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2006 January/February (13)

Thursday, 24 September 2009 11:49

Screening Room

Written by Ari Rosenberg

SCREENING ROOM
BY FRANK PITTMAN

Voices of Truth
What's the difference between honesty and spin?

When I was growing up, before TV came to our neck of the Alabama swamps, we had to imagine what the real world over the next hill might look like. We'd sit around the radio, envisioning the things we couldn't see—wars, baseball games, Burns and Allen, or Baby Snooks.

When TV finally came, in the early '50s, the world it brought into our living rooms was black and white, and dumbed way down. It hardly mattered—we'd watch anything, even test patterns, for hours. Anything was more interesting than Alabama in the '50s. Broadcasting only a few hours a day, TV gave us Hopalong Cassidy and Captain Video, relentless baseball games and wrestling matches, Lucy and Uncle Milty. And, of course, the news. TV news no longer came from disembodied voices, but from talking heads. Newsmen now had faces, and, as eyewitnesses, we could now determine who had an honest face and who didn't.

The most honest of the talking heads seemed to be the revered war correspondent Edward R. Murrow. He had a deeply trenched face and a nicotine-stained voice that seemed to arise from the depths of the world's wisdom. He sat calmly and spoke authoritarian truths through the haze.

The moment when TV ceased to be a silly toy and became the news itself was in 1954, when the audience watching at home became referees in a great debate over what was true, what was a lie, and whose view of the world we could trust. At that time, as the Cold War heated up, Joe McCarthy, a paranoid or merely unscrupulously ambitious senator, tried to stir the populace into a froth of fear over an imminent takeover led by hundreds of communist spies, whose names he claimed were inscribed on a piece of paper he'd wave at the TV cameras. Half of us were quaking in our boots over the imagined commies; the other half were terrified of the all-too-real McCarthy, who had the scary habit of declaring that anyone who disagreed with his hysterical demagoguery was, perforce, a communist sympathizer.

Murrow and his cohorts at CBS refused to bow to McCarthy. Murrow invited him to debate on TV and exposed him as a rabble-rousing showboat who, as the highly honorable Joseph Welch, special counsel for the Army, put it, had "no decency." With Murrow's inspiration, the Senate held hearings on McCarthy's antics. They censured the man and drove him into shamed retreat.

Now the actor George Clooney has put together a reenactment of the public clash between Murrow and the rabid senator. It's called Good Night and Good Luck. The hyperrealistic film is set in CBS television headquarters and studios, and shot in high-contrast black and white through air filled with cigarette smoke. It intercuts archival footage of McCarthy, sweating, raving, and ranting, with David Straithairn's Murrow, smoking calmly and cutting through the tirade with sepulchral voice and deep-set eyes.

Straithairn looks like a cross between Jason Robards and Abraham Lincoln, and sounds like the voice of God. Frank Langella plays William Paley, the founder and head of CBS, who'll have to bear the financial consequences if Murrow goes too far in offending McCarthy's loyal paranoids. He alternately tries to shield and rein in his iron-willed star. On the soundtrack, amidst the tension of the approaching duel between Murrow and McCarthy, the creamy-voiced Dianne Reeves sings jazz.

Clooney's film convincingly captures the look, sound, and feel of the early days of television, when this compelling and intrusive device brought the world into our livings rooms, dominating our picture of reality. It turned out that those who assaulted us, like McCarthy, didn't go over well on the intimate new medium. We preferred cool voices of reason, like Murrow, who dared to defend polite debate and proclaimed that "Dissension is not disloyalty."

Good Night isn't a biography of Murrow, but a reminder of the power of the people who come into our homes and tell us what's going on in the world out there. On See It Now, Murrow had gone to every corner of earth to report the news on location and firsthand. By the time he took on powerful politicians, we trusted him, maybe because he'd convinced us of his basic decency. Murrow wasn't neutral toward McCarthy. And he didn't attempt to silence him, but to prevent him from silencing everyone else. Murrow would fight with Paley as much as with McCarthy, to make sure no voice was silenced—-including, of course, his own. Ever since, our politics has been shaped by the powerful medium that Murrow mastered early on, as we continue to search for voices and faces who'll tell us the truth.

Those of us who learned to trust black and white may distrust color, or the tinge people put on the things they tell us and show us. The writer in the '50s who insisted most firmly he was telling the truth was Truman Capote, a self-styled genius and celebrity-seeking writer, who capitalized on the weirdness of his elfin body, the mousy squeakiness of his prepubertal voice, and the infantile beauty of his face. He wrote touching, ersatz memories of his fantasized childhood in Monroeville, Alabama, oiled his way into high society in New York, and became a famously catty purveyor of gossip among the Beautiful People. One of his most revealing creation was Holly Golightly in Breakfast at Tiffany's.

In 1959, Capote got wind of a murder in Kansas and set out to investigate it as the basis of a "nonfiction novel." He enlisted his childhood buddy from Monroeville, author Harper Lee, whose To Kill a Mockingbird won both the Pulitzer Prize and the hearts of the world around that time. The Alabamians set out for Kansas even before the murderers had been found. There Capote befriended the pair of ex-cons who'd killed a family while burglarizing their house. From them, he got detailed descriptions of the crime, but couldn't finish his book until he could write about the story's dramatic ending—the killers' execution by hanging, which was delayed by multiple appeals.

In 1965, Capote finally came out with the semi-journalistic, semi-novelistic In Cold Blood, which doesn't just focus on the murder of the farm family in Kansas, but examines the soul of one of the psychopathic murderers, Perry Smith, a stunted, part-Cherokee ex-con who'd been brutalized by his father, jerked out of school in the third grade, and turned loose on the world as a semiliterate, intellectually ambitious drifter.

In Cold Blood was an astounding success, and quickly, in the hands of Richard Brooks, became a great psychonoirish crime film. It tells the story of the murders, the town, and the murderers, but it leaves Capote out. Robert Blake played the perennial outsider Perry, who didn't understand that his partner, the charming chiseler Dick Hickock, talked tough about leaving no witnesses to a burglary, but that it was just talk.

The new film, Capote, written by Dan Futterman and directed by Bennett Miller, tells the story of the Kansas murderers from Capote's (tinted) perspective. The film is fittingly hyperrealistic. The photography, in Manitoba, which outflats Kansas, is grim and stark. The townspeople seem far more interested in the visiting celebrities than in murderers.

Capote is brilliantly played by Philip Seymour Hoffman, an actor who can transcend his physical ordinariness to do anything, from the suspicious rich kid in The Talented Mr. Ripley to the transsexual speech therapist in Flawless. Here he doesn't just capture Capote's fey gestures, he makes his body tiny, his face cherubic, his voice a chirpily drawling falsetto. He's indeed a mockingbird.

Catherine Keener, most notable as the depressive sexpot in Being John Malkovich, is the sparrowish Harper Lee, selfless, loyal, and calmly critical of Truman's intrusive narcissism. She's the earthling that keeps this space alien from being too weird for the plain folk of Kansas.

While Truman falls in love with his alterego Perry Smith, Lee notes his impatience with the appeal process, which keeps the murderers from hanging and means he can't finish his book and win the world's acclaim. She sees that Truman's enfant terrible posture disguises a murderous soul. When Lee isn't there, like Jiminy Cricket on Truman's shoulder, his coterie of cheerleaders and the glitterati of New York provoke and release his sadistic bitchiness.

Capote is the flip side of In Cold Blood. In it, we see the degree to which Capote lied and seduced the killers he "befriended." By the end, Truman's boyish innocence has faded, and we see him as a treacherously ambitious man, while we see Perry as an innocent, honest (albeit murderous) child. The film captures his tragic violence with an unforgettable line: "I thought Mr. Clutter was a very nice man. I thought that right up until I cut his throat." The boyish Perry's main concern, as he goes to the gallows isn't his life or the lives of the Clutters, but embarrassment over losing bowel control at the point of death.

Capote became famous for telling the "nonfictional" truth, about his childhood traumas, about the murders in Kansas, and about the secrets of his "friends." He always gave us facts, if not the facts, at least some facts, while managing to leave out his own influence on the reality he was shaping. The film Capote puts him back in and creates a far more compelling story.

The munchkinesque twitter of Capote's voice got him attention and made him unforgettable, but cost him friends every time he opened his mouth and barfed gossip. Maybe Capote's self-destruction is rooted in his furious need to say or be anything that would enable him always to stand apart, while still being the center of attention. His life may have all been fiction (some say even his voice was put on). But this great new movie is about more than this one insecure man. It probes deeply into the nature of truth, revealing how truth is always tinted, always subjective. At the end, we're left with only one certainty: the pretense of total honesty and nonfictional objectivity is always a lie.

Frank Pittman, M.D., is a contributing editor to the Psychotherapy Networker and is in private practice. Contact: fsp3md@aol.com. Letters to the Editor about this department can be e-mailed to letters@psychnetworker.org.

Thursday, 24 September 2009 11:48

From Research To Practice

Written by Ari Rosenberg

FROM RESEARCH TO PRACTICE
BY JAY LEBOW

The Verdict Is Clear
ESTs have an incontestable track record with anxiety

Every self-respecting therapist knows that the value of empirically supported therapies is a hotly debated subject these days. Critics repeatedly point out that, outside of therapy outcome studies, clients rarely present themselves with the sort of uncomplicated, pure, DSM-delineated diagnosis around which empirically validated treatments are structured and show such high success rates. To many therapists, manualized treatments feel rigid, agenda driven, and unequal to the messy reality they see in their offices every day. Even therapists who work on manual-driven projects have been known to report, off the record, that after the first few sessions, their work becomes increasingly variable and idiosyncratic—just like the real people they're treating.

Nonetheless, it can't be denied that, with certain problems, some empirically supported treatments (ESTs) have been proven highly effective. Probably the best example is anxiety treatment. The ESTs developed to treat anxiety have consistently demonstrated better results than medications, without the side effects and treatment dropout that often accompany meds. They've proven to be highly effective for the following problems:

Panic Disorder. Panic disorder strikes between three and six million Americans, and is twice as common in women as men. People diagnosed with it have recurrent attacks that include a variety of unpleasant symptoms—palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, choking feelings, chest pain or discomfort, lightheaded or fainting sensations, and fears of losing control. They also typically have pervasive fears of future attacks. Often, the fear of the fear is worse than the attacks themselves, so that people with panic disorder are endlessly worried about and preoccupied with the possibility of having an attack.

Although traditional talk therapies don't appear to have much impact on panic, there are several variants of cognitive-behavioral therapy that have been demonstrated to ameliorate this disorder. Most of these treatments share several interventions, including increasing clients' exposure to situations that lead to panic, helping them more effectively manage thoughts and feelings associated with panic, and teaching them how to engage in problem-solving self-talk.

Perhaps the most widely disseminated of the treatments for panic disorder is Panic Control Treatment (PCT), developed by David Barlow of Boston University and Michele Craske of UCLA. In PCT, clients are encouraged to experience the sensations of panic, so that they can master them. For example, Shannon, whose disabling panic in the workplace has left her reluctant to seek work, is encouraged in session to imagine being in an anxiety-laden work situation and to breathe in the same way that she does when she has a panic attack. By visiting her worst-case scenario, she's invited to master her fear.

PCT includes cognitive examination of the distortions typical in panic, as well as the automatic thoughts that go along with it—like overestimating the level of real threat during a panic attack. Thus, Shannon's dominant thought that her panic will lead to humiliation and rejection by others is elicited and examined in the light of her experience. This balanced examination of the evidence points to the fact that her panic is much more of a problem for her than for others. She's then encouraged to remind herself of this clear conclusion, and to engage in a rational examination of similar beliefs as they come into consciousness and influence her behavior. This therapy works with breathing to help people acquire the feeling that they can cope with the signs of impending panic and, eventually, acquire the ability to calm themselves down.

PCT has been frequently studied with impressive results. For example, in a large, rigorous, multisite study of this treatment conducted by David Barlow, Jack Gorman, and colleagues, clients were randomly assigned to groups receiving PCT, placebo, PCT plus medication, or PCT plus placebo treatments. The treatment period was three months. Although all the treatments produced more change than the placebo alone, several findings suggested the superiority of PCT. Adding medications to PCT didn't yield better outcomes than using PCT alone. And six months after treatment, there was greater relapse for those receiving medication alone or PCT plus medication than for those receiving PCT alone

Cognitive-behavioral therapy (CBT) for anxiety, following the protocol developed by Aaron Beck and colleagues and based on correcting cognitive distortions in self-talk, has amassed a similarly impressive record of outcomes when compared to medication in studies of treatments for panic. In fact, the evidence for the effectiveness of PCT and other cognitive-behavioral therapies for panic disorder vastly outweighs evidence for other approaches. As an example, a recent study by Michael Addis of Clark University and his colleagues found that 43 percent of those getting cognitive therapy in a managed care setting achieved clinically significant improvement, compared to only 19 percent of those getting other treatments in the same setting.

Just as CBT treatments are coming to be regarded as the treatments of choice for panic disorder, related treatments are emerging as especially potent in treating other anxiety disorders. Because conditioning plays such an important role in causing these difficulties, CBT seems to work by teaching clients new skills that override the earlier conditioned patterns.

Obssessive-Compulsive Disorder (OCD). This disorder includes recurrent obsessions and compulsions that interfere considerably with daily functioning. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and cause marked distress. Compulsions are repetitive behaviors designed to reduce anxiety that become problems in themselves. Examples include people who feel compelled to check and recheck their clothing, or the stove to make sure it's turned off, before leaving the house, making them chronically late. CBT treatments for these disorders, including those developed by Edna Foa of the University of Pennsylvania, typically feature exposure to the source of anxiety, coupled with disruption of the obsessive or compulsive behavior and the introduction of some other alternative behavior.

For example, Maurice, who engages in endless rituals of washing and straightening his clothes, is prevented from doing these behaviors. Instead, when thinking about going to school, a subject about which he has a good deal of anxiety, he's taught to fold his hands. Self-talk is also a frequent part of these treatments. So Maurice is helped to examine his belief about what'll happen if he doesn't engage in his compulsive washing. He and his therapist conduct a balanced examination of the chances that germs will harm him if he doesn't do his ritual washing is correct. As with panic disorder, he's taught a process of rationally examining his beliefs to be used when he encounters variants of these beliefs.

Here again, the CBT treatments are impressively effective. For example, a multisite study conducted by Foa found that both the exposure program and medication significantly reduced the symptoms of OCD, but that the exposure treatment was more effective than medication alone. The addition of the medication to the exposure treatment didn't seem to improve outcomes.

Simple phobia. Exposure-based treatments clearly are the treatment of choice for simple phobias. In these treatments, clients are gradually exposed to the feared situation, and given an opportunity to master their fear step by step. Generally, lots of exposure in short duration produces the best results.

