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by Susan Johnson
On the first day of a clinical placement in my doctoral program during the early 1980s, I was assigned to a counseling center and told by the director that because of unexpected staffing problems, I'd be seeing 20 couples a week. I'd never done any couples therapy, but I did have considerable experience as a family and individual therapist with emotionally disturbed adolescents--a tough, challenging group of clients if ever there was one! So my first thought when given this new assignment was, "After what I've done, how hard can this be?"
I plunged in and almost immediately was appalled by how hard it actually could be! People who seemed perfectly sane and reasonable often became totally unglued with their partners--enraged and aggressive or almost catatonically mute. I was in way over my head, with no idea what to do with these couples.
I remember one wildly angry pair, whose fight escalated to the point that they threatened to kill each other in my office. What I didn't know at the time was that while I was trying to prevent a double homicide, the clinic's director and staff were poised on the other side of the door, debating about whether someone should come to the rescue. "Do you think she can handle it?" one whispered to another. At that moment, they all heard me break into the melee and shout at the top of my lungs, "Shut up, both of you!!" In the ensuing stunned silence, the director said to the worried assembly, "I think she'll be just fine."
In spite of my complete befuddlement and frustration, I found the dramatic, intricate, baffling dances these pairs did with each other enthralling, and wanted to understand better what was going on. Clearly though, I needed some tool in my toolkit other than "Shut up!" if I wanted to make any headway with them. The drama enacted in front of me by a couple was so powerful, so emotionally compelling, and yet so complex and ultimately confusing, that I felt chronically lost. I desperately needed some sort of map that would help me make sense of what I was seeing.
I remember one woman, who mostly communicated with her husband by screaming at him, sitting in my office one day describing in gruesome detail all the horrible things she was going to do to the husband's body as he lay asleep in bed that night. As usual, he ignored her completely, except to occasionally yell back, "You're absolutely crazy! You belong in a nuthouse!" Sometimes a wife would sob to her husband, "I love you, I love you--you have my heart in your hands." Then a minute later, she'd be screaming at him, "You bastard! I'll never let you touch me again!" Partners wept, made outrageous threats, and sat sunk in depression, all the while knowing perfectly well they were destroying their relationships, but unable to help themselves. I had no idea how to help them, either.
by Barry McCarthy
At 52, Alex was worried about the state of his penis. He missed the easy, automatic erections he once had and sometimes was mortified by his inability to be hard enough to engage in intercourse. With every such "failure," he felt his sexual confidence waning. Alex was sold by the Viagra ads on TV and went to his internist, who was more than willing to give him a free sample of pills.
The first three times Alex took Viagra, it worked as promised. "Whew," Alex thought, glad he hadn't raised this touchy issue with Lorraine, his wife of 28 years. He felt he shouldn't have to talk about sex; he'd always been a take-charge kind of guy, who certainly had never had any problems on this issue, thank you very much.
But the fourth time Alex took Viagra, he got an erection and was able to insert, but he promptly began to lose his erection and felt very panicky. Lorraine tried to restimulate him, but Alex pushed her away. This wasn't supposed to happen. How could the "miracle drug" not work for him? It had to be Lorraine's fault.
The Truth About Erections
Adolescent and young-adult men learn that erections are easy, automatic, and most important,Â autonomous. They can experience desire, arousal, and orgasm without help, or even active cooperation, from their partners. Alex subscribed to the common belief about male sexual performance on demand: "A real man is able to have sex with any woman, any time, any place."
The Viagra media blitz both feeds and amplifies this male performance standard. The blue pill, the ads suggest, will restore to you the automatic, autonomous, rock-hard erections of your twenties. But even for successful Viagra users, 20 to 35 percent of the time, the drug doesn't work. More striking still, the estimated dropout rate for Viagra within a year is between 40 to 80 percent of users. This is caused by unrealistic expectations of returning the man to 100-percent guaranteed erections. Medication cannot be a stand-alone intervention. As with so many one-shot, simplistic solutions to human emotional problems, the promise of cure far exceeds the reality.
