, and then you have to stay in it, according to how the other person responds. Here, Dorothy doesn't say that she tried to raise any issues with her dad, although noticing them herself was a start. The implication is that he should have taken the initiative to raise issues with her, in which case I wonder if their pattern is that he's done that in the past, or perhaps that she wishes he had but he mostly hasn't. If she wants to take the risk of raising some issues involving latent tension with her dad, she'll have the opportunity to see what might come of that. It does take a certain amount of courage.

Songwriting and Psychotherapy

2010-07-21T22:33:00.002-05:00

(This essay is in the Summer 2010 issue of The Illinois Psychologist, the newsletter of the Illinois Psychological Association)

I’m a singer-songwriter, and I subscribe to a folk music listserve on which a singer-songwriter posted this question: “How do you separate ‘songwriting’ from ‘performance’ when listening to a song that you wish to evaluate for it’s merit?” He continued: “There are some aspects of the performance of a song that you can think of as purely ‘writing’ (clever use of metaphor), and some that are purely ‘performance’ (great voice). But some of the finer points of a song include ‘phrasing,’ ‘dynamics,’ and ‘emotional connection.’ Are these related to writing or performance?”

This question sparked a lively discussion, capped by this comment from another singer-songwriter, just returned from a major folk festival: “Having just witnessed many outstanding singer/songwriters, I truly believe that you can’t separate the performance from the song.”

It seems to me that the question of the quality of a song compared to how it is performed is similar to the question of the quality of a therapy compared to how it is actually done.

Take Gestalt Therapy. Fritz Perls cleverly selected aspects of psychoanalytic theory and practice, Gestalt psychology, Zen meditation and philosophy, psychodrama, and existential humanism, and amalgamated them into a form of therapy which, when he did it, was often very powerful. People who’d been in other forms of therapy for years suddenly found themselves having insights and making breakthroughs. Perls thought he was creating a new form of therapy which would create a kind of revolution in therapeutic practice, but it hasn’t really caught on.

Why hasn’t it? Perhaps because its practitioners haven’t enjoyed the same success that Perls did. And why not? The answer seems to be that, in addition to the structure or form of Gestalt Therapy--the empty chair, the free-floating and focusing of attention, the role playing, and the view of human nature--there was Perls‘ own personality, his therapeutic skills honed over a lifetime of intensive questing and practice, including his fluency at catching and using patient imagery and transference. There was also the special mileau that evolved around him at Esalen, the growth center in California where he did much of the work which he is most famous for, which facilitated a self-organizing population of patients who were mostly well prepared to work with him.

I like Gestalt Therapy, and continue to find it useful with some patients at some times, but it has not become the presence in the therapeutic marketplace that Perls hoped for. There is the “songwriting” of Gestalt Therapy, and the “performance” of it, and no one “played” it like Perls.

The metaphor of the “song as written” and the “song as performed” applies across forms of psychotherapy. I recently read (and wrote a continuing education test on) “Cognitive Behavior Therapy and Eating Disorders,” by Christopher G. Fairburn, in which Fairburn discusses a form of therapy that he calls ““enhanced cognitive behavior therapy,” or “CBT-E.” Describing the steps of CBT-E, which is expected to resolve eating disorders in most patients within 20 weeks, Fairburn emphasizes that “Engaging the patient is the top priority.” To achieve engagement, he recommends that therapists “Be empathic and engaging in manner; Ask the patient what name he or she would like you to use and state your name; Be professional but not intimidating; Actively involve the patient in the assessment process; Instill hope; Avoid being controlling or paternalistic; Repeatedly...check back that the patient is ‘on board’...(and) “Enquire about any concerns that the patient might have.” Clearly, before even getting to the steps of CBT-E, Fairburn is focusing on therapist “performance” here. It is as if he were saying, “My song will work for you as well as it works for me if you sing it the same way I do.”

Psychologist Jonathan Shedler, giving the keynote address at the recent Division 39 (Psychoanalytic Psychology) conference in Chicago, referred to research indicating that most of the effectiveness of psychotherapy is due to the alliance between patient and therapist. Looking at the work of Perls and Fairburn, we see two therapists who are expert at establishing a relationship in which patients feel hopeful, encouraged and engaged with a person and a method that can help them transcend their emotional suffering and behavioral pitfalls and get on with their lives in a better way. Yet the therapies practiced by Perls and Fairburn could hardly be more different.

If we can’t really separate the “song” from the “performance,” the form of a therapy from how each therapist practices it, then every therapist is, in a way, co-creating, or at least modifying, the form of therapy, every time she or he does it, with every patient.

How about that!

Truth and Turf in the Psychotherapy Wars: Two Hands Clapping?

2010-05-31T10:28:00.005-05:00

(This essay was originally published in the Winter, 2010, CAPPSTONE, the newsletter of the Chicago Assn. for Psychoanalytic Pychology, and subsequently in the Winter, 2010, PSYCHOLOGIST-PSYCHOANALYST, the newsletter of Division 39 of the American Psychological Assn., Psychoanalytic Psychology. Shedler's article was subsequently published in AMERICAN PSYCHOLOGIST)

The history of psychotherapy is, in part, the story of a long struggle among people and schools between searching for truth and staking out turf. Of course, that’s true of a lot of professions, but it might be more intense in psychotherapy, where the issues are about who owns the rights to understanding human nature and its treatment.

Jonathan Shedler, a psychologist at the University of Colorado-Denver, has written a monograph that advances accurate description of psychodynamic psychotherapy. “That Was Then, This is Now, Psychoanalytic Psychotherapy for the Rest of Us,” describes it in commonsense, non-jargon language that will be accessible to most readers. (http://www.psychsystems.net/shedler.html). Shedler avoids the morass of claiming turf, in the name of theory pronounced as received wisdom, that is so characteristic in the history of psychoanalysis. The psychodynamic method, practiced well, is more important and more powerful than the ability of any theory to explain it. Psychodynamic psychotherapy is better explained as a method, with the minimum of theorizing, and better understood, as much as possible, through models of neuroactivity, as Allan Schore is developing. This brings us closer to the truth about psychotherapy.

A new attack in the therapeutic turf wars was launched from Psychological Science in the Public Interest, the journal of the Association for Psychological Science, in the form of an article by Timothy Baker, Richard McFall, and Varda Shoham (from the University of Wisconsin-Madison, Indiana University, and University of Arizona, respectively), entitled, “Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care.” ( http://www.psychologicalscience.org/journals/index.cfm?journal=pspi&content=pspi/9_2 ) This is the article which, reported as truth in Newsweek, prompted so much discussion; including a flurry of comments on the Illinois Psychological Association listserve, and a rebuttal by Katherine Nordal, APA’s director for professional practice, as quoted in the November/December The National Psychologist (“Psychology gets slap in the face”). Its authors, implicitly defining randomized clinical trials (RCT) as science in psychology, explicitly define evidenced-based treatments as those which have been validated by RCT studies, and consign all other methods of therapy to the garbage pail of superstition and uninformed personal preference.

There’s a lot at stake here, including how clinical psychologists should be trained, how graduate schools should be accredited, and how third party payers should select treatments to recognize, all of which Baker, McFall and Shoham assert should be reserved for RCT-based programs and methods. The stakes were highlighted when I spoke with a psychologist who is an executive at a managed care company. “It’s all about the evidence,” he said, adding that psychodynamic therapy might enrich people’s lives but lacks evidence of efficacy as a treatment.

Of course, that raises the question of what the evidence is. Shedler, in an article entitled “The Efficacy of Psychodynamic Psychotherapy,” which has been accepted by American Psychologist (a draft is posted on his website), reviews an impressive list of studies showing efficacy for psychodynamic psychotherapy. I don’t know how our managed care executive colleague would react, although I expect that he would find a way to disregard it. Perhaps there’s some selectivity here about what evidence to include.