New technologies that seem to improve upon the impressive results from these treatments are evolving. One technology is the virtual-reality simulator, which provides vivid exposure to feared situations without having to go out of the therapist's office. For example, Mike, who's afraid of crossing bridges, experiences in virtual reality the sights and sounds of this feared activity. Recent research demonstrates that virtual-reality procedures are especially effective as exposure-based treatments.

Other research has begun to look at the use of cognition-enhancing medications in these treatments. Cognitive enhancers aren't like traditional psychopharmacological medications. These medications, such as D-Cycloserine, increase the ability to learn without affecting feelings directly. Experiments in animals and humans have shown that these drugs lead to better, classically conditioned learning (like that experienced by Pavlov's dogs), which are at the root of behavioral treatments for phobia. A recent study by Kerry Ressler of Emery University utilizing D-Cycloserine showed that using this drug in treatment was more effective in conditioning people to be less afraid of heights than was traditional behavior therapy conducted without the drug.

It's essential here to grasp the role of these medications. These are medications that help clients learn, not medications that reduce anxiety directly. It continues to be a well-established finding that simple phobias typically don't respond well to medications that reduce anxiety, because clients develop less confidence in their ability to master a situation when that mastery is achieved while taking meds. With anxiety-reducing medications, clients usually attribute the lessening of symptoms to the medication and, therefore, fail to learn new coping behaviors. In contrast, these new cognition-enhancing medications seem to improve clients' ability to recondition themselves.

Generalized Anxiety Disorder (GAD). Individuals with GAD worry pervasively much of the time. The tendency to worry is the meat and potatoes of many psychotherapy practices, encountered far more often by more therapists than the relatively rare OCD and Panic Disorder. What probably isn't well-known by many therapists, however, is that CBT treatments have been shown to be highly effective with GAD. In one study, conducted by Thomas Borkovec at Pennsylvania State University, 60 percent of the clients engaging in a treatment were able to attain a level of functioning of anxiety and worry comparable to that of the general population. The treatment used in the study included an array of CBT techniques aimed at the rigid behavior and thoughts typical of those with GAD, including active self-monitoring to understand the anxiety triggers, specific training and practice in such relaxation techniques as progressive muscle relaxation and diaphragmatic breathing, "self-control desensitization" in which clients imagine their worries while practicing relaxation, and having designated worry periods to establish a sense of control over this experience.

A recent metanalytic review by Kristin Mitte of the University of Jena in Germany found that across 65 studies, CBT for GAD worked as well as medication, but without either the side effects or treatment dropout. The dropout rate for medications, Mitte pointed out, was 25 percent, compared to 9 percent for CBT. She found that studies that directly compared the two treatments should CBT to be superior.

So what are the implications from this research for us as clinicians? For anxiety disorders, it appears clear that the variants of CBT described above are the treatments of choice at this time. Nevertheless, these methods don't work for everyone, nor do they produce change in every aspect of a person's life—they aren't all-purpose therapy. But when clients specifically want relief from the symptoms of anxiety, these are the treatments they should get.

This means that, as responsible therapists, we need to know how to practice these techniques or be prepared to refer these clients to therapists who do. However, this doesn't mean that clients with anxiety problems should see only CBT therapists. At the Family Institute at Northwestern, where I practice, clients who are receiving more traditional therapies focused on broader life issues are often referred to an Anxiety Clinic for CBT, when they need help with their anxiety symptoms. In short, CBT isn't necessarily the only therapy people suffering from anxiety disorders need, but it's hard to argue that their anxiety treatment can appropriately exclude evidence-based CBT interventions.

Resources:

Barlow, David H. Anxiety and Its Disorders. New York: Guilford Press, 2002.

Mitte, Kristin. "Meta-Analysis of Cognitive-Behavioral Treatments for Generalized Anxiety Disorder: A Comparison With Pharmacotherapy. Psychological Bulletin 131, no. 5 (September 2005): 785-95.

Nathan, Peter, and Jack Forman. A Guide to Treatments that Work. New York: Oxford University Press, 2005.

Jay Lebow, Ph.D., is a contributing editor to the Psychotherapy Networker, senior therapist and research consultant at the Family Institute at Northwestern, and Clinical Professor at Northwestern University. Contact: j-lebow@northwestern.edu.Letters to Editor about this department may be e-mailed to letters@psychnetworker.org.

Thursday, 24 September 2009 11:47

Networker News

Written by Ari Rosenberg

Networker News
BY ROB WATERS

Children in Crisis?
Concerns about the growing popularity of the bipolar diagnosis

Ten years ago, bipolar disorder was considered a disabling adult mental illness that was almost never described in children. Today child psychiatrists are diagnosing it in a growing number of children and adolescents, fueling a surge in the use of antipsychotic medications among the young. This has sparked a backlash from critics who see the rise of "juvenile bipolar disorder" as the latest fad sweeping the psychiatry field.

While the exact number of children diagnosed with the disorder is unknown, there's little doubt that it's risen dramatically. The Child and Adolescent Bipolar Foundation, a parent-led advocacy group, estimates that at least 750,000 American children and adolescents suffer from the disorder, most of them undiagnosed and untreated.

Data provided to the Networker by NDC Health Corp, an Atlanta-based firm that tracks trends in the use of prescribed medications, shows that the number of antipsychotic drugs prescribed to children and teenagers grew by 50 percent—from 250,000 to 375,000 prescriptions—between January 2002 and June 2005. While antipsychotics are prescribed to children for a variety of reasons, the most common, experts say, is to treat bipolar disorder.

Bipolar disorder was first flagged as a pediatric illness in the mid-1990s, when researchers led by Joseph Biederman of Harvard and Barbara Geller of Washington University in St. Louis published papers describing "mania-like symptoms" in young patients, many of whom were also diagnosed with attention deficit/hyperactivity disorder (AD/HD). Biederman and Geller contended that clinicians were failing to diagnose bipolar disorder in children, partly because the symptoms resemble AD/HD and partly because the disorder looks so different in children than in adults.

In the classic, adult version of the disease, people stay mired for weeks or months in a deep depression and then, almost overnight, fly into a manic phase, in which they're intensely creative, need little sleep, and exercise little control over their appetites for sex, alcohol, drugs, or gambling. With children, Biederman and Geller say, the shifts between depression and mania happen much more quickly—in days or even hours. The researchers term this "ultra-rapid cycling."

Critics scoff at this loosening of the criteria and argue that kids are being pathologized for normal behavior. "They're making a diagnosis of bipolar because a child has mood switches," say Dominic Riccio, a New York City psychologist and family therapist. "If a child goes from happy to sad and has impulsive outbursts, it's characterized as bipolar. But children have mood swings. To characterize this as mental illness is a serious flaw in scientific thinking."

Biederman and his colleagues at Harvard have redefined the disorder in another way, too. Bipolar kids, they say, are perpetually pissed off, slipping easily into explosive rages. These aren't just tantrums. Janet Wozniak, a Biederman associate and director of the pediatric bipolar clinic at Massachusetts General Hospital, describes such an episode as "an outburst with kicking, hitting, biting, and spitting that goes on for 30 or 60 minutes." Geller and her allies disagree with Biederman, however, contending that the use of irritability as the key sign of bipolar disorder in children stretches the criteria.

The debate over bipolar disorder's validity as a childhood diagnosis might have remained an obscure academic issue were it not for psychiatrist Demitri Papolos and his wife Janice, a journalist. Their 1999 book, The Bipolar Child, described the disorder as a "neglected public health problem," and put juvenile bipolar disorder on the map.

Spurred by the discussion of the Papoloses' book on morning talk shows, parents of children diagnosed with bipolar disorder created the Child and Adolescent Bipolar Foundation, with a large, active website and funding from pharmaceutical companies. Soon parents across the country began wondering whether their own children might have the disorder, and asking their doctors and therapists.

One such clinician was psychiatrist Jennifer Harris, who, in 2002, was completing a fellowship at the adolescent unit of Cambridge Hospital in Massachusetts. "We saw a huge number of kids coming in with that diagnosis," says Harris. "A lot of them turned out not to have it when you did a thorough assessment."

Harris's explanation for the increase of the bipolar diagnosis among children is that many clinicians find it easier to tell parents their child has a brain-based disorder than to suggest changes in their parenting. "The enormity of the problems many children face makes the simplicity of a biological explanation tremendously appealing," she says. "It allows us to feel we're doing something so that we can avoid feeling helpless with our most difficult patients."

Harris recently began working with a 10-year-old boy who was diagnosed with bipolar by another clinician and put on Neurontin, a mood stabilizer, and Zoloft, an antidepressant. When she probed deeper, she learned that his mother had metastatic cancer. She also found out that that child had a learning disability that made it hard for him to read social cues and, she believes, led him to erupt angrily when he felt someone was slighting him. In treating this boy, Harris did the kind of work few psychiatrists do these days: she met with his family and his teachers, worked with his counselor, and got him in a social-skills group. He's now off medications, and his behavior and moods have greatly improved.

Elizabeth Root, a social worker at a community mental health clinic in Cortland, a small town in upstate New York, has also seen a huge increase in children diagnosed with bipolar and taking medication cocktails. All of them, she says, have something in common: significant stress in their homes. "There are so many psychosocial pressures on parents and children today," she says, including divorce, family violence, and parents who work long hours with little time for shared meals or conversation. Food sensitivities and air pollution can also affect behavior, she feels. Also many children said to have bipolar disorder have previously been diagnosed with AD/HD, depression, or anxiety and put on stimulants, which are known to cause anxiety, or antidepressants, which can trigger edgy restlessness and manic behavior.

Instead of prescribing medications for seemingly out-of-control youngsters, Root says she works hard to learn about the stresses and strengths in the lives of children and their families, and to get family members to come in for therapy sessions. Mostly, she tries to get parents to use the Nurtured Heart approach designed by Howard Glasser, a Tucson-based child and family therapist.

Glasser developed his program for children with AD/HD, but says it works equally well for those said to have bipolar disorder. In fact, however, he rejects both labels; in his view, kids called AD/HD and those called bipolar are children with "more life force, more intensity, and more intense needs than they can handle. Some kids are born that way, and some kids acquire intensity living in homes that are stressful."

Glasser's approach takes typical behavior-management strategies and turns them on their head. Instead of setting out a program of escalating consequences for negative behavior, he advocates elaborately rewarding good behavior and accomplishments, while applying consequences for negative behavior in a low-key, nonemotional way.

Nurtured Heart therapy is one of several programs that offer parents techniques for supporting their children while managing their challenging behavior. Harvard's Ross Greene, author of The Explosive Child, has developed a system he calls Collaborative Problem Solving, which teaches children empathy and the ability to think through solutions before problems emerge.

Even the staunchest advocates of medication think such approaches are useful adjuncts to drug therapy. The trouble is that, in today's health care environment, medications are often the first resort, and psychotherapeutic approaches, if tried at all, are the first to fall away.

The message to all these children now being called bipolar is as distorted as is it reductionist. Instead of children's angry or disturbing behaviors being seen as essentially normal, if unproductive, responses to an increasingly fragmented and disconnected home and cultural life, the problem is located within the child. The explanation for their behavior becomes that their brains are biochemically imbalanced and need to be fixed. That's a message some parents and clinicians may find appealing, but it'll do little in the long run to address the serious family and social problems rampant today, which medications are powerless to treat.

Contributing editor Rob Waters can be contacted at robwaters@pacbell.net. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

Thursday, 24 September 2009 11:45

Higher Ground

Written by Ari Rosenberg

Higher Ground
What clinicians should know about the "vertical dimension"

by Jonathan Haidt

Our life is the creation of our minds, and we do much of that creating with metaphor. We see new things in terms of things we already understand: life is a journey, an argument is a war, personal growth is flowering. With the wrong metaphor we are deluded; with no metaphor we are blind.

The metaphor that has most helped me to understand morality, religion, and the human quest for meaning is Flatland, a charming book written in 1884 by the English novelist and mathematician Edwin Abbot. Flatland is a two-dimensional world whose inhabitants are all geometric figures. The protagonist is a square. One day the square is visited by a sphere from a three-dimensional world called Spaceland. When a sphere visits Flatland, however, all that is visible to Flatlanders is the part of the sphere that lies in their plane—in other words, a circle. The square is astonished that the circle is able to grow or shrink at will (by rising or sinking into the plane of Flatland) and even to disappear and reappear in a different place (by leaving the plane, and then re-entering it). The sphere tries to explain the concept of the third dimension to the two-dimensional square, but the square doesn't get it. He cannot understand what it means to have thickness, in addition to height and breadth, nor can he understand that the circle came from up above him, where "up" does not mean from the North. The sphere presents analogies and geometrical demonstrations of how to move from one dimension to two, and then from two to three, but the square still finds the idea of moving "up" out of the plane of Flatland ridiculous.

In desperation, the sphere yanks the square up out of Flatland and into the third dimension, so that the square can look down on his world and see it all at once. He can see the inside of all the houses and the guts (insides) of all the inhabitants. The square recalls the experience:

An unspeakable horror seized me. There was darkness; then a dizzy, sickening sensation of sight that was not like seeing; I saw space that was not space: I was myself, and not myself. When I could find voice, I shrieked aloud in agony, "Either this is madness or it is Hell." "It is neither," calmly replied the voice of the sphere, "it is Knowledge; it is Three Dimensions: open your eye once again and try to look steadily." I looked, and, behold, a new world!

The square is awestruck. He prostrates himself before the sphere and becomes the sphere's disciple. Upon his return to Flatland, he struggles to preach the "Gospel of Three Dimensions" to his fellow two-dimensional creatures—but in vain.

We are all, in some way, the square before his enlightenment. We have all encountered something that we failed to understand, yet that we smugly believed we understood because we couldn't even conceive of the dimension to which we were blind. Then one day something happens that makes no sense in our two-dimensional world, and we catch our first glimpse of another dimension. My claim is that the human mind perceives a third dimension, a specifically moral dimension that I will call "divinity." I am not assuming that God exists and is there to be perceived. Rather, my research on the moral emotions has led me to conclude that the human mind simply does perceive divinity and sacredness, whether or not God exists. This is an ancient truth that devoutly religious people grasp, and that secular thinkers often do not: that by our actions and our thoughts, we move up and down on a vertical dimension. An implication of this truth is that we are impoverished as human beings when we lose sight of this dimension and let our world collapse down to two dimensions. A further implication is that psychotherapists, who work hard to help people grow, may benefit from understanding this third dimension, on which many people are struggling to grow, whether they know it or not.