The real news
behind the Viagra sensation is what it says about men's misunderstanding of their own sexuality as they age. Young men can and often do get erections quite suddenly and unexpectedly, simply when a good-looking body swims into view or a sexual fantasy wafts through their brains. They don't need the stimulus of physical touch to become aroused. Middle-aged men expect the libido of young studs long past the time when their bodies can keep up the pretense.
Contrary to media myths, movies, and male braggadocio, sex is seldom 100-percent successful, especially as men age. The most important fact for our sex-saturated society to accept is that 5 to 15 percent of all sexual experiences among well-functioning couples are dissatisfying or dysfunctional. In other words, contrary to the cultural myth of ecstasy all the time as the norm, almost all happy, sexually fulfilled couples experience lousy sex occasionally.
Unfortunately, men who haven't gotten beyond the equation of sex = erection = intercourse become more vulnerable to sexual dysfunction as they age. Often, like Alex, they're only one or two flagging erections away from feelings of sexual inadequacy. Indeed, for men, the largest factor causing inhibited sexual desire is fear of erectile failure. By a certain age, men need to learn what most women already know: good, satisfying, pleasurable sex, particularly in midlife and beyond, is more a matter of intimate teamwork than of physical hydraulics.
Once "the machine" fails to function a few times as it always has, confidence in the normal cycle of positive anticipation, satisfying sex, and a regular rhythm of sexual contact is lost. Instead, a new, more pernicious, cycle takes its place: anticipatory anxiety, tense and failed intercourse performance, embarrassment, and sexual avoidance. The man becomes an anxious, self-conscious, sexual spectator, the worried and passive observer of his penis--a state of mind that's the very antithesis of eroticism.
It was at this juncture--post-Viagra failure--that Alex and Lorraine, at Lorraine's insistence, came to see me, a couples therapist with a subspecialty in sex therapy.Â As often occurs, Lorraine was more enthusiastic about addressing the sexual problem than Alex. He felt embarrassed, ashamed, and demoralized. In the first session, I normalized both the erectile dysfunction (ED) and his experience with Viagra.
Alex was used to being the expert, not the one seeking help, especially from Lorraine. Yet Lorraine was more than willing to help resolve this problem, as long as Alex didn't blame her for the ED. She enjoyed sex and wanted it to be a part of their lives. She missed not just intercourse, but the whole range of sensual, playful, and erotic experiences that went with it. At the end of this session, I gave them a chapter from Rekindling Desire , which I wrote with my wife, Emily, to reinforce the need for them to work together in the face of a common enemy: inhibited sexual desire and performance anxiety.
After the initial couples session, I see each person for one individual sexual-history session to tell his/her story of their psychological and sexual life. Then we have a couple-feedback session.
From those sessions, I developed a therapeutic plan aimed at revitalizing desire and helping Alex regain confidence in his erections. Alex needed to stop seeing sex as a competitive performance--in which Lorraine's existence and sexual feelings were almost incidental--and begin approaching his wife as his dearest, most intimate, friend, with whom he could share pleasure, eroticism, and arousal.
Alex had always felt that he shouldn't have to have his penis stimulated by Lorraine--his erection should be sufficient unto itself. I told him he'd need to be open to her penile stimulation. Even more potentially alarming for a man who so valued his own sexual self-sufficiency, Alex needed to learn to piggyback his arousal on Lorraine's arousal. Alex began to learn that it was both normal and manly to use the "give-to-get" pleasuring guideline, so that the more responsive and aroused she was, the more aroused he became. This was good news for Lorraine, who'd been afraid to let herself get too aroused for fear Alex would feel even more pressured to perform. I pointed out that a woman's arousal can be a major aphrodisiac for the man. The key to achieving change was Alex's willingness to try new ways of thinking about and experiencing sexuality, and Lorraine's enthusiasm for renewed intimacy and eroticism.
I asked Alex to tell Lorraine the emotional, physical, sexual, and interpersonal factors he found most attractive about her. Then he was to make one to three requests--not demands--that would make her more attractive to him. The next day, they were to switch roles, and Lorraine would do the same with Alex.