But the argument about which evidence is real evidence obscures the larger issues. I often tell couples whom I see in therapy that each one is probably the world’s best expert on the other’s shortcomings, and something like that situation applies in the opposition between the radical empiricist and psychodynamic traditions. The radical empiricists are right in characterizing much of what psychoanalytic therapists have believed about human nature and its treatment over the years as utterly without factual support. Much psychoanalytic theory is based on the Authoritative Pronouncement of some alpha analyst or other, a tradition begun by Freud and still rife in psychoanalytic culture. There is nothing scientific about it, and the claim of scientific validity for theoretical pronouncements given without a shred of evidence (even liberally defined) to support them is justly characterized by radical empiricists as ludicrous.

On the other hand, reducing human nature in order to fit it into the scientific method available at the time has ever been the problem of behaviorism’s search for scientific respectability in psychology. While the radical empiricists are right in asserting that merely claiming that what one is doing is scientific doesn’t make it so, this applies to their own position of defining science as equal to RCT as well; that’s a philosophy of science, not science itself. In fact, most of what we know about human nature, and particularly brain structure and function, has come about through autopsy studies of people with brain injuries, by neuropsychological and imaging studies of brain-injured people, by animal studies, and by imaging studies of normal people; not by RCT studies, although of course they have made a contribution. I expect that the most valuable research in therapy in future will be neuroimaging studies, once the technology improves enough to measure changes in volume and interconnectivity of parts of the brain. I expect those studies to show improvements in frontal lobe density (especially right frontal lobe), frontal-limbic interconnection, and interhemispheric connectivity, as a result of longer-term, conversational, reflective, relational therapy, when it is successful.

The truth is that, “Life,” as Chicago therapist and teacher Harold Balikov used to say, “is not user friendly,” and emotional pain and behavioral problems in living are part of being human and living life. DSM diagnosis is not the same as physical diagnosis, and therapy is often more like education--in which there are lots of different schools and methods of teaching, and students may have to find the ones that work best for them--than medical treatment, which at least aims for an expert consensus of recognized best practice for any disorder. Truth in marketing mental health treatment would be something like: ”If you need mental health treatment, you may find that therapy, medication, or a combination, may work best for you, and you may have to learn about the mental health treatment choices available, and search for awhile, before you identify the practitioners and the methods which are right for your needs at this time.” Instead, the marketing that we see takes a bit of truth and spins it into deception: ”If you’re depressed, take our clinically proven pill;” to which the radical empiricists would add, “our clinically proven treatment!”

The truth is that different methods and treatment relationships may work better for different people, or for the same person at different times. Twenty sessions of cognitive-behavioral therapy will work better for some people, five years of analytic therapy for others; or maybe both will work better for the same person, at different times in his or her life.

And the truth is that both psychoanalysis and radical empiricism have their roots in traditions in which the dedicated search for some kinds of truth and the dedicated gathering of turf evolved side-by-side. Both traditions offer keen insights into human nature and its treatment, both obfuscate the truth about it as well; most especially by claiming that their method is better than the other, when in fact it is better for some people at some times when practiced by some practitioners.

If this leads to problems about how to authorize and pay for therapy, how to monitor it’s effectiveness and how to do second opinions, then those are issues that psychotherapy, like any mature profession, must develop effective solutions for.

Meanwhile, I’m reminded of the reflection of the poet and teacher Jalaluddin Rumi, that things that appear to be opposed may really be working together; as when the “opposition” of two hands produces a handclap. Perhaps the opposition of the psychodynamic and radical empiricist traditions will produce an effect that will lead many therapists (and maybe even reporters, if they take the trouble to study up on it) to a more inclusive and commonsense mainstream understanding of what therapy is and how it works. Shedler moves in this direction when he acknowledges the overlap between cognitive-behavioral and psychodynamic therapy while respecting their differences. Maybe, even, the opposition between truth-seeking and turf-gathering, even when done by the same people, can help the rest of us, through observation, to learn to sort out the one from the other; leading to a more inclusive perspective that we can ground our work in, train students in, and communicate to the public. Wouldn’t that be a step forward for psychotherapy!

How Much Therapy is Needed?

2010-05-30T14:37:00.003-05:00

An out-of-state Mom, whose son attends a local school, called to discuss the possibility of my working with him, which I appreciated. During our conversation, she identified several issues that he's struggling with, including relationships with a roommate and a girlfriend, and asked how much therapy might be needed to deal with those issues.

My reply was that the length of therapy is not so much about the issues that the person has as about the person having them. On reflection, I'd add, "and the people he's having issues with."

When it comes down to it, just about all therapy is about relationships, whether it takes one session or a thousand. There's an enormous variation in how much time and help people need; including, at the beginning of therapy, what they know and can learn, what they do and can change, and how quickly they can get to work on their perceptions, emotions and behaviors in order to make things better. And who the roommate and girlfriend are, in this case, could be as important as who the client is.

Which Divorce "Camp" Are You In?

2010-05-02T22:36:00.003-05:00

“Becky” asks:

I am in the process of getting divorced, and I respect your opinion, experience and level head, so am hoping you will tackle a question I have. My husband decided to leave me, which apparently he’d been thinking about for a long time but not sharing with anyone, and it came as quite a shock. I have been reading copious amounts of studies, and opinions, on divorced families. Summarized briefly there seems to be an "If the parents are okay the kids will be okay" camp, and an "it doesn't matter what the parent's marriage was like (except in cases of violence), kids do better with their parents together" camp. Of course there are variations on this theme and a number of 'camps' in the middle. Do you have an opinion about this?

One aspect I am trying to work through is how to keep my kids’ lives as 'normal' as possible, especially my 14 year old son, who is beginning to show signs of 'feeling left,’ which of course I feel as well. He seems to “feel left” even by me, though I am here, because of course I am not 'here' the same way I was before. I guess I am looking for a validation of "if we are fine the kids will be fine", but I don't really believe it. What do you think? And what is your hourly rate for phone session, btw?

Dr. Einhorn replies:

Hi Becky,

Thanks for your compliments, and I hope my reply lives up to them!

Every situation and every person is different, so I'm not so sure that there is a rule of thumb about divorce. Kids will tend to take their cues from their parents, but each child might be sensitive to different cues, and there's also the impact on each child's relationship with her or his parents, which can vary from child to child within the same family. So I guess I'm not camping in any "camp." I'm all about the particular people in their particular situations. In your son's case, what matters is what happened to this child within this family.

Keeping things “normal” is good, but the very definition of what’s normal is changing in your family. It used to be normal for the family to live together, now the parents live separately, and perhaps have relationships with other people who are now coming into their children’s lives. Even the definition of what used to be normal is changing, because it now has become obvious that one parent had private thoughts and feelings that culminated in a separation and divorce for quite some time.

So, for those who “got left,” reinterpreting where you were may be part of being able to move ahead from where you are.

It makes sense to suppose that, in at least some respects, your son probably did "get left," and in a somewhat different way by each parent; Dad left with little or no warning, and Mom was probably freaking out--however quietly and self-containedly and trying to keep the children protected. So if your son didn't feel “left” he'd be pretty oblivious, wouldn’t he?

What he does with that feeling is another thing. Of course, I'm a fan of therapy, because I think talking about stuff like that with someone who can listen and help us think it through is a very good thing for our brains and our lives. Some kids are open to the idea, some not. Have you raised the possibility with him?

Contact me privately for rates for telephone consults. Be aware that such consults are not diagnosis or psychotherapy and can’t be submitted for insurance reimbursement.