Disgust and the Ethic of Divinity

I am a social psychologist. I study the moral emotions, and the first emotion I worked on in graduate school was the emotion of disgust. Disgust is fascinating: it clearly evolved to be a guardian of the mouth, to protect us from eating foods that may be contaminated by dangerous bacteria and parasites. But then why does disgust play an important role in so many religions? Why is there so much legislation in Judaism, Islam, Hinduism, and most traditional societies about issues of "purity and pollution"—issues such as menstruation, food, bathing, disease, and the handling of corpses? My collaborators Paul Rozin and Rick McCauley developed a theory that took seriously the culturally widespread use of disgust as a social regulator, and we posited that disgust has become in part a guardian of the "soul," of the human sense of being special, and different from other animals. It is as though there is a vertical dimension of social cognition, in which the animals are below us and the gods are above. Disgust happens whenever we see someone blur the lower boundary of the category of humanity. We turn away in disgust, and refer to people who disgust us as beasts, animals, or monsters. This vertical dimension was perfectly captured by the seventeenth-century New England Puritan Cotton Mather, who observed a dog urinating at the same time he himself was urinating. Overwhelmed with disgust at the vileness of his own urination, Mather wrote this resolution in his diary: "Yet I will be a more noble creature; and at the very time when my natural necessities debase me into the condition of the beast, my spirit shall (I say at that very time!) rise and soar."

After graduate school, I spent two years working with Richard Shweder, a cultural psychologist at the University of Chicago. Shweder does his research in the Indian city of Bhubaneswar, on the Bay of Bengal. Shweder's research shows that when people think about morality, their moral concepts cluster into three groups, which he calls the ethic of autonomy, the ethic of community, and the ethic of divinity. When people think in terms of the ethic of autonomy, their goal is to protect individuals from harm and grant them the maximum degree of autonomy, which they can use to pursue their own goals. When people think using the ethic of community, their goal is to protect the integrity of groups, families, companies, or nations, and they value virtues such as obedience, loyalty, and wise leadership. When people think in terms of the ethic of divinity, their goal is to protect from degradation the divinity that exists in each person, and they value living in a pure and holy way, free from moral pollutants such as lust, greed, and hatred.

To learn more about the ethic of divinity, I went to India for three months in 1993, to interview priests, monks, and other "experts" on Hindu worship and practice. When I arrived in Bhubaneswar, I quickly found that the ethic of divinity is not just ancient history. Even though Bhubaneswar is physically flat, it has a highly variable spiritual topography with peaks at each of its hundreds of temples. As a non-Hindu, I was allowed into the courtyards of temple compounds; and if I took off my shoes and any leather items (leather is polluting), I could usually enter the antechamber of the temple building. I could look into the inner sanctum where the god was housed, but had I crossed the threshold to join the Brahmin priest within, I would have polluted it and offended everyone. Hindu homes had the same concentric structure as the temples: leave your shoes at the door, socialize in the outer rooms, but never go into the kitchen or the room or area where offerings are made to deities. These two areas are maintained as zones of the highest purity. Even the human body has peaks and valleys: the head and the right hand are pure, while the left hand and the feet are polluted. As I moved around Bhubaneswar, I felt like a square in Spaceland, trying to navigate a three-dimensional world with only the dimmest perception of its third dimension.

The interviews I conducted helped me to see a little better. My main goal was to find out whether purity and pollution were really just about keeping biological "necessities" separate from divinity, or whether these practices had a deeper relationship to virtue and morality. For many of the people I interviewed, purity and pollution practices were really just means to the end of spiritual and moral advancement. For example, when I asked why it was important to guard one's purity, the headmaster of a Sanskrit school (a school that trains religious scholars) responded in this way: "We ourselves can be gods or demons. It depends on karma. If a person behaves like a demon, for example he kills someone, then that person is truly a demon. A person who behaves in a divine manner, because a person has divinity in him, he is like a god. We should know that we are gods. If we think like gods we become like gods, if we think like demons we become like demons."

The headmaster, who of course had not read Shweder, gave a perfect statement of the ethic of divinity. Purity is not just about the body, it is about the soul. If you know that you have divinity in you, you will act accordingly: you will treat people well, and you will treat your body as a temple. In so doing, you will accumulate good karma, and you will come back in your next life at a higher level—literally higher on the vertical dimension of divinity. If you lose sight of your divinity, you will give in to your baser motives. In so doing, you will accumulate bad karma, and in your next incarnation you will return at a lower level—as an animal or a demon. This linkage of virtue, purity, and divinity is not uniquely Indian; Ralph Waldo Emerson said exactly the same thing: "He who does a good deed is instantly ennobled. He who does a mean deed is by the action itself contracted. He who puts off impurity thereby puts on purity. If a man is at heart just, then in so far is he God."

Sacred Intrusions

When I returned to Flatland (the United States), I didn't have to think about purity and pollution anymore. Yet once I had learned to see in three dimensions, I saw glimmers of divinity scattered all about. I began to feel disgust at the American practice of marching around one's own house—even one's bedroom—wearing the same shoes that, minutes earlier, had walked through city streets. I adopted the Indian practice of removing my shoes at my door, and asking visitors to do likewise, which made my apartment feel more like a sanctuary, a clean and peaceful space separated more fully than before from the outside world. I began to notice the language of "higher" and "lower" that people used to talk about morality. I became aware of my own subtle feelings upon witnessing people behaving in sleazy or "degraded" ways, feelings that were more than just disapproval; they were feelings of having been brought "down" in some way myself.

In my academic work, I discovered that the ethic of divinity had been central to public discourse in the United States up until the time of the First World War, after which it began to fade. For example, advice aimed at young people in the Victorian era routinely spoke of purity and pollution. In a widely reprinted book from 1897 entitled What a Young Man Ought to Know, Sylvanus Stall devoted an entire chapter to "personal purity" in which he noted that: "God has made no mistake in giving man a strong sexual nature, but any young man makes a fatal mistake if he allows the sexual to dominate, to degrade, and to destroy that which is highest and noblest in his nature." To guard their purity, Stall advised young men to avoid eating pork, masturbating, and reading novels. By the 1936 edition, this entire chapter was removed.

But as science, technology, and the industrial age progressed, the Western world became "desacralized." At least that's the argument made by the great historian of religion Mircea Eliade. In The Sacred and the Profane, Eliade shows that the perception of sacredness is a human universal. Regardless of their differences, all religions have places (temples, shrines, holy trees), times (holy days, sunrise, solstices), and activities (prayer, special dancing) that allow for contact or communication with something otherworldly and pure. In order to mark off sacredness, all other times, places, and activities are defined as profane (ordinary, not sacred). The borders between the sacred and the profane must be carefully guarded, and that's what rules of purity and pollution are all about. Eliade says that the modern West is the first culture in human history that has managed to strip time and space of all sacredness and to produce a fully practical, efficient, and profane world. It is this world that religious fundamentalists find unbearable, and are sometimes willing to use force to fight against.

Eliade's most compelling point, for me, is that sacredness is so irrepressible that it intrudes repeatedly into the modern profane world in the form of "crypto-religious" behavior. Eliade noted that even a person committed to a profane existence has "privileged places, qualitatively different from all others—a man's birthplace, or the scenes of his first love, or certain places in the first foreign city he visited in his youth. Even for the most frankly nonreligious man, all these places still retain an exceptional, a unique quality; they are the "holy places" of his private universe, as if it were in such spots that he had received the revelation of a reality other than that in which he participates through his ordinary daily life."

When I read this, I gasped. Eliade had perfectly pegged my feeble spirituality, limited as it is to places, books, people, and events that have given me moments of uplift and enlightenment. Even atheists like me have intimations of sacredness, particularly when in love or in nature. We just don't infer that God caused those feelings.

Elevation and Love

My time in India did not make me religious, but it did lead to an awakening. Shortly after moving to the University of Virginia in 1995, I was writing yet another article on how social disgust is triggered when we see people moving "down" on the vertical dimension of divinity. Suddenly it occurred to me that I had never really thought about the emotional reaction to seeing people move "up." I had referred in passing to the feeling of being "uplifted," but had never even wondered whether "uplift" is a real, honest-to-goodness emotion. I began to interrogate friends, family, and students. I found that most people had the same feelings I did, and the same difficulty articulating exactly what they were. People talked about an open, warm, or glowing feeling. Some specifically mentioned the heart. Some people mentioned feelings of chills, or of getting choked up. Most people said that this feeling made them want to do good deeds themselves or become a better person in some way. Whatever this feeling was, it was beginning to look like an emotion worthy of study. Yet there was no research of any kind on this emotion in the psychological literature.

If I believed in God, I would believe that he sent me to the University of Virginia for a reason. At UVA a great deal of crypto-religious activity centers around Thomas Jefferson, our founder, whose home sits like a temple on a small mountaintop (Monticello) a few miles away. Jefferson wrote the holiest text of American history—the Declaration of Independence. He also wrote thousands of letters, many of which reveal his views on psychology, education, and religion. After arriving at UVA, having an Eliade-style crypto-religious experience at Monticello, and committing myself to the cult of Jefferson, I read a collection of his letters. There I found a full and perfect description of the emotion I had just begun thinking about.

In 1771, Jefferson's relative Robert Skipwith asked him for advice on what books to buy for the personal library he hoped to build. Jefferson, who loved giving advice almost as much as he loved books, happily obliged. Jefferson sent along a catalogue of serious works of history and philosophy, but he also recommended the purchase of fiction. In his day, plays and novels were not regarded as worthy of a dignified man's time, but Jefferson justified his unorthodox advice by pointing out that great writing can trigger beneficial emotions:

When any . . . act of charity or of gratitude, for instance, is presented either to our sight or imagination, we are deeply impressed with its beauty and feel a strong desire in ourselves of doing charitable and grateful acts also. On the contrary, when we see or read of any atrocious deed, we are disgusted with its deformity, and conceive an abhorrence of vice. Now every emotion of this kind is an exercise of our virtuous dispositions, and dispositions of the mind, like limbs of the body, acquire strength by exercise.

Jefferson went on to say that the physical feelings and motivational effects caused by great literature are as powerful as those caused by real events. He considered the case of a contemporary French play, asking whether the fidelity and generosity of its hero does not "dilate [the reader's] breast and elevate his sentiments as much as any similar incident which real history can furnish? Does [the reader] not in fact feel himself a better man while reading them, and privately covenant to copy the fair example?"

This extraordinary statement is more than just a poetic description of the joys of reading. It is also a precise scientific definition of an emotion. In emotion research, we generally study emotions by specifying their components, and Jefferson gives us most of the major components: an eliciting or triggering condition (displays of charity, gratitude, or other virtues); physical changes in the body ("dilation" in the chest); a motivation (a desire of "doing charitable and grateful acts also"); and a characteristic feeling beyond bodily sensations (elevated sentiments). Jefferson had described exactly the emotion I had just "discovered." I began to call this emotion "elevation," a word Jefferson himself had used to capture the sense of rising on a vertical dimension, away from disgust.

For the past seven years I have been studying elevation in the lab. My students and I have used a variety of means to induce elevation and have found that video clips from documentaries about heroes and altruists, and selections from the Oprah Winfrey show, work well. In most of our studies, we show people in one group an elevating video, while people in the control condition see a video designed to amuse them. So far we have found that elevation makes people feel warm, calm, and loving feelings. It makes people want to become better themselves—it motivates them to rise on the dimension of divinity. It seems to open people up, releasing the milk of human kindness.

In our most exciting discovery, my student Jen Silvers found that elevation seems quite literally to release milk: she brought lactating women into the lab with their babies. One half of the women watched an elevating video; the other half watched a comedy video. The women who were elevated were much more likely to nurse their babies in the minutes afterwards, or to leak milk into a nursing pad. Why? Because elevation may trigger the production of the hormone oxytocin, and oxytocin is the direct trigger for milk release. So those warm fuzzy feelings you get in your chest when you see someone do something kind, loving, or beautiful may reflect real physiological changes in your heart and lungs brought on by oxytocin.

Awe, Transcendence, and the Satanic Self

Virtue is not the only cause of movement on the third dimension. The vastness and beauty of nature similarly stirs the soul. Immanuel Kant explicitly linked morality and nature when he declared that the two causes of genuine awe are "the starry sky above and the moral law within." The New England transcendentalist movement was based directly on the idea that God is to be found in each person and in nature, so spending time alone in the woods is a way of knowing and worshiping God. Ralph Waldo Emerson, a founder of the movement, wrote: "Standing on the bare ground, — my head bathed by the blithe air and uplifted into infinite space, — all mean egotism vanishes. I become a transparent eyeball; I am nothing; I see all; the currents of the Universal Being circulate through me; I am part or parcel of God."

There is something about the vastness and beauty of nature that makes the self feel small and insignificant, and anything that shrinks the self creates an opportunity for spiritual experience. Sages (and psychologists) have long written about the many ways in which people feel as though they have multiple selves or intelligences which sometimes conflict. This division is often explained by positing a soul—a higher, noble, spiritual self—which is tied down to a body—a lower, base, carnal self. It's as though the soul were a helium balloon tied to a brick. The soul escapes the body only at death, but before then, spiritual practices, great sermons, and awe at nature can give the soul a taste of the freedom to come.

Awe is the emotion of self-transcendence. My friend Dacher Keltner, an expert on emotion at the University of California at Berkeley, proposed to me a few years ago that we review the literature on awe and try to make sense of it ourselves. We found that scientific psychology had almost nothing to say about awe. It can't be studied in other animals or created easily in the lab, so it doesn't lend itself to experimental research. But philosophers, sociologists, and theologians had a great deal to say about it. As we traced the word "awe" back in history, we discovered that it has always had a link to fear and submission in the presence of something much greater than the self.

Keltner and I concluded that the emotion of awe happens when two conditions are met: a person perceives something vast (usually physically vast, but sometimes conceptually vast, such as a grand theory, or socially vast, such as great fame or power); and the vast thing cannot be accommodated by the person's existing mental structures. Something enormous can't be processed, and when people are stumped, stopped in their cognitive tracks while in the presence of something vast, they feel small, powerless, passive, and receptive. They often (though not always) feel fear, admiration, elevation, or a sense of beauty as well. By stopping people and making them receptive, awe creates an opening for change, and this is why awe plays a role in most stories of religious conversion.

In what is still the greatest work on the psychology of religion, William James analyzed the "varieties of religious experience," including both rapid and gradual religious conversions, as well as experiences with drugs and nature. James found such extraordinary similarity in the reports of these experiences that he thought they revealed deep psychological truths. One of the deepest truths, James said, was that we experience life as a divided self, torn by conflicting desires. Religious experiences are real and common, whether or not God exists, and these experiences often make people feel whole and at peace. In the rapid type of conversion experience the old self, full of petty concerns, doubts, and grasping attachments, is washed away in an instant, usually an instant of profound awe. People feel reborn and often remember the exact time and place of this rebirth, the moment when they surrendered their will to a higher power and were granted direct experience of deeper truth. After such rebirth and revelation, fear and worry are greatly diminished and the world seems clean, new, and bright. The self is changed in ways that any priest, rabbi, or psychotherapist would call miraculous.