Alex told Lorraine that he appreciated her spunkiness, her interest in working with him to revitalize their sexual life, her work skills, her help in caring for his mother when she was dying, and her staying in good physical shape and carrying herself in an attractive manner. Making requests was harder for Alex. His three requests were to give penile stimulation before he had to ask for it, to be sexually receptive and responsive, and to not talk about sexual problems when in bed. Lorraine enthusiastically agreed to them.
Lorraine wrote out the characteristics she found attractive about Alex. Alex had developed such a negative sexual self-esteem, it was difficult to accept Lorraine's genuine compliments. From this exercise, Alex realized how contingent on performance his sexual self-esteem was.
Alex was surprised by Lorraine's first request--to remember her birthday and plan something special--but was quite willing to do this. The two sexual requests that followed--that Alex shower before a sexual encounter so that oral sex would be more inviting and that he not apologize if they didn't have intercourse, but to just hold her--were more difficult for him. Alex realized with surprise that he had no idea that these three issues bothered Lorraine. But as he thought about it, they really were pretty easy requests to fulfill. At this stage, both Alex and Lorraine felt more positive and hopeful, realizing this wasn't an adversarial process; they could be on the same intimate team.
Lorraine had previously only achieved orgasm occasionally during intercourse. I suggested they refrain temporarily from having intercourse, and encouraged them to explore erotic stimulation to orgasm. She reported that she enjoyed the pleasuring exercises she and Alex were trying and found it considerably easier to reach orgasm, and they were more intense and satisfying than those she'd experienced during intercourse. Alex was ambivalent about these developments. He was glad that he could please Lorraine sexually, but afraid that she might not enjoy intercourse as much as he. I assured Alex (and Lorraine reinforced this) that intercourse would continue to be an integral part of their sexual relationship. The problem wasn't intercourse, but Alex's pass-fail approach to it. The goal of therapy was, in part, to help him realize that there was more to making love than successful intercourse.
Alex was enjoying the pleasuring exercises, especially the comfort exercise, in which they engaged in playful (mixing nongenital and genital) touch in the living room with music on but no talking. The hardest thing for Alex to accept was that instead of being the Lone Ranger, he enjoyed and even needed Lorraine's stimulation.
The most helpful exercise was the "wax and wane erection" experience. When Lorraine stopped manually or orally stimulating him, Alex's penis would become somewhat flaccid. While this sent him into a panic at first, after coaching in therapy, he let himself simply relax and allow Lorraine to begin stimulating him again until his erection came back. The realization that relaxation was a more powerful erection enhancer than force of will was itself reassuring.
We reintroduced intercourse into Alex's and Lorraine's sex life at the sixth therapy session. I emphasized that intercourse wasn't the preeminent goal of sex, but a natural (though not inevitable) extension of the pleasuring/erotic play/arousal process. The experience now was far different from their previous pattern of foreplay before intercourse, in which Alex paid less attention either to Lorraine or to his own erotic sensation than he did to the problematic state of his penis. Once Alex accepted that Lorraine's arousal could be an aphrodisiac, he let go and was involved with the erotic flow, piggybacking his arousal on how sexually excited, aroused, and orgasmic she was. Lorraine's being highly aroused with Alex's stimulation was a powerful erotic stimulant.
Bridges to Desire
An important component in sex therapy is helping couples do what I call "building bridges to sexual desire--his, hers, and theirs." Bridges to desire means discovering individual cues, places, and scenarios that are sexually inviting for one or both partners. Alex was so used to the idea that the signal that he wanted sex was his erection that the concept of planning sexual dates or consciously inviting sexual encounters was foreign to him. Lorraine took the lead in setting the mood to be sexual. She compared making a sexual date to preparing to attend a play you really want to see: you plan for it, you set aside time to do it, you look forward to it, and, chances are, you enjoy actually doing it.
One of Lorraine's favorite "bridges to desire" was to shower with Alex and have a lit, scented candle in their bedroom. Alex's favorite bridge to desire was cuddling on the couch and becoming more and more turned on before moving into the bedroom. The bridge to desire they both enjoyed the most was a weekend away, especially to a romantic B&B with access to hiking trails. The different environment was a major desire cue for Alex. He liked variety and new challenges in other aspects of his life, and came to understand that was true sexually as well.