Best wishes to you and your family,
Dr. Einhorn

Mother In Law

2010-03-10T21:45:00.009-06:00

“Julia” writes:

Hello,

I’ve had an issue with my MIL not letting go of her son since before we got engaged. She wants to be the center of his attention constantly and makes nasty remarks (which my husband will NEVER recognize as nasty or says he didn't hear it) to me.

I'm of Hispanic descent and over breakfast she told her little grandson (my blonde, blue eyed nephew) that he should never ever date dark haired women, only blondes...and if they are dark haired, then they'd better highlight their hair blonde. As a Latina, we are very proud of being "brown" and having dark hair (some of us...since we come in a rainbow).

This is about the 20th incident in the past year where she has made some type of dumb/insensitive remark. My husband sat silently as usual, and when I brought it up later, he got very defensive of her as he always does...she can do no wrong.

Any advice?

Thanks.

Dr. Einhorn replies:

Well, it might mean something that he didn't marry someone like his mother!

“Julia’s” question raises a couple of interesting questions: How do we know what we’re getting ourselves into? And, How do we deal with prejudice?

Disappointment, as Idries Shah points out, occurs because we have an expectation. We can’t always know what the expectation was, but we can sometimes discover it by tracing back our disappointment.

Julia says that her MIL hasn’t wanted to let go of her son since before they got engaged, and her son thinks she can do no wrong, so she certainly had information about what she was getting into. I wonder if Julia expected that her MIL and son would change after they got married, and if so, why she would assume that?

Now, prejudice, as I said at the National Fair Housing Conference of the Department of Housing and Urban Development in 1994, is a natural function of how the brain works. The efficiency of mind is that it categorizes everything and then we can recognize and respond very quickly and with minimal effort to what we have categorized. Perception itself is prejudiced, one might say, in that we pre-judge everything, noticing very little about what we actually see, hear, and so on. That makes life efficient, because we can concentrate on what we need to, instead of having to re-learn about everything we see. The problem with the system is that stupid prejudices develop, and we don’t naturally differentiate between the efficient prejudices and the stupid ones. That takes work. As Edward de Bono points out, the brain forms perceptions of patterns as it goes forward, and then those patterns become perceptual habits, and it does that very efficiently. Once patterns are formed, however, changing them requires special effort and methods.

So--taking Julia’s report at face value, and remembering that there is always more than meets the eye and more than is contained in the initial report--Julia is faced with the prejudice of the MIL and the habit of relationship between the MIL and her son, Julia’s husband. Now that Julia’s expectations that her MIL will come around and that her husband will stand up for her on his own have been pretty well disconfirmed, what are some of the choices she has in this situation?

It seems to me that she can choose one or both of two paths; she can try to directly discuss the issues with her MIL and husband, or she can try to engage with them emotionally and relationally to change their minds and behavior. We might call them the straightforward path and the sneaky path.

The straightforward path involves having direct conversations with her MIL and her husband about the fact that her MIL is making racist comments about her in the presence of their nephew/grandson. It sounds like Julia hasn’t really had a conversation with her MIL about it. Widening the focus, Julia might open up the conversation to include her impression that her MIL has never really welcomed her into her son’s life, or her own. She might emphasize that she really loves her son and wants to be a part of the family, and she might remind her MIL that many families today include people of different backgrounds and ethnicities; and are the richer for it, as long as everyone has a place at the table.

Julia might also have a straightforward conversation with her husband about his not standing up for her. It sounds like she does mention it to him, but then he makes some excuse and that’s where their conversation stops. She might tell him that the conversation doesn’t stop there as far as she is concerned, and that this is something that very much concerns and hurts and frustrates her and that she expects him to recognize that and wonders why he doesn’t, and why he allows it to continue to happen without stepping up to speak with his mother about it.

Those are straightforward verbal conversations Julia might have. There’s a section on “Difficult Conversations” elsewhere in this blog with some information about having them more effectively and avoiding some of the pitfalls that difficult conversations can fall into.

Then there’s the indirect approaches; which, from a brain function point of view, might actually be more direct, because they go directly for the prejudicial and habitual behavior processes themselves. The key here is that that the way to respond to emotionally off-putting behavior from MIL is to engage positively with her around it. Here’s a couple of ideas about how to do that, offered constructively and somewhat tongue-in-cheek, and I hereby disclaim all responsibility if you try them and they blow up in your face!

Humor can sometimes be more effective than straightforward verbal discourse. For example, when MIL makes denigrating comments about dark-haired people, you can point out that all humanity seems to have emerged from Africa, and the light-haired ones just went further north and got pale to get more Vitamin D from sunlight (I don’t know about that last part, just made it up). Say it with good humor, and never mind if she doesn’t respond or shrugs it off. It might have the effect of disconcerting her for a moment, during which some fresh air might get into her mental stereotypes and prejudices. Collect a bunch of comments like that, good-humoredly showing how dark-haired people are better, or came first, or have advantages, which might not be noticed at first by lighter complexioned folks, and just keep bringing them up when she makes prejudicial comments, as kind of throwaway remarks. It’s a more indirect way of responding to her prejudice, that might facilitate some change over time.

Although it’s politically incorrect to suggest it nowadays, you might consider engaging relationally by responding in kind; although you'd have to do it in a better-natured way than she is, teaching by demonstration, by raising the bar higher. "Oh, there you go, those light-haired people, always thinking that they're better!" Or, "You can always tell a light-haired person, but you can't tell her much!" But you have to really do it in a good natured way, not in an implicitly resentful one.

These remarks focus more or your MIL than your husband. Maybe it's time to think about marital therapy to work on this lack of communication in your relationship, and the obstacle that his relationship with his mother presents?

Here’s the ultimate manipulation, which I take absolutely no responsibility for if you decide to go ahead and do it: get pregnant and give Grandma another grandchild. She’ll probably fall in love with it and then you’ll rise up in her esteem. Except, with your luck, it’ll probably have your husband’s light features and you’ll still be in the doghouse. Asi es la vida.

Julia replied:

Thanks so much - this is such an insightful response! To answer your question...when he is defensive of her, I immediately get aggressive and not nice because it hurts me that he is "choosing" her over me yet again. It also angers/hurts me that he doesn't take the time to recognize that this is a real issue...I certainly thought about the repercussions of marrying into a non-Latino family, I don't think he did. I'm expected to "blend", and we sweep these types of things under the rug instead of settling them.

Ay, yay, yay - well, thanks again, I really do appreciate it!

Dr. Einhorn reflects:

Julia's problem is of particular psychological interest because it shines a light on two usually hidden sources of unnecessary suffering. The first is the activity of prejudice itself, and I think the cure for prejudice is not to try to eliminate it--because if prejudice is a natural product of brain activity, it can't be eliminated--but to make a human connection with people so that they can realize, through that human connection, that their prejudice was mistaken. The second is Julia's own unconscious assumptions that somehow time and marriage would cure her MIL of her prejudice, and her husband of his non-critical attachment--I'm trying to use neutral language here--to his mother.

P.S.: A reader sends this youtube link: http://www.youtube.com/watch?v=b0Ti-gkJiXc.

Couldn't Say It Better

2010-03-09T23:11:00.000-06:00

A client said:

"You just kind of get locked into your own deal. I needed your help to step outside."

Dumbed-Down Parables

2010-03-09T11:27:00.005-06:00

David Gergen, a political commentator who worked for several presidents including Ronald Reagan, writes approvingly about Reagan’s ability to communicate with the public through stories that were, effectively, parables (in “Eyewitness to Power”).