Yet the self is one of the great paradoxes of human evolution. Like the fire stolen by Prometheus, it made us powerful but exacted a cost. In The Curse of the Self, the social psychologist Mark Leary points out that many other animals can think, but that none, so far as we know, spend much time thinking about themselves. Only a creature with language has the mental apparatus to focus attention on the self, to think about the self's invisible attributes and long-term goals, to create a narrative about that self, and then to react emotionally to thoughts about that narrative. Leary suggests that this ability to create a self gave our ancestors many useful skills, such as long-term planning, conscious decision-making, self-control, and the ability to take other people's perspectives. These skills are all important for enabling human beings to work closely together on large projects, and so the development of the self may have been crucial to the development of humanity's extreme sociality. But by giving us each a world inside our own heads, a world full of simulations, social comparisons, and reputational concerns, the self also gave us each our own personal tormenter. We all now live amid a whirlpool of inner chatter, much of which is negative, most of which is useless.

Leary's analysis shows why the self is a problem for all major religions: the self is the main obstacle to spiritual advancement, in three ways. First, the constant stream of trivial concerns and egocentric thoughts keeps people locked in the material and profane world, unable to perceive sacredness and divinity. This is why Eastern religions rely heavily on meditation, an effective means of quieting the chatter of the self. Second, spiritual transformation is essentially the transformation of the self, weakening it, pruning it back—in some sense, killing it—and often the self objects. Give up my possessions and the prestige they bring? No way! Love my enemies, after what they did to me? Forget about it. And third, following a spiritual path is invariably hard work, requiring years of meditation, prayer, self-control, and sometimes self-denial. The self does not like to be denied, and is adept at finding reasons to bend the rules or cheat. Many religions teach that egoistic attachments to pleasure and reputation are constant temptations to leave the path of virtue. In a sense, the self is Satan, or, at least, Satan's portal. For all these reasons, the self is a problem for the ethic of divinity. It stands in the way of spiritual and moral progress.

Divinity in Therapy

What does all of this have to do with psychotherapy? Here are three thoughts, three possible ramifications of these ancient ideas for the modern therapeutic community.

First, nearly all Americans are religious to some degree, yet psychologists are much less religious than the average American. This means that there may often be a mismatch between the "dimensionality" of the client and the therapist. Secularly trained therapists might not recognize the striving to "rise" on the dimension of divinity. (Even secular clients may have such feelings without understanding them.)

Second, the modern psychological emphasis on self-esteem, self-knowledge, and self-development more generally might be counterproductive. Particularly for religious clients who would like to weaken their grasping, petty selves, encouragement to strengthen the self and satisfy the self's needs might be in conflict with other ways of growing and improving.

And third, this perspective on divinity may help therapists to find new tools, such as the emotions of elevation and awe, that may be powerful adjuncts to the therapeutic process. Might talking about role models and moral exemplars create windows of opportunity? Might self-transcendent emotions create brief "melting moods" in which the client finds him or herself "washed and soft of heart and open to every nobler leading"—that is, to leading upwards on the dimension of divinity?

From the book The Happiness Hypothesis by Jonathan Haidt. Copyright © 2005. Reprinted by arrangement with BasicBooks, a member of the Perseus Books Group (www.perseusbooks.com). All rights reserved.

Thursday, 24 September 2009 11:45

You Gotta Have Heart

Written by Ari Rosenberg

You Gotta Have Heart

by Christopher Germer

Mindfulness has become one of the hottest growth areas in the field of psychotherapy in the past few years. It's a surprising hit even among cognitive-behavior therapists, whom nobody would ever accuse of being frothy-brained New Agers. Our scientific colleagues, such as Steven Hayes, regard "mindfulness and acceptance-based therapies" as the "third wave" of empirically based treatments, after behavior therapy and cognitive therapy.

The distinctive focus of the mindfulness-based approach is the intractability of emotions, and the recognition that pushing around difficult feelings often only makes them worse. In contrast, in the spirit of the mantra of the mindfulness approaches—"Change follows acceptance"—they prescribe a combination of awareness and acceptance as the primary intervention.

Several therapy approaches incorporating acceptance have proven to be effective with such difficult-to-treat conditions as the suicidality connected with borderline personality disorder (Dialectical-Behavior Therapy), recurrent depression (Mindfulness-Based Cognitive Therapy), psychotic delusions and hallucinations (Acceptance and Commitment Therapy), and a host of chronic, mind-body disorders, such fibromyalgia, psoriasis, and chronic pain (Mindfulness-Based Stress Reduction). Although the techniques used may differ, these programs share common psychological processes, such as disentangling from thinking ("thoughts are just thoughts") and learning to stay with unpleasant experience.

Nevertheless, in their enthusiasm for these new approaches, therapists run the risk of ignoring another psychological process essential to mindfulness practice—lovingkindness. Throughout the 2,500 years that mindfulness has been a part of the Buddhist contemplative tradition, it never was intended to be strictly an awareness or attention-regulation exercise. Take away lovingkindness and mindfulness is like being forced to watch a frightening scene, close up, under a bright light. That isn't an experience that most of the emotionally distressed patients we see need to have.

What we're trying to do with mindfulness is evoke a complete state of mind, much as a hologram can project an image into the center of a room, or a poem can illuminate a perception in the heart of the listener. Within the cognitive-behavioral tradition, the word acceptance, or radical acceptance (to use Marsha Linehan's expression), is used typically to convey the nature of mindfulness. I've found, however, from personal and clinical experience, that other words are necessary to evoke the heart quality of mindfulness. They include tenderness, care, self-compassion, lovingkindness, and simply love.

Thinking with the Heart

My path to understanding the importance of lovingkindness in mindfulness-based psychotherapy wasn't always smooth. Madeline was one of my first client-teachers.

She was an 82-year-old woman who, even though in good health and of sound mind, despaired that she'd have to leave her beloved home of 45 years, because she lived on a portion of a suburban street where neighborhood children congregated to play . . . and scream. The noise kept her from sleeping, and she was experiencing chronic stomach and neck tension. She'd tried what she could to reduce the noise level—talking to the children's parents, playing soothing music to shut out the sounds. In spite of such steps, however, she lived in fearful anticipation of the next child's shriek. Madeline felt sad about her noise sensitivity because she wanted to enjoy the ebullience of her neighborhood kids, just as she'd enjoyed her own children's energy earlier in her life.

Initially I thought Madeline might benefit from listening in a more spacious way to the sounds around her—not focusing all the time on the children's screaming. I made Madeline an audiotape, "Mindfulness of Sound," that taught her to passively notice all the sounds in her environment. It didn't work. She said she just found the noise of the children too disturbing.

Next I thought she might benefit from internal exposure. If she could mindfully explore her physical and emotional reactions to the noise, perhaps she'd be able to relax. And if her body felt better, I hoped, maybe she'd obsess less about the noise. Ever cooperative, Madeline explored her sensations, thoughts, and emotions whenever she noticed she was anxious: "Where does it hurt?" "What does it feel like?" "Does the pain come and go?" "What thoughts and feelings come along with the stress of those noisy kids?" I instructed her to simply notice what she was feeling in her body and how her body reacted to the external sounds. This exercise didn't help either, not the least little bit. All it did was focus Madeline on just how bad she felt, and made her even more upset with herself and her situation.

The closer Madeline got to her distress, the more overwhelmed she became. We might call this exposure without desensitization, or mindless exposure. The trick with mindfulness techniques is to maintain attentional stability and a certain nonattachment as uncomfortable experience is allowed into awareness, but not become emotionally overwhelmed. In some cases, medication may be required as an adjunct to mindfulness-based treatment. I suggested to Madeline that she discuss taking Klonopin or Paxil with her physician. But she demurred—she rarely took medicine, on principle, and wanted to continue exploring behavioral techniques.

By now, I seriously doubted that I could help Madeline. Then I recollected that she'd volunteered for many years at a nursing home, brought Vietnamese children to the United States after the war, and was active in her church. I started to wonder whether she could bring the same quality of compassion that she had for others to herself. Would lovingkindness help her better tolerate her distress?

Together, we came up with a new meditation: "Soften, allow, and love." Madeline was enthusiastic about this one from the start, so I made another 20-minute audiotape for her to practice with.

The meditation begins with simple awareness of whatever sensations may be occurring in the body. Can you feel the pressure of your body on the couch? Can you notice the movement of your breath? After a minute, attention is shifted to an unpleasant physical sensation. For Madeline, this was either her tense stomach or her neck. The first component of the meditation, "softening," refers to relaxing that uncomfortable part of the body. However, to avoid frustration if relaxation doesn't occur, softening is an invitation to relax.

When you feel discomfort, can you soften that part of your body? You don't have to relax; just allow that spot on your body to soften—if it's ready to.

The next component is "allowing." This refers to allowing the physical sensations of the body to be just what they are—unpleasant, neutral, or pleasant. It's an ancient Buddhist meditation technique.

Can you allow yourself to feel the discomfort as long as it lingers? Can you just let it be, as long as it's there, even if it hurts? You don't have to change it—it'll pass at its own time. Can you let it come and go as it wants to?

Finally, in the "love" component, you try to recollect a feeling of love that can be redirected at your own body. This is a variation on the lovingkindness practice. Instead of reciting phrases, we capture a feeling—a brain state, if you will—and associate it with a new object of awareness. In this case, the new object is a difficult body sensation.

Now, imagine what it was like when one of your children had a tummyache, just like you. Can you sense in your heart what you might have felt, or feel, as you sympathize with his or her struggle? Can you hold that feeling in your heart?

Now, can you give your own stomach the same love that you'd feel for your child if he or she were suffering in the same way? Can you bring some love to the very place where it hurts?

This meditation then led Madeline to fill her whole body with the same love she'd identified, and let that feeling of love gradually radiate out into the room and into her community.

After Madeline learned this meditation, she innocently inquired, "Where does the love come from?" "Where can I draw it from, if it doesn't come up on its own?" We decided that love just seems to be a quality that comes naturally to everyone. Sometimes we feel it most for a child or a pet. It seems to be inherent in all of us, just like awareness. The skill is to recollect what love feels like and to direct it where it's needed most.

Eventually we expanded Madeline's loving awareness beyond her physical pain to encompass the emotional discomfort she felt when her home became too noisy.

Two weeks after learning this exercise, Madeline reflected aloud, "I think I have to learn to love myself more!" Four weeks later, she was feeling some enthusiasm for "working" with her noise sensitivity, and she said she felt 50 percent better. She surprised herself that she was actually beginning to feel affection for the noisy kids. She bought a lovely hat for one neighbor girl—one just like hers—when the child admired it.

Six months after Madeline learned this practice, I called her to inquire how she was feeling. She was still practicing self-compassion on a daily basis. She said, "When I hear a scream and I'm up and about, I kind of welcome it, because it's a part of my world. It gives me a chance to practice, too. I'm not saying I'm 100 percent cured, because there are times when I get annoyed, like when I'm reading the Bible and am with God. Then the noise is intrusive. But I'm generally much happier. I didn't know I could give love to myself!

I asked her if the practice changed anything else in her life. She replied, "I have a sense of my own worth. I don't have to please people. More on top of things, you know? I don't feel victimized. I'm more accepting. If people say something wrong, I let it go. I don't have to be right. I can let it go."

I still wanted to know specifically how she was practicing lovingkindness. She said she intentionally recalled the great compassion she'd felt for her youngest son, about 44 years ago, when he'd awoken with his eyes sealed shut from discharge. Her little boy was terrified, and she was filled with love for him at that moment. "Now I direct that love at myself," she said. "Where exactly do you direct it?" I asked. "I direct it at my upper body. I don't quite know how to describe it; my heart, yeah, it's a heart thing," Madeline replied.

Mindfulness Plus

Lovingkindness and compassion are heart qualities. They bring heartfulness to mindfulness. It's curious to me that heart qualities are marginalized in our profession. Perhaps they're not masculine or scientific enough. Lovingkindness isn't a secondary component of mindfulness; when we have to deal with difficult emotions, lovingkindness is primary and indispensable.

The "Soften, allow, and love" exercise was subjectively different from Madeline's (and my) earlier attempts at mindfulness, because it allowed her to expend less effort to change her experience. The loving attitude allowed her to "let go" and abide in the midst of her suffering with greater equanimity.

Our patients come to therapy to get better—to be cured. They want to become something other than they are, in an effort to avoid pain and maximize pleasure. Therapists shouldn't buy into this agenda though. Even Sigmund Freud noted, "A man should not strive to eliminate his complexes, but should get into accord with them." Lovingkindness allows our patients to just "be." No wasted effort.

Sharon Salzburg, a meditation teacher at the Insight Meditation Society in Barre, Massachusetts, and
the author of Lovingkindness: The Revolutionary Art of Happiness, may be credited with bringing lovingkindness practice to the West. The four phrases Sharon suggests as a starting point for this practice are:

May I be free from danger.

May I have mental happiness.

May I have physical happiness.

May I have ease of well-being.

Repeating these phrases inclines the heart toward our suffering, rather than falling prey to the instinctive tendency to run away. We are not trying to eliminate what's happening at the moment. We're simply practicing love while in pain. It's the practice of care, not cure. But, paradoxically, with emotional suffering, cure often follows care.

For most people, self-compassion in the moment of suffering is a radical act. We're quite good at loving others, but rarely think of directing love toward ourselves in our moments of suffering. Perhaps we don't know how. Maybe we think we don't deserve it. Often we just can't find ourselves in the crowd—we're too busy toughing it out even to know when we're suffering. Practicing mindfulness with self-compassion allows us to know when we're in pain, and it calls forth a new response.

Simply reading about lovingkindness practice is no substitute for the therapist's own personal experience. The reader is invited to write down the four lovingkindness phrases and simply to recite them over and over for a few minutes the next time you feel upset. The more distressed you feel, the more likely you are to experience the deep, internal softening that accompanies the practice. When the mind throws up arguments against the practice, simply take notice and return to repeating the phrases. If the mind didn't protest, there'd be little need to practice.

My client Rachel panicked whenever she blushed, fearing it would signify that she wasn't a competent, intelligent colleague. Anticipatory anxiety led her to avoid social settings. She avoided the coffee room for fear of personal conversations; she was afraid to use a public restroom when others were around; and she avoided public speaking, at considerable cost to her career. She took antianxiety and antidepressant medications for her condition.