Now Alex was beginning to gain a more realistic sense of middle-aged sexual expectations. In one of our last sessions, Alex announced proudly that, a few nights previously, they'd not been able to finish intercourse but, for the first time in his life, he felt okay about it. He comfortably laughed it off and went to sleep cradling Lorraine in his arms. He and Lorraine were enjoying a broader sexual repertoire, and he valued a richer, deeper sexuality, even if it didn't always lead to intercourse.
Couples who are comfortable with their sexuality can genuinely value erotic play that leads to high arousal and orgasm for one or both partners, as well as sensual scenarios--mutual massage or close cuddling--that allow warm, loving, physical encounters without involving arousal or orgasm. Sharing intimacy, pleasure, and eroticism makes sexuality more human and genuine. The man who accepts and values a variable, flexible approach to sexuality in his fifties will inoculate himself and his marriage from sexual problems in his sixties, seventies, and beyond.
This isn't to say that medical interventions to facilitate erections and intercourse shouldn't be used. There are times when men are so anxious that they can't relax, even with coaching. Until the process of allowing their erections to wax and wane comes more naturally, Viagra can be used and integrated with pleasuring exercises as a backup resource. But these medications will only work--in the sense of contributing to a richer, more satisfying sex life--if a man values sharing intimacy and eroticism in both intercourse and nonintercourse sexuality.
The man who has a more spacious, healthy understanding of sex knows that it involves two people, not two sets of sex organs (with his clearly the most important). Sexuality is as varied as human interaction in general, encompassing many daily, intimate moments of tenderness, sensuality, pleasure, and mutual teamwork with a beloved mate and friend, not just the culminating drama of intercourse. Real-life, adult sex isn't a kid's game--it can be really well played only by men who've gained some wisdom and experience about the world and themselves, even if their penises are no longer the envy of the locker room.
By David Treadway
While it may not be true that men's brains reside in their penises, their fascination with their own performance in the bedroom often gets in the way of the shared experience of sexuality with their partners. One woman in my practice said it very succinctly to her husband: "I feel like you're more involved with your thing than you are with me."
Barry McCarthy's discussion of his excellent work with Alex and Lorraine gets to the heart of the matter. Middle-aged men who are naturally losing some of their performance abilities may be drawn to some quick pharmacological fix, but, ultimately, they need to learn that sexuality isn't about performance. In fact, boys of all ages need to learn this message. As women become freer to express their own sexuality, performance anxiety in men is skyrocketing, and even college men are having more instances of erectile dysfunction.
Both men and women need to understand that men's preoccupation with their sexual performance isn't simply about testosterone and narcissism. Boys still are being socialized in latency to master and deny their neediness, vulnerability, and insecurities. When they go through puberty, all those socially unacceptable and repressed feelings suddenly assert themselves relentlessly below the belt. The tender feelings that little boys have are transformed into the insatiable demands of the ever-present erection. Thus the often voracious sexuality that drives boys and men, frequently experienced by women as impersonal and hurtful, is really an expression of the same yearnings that women bring to relationships: the desire to be seen for who one truly is; the wish to love and be loved without shame.
In teaching Lorraine and Alex how to truly make love with each other, McCarthy is really helping them risk being vulnerable, needy, and insecure together. Alex's fear of Lorraine's disapproval or disappointment and his reluctance to discuss these things with his wife are the real issues. Unfortunately, many men still presume that they're supposed to be skillful sexual partners without ever consulting their partners. Why does it take over a million sperm to fertilize just one egg? None of them will stop and ask for directions.
I confess that Alex and Lorraine's willingness to take direction in the couples therapy and do their therapy homework did give me a case of client envy. My clients frequently have difficulty doing their therapeutic homework, particularly in situations involving sexual intimacy. It would have been useful in this case if McCarthy had added a little more discussion about how Alex, who'd been very private and unilateral in his approach to sexuality, became such a willing participant in the exercises, both with Lorraine and in discussions in front of the therapist. Clearly, McCarthy joined with Alex very skillfully, and I wanted to see a little more how he did that. Unlike the doctors in white coats measuring blood flow with electrodes and prescribing medications, McCarthy is practicing sex therapy based on a strong therapeutic connection that's based on healing the couple's relationship. The case is a helpful demonstration of the limits of pharmacological solutions. Ultimately, it's not Viagra: it's the vitality of relationship that makes a difference in the bedroom.