I agree with Gergen’s analysis of Reagan as a talented and skilled story-teller, which contributed in no small part to his becoming known as “The Great Communicator.” However, I think that Reagan often used dumbed-down parables that would be easily accepted and responded to by the electorate, rather than giving them the parables that actually described the situations they were in and what should be done about them.

Such parables are like junk food; cheap to make, buy, and eat, and they may make you feel good going down, but later on you get digestive problems, like diabetes, obesity, hypertension, and cardiovascular problems, especially if you make a steady diet of them.

I’m all for parables, analogies, metaphors--which are both expressions of how we think, and food for thought--but they need to be ones which help the receiving mind adjust to the reality of its situation, not pretend to adjust while really avoiding it.

Of course, adjusting to reality may make us feel worse, at first, even though it’s better in the long run, while settling for a pretense will make us feel better at first, and worse later. I wrote a song about that, called “I Must Be Getting Better ‘Cause I Think I’m Getting Worse.” It’ll be on the CD I’m completing work on now.

Worship and Body Image

2010-02-20T21:44:00.003-06:00

I’m reading some interesting articles by Bucknell psychologist Chris Boyatzis on the relationship between women's body image and religion and spirituality. One of the take-away points is that “Research has confirmed a healthy link between young adults’ religiosity and body image.” Now, why would that be? 

I have often observed that nearly everyone worships something, although the object of their worship may not be immediately apparent. In the case of women’s body image, women with eating disorders are often striving for a “perfect” physical self. Now, perfection is one of the attributes of divinity, and for people of faith, one doesn’t have to be perfect because divinity is. People can participate in aspects of divine perfection, but perfection itself belongs to divinity. Thus, living a healthy life, a balanced life, a life of service, etc., are ways to approach participating in various aspects of divine perfection. If one is without faith in an object higher than oneself, living in a materialist world in which there is no higher power and no higher order than everyday life, then the self may become the embodiment of perfection--we are certainly bombarded with a certain version of feminine beauty--and, in the world of appearances, physical appearance can become the pinnacle of perfection. Thus follows disordered body-image and self-concept, with eating disorders and the other problems that accompany them.

For religious naturalists, a concept of divinity isn’t necessary to have a relationship with something higher than the self. Constructs such as nature as a whole, humanity as a whole, evolution, the genetic code, and the universe, will suffice to call one to relationship with a higher order of life in which one’s healthy self-image and lifestyle are important parts of that relationship.

Knowing It All

2010-02-08T06:35:00.002-06:00

There’s a lot of talk today about addictions of various kinds: to substances, gambling, sex, video gaming, etc. There’s some controversy about what constitutes an addiction and whether all of these behaviors really qualify as addictions. Whatever they are called, one characteristic that I’ve found among people with such fixations is a know-it-all attitude. You can’t tell them anything that will help them to change their behavior, minds and lives for the better, because they know it already.

It’s interesting to reflect on how this connects modern psychological and traditional spiritual values. What would be considered to be a kind of ego defense, in psychoanalytic terms, or cognitive rigidity, in cognitive behavioral psychology, equates pretty well to what would be regarded as arrogance in spiritual terms; meaning simply that the person thinks that she knows things that she doesn’t, and therefore doesn’t have important learning to do, including thinking about what is being said to her by someone whom might be saying something useful if listened to. Two qualities that are missing in such people are humility (without humiliation) and spiritual motivation (motivation for experience of relationship with divinity, higher power, higher purpose, etc.). Interestingly, these qualities are directly cultivated by 12-step programs.

It’s all about brain chemistry, at some level. Substance addiction alters brain chemistry directly, while compulsive gambling, sex, and video gaming alter it more subtly, as research as indicated. But so does humility and a proper kind of motivation for higher or deeper experience, even if we haven’t been able to measure that yet.

Paradoxically, we can know more by sincerely thinking that we know less, and identifying, with humility, with a higher power or purpose; although that involves a different kind of "knowing." It's interesting, to me, that such identification connects the individual brain with the brainwork, the thought and lives, of very many people, past and present; and, who knows, maybe future as well.

Notes on Borderline Personality

2010-01-23T22:07:00.002-06:00

Here are the notes I sent to a colleague who asked me for some help in understanding another colleague who has borderline characteristics. I wasn’t trying to be definitive, or to address the issues and controversies surrounding this diagnosis, just to give some practical advice. Perhaps others may find it useful.

While the borderline personality style can present in different ways, one of the most frequently encountered is the person who has genuine skills in both productive work and relationships, but whose attachment dynamics have been severely compromised at a young age, such that she (or, of course, he) cannot really attach in a trusting and trustworthy way on a long term basis aside from being on either side of a very clear dependency relationship; up or down. The individual's unconscious (and it is unconscious) formula for attachment survival is to divide others so that her alliance with key supporters is attained by their alliance with her in rejecting another or others; this is the "splitting,” “triangulating” dynamic. A borderline patient on an inpatient unit famously splits the unit by allying some staff with her against other staff, and sometimes it takes lots of work to unravel the knot the borderline person has created.

Such people can't really be wholehearted members of teams, because they can't trust colleagues; but they can be members of productive teams in which specified tasks are done by various people in order to come together into a result. However, their relational pattern as team members will still be to split, even at the expense of the success of the team, so that both their work and their tendency to split will have to be managed by the team leader.

There are different hypotheses about how borderline personality disorders come about. Barbara Oakley attributes it mainly to genetics, in "Evil Genes." Psychoanalytically oriented theorists look to early childhood experiences, in which the patient was alternately seduced (in one way or another) and rejected by a powerful parent, usually with the other parent being too weak to make a difference. As in most things psychological, probably it’s a combination of nature and nurture.

There are lots of nuances of this, of course. As a therapist, I often see patients with family histories in which a parent allied a child with himself or herself at the expense of other family members, who are rejected. Sometimes my patient is the child who was seduced, sometimes the one who was rejected. Sometimes the seduction-rejection behavior cycles, such that the parent seduced (not necessarily sexually, but emotionally) the child and treated her as very special, then rejected her and treated her as a bad person or a non-person, then cycled that treatment again and again.

The result is that the borderline tends to have a "good object/bad object" attitude toward others in his life, alternately feeling beloved and betrayed. So, those who have been "good objects" and thought they had a trustworthy and dependable interlocutor suddenly find themselves excoriated and vilified, and wonder what hit them. Of course, the cycle can turn the other way as well, so that the person who was opposed and undermined can suddenly become the special and perfect and desired one. The seduction/betrayal dynamic repeats, and people who relate with people with borderline personality styles have that “walking on eggshells” feeling, of always being about to do something wrong, without knowing it.

Working with such a person means that the working relationship has to be managed, because trust is not really available, especially if you are the person who threatens the borderline and whom he is trying to ally with others against. Over the run of time, as the borderline becomes more secure, he may alter his focus in terms of whom he tries to split off from whom.

The key to managing a working relationship with a borderline is in two parts: 1. Keep your productive agenda going, and 2. Deflect splitting by refocusing attacking energy onto productive work; not by taking it personally and rising to the bait. The splitting behavior is unconsciously strategic, a substitute for healthy attachment, which the borderline person never really had. Therapy for people with borderline personality tendencies aims at establishing secure attachment. Dialectical Behavior Therapy (DBT) is a new therapy that has been developed for helping borderline patients feel a secure sense of attachment within their therapeutic relationship.

Borderlines typically feel a great deal of apprehension and anxiety, much of which is repressed and projected out onto others. They are masters at appearing calm while provoking and upsetting others by attacking them, then pointing to those whom they have provoked and saying, "What's wrong with them?" For this reason, maintaining a low-key emotional tone can be important in dealing with a borderline-type person.