Poetically inclined, Rachel rewrote the lovingkindness phrases as follows to help her accept her anxious temperament and blushing, to anchor her awareness in the present moment, and to encourage her to continue to participate in life, even though she usually felt quite vulnerable.

May I have a peaceful spirit-mind and be free from sickness and harm.

May I paddle my currents and laugh with my quirks.

May I see the pulse of waves, feel the gusts of falling snow, hear the cry of the loon, sense the awe of the wilderness.

And may I hold my exposed heart in the embrace of my soul.

A mere three weeks after beginning to practice, she reported that she was taking less Prozac, had stopped Klonopin altogether, and was more energetic in meetings with colleagues. She related another effect of lovingkindness practice that I've often heard from patients: she'd begun talking more encouragingly to herself. Her inner dialogue included supportive comments like: "You'd like yourself if you met you!" "You're who you are, so say what you want to say!" and "Go ahead, quirk out!"

Rachel's increased capacity for self-compassion had another surprising effect. She found she no longer had to turn off the TV when tragic stories, like starvation and disease in Sierra Leone, came on the screen. She had the emotional capacity to handle them. She said, "I'm less afraid of what might come in—yes, the world has terrible beauty."

Bringing Love to Therapy

At the present time, there's only one clinical study I'm aware of that examines the use of lovingkindness exclusively to treat a clinical condition—in that case, back pain. However, a warm attitude can be discovered implicitly in all the empirically validated protocols mentioned earlier. Zindel Segal's Mindfulness-Based Cognitive Therapy (MBCT) and Jon Kabat-Zinn's Mindfulness-Based Stress Reduction program use poetry to help inculcate the gentle quality of mindful awareness. One such poem is "Wild Geese," by Mary Oliver. It begins:

You do not have to be good.

You do not have to walk on your knees

for a hundred miles through the desert, repenting.

You only have to let the soft animal of your body

love what it loves.

The healing qualities of allowing, acceptance, and letting go permeate Oliver's lines. Through this poem, the word love has even found its way into the MBCT treatment protocol. That's a milestone for empirically-based treatment.

Often therapists find themselves working for years on end with the same patients, giving love and compassion, and hoping that it'll rub off in some way. We hope that the kindness we extend to our patients will eventually be brought by the patient to his or her own suffering. Often that doesn't happen. It's as if there's a hole in the bottom of the pot. Sometimes, within minutes of leaving our office, a patient may be hit by despair, just like smacking into a stone wall. These patients are usually the ones with few friends or family to support them. How can we help such vulnerable people nourish themselves?

I'd been treating a 35-year-old man, George, for approximately four years before I taught him lovingkindess practice. He'd been so severely neglected as a child that he could barely walk when he went to kindergarten—he just flopped around. No one cared. He'd also been physically abused on a daily basis by his single, alcoholic mother. He ran away at age 15, and never returned home.

When I asked him how he'd managed to stay alive, and even finish high school, he said he remembered some kind moments with his grandfather. His mantras for overcoming adversity came from muscular role models in World Wrestling Entertainment, such as Ric Flair: "Win if you can. Lose if you must. And you can always cheat!"

He's one of those patients that make you wonder if people can ever recover from a horrible childhood. He was underemployed, but employed. He didn't have any friends, because he didn't think he was worth their time. He was quite overweight, suffered from depression and insomnia, and had been taking antidepressants for years.

Therapy with George was always a delicate dance. I didn't want him to open up his wounds too much, lest he become overwhelmed and unprotected outside the session. This is often a dilemma with trauma victims—they don't have the self-compassion skills to manage reawakened memories, so they may decompensate and regress in therapy. Loving attention by the therapist, which opens up the heart like a flower and exposes old wounds, may cause difficulties outside the session, when clients remain open and vulnerable, but defenseless. Hence, I had to go slowly with George. Fortunately, he'd managed to marry a nice woman, who came to sessions occasionally when he resorted to such primitive self-regulation strategies as cutting himself and punching walls.

I taught George lovingkindness a few months ago, and the impact was almost immediate. As I repeated the phrases to him, his eyes became red and moist. He slowly lowered his head and said softly, "I can do this."

George announced the following week, right off, "I'm coming into my own!" He'd applied for a better job, even though it meant risking rejection. He said he was tired of being ashamed of his childhood, which meant not trying to get ahead. When I inquired what led to this change of mind, he said he was doing lovingkindness in bed, morning and night. He'd taped the phrases to his office computer, and he repeated them to himself whenever he felt "overwhelmed with self-doubt."

It was as though he'd woken up overnight and could see life from a broader perspective. He said he realized his elderly father-in-law said cruel things to him, not because George was actually "stupid" or "useless," but because the feeble, old man was demented. He added, "I'm not personalizing bad news so much."

Over the following weeks, this remarkable trend continued. George said he was volunteering for projects at work, he'd signed up for an art class, and had taken his wife on a "road trip." Where? They visited his old housing project for the first time since he'd left 20 years earlier. He said he was flooded with traumatic memories, but then started enjoying pointing out the sights, like the corner where he often found the dead bodies of junkies on his way to school in the morning. "Now I'm not ashamed. I have a lot of people who love me. Like the Tin Man in the Wizard of Oz. I think, 'I can do this,' 'I deserve this.'" Tears filled his eyes as he told me that he deserves friendship and love.

"I've spent a lot of time motivating others," he added, "at work and at home. Now I am motivating myself!" Months later, his general level of happiness and sense of humor continue to improve.

In George's case, self-compassion practice led to a radically different sense of himself in the world. He developed the nonattachment and happiness of someone who feels truly loved. As Tara Brach wrote in her beautiful book, Radical Acceptance, many people suffer from a "trance of unworthiness." When people feel bad about themselves—self-loathing, shame, self-doubt—they need an antidote at the same gut level of feeling. They need love.

Most of our clients come to therapy already exhausted by heroic but futile efforts to change themselves. We shouldn't further disappoint them by buying into the change agenda. It's ironic that clinicians themselves, when looking for their own therapists, don't usually choose experts in behavioral change. They seek therapists who are known to be warm and kind. Why would we want to offer anything less to our clients? The compassionate attitude has to come first. Kindness is the change agent.

As mindfulness is codified and manualized within our profession, we need to be especially careful not to overlook the primary healing process of lovingkindness. With self-compassion, our patients can bear seemingly unendurable emotional pain. Without it, awareness is barren and lifeless, and can even be harmful.

Christopher Germer, Ph.D., has been integrating meditation into psychotherapy since 1978. He specializes in mindfulness-oriented treatment of anxiety and in couples therapy. He's a clinical instructor in psychology at Harvard Medical School, and is on the teaching faculty of the Institute for Meditation and Psychotherapy. He's also a coeditor of Mindfulness and Psychotherapy. Contact: campsych@earth link.net; website: www.meditationandpsy chotherapy.org. Letters to the Editor about this article may be e-mailed to letters@
psychnetworker.org.

Thursday, 24 September 2009 11:44

Family Matters

Written by Ari Rosenberg

FAMILY MATTERS
By Dennis Butler

Chew Pow
There are many ways to say "I don't know"

She was a diminutive woman, perhaps five feet tall. When she took the seat across from me in the consultation room, her feet dangled above the floor. Her gray hair was tied back in a bun. Her worried face told a thousand stories.

The call from the Refugee Mental Health Program I'd received about her a few days earlier was similar to many others I've gotten through the years: "We're referring Mrs T., a 47-year-old Hmong refugee woman who's experiencing low energy, fatigue, and frightening dreams," the voice on the phone had said. "Two sessions for evaluation, eight sessions for treatment. Submit a treatment plan if you need more."

Because neither of us had any facility with the other's language, a translator was always present. Some were young, and like her, Hmong—indigenous people originally from the highlands of Southeast Asia. They were the ones moved to tears by her stories of death and atrocities in Viet Nam and Laos. When she left the room after one session, a young translator in her twenties told me that these were the stories her own parents wouldn't disclose. Other translators were older, multilingual, from other Southeast Asian ethnic and cultural groups that, I later learned, looked down on the Hmong. They weren't moved in the same way, sometimes even tending to take control of the session and give advice.

Despite my unfamiliarity with her language, I came to recognize by the second session one recurrent phrase, Kuu tsi paub, which sounded like "Chew Pow" to me. It was always translated, "She doesn't know." The phrase was frequently repeated at each session, especially after I asked her a question that started about how long, how many, or how often.

As the Chew Pows multiplied, I considered the possibilities. Was she resistant? Dissociating? Even malingering? I tried to conceal my frustration. A Hmong colleague said that her people were poor historians, that they look at the world in a different way, and that they didn't think in quantifiable terms.

So we moved on session by session, with the Chew Pows ever present. Bit by bit, her history became clearer to me, and her symptoms of a prolonged post-traumatic stress disorder more apparent—fatigue, nightmares, worrying, avoiding contact with other Hmong families, not cooking for her family. Sometimes, she told me, she felt a "bad wind" around her. Especially telling were her stories: images, repeated in her dreams, of villagers killed and mutilated along the trail of escape; the sound of gunfire and screams in the night; one of her children dying of starvation in the jungle.

Now we were getting somewhere, I thought. I was ready to try some techniques. I suggested that when the dreams awakened her, she should say to herself, "I'm in the United States; the enemy isn't here and can't harm me now." At the next visit, she reported, "Yes, I tried that. I hear your voice when I awake and I'm not so scared. But I still have the dreams." "How often?" I asked? "Chew Pow." "Have the dreams changed?" "Chew Pow."

I asked if she'd leave her dreams with me on an audiotape—give me some of her fears to lock up in the drawer of my desk. She agreed. And so, in the sixth session, she related the content of her dreams, in Hmong, of course. For 30 minutes, she spoke softly, pausing only occasionally. The translator, an older Hmong man, sat transfixed. When the session was over, he was quiet and somewhat pale as he left the room.

At the next visit, I suggested that we listen to the tape and have the translator tell me what she'd said. "No, no need," she told the translator. "Now you have the dreams and can lock them up." "Was it helpful to record your dreams?" "Chew Pow."

After that session, her appearance changed. She came in wearing more colorful, but oddly matched, clothing. Sometimes I saw a slight smile on her face. Her legs would swing gently under the chair as she talked about her children. I asked her if she thought these were good signs. "Chew Pow, but if you think this is important, then I accept it as a good sign."

I often explain to the family-practice residents I teach that they acquire much knowledge, but some day they'll achieve understanding—a different way of knowing. Now I began to wonder if there were different levels of not knowing, too? I paid closer attention to each Chew Pow. There were variations. Some were stuttered, some had a flip inflection, others were abrupt. Some seemed angry; others ended in a whine. Clearly she could say "I don't know" in many different ways, reflecting, I suspect, that she'd come to accept that she really didn't know or understand many things in many different ways.

Meanwhile, she was sleeping better. "How Long?" "Chew Pow." The dreams didn't awaken her as often. "How often?" "Chew Pow." "What was different?" "Chew Pow."

She had more energy. She told me she missed the freedom she'd had in her village and the highlands. She told me she didn't know how to help her children with their homework and feared the influence of the gangs in her neighborhood.

Around the eighth session, knowing that the managed care company would require documentation to authorize further treatment. I asked her if her symptoms had changed. "Chew Pow; but I do know that you're a good person, and I'll remember you and will be thankful to you until the day of my death."

In the ninth session, again seeking to put things in quantifiable terms, I asked about her symptoms again. "Chew Pow. I'm grateful for all you have done, and I'll remember you in the final hours of my life on the day I die," she replied. Feeling pressured to satisfy managed care, I tried one last time. "Chew Pow, but I'll remember all you've done, even in the last breath I take in the last minute of my last day." I chose not to ask again, saving me, and perhaps her, some serious embarrassment. We agreed that she'd return to see me when and if she needed.

It took a while for her words to sink in. This woman had witnessed terror beyond my comprehension, experienced a total disruption of her family and culture, and had been resettled into an incomprehensible new world. Yet she'd determined that I was a good person, was grateful for my help, and would remember me until the day she died—something I'd never expected to hear any patient say. She accepted how much she didn't know (in many different ways), but she knew I'd helped her, and she was grateful.

Trauma forces us to recognize that there are things in the world that we don't know and don't understand. Whom can we trust? What's really important in life? For what are we truly grateful? After what Mrs. T. had experienced, seemingly nothing could ever be certain again. But recovery isn't based on knowing how many. It's based on reconnecting with that which is basic and essential in oneself, in relationships, and in life.

Mrs. T said she'd remember me until the day she dies. I, too, won't forget Chew Pow and the lessons she taught me. I occasionally pull out her tape and listen. What did she record? Chew Pow—I don't know. But it really doesn't matter. It isn't about the words, it's about what happened when we were together. She taught me to become more comfortable with not knowing many things, yet staying connected to who my patients are and what's important to them. Is she adjusting? Yes. How do I know? I can't tell you how, but I know it's true. And I'm deeply grateful to her for helping me reconnect with why I do what I do.

Dennis Butler, Ph.D., is a psychologist and professor of family medicine at the Medical College of Wisconsin in Milwaukee, Wisconsin. Contact: dbutler@mcw.edu. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

Thursday, 24 September 2009 11:44

Editor's Letter

Written by Ari Rosenberg

From the Editor
Jan/Feb 06

As an undergraduate English major, I was unimpressed with my required foray into Psych 101. The leaden jargon of operant conditioning and psychoanalysis seemed more like assaults on the English language than methods for understanding the mind or healing the wounded psyche. It was the great authors I read in my literature classes—Shakespeare, Blake, Yeats, Austen, Hawthorne, Dickinson, Melville—who seemed a far superior source of wisdom about human nature, and who certainly had more to say about truth, virtue, and happiness.

But when it came to making a career choice and perhaps following in the footsteps of my impressive-sounding Lit professors, there was a problem. The more I learned about the politics of the English Department, the more it seemed to be a rank stew of envy, backstabbing, and professional claustrophobia. And my professors themselves, I eventually discovered, were, for the most part, frustrated, bored, and often alcoholic. The study of literature in itself apparently wasn't a failsafe ticket to moral elevation and personal enlightenment.

With so many of my role models seemingly in need of psychotherapy, I decided to give that profession another look. Now, after 30 years in the field, I suddenly find much to remind me of my graduate years, when I was uplifted by great literature. After decades of being preoccupied with emotional pathology in all its DSM-documented permutations, psychology seems to have shifted its attention to the study of what's best in us, where it comes from, and how it emerges to enrich our lives. From a growing body of research into what's called Positive Psychology has come the news that mental and emotional health may have a lot to do with being good, rather than merely being happy. Social psychologist Jonathan Haidt reminds us in his article, "Higher Ground," of how important for emotional well-being are the "moral" emotions—gratitude, compassion, altruism, forgiveness, and, particularly, awe, the feeling of emotional elevation we get when we engage in religious worship, contemplate a magnificent landscape, or witness acts of charity, selflessness, and courage.