Despite all the obvious distinctions between men and women, our hearts share the same fears and yearnings. Learning how to hold each other's hearts tenderly is the art of lovemaking.
Barry McCarthy, Ph.D., is a professor of psychology at American University and practices at the Washington Psychological Center. He's the coauthor of Rekindling Desire: A Step-By-Step Program To Help Revitalize Sex . Address: AU Psychology, 321 Asbury Building South, Suite 321, 4400 Massachusetts Avenue, N.W., Washington, DC 20016. E-mails to the author may be sent to email@example.com.
David Treadway, Ph.D., is director of the Treadway Training Institute in Weston, Massachusetts. He's the author of Before It's Too Late: Working with Substance Abuse in the Family and Dead Reckoning: A Therapist Confronts His Own Grief . Address: 228 Boston Post Road, Weston, MA 02493. E-mails to the author may be sent to firstname.lastname@example.org.
Letters to the Editor about this department may be sent to email@example.com.
by Babette Rothschild
Empathy is the connective tissue of good therapy. It's what enables us to establish bonds of trust with clients, and to meet them with our hearts as well as our minds. Empathy enhances our insights, sharpens our hunches, and, at times, seems to allow us to "read" a client's mind. Yet, vital as it is to our work, empathy has remained a rather fuzzy concept in psychotherapy. To many of us, it seems to arise from a kind of potluck stew of emotional resonance and insight, seasoned with lots of attuned presence and a generous dollop of luck.
Far from the therapy office, in the precisely measured environment of the research lab, brain scientists are discovering that a particular cluster of our neurons is specifically designed and primed to mirror another's bodily responses and emotions. We're hardwired, it appears, to feel each other's happiness and pain--more deeply than we ever knew. Moreover, the royal road to empathy is through the body, not the mind. Notwithstanding the river of words that flow through the therapy room, it's the sight of a client looking unhappy, or tense, or relieved, or enraged, that really gets our sympathetic synapses firing.
This news is both exhilarating and scary. The good news--for therapists, their clients, and the world at large--is that human beings may be more deeply capable of empathy than we ever imagined. If we're truly born to connect, perhaps there's hope for us all. The scarier news: if we're truly designed to mirror each other's feelings, we therapists may be exquisitely vulnerable to "catching" our clients' depression, rage, and anxiety, and succumbing to the ravages of "compassion fatigue." Given the hardwired nature of empathy, is it possible to say yea or nay to its effects on us? What steps might we take to harness and channel our natural-born empathy for the good of our clients--and ourselves?
I first recognized the physical force of empathy as a college student, with the help of my friend Nancy, who was studying to be a physical therapist. As we walked down a street together, she'd follow total strangers and subtly mimic their walking style. Copying a stranger's gait, and feeling it in her own body, gave her practice in identifying where one of her patients might be stiff, or in locating the source of a limp. Intrigued by this mysterious way of "knowing" someone, I asked her to teach me to do it, too. I began to surreptitiously mimic the walks of all manner of unsuspecting folk, from unsteady older people to cooler-than-thou teenage hipsters. What startled me was that not only did "walking in someone else's shoes" change the way I felt in my body, but it often altered my mood as well. When I copied the swaggering gait of a cocky young man, for example, I'd momentarily feel more confident--even happier--than before. I found this secret street life fascinating and fun, but I didn't think much about it until a few years later, when I started practicing clinical social work.