Few people are severe borderlines all the time; they couldn't function in society if they were. Lots of people have borderline tendencies, and some people have them more strongly than others. Such tendencies can be exacerbated by stress that can be brought about by big life changes, even apparently positive ones like starting a new job, entering a new relationship or a more intimate level of relationship, etc.

Because the person with a borderline personality disorder may seem to be quite normal much of the time, and can be quite charming (remember, the borderline person was often seduced emotionally as a child), the observer may be fooled into thinking that the borderline pattern is over. The truth is that, without personality change so deep that it affects the foundation of the person's being, the borderline pattern is still there, beneath the surface, just waiting for the right conditions to activate it. It takes insight and wisdom for a borderline personality pattern to change.

Fear

2010-01-02T11:30:00.002-06:00

Discussing fear with a client, we realized that sometimes the fear of death can help us to overcome the fear of life. So many things that we want to do but avoid doing because we are afraid of being uncomfortable, or embarassed, or failing, become possible when we see them with the perspective of a limited amount of time left in which to do or not do them. Fear is essential, of course, when it really is needed to save us from taking risks to our survival. But fear, outside of its use in preserving our safety and well-being, becomes an obstacle to achieving what we were born to achieve; which always involves transcending unnecessary limitations.

Some Thoughts About Conflict Resolution

2009-12-20T14:08:00.002-06:00

Conflict exists in all relationships and organizations, so the purpose of conflict resolution training or programs isn’t to eliminate conflict, but to provide more thoughtful and positive ways of addressing it than might otherwise be available. At best, conflict resolution can improve a relationship or an organization; at least, it can avoid increased antagonism.

Conflict resolution training or programs don’t replace the responsibility for people in relationships to work things out, and they don’t replace authority in organizations. People remain in charge. In relationships, they are responsible for themselves and their decisions. In organizations, people are responsible for the duties of their positions. Conflict resolution training or programs may help people to understand themselves and others better, and therefore to communicate more effectively and make better decisions.

Mediation can be an important function in conflict resolution, by supporting communication and negotiation among the parties. The people involved in the conflict need to express their points of view meaningfully and listen to one another; that’s the communication part. Once that’s done, the solution to the conflict may present itself, so to speak. If it doesn’t, there may be a need for negotiation. The mediator may have to teach communication and listening skills before the parties will be able to use them. While people vary in their communication and listening skills; few people without training and practice are able to think or speak clearly in conflict situations.

As a conflict resolution consultant, I’ve found that it’s often useful to speak with people separately before meeting together to try to resolve the conflict. People often haven’t thought through what the conflict is about, even from their own point of view, much less that of the other party. It can require one or even several 1:1 conversations before people can articulate what matters about this situation, from their own point of view, and then to begin to look at it from the other person’s.

Some conflict resolution consultants think that finding the truth of situations is not necessary to conflict resolution. They think that everyone has their own story, and people agree to whatever they can agree to if they're speaking clearly and listening to each another, and that's that. Other conflict resolution consultants think that the truth must be discovered in a way that everyone can agree to in order for the way forward to become apparent. My experience indicates that situations are different from one another, but in each one there’s a sort of minimum necessary truth that has to be acknowledged by everyone in order for resolution to happen.

Attorneys and Experts

2009-11-23T01:31:00.002-06:00

Attorneys and experts tend to approach the role of the expert from quite different perspectives. Attorneys tend to be intent on building a case, and to see the expert's testimony as slotting into the narrative which they are constructing. They are also interested in containing costs, and thus minimizing the amount of time the expert provides; except in really big cases where there's enough at stake, and enough opportunity to win, that the attorney wants the expert to do whatever is necessary to contribute to the most credible case. Experts, on the other hand--assuming they are working as experts and not as "hired guns" to produce whatever testimony the attorney is paying for--are approaching the case from the perspective that they have to find out whatever they might need to know to actually function as experts. The end results may or may not slot neatly into the narratives the attorneys are trying to construct, and arriving at them will take as long as it needs to take for the experts to find out what they need to find out.

Now, if the expert is just asked to testify to a point in his or her field--for example, whether vocational rehabilitation programs have a responsibility to supervise their clients in order to protect them from abuse by other clients, or whether children have been known to produce false claims of sexual abuse as a result of suggestive or otherwise defective interview technique, or whether blows to the head in a fight can cause brain damage--that's a pretty cut-and-dried project. An expert could reasonably give a pretty good estimate of how much time such a project would take, and wouldn't need a lot of time to complete it. However, if the expert is asked to testify about whether a particular vocational rehabilitation program was negligent in a particular case in which one client was allegedly abused by another, or whether a particular interviewer interviewing a particular child used defective technique that could reasonably be expected to have produced a false report of molestation, or whether a particular client has brain damage, which may or may not have resulted from an alleged altercation, that involves the kind of investigation about which the expert, at the start, knows neither what the end result will be nor how much time it will take to get there. The best one could do would be to give pretty wide parameters of estimate.

Perception and Reality

2009-11-14T23:22:00.002-06:00

I was out walking my dog the other night, crossing a well-lit neighborhood street at a stop sign, when a car approached the intersection, slowed down but didn't stop, and then began to turn and came straight at us as we were crossing. I shouted at the driver, who stopped, lowered her window, and shouted back at me that I should have been wearing a light.

Well, I was flabbergasted. The intersection was well lit, there was a stop sign, I was crossing at the corner, and it was still my fault that she didn't stop, didn't see us, and almost hit us. There are at least a couple of things to be learned from this about how the mind works, and what the relationship is between what we perceive and what is real.

First, the job of the mind is to make sense of what happens going forward. She didn't see us in the intersection, therefore it was my fault for not wearing a light. Second, she had no capacity to retrospectively self-evaluate and self-correct.

So here we have an example of how we can misperceive reality without realizing it at the time, and how we can still not realize it even after it has been pointed out to us in a situation in which a potential disaster, which would have been entirely our fault, has just been narrowly averted.

Medill News Service Article w. Interview

2009-10-17T01:24:00.002-05:00

Study says they're happy, but young people say they're stressed
by JESSE CURTI
Oct 15, 2009
Past pimples and prom, a recent study says adults 18 - 25 have the highest happiness rating.
The survey by Gallup based on more than 600,000 interviews revealed that happiness is highest among younger Americans and lowest for those in their 50s and late 80s.

Young adults may be happier because of the obligation-free days of youth, said Kathryn C. Keller, a licensed clinical social worker.

"They have a future ahead of them and nothing bad has happened," she said.

Upbringing can also play a role in the happiness, said Dr. Lisa Razzano, a professor of psychiatry at the University of Illinois at Chicago.

"They've [parents] become more engaged," Razzano, said. "This creates positive affect, which we associate with happiness."

Even with a recession, young Americans in college can stay on the bright side, said Dr. Michael Bricker, clinical psychologist.

"Those individuals are experiencing the downturn in a different way than those who must work and provide," he said. "There's a little more freedom in youth."

Those assessments are in contrast to how some young adults feel.
"There's a lot of pressure on us," said Gevorg Azizi, 20, a DePaul junior. "Yeah we're happy and we go out, but there's also a lot of pressure, and that can lead to unhappiness and depression."

Paul Evangellu, 20, explained the pressure.

"We're in college right now during some of the worst times right now during this recession," the DePaul sophomore said. "Hopefully by the time we graduate it will be over, but right now, we can't really tell."

One psychologist expressed doubts about the study, which asked people if they had smiled, laughed or had positive feelings the previous day.

"There are two different kinds of smiles," Dr. Jay Einhorn, a clinical psychologist, said. "One that's genuine with involuntary movements, then a conscious smile that means, 'I'm not hostile and I want you to like me.'"