Much of the credit for this interest in self-transcendence goes to psychologist Martin Seligman, the de facto CEO of a Positive Psychology movement that's yielded a large and growing body of solid research into what gives people "authentic happiness" (the title of Seligman's bestselling book). According to Seligman and his cohorts, the keys to a satisfying and meaningful life sound a lot like what your grandmother might have advised: hard work, self-sacrifice, purpose, duty, a positive outlook—in short, moral character. What's more, Seligman has even worked out a tough-minded course for helping people actually achieve happier lives. It's a kind of happiness boot camp, replete with morally prescriptive exercises encouraging gratitude, appreciation, optimism, and similar virtues.

Networker Book Review Editor Richard Handler, who isn't himself personally inclined to Pollyanna-ish excess, took Seligman's 20-week Telecourse (with almost 200 other happiness seekers) and found it deeply instructive, if not always in ways that the Positive Psychology people might have expected. While recognizing the contribution Seligman and his band of merry men (and women) have made to therapy, Handler was left wondering whether science can really understand happiness. More to the point, he wonders if it's really possible to devise "a practical system, a curriculum, a didactic course of happiness and wisdom" whose tenets can be absorbed like those of any other skill or habit.

Perhaps, he suggests, elixirs as fundamentally mysterious, elusive, and undefinable as happiness, awe, wonder, gratitude, and appreciation aren't quite ready for mass-market bottling just yet. Nonetheless, as a corrective to the standard, largely amoral, psychopathology-based and self-absorbed psychological culture—in which the words virtue and self-sacrifice are almost taboo—Positive Psychology and the contemplation of what Haidt calls the "vertical dimension" of human experience are long overdue. Positive Psychology isn't therapy, nor is it intended to be; but in its various manifestations, it certainly might enrich even the most traditional therapist's understanding of what makes human beings tick.

Thursday, 24 September 2009 11:43

In Consultation

Written by Ari Rosenberg

IN CONSULTATION
By Frank Dattilio

Throwing Away the Script
Helping trainees trust their gut

Q: As a supervisor, I often find that trainees are overly rule-bound and rigid in the way they approach clients. How can I get them to loosen up and learn to trust their own gut instincts more?

A:It's true that students often feel more secure approaching every clinical encounter strictly "by the book," and are frequently so afraid of making mistakes that they stifle their own capacity for therapeutic intuition and emotional connection with their clients. Sometimes freeing their therapeutic imagination requires bold steps.

I remember one time, years ago, while teaching a graduate course in abnormal psychology, assigning an exercise to several class members in an attempt to help them understand what it feels like to be considered abnormal. I had them board a city bus during the morning rush hour and sit in the back. Then they were to yell out the name of each stop as the bus came to it. Half the students couldn't muster the nerve to complete the assignment, which drove home the point. Those who did follow through quickly found themselves sitting alone on the bus and feeling quite "odd."

Getting students to loosen up and rely on their own instincts—use their own radar systems in therapy—is one of the greatest challenges for any teacher, and requires a willingness to be unorthodox. You must be able to let instinct be your guide, maybe to the point of mild wackiness.

Gail was at a crossroads in her training. A highly intelligent and technically adept third-year psychiatry resident, she was wondering whether she'd chosen the wrong field. "I don't know what's wrong," she said to me one day during supervision. "I just can't get a handle on being a therapist." A newly married woman of 28, she wanted so much to do the right thing as a budding psychiatrist, but was somewhat rigid and a bit concrete in her thinking. For example, she'd told a patient who was struggling with a life decision for more than a year to "just decide and be done with it!"—failing to recognize that the "struggle" was the actual problem, not the inability to decide.

She attributed her narrow focus to the pressure that science instilled in her to always be analytical and sharp. Whatever the reason, it wasn't the first time she'd complained in these terms, and in exactly this same, tired, discouraged tone of voice, and I was beginning to wonder whether she was in the right profession.

"What do you mean you can't get a handle on being a therapist?" I asked, suppressing my own impatience.

"I just don't think that I'm in touch with my patients," she said. "I'm going through the motions, asking all the right questions, using the proper techniques that I was taught, but something just doesn't feel right to me. It's just not clicking—I can tell by the look on my patients' faces."

When I asked Gail what she thought she was doing wrong, she sighed and said she just didn't know.

"Well, you say things just don't 'feel' right," I probed. "What would 'right' feel like to you?" She didn't know the answer to that, either.

"I just know that it feels as if I'm doing therapy with blinders on—I just can't get a grip on what's happening," she noted.

"And what's so bad about that?" I offered. "That describes what most of us encounter initially in the therapy process. Sometimes not really knowing what's happening is the best route to feeling your way into a real sense of your client's struggle. Sometimes you just have to let go of what you know and let the therapy flow along its own course."

Gail looked at me as if I'd suddenly started speaking Farsi. "I just don't get it," she said flatly.

I was close to telling her to just forget it, that I couldn't help her, when an idea popped into my head and I decided to try something just a bit weird. I had nothing to lose and, even if it didn't help her, the thought of trying it out made me feel better right away. I told Gail that I had an idea for her next supervision session. Instead of watching her with a client, I'd meet her at the nearby Starbucks, and then we'd go to an unnamed destination. All she should do to prepare for this outing was to think about a shape. "It can be any type of shape someone might hold in his or her hand. I just want you to think about that shape and what it would look like, and keep the image fixed in your head." Gail all but rolled her eyes at this apparent tomfoolery, but nodded her head. "Fine," she replied sardonically.

A week later, Gail and I trekked across the snow-covered medical-school campus toward a Gothic-style structure known as the College of Arts. When she'd said she couldn't get a handle on being a therapist, the word, hands popped into my mind. So I'd arranged for a colleague in the art department to allow us to use one of the pottery wheels.

I sat Gail down in front of the foot-driven wheel, plopped a lump of wet clay in front of her, and told her to try to form the shape that she'd been thinking about all week on the pottery wheel. With a bucket of water to her right and a towel on her knee, Gail began to pedal the wheel and dove into shaping the amorphous lump into the image that had been percolating in her mind.

"You're so weird," she said, laughing nervously.

"I know," I replied, "but just be patient with me and think about feeling your way around this undefined shape until you've molded it into the form you want. But first, we need to add one crucial thing." I took out a blindfold and covered her eyes and said, "Now I want you to make that shape you've been carrying around in your head."

"What?" Gail screeched.

"Remember the shape in your mind and then mold this clay into that shape the best way you can," I instructed.

"This is ridiculous," she said. "I don't understand what this is supposed to prove." She was becoming a little agitated, but I persisted.

"Look, just see if you can do it. Keep the shape in your head and form it as you go along. Try to work at translating your thoughts to feelings as you feel out the shape of the item in your mind. Focus on the emotional sense of struggle and try to rechannel it by creating the shape you desire."

As Gail began to form her shape—a cherished vase she'd recently broken by accident—I suggested that by feeling the actual form evolve through her fingertips and molding the moist clay, she might begin to develop a sense of freedom to follow her instincts, to let herself go and wing it—the kind of freedom required when doing therapy. As I talked, it occurred to me that the same thing was happening to me as a teacher. In guiding Gail, I was being guided by my own intuitive sense of how to communicate with her. This experience was as much a revelation for me as I hoped it would be for her.

I remembered that during my own early learning, when I was working with difficult families, I'd felt similarly to Gail. I also recall that I was helped enormously by an unexpected experience—attending a concert. The concert opened with the crashing of kettledrums. It was as though the drums were alerting the audience to the fact that the percussion was to play a very important role in the concert. After a time, the drums fell silent, while the other instruments in the orchestra laid down a solid foundation of sound. Then the drums joined in again and blended with the orchestra. What struck me that evening was the concept of keeping some themes silent for a while, which is sometimes the way families cope with certain dynamics or stressors. Initially inspired by that concert, this insight regarding the ebb and flow of communication has remained with me during the course of my work as a psychotherapist.

About a half-hour later, with much laughter and a little bit of cursing, Gail had created her vase out of a shapeless mass. I took off the blindfold and said, "Okay, take a look."

Gail made a show of being unimpressed. "Ooh, did I make that?" she jeered sarcastically. "So, what's your point?" But she was smiling and her eyes were bright—at least she showed more energy and spirit than she had for some time.

"You need to do something like that with your clients," I said. "Don't always be so driven by the rules. You can't be afraid to try something outside your usual frame of reference. You might want to try not to be so calculating and take a risk—just like I did with you. Risk letting yourself not know how things are going to turn out all the time with your clients."

Hearing this, Gail sat up straight in her seat as if she were intent on taking a new posture.

As we talked further, we agreed that you need a good therapeutic plan—a directional map—once therapy is well underway, but that, sometimes, you must first feel your way blindly along in the dark to determine which direction you want to go, what strategy you want to use. Whatever techniques and interventions you use, you can't neglect your basic instincts about people—the gut-level intuition, that helps shape the course of therapy. Letting go and being patient are integral to finding your way.

Gail was definitely intrigued, yet still puzzled. "But I don't feel I have a real sense of collaboration with clients during treatment—that feeling of working together with someone."

I told her to think about the clay; once she allowed it to happen, wasn't the clay really guiding her fingers? "Sometimes you simply have to let go in therapy and trust that you'll discover the way by allowing it to emerge, particularly in the beginning, when clients are very guarded. Use your delicate fingertips," I urged.

"With the clay, you combined your sense of feel and touch with your knowledge of what you were trying to shape. It was instinct as much as intellect that allowed you to make your vase."

The same thing held true for therapy, I told her. "You have to trust your 'fingertips'—your own feelings—as much as your brain. If you can let yourself take a risk and not feel you have to calculate every move, a real felt understanding of the situation and the people involved will emerge. And out of that, your sense of collaboration during the course of treatment will begin to take shape, as well as your sense of mastery."

In my subsequent supervisory meetings with Gail, she appeared a lot less anxious and discouraged. "It's still a struggle for me, but I'm learning to let go. I think about that pottery wheel a lot, and I've put that crummy vase I made on my desk at the office to remind me to 'let go.'" In later sessions, Gail reported that she was making headway with her patients and had actually begun to look forward to seeing them.

Gail's memory of this important lesson will consist in part of that sloppy mess of clay that she was able to turn into something resembling a vase while blindfolded. And when she gets stuck in her head, unable to "think" her way through a tough case, perhaps she'll remember her eccentric supervisor. Perhaps she'll not only recall his advice, but also how she "got it"—just as I, to this day, recall those kettledrums.

Frank Dattilio, Ph.D., A.B.P.P., is a clinical psychologist in private practice in Allentown, Pennsylvania. He's on the faculty of psychiatry at Harvard Medical School and the University of Pennsylvania School of Medicine. Contact: datt02cip@cs.com. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

Thursday, 24 September 2009 11:42

Clinician's Digest

Written by Ari Rosenberg

Clinician's digest

By Garry Cooper

Exercising for Mental Health

Therapist Jane Cibel really makes her clients sweat. After a brief check-in, during which they report how their lives and therapy homework have gone in the past week, they get on her treadmill for five to eight minutes, and then hit the weight machines in her office for a full workout. Throughout their workout, she'll ask them the kinds of questions about their thoughts, feelings, and memories that other therapists ask clients.

For years, Cibel, who's certified as both a social worker and personal trainer, had been thinking about integrating exercise and therapy. Then four years ago, as the research continued to accumulate showing that exercise is as effective as therapy or meds for certain conditions, Cibel finally made the break with tradition. She set up her Washington, D.C., office with exercise equipment and told her clients to wear workout clothes to sessions. As word of her unique practice spread, her caseload shifted toward clients who are unhappy with their bodies, although she doesn't specifically treat body-dysmorphic or eating disorders. Underlying her clients' dissatisfaction with their bodies, she says, is usually depression, anxiety, or other mood disorders, and those are the issues her distinctive approach primarily addresses.

Cibel believes that much of the benefit of exercise comes both from making an initial commitment to taking action and from an increasing sense of accomplishment. While her clients work on their bodies, she reinforces their courage to change, their strength, their endurance, and their balance. "I'm not just commenting on their physical effort but using metaphors for how resilient they are," she says.

Cibel also uses homework exercises to build psychological strength. She'll tell depressed or isolated clients to call a friend or check the newspaper for community activities. She'll instruct clients trembling at the brink of career transitions to bring in a draft of their re'sume' or schedule a few job interviews. She also advises them to do at least two workouts between weekly sessions. The sense of mastery they gain from their workouts and from her positive feedback, she says, stays with them during the week and encourages completion of the homework assignments.

Cibel carefully monitors her clients to make sure the exercise doesn't harm them. She warns that therapists who start their clients on exercise regimens without appropriate training might be exposing themselves to liability. But, she says, therapists who want to use exercise to bulk up clients' emotional confidence and strength can always suggest that they head for the nearest gym and sign on with a personal trainer.

Autism Epidemic?

It's been widely reported in the media that autistic disorders, once considered rare, are approaching epidemic proportions. As many as 1 in 150 children are now thought to have autistic, Asperger's, Rett's, childhood disintegrative, or pervasive developmental disorders. The Autism Society of America estimates that more than a million people, both children and adults, in the United States have an autistic disorder. In California, the number of individuals seeking services for autistic disorders jumped 273 percent between 1987 and 1998, and then doubled in the next three years; all told, that's a 634-percent increase from 1988 to 2002.

Many claim the epidemic is caused primarily by childhood vaccinations, with the major suspect a mercury-derived preservative called thimerosal. Animal studies clearly demonstrate its toxic neurological effects, and since 1991, when the Food and Drug Administration mandated three additional childhood vaccinations that were heavily laced with thimerosal, the incidence of childhood autism has increased fifteenfold. A few years ago, the FDA and other federal health agencies, responding to public concerns, called for eliminating and/or significantly reducing levels of thimerosal in childhood vaccines, while still maintaining that today's vaccines are safe.

This spring, an article in the April Current Directions in Psychological Science claimed that there never was an "epidemic," and that the increases in autism are actually caused by an expansion of diagnostic criteria. Morton Ann Gernsbacher from the University of Wisconsin, the article's lead author, points out that between 1980 and 1994, the DSM significantly broadened its diagnostic criteria for autistic disorders. The 1980 diagnostic markers of "pervasive lack of responsiveness" to others, "gross deficits in language development," and "peculiar speech patterns" evolved in 1994 into "impairments" in social interaction and communication and "restricted, repetitive and stereotyped patterns of behavior, interests and activities." While the 1980 DSM had only two autistic categories—Infantile Autism and Child Onset Pervasive—the 1994 edition has five.