On my first job in the mid-1970s working in a family service agency, I began to notice peculiar things happening in my body when I sat in my office with clients. Some of my responses could be blamed on newbie jitters, but I strongly sensed that there was more to it than that. I particularly remember my bodily reactions to a young client named Allison. As she recounted the crises of her week in a spacey, disconnected way, she kept her body very still, and I had to lean forward to hear her whispery, almost inaudible, voice. As we worked together, I began to notice that I often felt lightheaded. When I began to pay attention to what was happening in my body, I found that my breathing had become very shallow--in fact, nearly undetectable. No wonder I was feeling lightheaded and spacey: I wasn't getting enough oxygen!
Turning my attention back to Allison, I noticed that her chest was barely moving. I was taken aback: we were breathing alike! I remembered then how my mimicry of walking patterns in college had often affected my bodily sensations and moods. Were my lightheadedness and general feelings of disconnectedness just the result of new-therapist nervousness, or the direct result of my imitation of Allison's breathing? If our breathing had actually become synchronized, I realized, it was totally unconscious on both our parts.
In all of my graduate-school discussions on the therapeutic relationship, including the fine points of transference and countertransference, I couldn't remember anyone who'd ever mentioned the possibility of "catching" bodily behaviors. Intrigued and a bit bewildered, I took my observations to my supervisor. I still remember her look of startled skepticism. "What an odd hypothesis," she finally remarked, her cool tone clearly implying that my experience wasn't to be taken seriously. I was dumbfounded by her lack of curiosity, but I never doubted my own sensations. On the contrary, increasingly fascinated with the role of the body in relational and emotional life, I began a serious study and practice of body psychotherapy.
In contrast to my suspicious supervisor, my body psychotherapy colleagues and teachers seemed to accept readily that their bodies were "in tune with" or "resonating with" those of their clients. Like actors, they regarded their bodies as essential, finely honed instruments of their craft. From these practitioners, I learned "postural mirroring," a technique instigated by dance therapists, wherein I'd attempt to get a reading on a client's emotional state by copying the way he sat, stood, or moved. There wasn't a lot of debate about the usefulness of such a technique: body psychotherapists simply assumed that "the body doesn't lie."
Tracking Down the Source
While I was heartened by the confirmation of my own observations, I was concerned about body psychotherapy's uncritical acceptance of a link between a therapist's and client's body states and emotions. I needed to know more: Where does our ability to resonate with each other, with such stunning immediacy and accuracy, come from? What core processes drive the dancelike synchronizations of movement and mood that I kept encountering?
Throughout the 1990s, I became a voracious student of neuroscience--at first, as a way to learn about the physiology of trauma. In the course of those studies, I discovered the term "vicarious traumatization" and documentation that therapists could actually suffer symptoms similar to their traumatized clients. At once, I was both concerned and excited. I wondered if the physiological and emotional reactions that accounted for this might have any relationship to my earlier gait experiments with Nancy, the incident with Allison, and my body psychotherapy colleagues' enthusiasm for client mimicry. I'd need to dig further.
I nurtured my curiosity at the library, on the internet, and through the PsychInfo and Medline databases. From the vast literature of social psychology, I learned that facial expressions were contagious--when baby smiles, Mom usually does, too--and that such synchrony affects the nervous system and can convey emotions. I also learned that people commonly, if unconsciously, copy each other's posture and synchronize breathing patterns.
As exciting as that research was, I still felt something was missing. The writings of neurologist Antonio Damasio, attachment specialist Allan Schore, interpersonal neurobiologist Daniel Siegel, and others told me that scientists could locate the effects of empathy in the brain. But, astonishingly, until the mid-1990s, no one had looked for a source of empathy in the brain. And, as I was to find out, the later discovery of the source of brain-to-brain empathy happened by accident.
Monkey See, Monkey Do
In 1996, an Italian neuroscience research team led by Giacomo Rizzolatti and Vittorio Gallese was studying grasping behaviors in monkeys. They attached electrodes to the monkeys' brains to observe precisely which neurons fired when a monkey grabbed a raisin with its hand. The research was routine: monkey grasped, specific neurons fired.
Then, during a break, one of the researchers hungrily reached out for a raisin. His fellow researchers coincidentally noticed something extraordinary on the monitor: neurons in the monkey's brain fired-- the exact same neurons that had fired earlier when the monkey grasped a raisin itself!