Nonetheless, Einhorn emphasized the importance of mental self-care with regular exercise, deep relaxation and self-observation.

"If we're more aware of ourselves, we have more psychological freedom, which allows for more behavioral choices," he said.

Related Links
Gallup polls

©2001 - 2009 Medill Reports - Chicago, Northwestern University. A publication of the Medill School.

My 2¢ on Healthcare Reform

2009-08-16T10:04:00.003-05:00

My 2 ¢ about health care reform reflects my experience as a healthcare consumer, a healthcare provider, a former administrator of a healthcare facility that both operated on healthcare payments and purchased healthcare for its employees, and as a parent of young adults trying to make their way in the world.

First, there are obvious and glaring problems with the current system. The worst of those is that too many people are uninsured and unable to purchase even a basic package of insurance coverage. Our current system of employer-provided insurance evolved in a time when people worked for one or two employers for their entire careers. It is badly out of adjustment at a time when people change jobs often, have periods of unemployment between jobs, and are often working as independent contractors rather than full-benefit employees. The business model has changed dramatically, but the insurance model hasn't caught up with it.

Next are a set of problems inherent in an industry that is set up entirely as a market: loss of coverage for high-expense illness and treatment, loss of coverage when changing jobs for "pre-existing conditions," refusal to pay because of narrow interpretations of policies, and, often, erroneous nonpayment because of sheer incompetence resulting from poor training and supervision of insurance company employees--which, of course, benefits the companies which don't pay benefits that customers are entitled to. This requires the customers to engage in lengthy and frustrating campaigns to receive benefits which they have paid for and are entitled to; often they just give up.

On the provider side, doctors and other healthcare providers have had to deal with increasing costs for repetitious claims submissions and wasteful, often idiotic, and sometimes downright unethical hoops that they had to jump through in order to receive insurance reimbursement for services they've provided to patients. (This got so bad in my clinical psychology practice that I withdrew from all third party payment several years ago.) With the exception of very brief treatment, the entire inpatient mental health system has been scrapped, except for the very wealthy. Coverage for extended intensive outpatient treatment, while less expensive than inpatient treatment and often preferable, is very rare.

Healthcare is trending toward unsustainable costs at the individual, family, and national levels. For children covered under their parents' insurance, finding an affordable policy that provides adequate coverage is impossible when they become adults, and can't find, or don't want to take, jobs that provide insurance. Meanwhile, healthcare gets more and more expensive, critically cutting into business competitiveness and government solvency at the state and national levels. All these problems are very serious and that is what drives the urgent need to reform the healthcare system

On the other hand, there are genuine reasons to be concerned about reform. The first reason is that whatever form it takes, reform is going to have to vastly expand coverage while managing costs, and that means that there will inevitably be some sort of a two-tier system, consisting of a first tier of basic care that everyone receives, and a second tier for those who can buy supplemental private insurance or pay out of pocket. Many people react to this situation with dismay, insisting that health care should be a completely equal right for all, and that everyone should receive the same level of care. The problem with that wish is that it's an economic non-starter, an example of "the 'perfect' being the enemy of the good." In fact, we already have a multi-tier system, except that the lowest tier is composed of some 50 million people with no coverage at all. Everyone will be better off if everyone is covered with a basic package, and costs for that package are going to have to be carefully managed if the system is to remain solvent.

It would be better if leaders of the national push for healthcare reform could say this forthrightly. Unfortunately, they can't. It would be politically very unpopular, unacceptable to many people, to acknowledge the need for a two-tier system, even if it addresses the worst problems in our current one. The result of reform leaders not being able to acknowledge the necessity for a two-tier system is that the reform leaders become hypocritical in asserting that all these uncovered people can be covered without the system becoming unaffordable if we just apply best practices and eliminate waste. That is bullshit, pure and simple, and anybody with common sense knows it. The reform leaders who know better are dissimulating, the ones who don't are deluding themselves.

How people react to it will depend on whether they are inclined to trust the government or not. Those who are inclined to trust the government will interpret the reform leaders' posturing as politically necessary to get the job of health care reform done. Those who are inclined to distrust the government will interpret it as a snow job in order to extend the power of government at the cost of the freedom of the people. That's a lot of what is happening now in the opposition to healthcare reform. It would be better if the reform leaders could acknowledge the issues. Of course, the genuine concerns of people who don't trust the government are being fanned by the usual parties for the usual reasons.

My own attitude, having been in all these roles with regard to the healthcare system, is that reform is urgent and necessary. And it seems to me that we finally have a climate in which most legislators are willing to say that publicly. However, a serious obstacle to reform is the feeling on the part of many legislators that we really have to take our time and get this right the first time. Simply put, I don't think we can. The systems are too big, the issues are too many and too intertwined, to get it right the first time. So my perspective is that we are just going to have to go ahead and fix what's most broken, understanding that we won't get it all right and we're going to have to keep correcting and adjusting and fine-tuning as we go along. I frankly doubt that the take-it-slow legislators have adult children who are, or will soon be, without health insurance, or family members whose care has exceeded the benefits in their policies, or who have been prevented from receiving necessary mental health or other services because they are excluded from coverage, or who haven't been able to change jobs for fear of being ineligible for insurance because of an illness they needed care for while working on their current job, or who perhaps even were not hired because they or a family member have an illness which would threaten to raise the company's insurance premium.

The bottom line is that the problems in healthcare are too urgent not to go after, even with the understanding that we'll have to adjust as we go. Reform will result in a two-tier system in which everyone has a basic care package and those who can afford to supplement can do so through the insurance marketplace. A marketing consultant might call it "basic care plus," meaning that everyone gets basic care and those who can afford supplemental policies can add a "plus." No, it's not perfect. But in healthcare reform, the way things are right now, the perfect is the enemy of the good.

Two Deaths: Robert McNamara and Michael Jackson

2009-07-12T15:44:00.004-05:00

Robert McNamara died on July 6, and Michael Jackson died on June 25. News of the death of Jackson, the megastar entertainer, has driven news of the death of McNarama, architect of the Vietnam war, to the margin of the news cycle. On George Stephanopoulos’ program this morning, Michael Jackson was discussed at the Round Table (will a group of commentators, on the air), while Robert McNamara got a few pictures, without comment, on the In Memoriam section.

I suppose that the Vietnam war is old news. It may reside in the political and military DNA of the U.S.A., but it’s not a hot item; and not very important to the fans of Jackson, most of whom were too young to have been around during the war. Besides, Vietnam is a war that many in the U.S.A. would rather not remember.

McNamara and Jackson are worthy subjects for reflection: each outstandingly talented and achieving the pinnacle of success in his field--managerial leadership for McNamara, popular entertainment for Jackson--and each the tragic victim of his success.

It seems to me that neither the public effusion of emotion following Jackson’s death, nor the relative silence following McNamara’s, feels right. Both men were brilliant in some ways and tragically flawed in others. McNamara’s life has been looked at in detail, while Jackson’s has yet to be, notwithstanding all the publicity he received. But neither man’s life, to borrow a phrase from a Jackson song, can be understood entirely in “black or white.”

McNamara, the man with the quieter obituary, seems to me to have lived the much more consequential life, and in fact did a lot more damage. He goes to his reward, such as it may be, with the deaths of 58,000 Americans and between 1 and 3 million Vietnamese on his hands; as well as the pain of the physically and psychologically wounded, and their children and theirs, and generations poisoned by the toxic residues of the defoliant Agent Orange, millions of gallons of which were dumped on Vietnam. He spent the rest of his life trying to do good, trying to balance the books. Of course, he felt that he was trying to do good as Secretary of Defense, managing the Vietnam war. His life is a case study in good intentions.