While those convinced there's an autism epidemic point to the alarming increases in cases reported by school districts around the country, Gernsbacher says that the increase is due to new reporting requirements. In the years since the reporting requirement changed, she argues, larger and larger numbers of previously undiagnosed or misdiagnosed children have begun to show up. Such an increase isn't new. Gernsbacher points out that after "traumatic brain injury" became a mandated reporting category, its incidence increased 5,059 percent in a 10-year period, and no one would suggest a sudden epidemic of traumatic brain injuries.

The stakes are high in determining whether an autism epidemic exists. If increasing levels of mercury in the environment are causing more cases (in addition to thimerosal, mercury is present elsewhere in the environment), everyone needs to know. For legal and psychological reasons, parents need to know whether their child's autism has come from genetics, vaccines, the environment, or broader and more accurate diagnoses. Gernsbacher, whose 9-year-old son Drew is autistic, has her own personal stake. She believes that if people accept that autistic disorders are distributed randomly and in large numbers across the population, most of the stigma associated with autism will disappear.

Are Gay Parents Good for Children?

Last January, President Bush announced at a press conference, "Studies have shown that the ideal is where a child is raised in a married family with a man and a woman." But when you look more closely at the research, you begin to wonder about the validity of the studies the President had in mind.

The American Academy of Pediatrics (AAP), the established organization of pediatricians, has no doubts about the issue. Its guidelines, arising from a 2002 review of research by Tufts University Professor of Pediatrics Ellen Perrin, say there should be no barriers to gay-parent adoption and custody. "There's no good evidence that same-sex parents are any less fit than heterosexual parents, and some of them may provide subtle advantages," Perrin says. She admits, however, that there have been no definitive studies of the psychological effects of growing up in a gay household, primarily because of sample problems. Until recently, there just weren't that many openly gay parents. But that's been changing, she says.

The AAP stance is in marked contrast to that of the American College of Pediatricians (ACP), which says that children of gay parents are definitely at risk for emotional problems. But the ACP, a small organization that broke away from the AAP over its position paper, seems as concerned with promoting certain values as with promoting children's emotional and physical health. The college says its mission is "to develop sound policy based upon quality research," and that it "recognizes the inherent value of both a father and a mother, united in marriage." The ACP position paper opposing gay parenting cites no peer-reviewed studies that directly find a negative effect of gay parents on children. Instead, it draws its conclusion primarily from studies finding that gay adults have higher incidences of psychological and health problems.

In fact, the idea that children do worse when raised by gay parents appears to be based on the assumption that there's something inherently wrong with homosexuality. "Homosexual parents don't do well because they have more partner changes, more drug abuse, more history of missing work, and all these things conspire to make a homosexual parent less suitable," says psychologist Paul Cameron, perhaps the most prominent researcher who opposes gay parents. Cameron is Chairman of the Family Research Institute, an organization that believes "in preserving America's historic moral framework and the traditional family." Perrin, he says, used "biased studies from homosexual journals." (About 7 of her 23 journal citations come from peer-reviewed journals such as the Journal of Homosexuality). By contrast, 10 of Cameron's studies about homosexuals have been published in one journal, Psychological Reports, which, says Perrin, authors have to pay to be published in.

Responding to positions of researchers like Cameron, Perrin insists that it "isn't the sexual identity of the parents that matters: it's things like how well the parents get along, how integrated the kids are in school—the same social factors that matter to all kids."

On-line Case Consultation and Confidentiality

On a therapists' listserv, a therapist recently asked for advice about a client who'd been thinking about breaking up with his girlfriend, who's eight months pregnant and obsessed with a rock star. In using an online listserv to seek help, is this therapist leaving herself open for professional sanctions and lawsuits? Yes, says John Riolo, a social worker and consumer advocate for therapy clients.

Therapists don't realize, Riolo contends, that even their posts to invitation-only listservs are widely accessible—often for years—to a much wider audience. In actuality, the screening process for ensuring that only mental health professionals join a listserv is far from effective. It's easy for anyone, including clients, to join listservs under assumed identities. Meanwhile therapists, often lulled by the supposed anonymity of listservs, may think that by not naming their agency or the state in which they work, they're protecting their clients' confidentiality. But anyone can easily track down a therapist's location and affiliation from their name or e-mail address. From there, a husband can discover, for example, that his wife is having affairs, even from a seemingly innocuous statement like, "At our agency, a 30-year-old borderline married client confided to me that she's picking up men in a bar."

Not all professionals agree with Riolo. Social worker Joel Kanter, who moderates a listserv of clinical social workers, thinks that Riolo is being too alarmist. Therapists often share case material, prudently disguised, at conferences and in articles, he says, and if they take the same camouflaging precautions on listservs, they can adequately protect confidentiality. The advantages of online consults—getting quick feedback from a large community of professionals—far outweigh the small confidentiality risk, he says, pointing out that he's never heard of any complaints or sanctions arising from on-line consultations.

But Frederic Reamer, chair of the National Association of Social Workers (NASW) task force that wrote the association's code of ethics, points out that discussing a client on the Internet can run afoul of several of NASW's confidentiality provisions, including the proscription to "avoid discussing confidential information in any setting unless privacy can be ensured." The American Psychological Association's ethics code has similar provisions.

Some listserv moderators have modified their policies in response to Riolo's articles. One listserv asks members to send case consults directly to the moderators instead of to the entire list, so that the moderator can disguise identifying information about the clients and the therapist. That, Riolo contends, is insufficient, pointing out that several members of that listserv, forgetting the provision, have posted to the entire list, leaving themselves and their clients wide open to trouble.

Riolo's series of articles on confidentiality can be found at www.psychjourney .com/cseries.htm.

Examining Controlled Separations

Ever since the Wall Street Journal published an article last summer about therapists who use controlled separations with couples, Meg Haycraft, a therapist from Skokie, Illinois, who was mentioned in the piece, has been getting calls from couples who want to try it. The idea of a controlled separation, which its adherents paradoxically insist is a powerful tool for encouraging couples to stay together, is catching on, even, surprisingly, among the staunchest marriage proponents.

The intervention has been around since 1998, when Lee Raffel, a therapist from Port Washington, Wisconsin, published Should I Stay or Go: How Controlled Separation (CS) Can Save Your Marriage. The book lays out guidelines for helping couples craft a detailed agreement for temporarily living apart. But unlike standard separation agreements, the couple agrees not to file for divorce while they're separated. They also discuss how to continue seeing each other, and agree to work on their relationship through exercises, homework, and occasional conjoint therapy sessions.

It isn't for everyone. Raffel advises against it when there's violence or substance abuse involved, primarily because abusers and violent spouses probably won't honor the separation agreement. She also cautions therapists not to use it solely because they feel unable to manage conflictual sessions. She herself offers couples an eight-session contract in which to address their conflicts, only suggesting a controlled separation when they can't seem to make progress or avoid arguments. Other couples whom she considers candidates for controlled separation are already separated and may need the structure offered by this approach.

Raffel estimates that two-thirds of her controlled-separation couples have saved their marriages. Elsie Radtke, who counsels couples for the Archdiocese of Chicago, estimates that about half of her clients who separate end up divorcing. Whichever figures you use, it's still a lot of divorces avoided. "Controlled separations," says Haycraft, "may be the missing piece in today's culture that sees the only options as toughing it out or divorcing. It's a device to slow things down, to be the springboard of hope again."

When Grief Lasts

In recent years there's been a growing shift within the grief-counseling community: the old idea that grieving people must detach completely from the deceased has given way to a gentler notion that the bereaved should accept the reality of the death while maintaining thoughts of the deceased that are integrated into their ongoing lives. Now a new kind of grief therapy explicitly incorporating this perspective has been shown to work with the most stuck mourners of all, those people suffering from complicated grief.

While the usual acute grieving lasts anywhere from 6 to 18 months (with or without a therapist's help), the symptoms of complicated grief last much longer. Sufferers remain stuck in the initial, most debilitating stage of grief—longing for the deceased, avoiding places and situations that evoke memories of their loved one, experiencing recurrent pangs of grief, and unable to think about the future with any enthusiasm or hope. Now an article in the June Journal of the American Medical Association presents promising results for Complicated Grief Therapy (CGT), a therapy adapted from effective PTSD and depression treatments.

CGT, which takes about 16 sessions, begins with a history of the relationship with the deceased, including the story of the death, and psychoeducation about grief. The exercises and discussion that follow shuttle between helping grieving people engage with the loss and encouraging them to consider the future. This helps clients feel they can move forward at the same time that they cope with the loss of their loved one. Unlike previous models, it doesn't try to get people to achieve "closure" in their grief.

After the psychoeducation phase, "revisiting" begins. This is an exercise in which the bereaved person imagines that he or she is back at the time of the death and retells the story of how the person died, says the study's lead author, psychiatrist Katherine Shear, from Columbia University's School of Social Work. The therapist tape records the story, occasionally asking what the client is feeling. Clients take the tape recording home and listen to it between sessions.

After three to five sessions, the therapist introduces structured-memory exercises, instructing clients to recall favorite or positive memories of the deceased, then not-so-positive and even negative recollections. This helps clients feel that they're free to think about the deceased person in a range of ways. Interspersed with the memory work, therapists encourage clients to revisit situations and activities they've been avoiding. This strategy is similar to in vivo exposure in PTSD treatment. For instance, if the person has been avoiding movies, because going to movies was a favorite activity with the deceased, the therapist may encourage the client to merely look at the movie section of the newspaper and contemplate seeing a movie, with the eventual goal of actually sitting through a show.

A full manual of CGT will be ready in a few months. Shear encourages therapists to adapt the overall orientation and any of the techniques with their clients who are experiencing protracted grief.

Resources

Exercising: Cibel's website is at www.psychfitinc.com. For the latest review of research on exercise and mental health, see Harvard Mental Health Letter (December 2005); Autism: Current Directions in Psychological Science 14, no. 2 (April 2005): 55-58 ; Gay Parents: Perrin's report is at: http://pediatrics.aappublications.org/cgi/content/full/109/2/341 and the ACP's position is at http://www.acpeds .org; Grief Therapy: Journal of the American Medical Association 293, no. 21 (June 1, 2005): 2601-08.

Thursday, 24 September 2009 11:42

Case Studies

Written by Ari Rosenberg

CASE STUDIES
By Dan Short

Erickson's Legacy
Strategic therapy rests on skillful information-gathering

Milton Erickson has become a legendary figure among therapists for his skill in standing the traditional idea of "resistance" on its head. With his keen observational skills and his grasp of the multiple dimensions of people's lives, Erickson demonstrated again and again that getting a clear and detailed idea of his clients' unique needs, beliefs, and behavior patterns was the key to successful therapy, especially in cases that hadn't responded to more traditional approaches. Known most of all for his strategic use of existing personality features, he carefully utilized every bit of information
he gathered from the client. The case that follows, inspired by his approach, shows the unfolding of a strategic approach as more and more relevant clinical information emerges.

Sophie entered the office looking defeated and demoralized. Every movement seemed to require effort. She had dark rings under her eyes, her short hair lay flat on her head, and she was obese. The therapist who'd referred her expressed concern that her depression was worsening, despite a regimen of antidepressants and supportive counseling.

On her small frame, Sophie carried 191 pounds. "My arms are larger than most men's thighs," she said wearily. During the previous 12 months, she'd watched her weight increase as her motivation for self-care decreased. Treatment wasn't working—even the mental health experts didn't seem to be able to help her—which made her situation seem hopeless. She was slowly sinking into a dark place, from which she could see no escape.

So I asked her, "Will you tell me what it is about the problem of weight that causes you the most distress?" As is often the case, Sophie surprised me with her response. Depression, she said, was the most loathsome consequence of her obesity, because the condition forced her to take antidepressant medication and, as she put it, "These drugs make me feel like I'm not living in my own body." Then she added, "But no one will work with me unless I take medication. What's your opinion?"

I suspected that the question of whether to take medication was an issue of power and control, just as her eating disorder was. In both cases, she felt that she had no control over what went into her mouth, and no more ability to say no to a doctor than to stop herself from overeating. I didn't want to be just one more authority figure telling her what to do.

Nevertheless, Sophie wanted an answer, as well as validation. So I chose my words with care, "I'm not licensed to practice medicine. It isn't appropriate for me to tell you to take medication or to stop medication." Then, leaning forward for emphasis, I continued, "I can only give you psychological advice. And my psychological advice is that you do everything you can to take care of your body."

One of my basic strategies in therapy is to tell clients it's okay for them to take care of themselves as best they know how. This blanket permission was intended to avoid a covert power struggle, help Sophie access her own latent resources, and validate her fundamental right to take care of herself.

Hearing this, Sophie seemed more animated. She began telling me how miserable she was on her medication, of which she'd tried a variety. She'd been depressed most of her life, with good reason. Her mother had abused her, as had her husband, a crack cocaine addict, until the day she found him dead, having committed suicide. "After his death, I gained 40 pounds," she said. "At this point, I've experienced a complete loss of motivation. I can't make myself exercise, or even clean my house."

I let her continue telling her story uninterrupted until she seemed content to stop, then told her I was sorry that she'd experienced such terrible events. People like Sophie, who've been abused since childhood, tend to blame themselves for all the bad things done to them, and often have never been told that they don't deserve to suffer. I don't like to focus on the past or on a person's symptoms, but people shouldn't suffer alone, so I listen to these stories with respect and acceptance.

Then, I inquired about her goals. "Now tell me, what do you really want?" Suddenly, a different Sophie appeared. With energy in her voice, she said, "I have eight grandchildren who I absolutely adore. I want to be there for them. I'm also good at my job and like the recognition I get. I don't want to be forced to do things I don't want to do. I don't want to be forced to take medication! I want to get off my blood-pressure medication. I want to be able to eat food and enjoy it. I want to live life." She paused, "I want you to use hypnosis to make me lose weight."

Sophie wanted me to "make" her lose weight. The only way she could see herself succeeding was for someone to take control. This put me in a bind. After a lifetime of resenting always being told what to do, she'd resent me, too, if I did as she asked. At the same time, refusing her request would only add to her sense of powerlessness. So I replied, "I'll agree to use hypnosis with you, as you've requested, but first you must get your weight down to 185 pounds." She stared in confusion: "But how?"

"Use any means that you can believe in." By saying this, I was able to show a willingness to do what Sophie asked of me, as long she demonstrated a willingness to cooperate. I learned from Erickson that, while therapy should help a person learn to believe in his or her capabilities, it's this spirit of cooperation that gets the client's energy activated.