It is certainly a special contribution that he came forward, in a memoir, "In Retrospect: The Tragedy and Lessons of Vietnam," and a documentary film by Errol Morris, “The Fog of War,” to try to present what he had learned from his mistakes in Vietnam. While I agree with those critics of McNamara who feel that he didn’t go deep enough in his public self-reflections, didn’t get down to the core of what he believed about himself that allowed him to do what he did, it’s also true that he didn’t have to come out with a public examination of his decisions at all, especially when he admitted making mistakes of such dreadful consequence. I think everyone should see “The Fog of War.”

There is still not much reliable information about Jackson’s life, notwithstanding all the publicity that he benefited and suffered from. It will emerge over time, I expect, as reporters do the research, talk to people, get the facts, and publish them. The haste with which so many public mourners seem to be trying to build a Jackson legend makes it seem like they are trying to erect a monument over his life which will keep the facts buried beneath it. To the extent that there’s any validity in that impression, I don’t think it will work over the long run. There’s too much curiosity about this King of Pop, and too much market value in his biography, so I expect that the facts will come out.

I asked a client, a middle aged woman who is often wise notwithstanding a bunch of learning disabilities, what she thought about Jackson. “I really liked him when he was a kid and young man,” she said, “but then he got really weird.”

Unlike McNamara, Jackson never did any public self-examination. Perhaps he might have if he’d lived. There’s no evidence of real self-reflection in his referrals to suffering the intrusions of his life; that of abuse by his father, of prying from media, and of repeated legal accusations. While the cause of his death remains to be announced--it was not included on his death certificate--speculation is that some lethal cocktail of drugs, prescription and perhaps illegal, was involved.

Jackson’s tragic personal decline after achieving the pinnacle of pop fame recalls that of the earlier King of Pop, Elvis Presley; also dead in middle age, reportedly of a lethal cocktail of prescription drugs, after his personal life had spun out of control following his unprecedented success as an entertainer. Jackson had reportedly set himself to become the King of Pop. His marriage to Presley’s daughter may have been more about merging with the legend of the King than love; although they might have found union in their experiences of the spectral ups and downs of the limelight.

Jackson seems to have lived his way into the roles that he aspired to, even changing himself physically with plastic surgery. There can be a particular genius in that--Bob Dylan’s career shows a similar pattern of the artist vanishing into different roles. Perhaps it was a combination of this type of genius and a tragic lack of self-reflection or sense of boundaries that made Jackson merge with others through his physical appearance, rather than just through his personality and his art.

I wonder what kind of personal integrity, what kind of anchoring of the self, is necessary for performers like Presley and Jackson to be able to manage so much fame and wealth without being damaged by it. The Beatles famously decided to stop touring because they couldn't hear themselves play over their screaming fans, and however much their heads may have been turned by their fame and wealth, the impression is that at some point, after all the hard work and insane success, each one got his feet more or less on the ground and put his life ahead of the pursuit of more and more success. But they were a group, not an individual.

I wonder whether an individual performer who did have sufficient personal integrity and self-anchoring would even go after so much fame in the first place; although, if that's where your whole life had been pointing you, how could you not? I wonder if Jackson, so talented and driven by his father’s ambition before his own took over, ever had a chance to go through any other door than that of pop fame. I wonder if there was ever a time when his self had a chance to develop for its own sake. For McNamara, it seems to have been power, not fame, that drew him; power and a desire to serve that was warped by a self in need of serious work before he could manage the power he was reaching for.

There’s a certain bleak amusement in imagining the souls of Michael Jackson and Robert McNamara, having died within a couple of weeks of each other, and so different from each other, together in a waiting room in the afterlife (heaven or hell, you choose), awaiting their judgment, having a conversation about the successes and failures, as they would like to see them, of their lives. Perhaps, as they listen and respond to each other, the super-dynamic performer who touched so many people with his art and hurt some with his life, and the super-analytical director whose power hurt so many people and who then tried to help on a commensurate scale, might begin to find some of the the perspective that was so lacking in their lives. But someone else would still have to teach them about self-reflection, about insight, for neither could teach the other about that.

A Caveat on Tests and Scores

2009-06-07T00:07:00.002-05:00

For many years I've included a Caveat on Tests and Scores in my psychological evaluation reports, before I report the test results. Here's the current version, taken from a report in process.

Before the Test Results: A Caveat About Tests and Scores

Psychological tests are useful tools as long as we remember their limitations. They are sampling procedures whose goal is to elicit examples of behavior which represent how the person being tested functions on those abilities which the tests seek to measure. The people who make the tests try to select items which are representative of those abilities, and to name those abilities accurately. Tests are interpreted by comparing individual results to how a broad sample of comparable people have responded to the same sets of items. There are thus several steps in the process at which test results can be misleading: test items might not be representative of the abilities being assessed, the abilities being assessed might not be accurately named, and the normative group on which the test was statistically standardized might not be representative of the population to which the individual’s results are being compared. In simple language, tests might be more or less well constructed, accurately named and meaningfully interpreted. All tests are approximate and all are works in progress. Each has its own history of evolution through theory and practice, and will continue to be modified and superseded.

“Intelligence tests,” for example, would be more realistically named, “Samples of Some Aspects of Intelligence.” Measuring human ability is not like measuring a plank of wood, even though we call them both “measurement” and express both as numbers. No one has ever seen “intelligence,” or the difference between one point and another on an I.Q. scale; intelligence is always inferred from samples of observed behavior.

Unlike the measurement of a plank of wood, the scores of psychological and psychoeducational tests nearly always show some variability. The scores of a person who takes the same test at different times, or equivalent forms of the same test, will probably not be quite the same. Similarly, a person who takes two different tests which are supposed to measure the same thing will nearly always receive somewhat different scores.

Test results that are presented as approximate grade or age levels can be affected by many factors, such as the availability of the child to instruction at the time the subject or skill being measured was learned, and the person’s functional abilities, then and now, in attention, receptive language, and working memory. Test results also may not reflect the potential benefit of repetition, study, or remediation, so they may not reflect overall ability. Considerable controversy exists about whether it’s even possible to have nationally accepted age and grade equivalent standards. In addition, a nationally balanced normative group, if such could ever be constituted, may not be representative of the level of academic achievement expected in, or typical of, a particular locality, so students might score higher or lower depending on the particular education they’d received.

Thus, it is usually the overall pattern of scores which are important, how they relate to one another and what they mean about how the person’s performance relates to that of his or her peers, and not individual scores.

It is also important to remember that scores might not always mean what we assume they do. Careful attention has to be given to the reasons why a child makes errors on some items. For example, a child may make an error on an item involving phonological processing because of a true phonemic processing deficit, because of a syntactic mistake rather than a phonemic mistake per se, because of lack of comprehension of what the item was asking of him or her, because of a lapse of attention, or because of some combination of factors.

Furthermore, the nature of intelligence and personality are still being researched, reconstrued, and debated, and the tests which we use to assess them are, of necessity, imperfect. Abilities such as practical intelligence, social intelligence, problem solving, creativity, and what might be called “self intelligence,” meaning ability to manage one’s emotions and behavior and improve through reflection on one’s experiences, are largely ignored by existing tests, but are vitally important for success in life. Wisdom, a vitally important characteristic, is virtually unmeasurable by any extant test.

In summary, psychological tests are useful to help develop an impression of how a particular person is functioning in some ways at a particular time in his or her life, as long as we keep their limitations firmly in mind.