For her second visit, Sophie entered my office making jokes about her progress. She'd lost eight pounds in seven days! She held out her hands and feet to show me that they were no longer swollen. "I think all eight pounds were water." She attributed her rapid success to her own decision to stop taking antidepressant medication. Ironically, by exercising her right to take care of herself, as suggested, she'd helped herself by rebelling against the people seeking to help her.

As the session progressed, Sophie described deep feelings of worthlessness and a chronic need to punish herself. "I know I set myself up to be in an unhealthy relationship and stay in it. I somehow just have to keep hurting myself," she insisted. Because it seemed highly unlikely that I'd be able to convince her otherwise, I decided to use her existing belief as a therapeutic contingency.

After asking her to close her eyes and go into a trance, I stated in a frank tone of voice, "You've made it clear that you're unable to stop punishing yourself, so you might as well face the facts and punish yourself with clear intention. You feel very little self-worth. You'll spend more money than you can afford buying gifts for others, but you won't buy anything nice for yourself. I know that it's almost painful for you to do anything kind toward yourself. Therefore, this upcoming week, you're to punish yourself with acts of self-kindness!"

The strategy here is that, if a negative behavior can't be stopped, it should be made useful by connecting it to something positive. One of many benefits of this approach is that it helps clients feel less helpless and less antagonistic toward their behavior.

Starting the third visit, Sophie was smiling and laughing as she told me about a very positive review she'd just gotten from her supervisor, who'd called her a "model employee." She looked healthier. She told me proudly that she'd been feeling less of a need to punish herself, and that her internal voice was less condemning. She'd also bought herself a new bedroom suite.

Then, without my asking, Sophie shared some very painful information about her mother. Eyes cast downward, she said, "She was physically abusive." I could tell from her eyes and posture that she didn't want to say any more. She'd been thoroughly conditioned as a child to respond to authority with slavish obedience, but making her talk about painful memories wouldn't be different from forcing her to take a pill she didn't want. Neither of these are intrinsically problematic, but when this type of client feels forced by the therapist to suffer through a healing ritual, then there's risk of creating greater amounts of depression. Following a lifetime of education in learned helplessness, Sophie needed to see that she has choices. So, after a brief pause, I asked her what she'd like to use the rest of our time talking about.

She raised her head and a smile shot across her face. "I made my phone call to get signed up at a gym!" she replied. We spent some time marveling over this wonderful accomplishment and her stunning progress in therapy, and then talked about possible solutions for her problems with one of her daughters and a grandchild for the rest of the session.

The Central Problem

Sophie's fourth and fifth visits with me didn't go as well. She came into the fourth session criticizing herself harshly and left doing the same. "It's my complete lack of self-discipline that keeps me fat," she doggedly insisted. At the start of the fifth visit, she was still clearly in an unhappy state, insisting that she hated everything about her physical being. There seemed to be nothing I could do to help her think well of herself. All the joy from her initial breakthrough had faded. It seemed as if Sophie was sliding back into the darkness that had dominated most of her life. I was reaching out with a helping hand, but didn't know where to grasp.

Then I remembered one of my basic therapeutic guidelines: whenever you're uncertain of what to do, collect more information. Like riding a teeter-totter, highly complex therapy requires a back-and-forth process of assessment and experimental intervention. So after pausing a while to silently study Sophie's demeanor, I decided to risk a question designed to stir up emotions and, hopefully, help me better understand her needs: "Sophie, what secret are you still keeping from me?"

Hearing my question, Sophie regressed. It was as if the reply were coming from the lips of a 6- year-old child. "I dirty my panties," she whispered. In short, fragmented sentences, she alluded to problems with involuntary discharge of urine and feces, which she'd suffered with intense shame for decades.

After sharing such a carefully guarded secret, the most urgent question in Sophie's mind must have been, "Will he now reject me?" I wanted to communicate complete and total acceptance. However, it would have been impossible to show I accepted her fully, even with her problem, if I immediately tried to fix or eliminate it. So, I looked directly into her eyes and told her warmly that I was very pleased she'd found the courage to share her secret with me.

She visibly relaxed. My response seemed to communicate that, whatever her circumstances, she was fundamentally alright as she was.

Content with my response, Sophie shifted her attention back to the problem of overeating. This was much less distressing for her to talk about. I asked if there was a food that she felt was irresistible. Sophie responded without delay, "Krispy Kreme donuts!" Merely talking about the donuts seemed to create excitement in her. I asked if it seemed logical that once cured of her addiction to this most irresistible food, she'd be able to gain self-control in relation to all other foods. Sophie agreed that this made sense, but as she put it, "There's no way you can get me to stop eating Krispy Kreme donuts."

I agreed with her, but qualified her statement. "There's no way I can get you to stop eating Krispy Kreme donuts unless you give me permission to. If you give me permission, then I can help you end the addiction this week, and it won't even require the use of hypnosis."

Sophie shook her head. "This is my week to go on vacation to Puerto Penasco. My favorite thing to do there is to treat myself to all the wonderful greasy food you can buy from street vendors."

I responded enthusiastically. "This is perfect! All you have to do is give me permission to intervene, and then follow my instructions as fully as possible."

Sophie cautiously agreed, so I explained the intervention. "After you leave my office, buy yourself half a dozen Krispy Kreme donuts. Take them home and put each donut in a baggie. You leave for your vacation tomorrow, so you can pack the donuts in your suitcase tonight. While on vacation, eat all the food you want during the day. Don't deny yourself anything. Then each night, just before you brush your teeth, pull out one of the baggies and eat a Krispy Kreme donut. Do this every night. It'll be difficult, but do your best to eat all six donuts."

To understand the logic behind this intervention, it's important to recognize the large number of failure experiences Sophie had accumulated while trying not to eat this type of food. She was waiting for me to ask her to do something that she knew she couldn't do, and if I had, the exercise would have doomed her to more failure. However, asking her to do something which she believed she couldn't stop herself from doing was a safe way of laying a foundation for hope.

Sophie looked at me with an incredulous stare and said, "You just don't understand how much I love these donuts." Then she agreed to give the exercise a try.

Sophie came in for her sixth session wearing a mischievous smile. After exchanging a few pleasantries, she caught my eyes in a sideways glance. "You already know that I'll never again eat Krispy Kreme donuts, don't you?"

With a chuckle, I confessed, "I've had the unhappy experience of eating old, stale, soggy donuts out of plastic baggies. It really ruins your taste for donuts!"

Then she confessed. "I stopped eating them after the third one. I thought to myself, 'There's no way I'm going to eat these things, no matter what Dr. Short says!'" The situation was comical and Sophie was enjoying herself. Even more important, she'd learned she could look in the face of an authority figure and joyfully confess that she'd followed her own will, not his.

The Power of Hope

Having shifted toward an internal locus of control, Sophie confidently declared, "Once I get disgusted with something, I'll make whatever changes I need to make." She was now ready to take on the central problem, so I asked one last set of questions before discussing an intervention. I wanted to make absolutely certain I had an accurate understanding of the situation.

"I'm sorry to have to bring up this unpleasant topic, but I feel that I need to know a little more about the problem of your dirtying your panties," I said gently. I didn't want to be in a position of trying to help her change something I didn't fully understand and, at the same time, I didn't want to shame her in any way.

As she talked more about this, it turned out that the behavior dated back to early childhood, when Sophie was severely beaten by her mother after accidentally staining her panties. From that point on, this part of her biological functioning became the focus of obsessive, negative attention. The mother even got the family doctor to examine her daughter for defects, which Sophie experienced as painfully intrusive and mortifying. The doctor told her that she should do Kegel exercises to strengthen the muscles used to hold back urine, which only increased her anxious preoccupation with this part of her body.

Sophie began checking her panties several times a day and hiding them in the trash whenever she thought they were dirty. This habit carried over into adulthood. With a look of shame, she confided, "The problem happens while I'm at work. I hide my panties in the trash, feeling that everybody in the building knows that it's me doing this. It's so humiliating." Because of the problem, she felt horribly inferior to others, and lived in constant fear that somebody might discover her "dirty" secret.

After she finished this sad story, I said, "Would you like me to help you cure yourself of this?"

Sophie's face turned pale. "But it's impossible," she said. But the idea had so riveted her attention that she didn't seem to be breathing.

I responded with great confidence, "Sure it's possible! I can help you initiate the cure in a single session."

Sophie was highly skeptical. "But the doctors have already tried everything. I did the Kegel exercises; they didn't work. When I had my hysterectomy, the surgeon went in and surgically altered my bladder, but it didn't help, either. They told me nothing else can be done."

"The doctors that worked with you can believe whatever they'd like. But I happen to believe that you have perfectly good muscles in your body, and I can prove it to you by asking a single question."

Still fresh from the Krispy Kreme donut cure, Sophie was ready to place tremendous confidence in our alliance. More important, she was ready to be released from the bondage of her neurotic behavior. So I asked a question to which I already knew the answer, "Do you ever dirty or wet your panties during the night?" Sophie shook her head no. I gleefully responded, "There you have it! If your muscles are good enough to hold your urine during eight hours of sleep, then they're certainly good enough and strong enough to hold your urine during the four to five hours between your daytime bathroom breaks."

Sophie began to get enthusiastic, "You mean if I can keep clean at night, then I can keep clean during the day!?"

"Yes," I said. "You just have to give your unconscious mind permission to start using the ability you already have."

With eager anticipation Sophie asked, "But how do I do that?"

I felt there could be added value in helping Sophie say "no" to me. So I indulged my creative side and gave her a plan I thought she'd reject. My plan involved a paradoxical ritual that was likely to work, but wasn't right for her. She quickly exercised her option to reject it.

"Well," I responded, "if you don't want to do it my way, then you can come up with your own plan. We'll have you implement that one first, and if it doesn't work, then you always have my plan as a fallback."

Sophie thought for a moment, asked some questions about self-hypnosis, and decided she'd go to bed each night repeating to herself, "Unconscious mind, make my bowels and bladder work as well during the day as they do at night." She'd repeat this until she fell asleep. The plan was clearly identified as hers, and I conceded that perhaps it was better for her than my plan, which, of course, was true, because it gave her greater agency.

The seventh visit would be my last opportunity to meet with Sophie. She came in smiling and let me know early in the session that she was ready to continue her progress on her own. Raising both arms in the air like an exotic belly dancer, she happily announced, "I feel so good about myself, I hardly care if I lose any more weight . . . but I have a strong feeling that I will." It was clear that things were going well. Interestingly, she didn't bring up the topic we'd discussed in the previous session.

Eventually, my curiosity got the best of me. Apologetically, I asked, "Sophie, it's really not any of my business, so you do not need to answer this question, but I'm wondering how the self-hypnosis worked?" With a coy smile, Sophie cautiously stated, "It came so close to being a perfect week." Then a tear ran down her cheek, "I'm almost too scared to think that it's true."

At first, I misinterpreted her statements. I insisted, "Even just one day of clean panties is a wonderful accomplishment you can continue to build on!"

She interrupted, "No. I made it to the bathroom each time! It's just that I was so scared I'd dirty my panties that I kept running to the bathroom to check. I must have gone to the bathroom 300 times this week, but each time there was nothing there."

My jaw dropped, "Amazing!" I said, "You managed to pull off a complete cure on your first attempt. Congratulations!"

Sophie left the office full of pride and enthusiasm for the future. A year has now passed without her requesting any further assistance.

When a clinician uses a strategic approach to therapy, it means that each interaction is guided by an understanding of what variable experiences the client needs to glean from therapy. To work strategically, you have to get to know the person in front of you. It isn't enough to read textbooks or study group statistics. Most important, it's necessary to recognize that healing emerges from within the client and, therefore, that's where a foundation of hope is constructed.

As this case illustrates, life transformations occur by simply shifting clients' attention away from that which they've failed to do, onto those things that they can, without question, accomplish.

Case Commentary

By Carol Kershaw

"We tell ourselves stories in order to live," a haunting line from Joan Didion's The White Album, came to mind as I read this case by Dan Short. While the hypnotic story his client tells herself is one of obesity and imprisonment by a shameful secret, Short succeeds in focusing her on possibility rather than deficit. As her depression begins to lift, she becomes more interested in losing weight her way. Rather than siding with her victimhood, he sides with her strength and self-empowerment.

As with many overweight patients who begin to have success losing weight, Sophie stumbles and stops her self-improvement program. Short senses there's something unspoken and asks her to reveal the secret. Sophie is relieved to tell the truth to someone who's fully accepting of her problem. Convinced that Sophie has the internal resources to keep from having accidents while asleep, Short helps her develop her own plan for successfully controlling her soiling.

Theory often follows the successes of an astute clinician, and in Erickson's case, there are many interpretations about what he did. While Short emphasizes Erickson's devotion to doing strategic therapy, some people believe he did neurolinguistic programming, and others insist he did paradoxical therapy. Still others focus on the symbolic-communication aspect of his work. In fact, he did all of this and more. He was a master at assessing what clients needed to learn and how to help them do so, no matter how unorthodox the methods required.

Throughout this case, Short mentions some of the general therapeutic strategies that guide his work. But such general strategies must always stand the test of their relevance to an individual case and I had some questions about the overall relevance of some of the strategies he mentions. For example, he says, "One of my basic strategies is to tell clients it's okay for them to take care of themselves as best they know how." Of course, this isn't something we'd say to a child abuser. Sometimes the best way clients know how to take care of themselves is through harmful measures. A better guideline might be to emphasize the part of the client that wants to make "better choices."

Elsewhere Short says that if a negative behavior can't be stopped, try to make it useful by connecting it to something positive. But the opposite can also work. It can be helpful to suggest the negative behavior is an attempt to learn something and query what that might be.

Short also states that whenever you're uncertain of what to do, start collecting more information. While this may work sometimes, it's frequently more helpful to be quiet and allow your own unconscious mind the opportunity for creative thought, which will also make the client carry more responsibility for change as well.

Author's Response

The reviewer makes an important point that I'd like to further emphasize: skillful therapy requires discernment. It isn't enough to memorize a set of rules and then rigidly apply them to every person who enters the office. Paradoxically speaking, one should never sacrifice learning for the sake of preserving absolute generalizations.

Dan Short, Ph.D., is a clinical psychologist and trainer in Ericksonian hypnosis, living in Phoenix, Arizona, who specializes inbrief treatment of recalcitrant problems. He's the lead author of Hope & Resiliency: Understanding the Therapeutic Strategies of Milton Erickson. Contact: hope@IamDrShort.com; website: www.Hope AndResiliency.org.

Carol Kershaw, Ed.D, is codirector of the Milton Erickson Institute of Texas and a psychologist in private practice who specializes in hypnotic psychotherapy and neurofeedback. She's the author of The Couple's Hypnotic Dance. Contact: hypnopsych@aol.com;
website www.mhehouston.com.

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