My Friend Talks of Suicide

2009-05-03T15:48:00.002-05:00

“Laura” writes:

Dear Dr. Einhorn:

I am a 13 year old girl with a friend that talks of suicide. She
refuses to tell her parents, and I live too far away from her to talk
to them. I know she needs help, but she will not talk to her parents.
Will you please see if there is anything you can do?
I realize you are very busy, but if there's anything at all, please
respond to this email.
Thank you so very much,
Laura D.

Dr. Einhorn replied:

Well, you could call her parents, Laura. Or you could talk to your parents and ask one of them to call her parents.

Laura replied:

Yes, however they don’t believe she is serious, and my parents have never met her before, as I met her at summer camp.

Dr. Einhorn discusses:

Laura’s concern for her friend and feeling of helplessness come through clearly in her question, and this is often the position that friends, family, and even professionals are in when caring for adolescents, or adults, who are, to any degree, suicidal. There is lots of help that can be brought to the suicidal person--including therapy, medication, outpatient and inpatient programs, and support from friends and family--but often the person herself, or, as Laura indicates is the case here, her family, don’t take the risk seriously enough. And it is a serious risk: suicide is rated as the third largest cause of death for adolescents.

Of course, we can only talk in generalities here, because we have no information about the people involved. We don’t know, for example, whether Laura’s friend is talking about suicide as a way of expressing her emotional overload, maybe blowing off steam, without really intending to do anything (in which case she still seems to be in need of help), or whether she is seriously at risk for self-harm. So, the question becomes, not what Laura can do for her specific friend, but what someone in Laura’s position might consider doing to follow through on her concern.

Laura feels like there’s nothing that she can do and she’d like me to step in and do something here. But this is a situation in which I have no “standing,” to borrow a legal term; I don’t know any of the people involved, and they don’t know me. Laura is the person who knows the girl who talks of suicide, so, like it or not, she is the person faced with the choice about what to do. She’s reached out to me, hoping to pass this “ball” to someone who can carry it better than she can, but the truth is that no one can carry it better than she can at the moment. That’s one of the problems and challenges of knowing someone who is suicidal. If you do something to try to help them, your attempt to help might be rejected as inappropriate, interfering, or silly. If you don’t, and the person does make a suicidal attempt, or, actually commits suicide, you might regret not at least having spoken up in some way to try to help. There is no easy way to deal with a situation like this.

I can think of a couple of options that Laura might consider, and readers might think of others. She could advise her friend to talk to a school counselor, who would then be in a position to evaluate the seriousness of her talk and call her parents to advise them to get treatment for their daughter. This might be the easiest path for all concerned if the girl would talk to the counselor. If she won’t, and Laura is still concerned, she can still talk to her parents and ask them to call the girl’s parents, even though they don’t know each other, to express parent-to-parent concern. That might help the friend's parents take a second look at their daughter's state of mind and risk for self-harm. Sometimes students will anonymously advise counselors in schools that a fellow student is making suicidal statements, but I don’t know that Laura would even know what school to send an anonymous letter to. And of course that could always boomerang on her, if it prompts intervention that the girl or her parents resent.

One issue that this raises is what the responsibilities and limits of friendship are. That’s a question that each one of us has to answer for ourselves, in different relationships, sometimes over and over again. It’s a real challenge, and no fun at all, to have to deal with this question in this relationship at this time, but that is the place where Laura’s life has taken her, even at her young age.

It’s a shame that adolescent suicide is such a problem in our society, and it’s worth our time to ask why that should be; what pressures are adolescents responding to? Answering that is beyond the scope of this Q and A, but I’ll appreciate any thoughts that readers care to contribute.

As for you, Laura, you are to be commended for your caring in raising this issue about your friend and reaching out for help, and supported as you seek within yourself for the wisdom to find, and the courage to do, the right thing; whatever, in this situation, that may be.

2009-04-19T13:00:00.002-05:00

I've just read "The Writing On My Forehead," a novel by Nafisa Haji, and recommend it. Written from the point of view of a feisty and questioning first generation American daughter of Indian-Pakistani Muslim parents, it covers a lot of ground about culture, family, morals, choices, and traditions, within the context of a very readable story. I was interested in the characters and, at one or two points, it bought a tear to my eyes.

When a Privacy Guarantee Means You Give Yours Up

2009-03-07T22:28:00.005-06:00

A colleague, on a professional listserve, reports that she was contacted by a hospital's development department after her daughter had been treated there. "Hello Barbara," said the development caller (not real names). This is Jonathan calling from ____ Hospital. How are you tonight? I'm calling because your 12 year old daughter, Laurie, was a patient here. Is that correct?" Jonathan went on to ask Barbara for a donation to the hospital.

Barbara was appalled, and asked her colleagues whether this wasn't a violation of privacy laws. Another colleague did some research and found this on the hospital's website: "In the continuing effort to enhance _____ Hospital's mission of service, periodic communications and invitations to consider philanthropic support may be sent to patient families..." This language must have been included in fine print on one of the required documents, probably the one that guarantees patient privacy.

So a guarantee of patient privacy is actually a violation of it. You think you're signing a privacy guarantee when you are actually giving up your privacy.

The linguist Geoff Nunberg, commenting on Terri Gross' "Fresh Air" program on NPR, highlighted a similar deceptive use of language when he said that most "guarantees" were actually "limitations of liability."

This kind of misuse of language is actually a violation of trust. And right now I am seeing violations of trust as being at the heart of many psychological problems in human relationships in our society.

Although the legal structure, pace of life, social decentralization, constant persuasion pressure from multiple sources, and technological sophistication of our culture bring it to a whole new level, the basic problem of violation of privacy is a very old one. Idries Shah, in his "Caravan of Dreams," quotes a tradition of the Prophet Mohammed about this: "Whoever invades people's privacy corrupts them."

There's probably no more important psychological issue today than the reestablishment of public trust in institutions, and for that, institutions are going to have to become more trustworthy. One of the chief changes that will require is the recognition of the importance of institutional honor in the relationships that institutions have with people at all levels; consumers, investors, workers, regulators.

We have no trust in our institutions because they have no honor. The hospital's treatment of Barbara is, in a word, dishonorable; not in that it asks patients for donations, but in that it slips the permission to do so into a document that purports to be a guarantee of their privacy rights.

Clean Slate

2009-02-14T08:34:00.002-06:00

We never start with a clean slate, because we always have a history that is embedded in the neurons of our brains and bodies. We always start with a clean slate, because awareness is always now.

Obstruction

2009-02-14T08:30:00.004-06:00

Hanging my bathrobe in the closet, I felt a tug as the belt came out of the loops and fell onto the floor. Looking to see what the belt had gotten snagged on, I discovered that I was, in fact, standing on one end of it. And I wondered how many times we try to accomplish something that doesn't work out--in this case, hanging up my robe--and think that something in the environment is obstructing our success--whatever the belt had become snagged upon--when in fact the obstruction comes from ourselves. We are, so to speak, "standing on one end of the belt while trying to hang up the robe." Of course, it's because we haven't noticed in the first place that one end is longer than the other, and dragging on the ground...

Self-Respect and Self-Esteem

2009-02-14T08:28:00.001-06:00

Some people equate self-respect with self-esteem, which is usually understood as having a good opinion of oneself. But I would say that self-respect is saying what needs to be said and doing what needs to be done.

Rear View Mirror

2008-12-27T14:31:00.012-06:00

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

2008-11-30T22:23:00.006-06:00

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

2008-11-09T00:21:00.005-06:00

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

2008-10-19T20:09:00.004-05:00

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

2008-10-06T23:29:00.002-05:00

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

2008-09-30T00:11:00.004-05:00

"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"

2008-09-21T12:02:00.002-05:00

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

2008-09-16T00:31:00.000-05:00

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.