The team was astonished: nothing like this had ever been seen before. Their serendipitous finding was the first clue to the existence of what scientists now call "mirror neurons," so called because they appear to actually reflect the activity of another's brain cells. The monkey's response wasn't just simple recognition, as in "I know what the researcher is doing." That kind of observation activates other areas of the brain. What happened between monkey and researcher required a brand new concept, an altogether new theory of behavioral interdependence. The monkey's neurons fired as if it had made the same movement itself. This was a genuine brain-to-brain connection. In an instant, the definition of interconnectedness, the notion of empathy, changed forever.
Subsequent neuroimaging research in humans suggests that we, too, may have a similar mirror-neuron system that allows us to deeply "get" the experience of others. When people watch other individuals drumming their fingers, kicking a ball, or biting into an apple, the sectors of their brains that turn on are the same sectors that activate when they perform these behaviors themselves. Meanwhile, in a paper published last year entitled "The Roots of Empathy," Gallese pushed the envelope further by hypothesizing that "sensations and emotions displayed by others can also be 'empathized,' and therefore implicitly understood, through a mirror matching mechanism" in the brain. Soon, he believes, scientists will discover a mirror-neuron network that establishes, beyond a doubt, that we're born to resonate with one another at the deepest emotional levels.
While neuroscientists continue the slow work of confirming these promising findings and theories, therapists can begin to apply them now to empathize more strategically and effectively with their clients. Because empathy is rooted in the body, the more mindful therapists are of their own somatic responses, the more skillfully they can choose to engage mirror neurons to gain valuable information about a client's emotional state. Equally important, a therapist can choose to slow down, or even halt, the brain's rush to empathize when it might overwhelm the client--or the therapist.
Let's begin with the body's gift for sleuthing. When you want to get a literal feel for what it's like to be in your client's skin, you can consciously mirror some aspect of his or her behavior or expression. I tried this when I worked with Fred, a new college graduate who'd come into therapy to address his anxiety about dealing with authority in his first "real job." Though he'd grown up with a tyrannical father who'd beaten him regularly as a child, Fred couldn't see or feel any relationship between his childhood trauma and his current fear of standing up to his boss.
One afternoon, Fred arrived for his session deeply depressed. He'd been thinking about suicide, he said, but had no idea why. I wasn't sure either. As I asked him to describe what "suicidal" felt like in his body, I tuned in by copying his flat facial expression and slumped posture. Almost immediately, I began to experience in my own body the sense of deadness he'd just described to me. It reminded me of the "freeze" response that's an instinctive reaction to inescapable threat.
All at once, a light bulb flashed in my mind. "Fred," I asked, "have you ever seen a mouse that's been caught by a cat?" He nodded yes. "What does the mouse do?" I prodded. "It plays dead," he replied, his face beginning to brighten with interest. We then discussed the protective function of freezing for all prey, both animals and people. Finally, I asked Fred if he'd ever reacted that way himself.
"Yeah," he said softly, "when my dad beat me." As his father hit him, he told me, his body would lose all power and "go dead." For the first time, he made a felt connection between his childhood horrors and his current emotional state. It seemed a light bulb was also flashing in Fred's mind. As he began to talk thoughtfully about his own "internal mouse," his body posture gradually became more upright and animated, and by the end of the session he reported that his thoughts of suicide had receded.
Could I have helped Fred make this breakthrough with talk alone? Perhaps, but it would likely have entailed several more sessions full of the usual conversational roundabouts, byways, and detours. Instead, by mirroring him, I could quickly feel and then understand Fred's deadness.
While purposefully synchronizing with your client can often provide added insight or even jump-start a stalled session, be aware that the data you pick up isn't "pure" information. Just as gaps can occur between speaker and listener in verbal communication, so can somatic communication be distorted by your own filters. If, for example, you mimic your client's head tilt and get a feeling of anxiety in your chest, your client may indeed be anxious. But it also could be that you habitually tilt your head when you're anxious, so that repeating this action triggers the emotion. So be sure to check out your bodily hunches with your clients, as I did with Fred.
The Risks of Resonance
Mirroring a client can be a bit of a tightrope act. You can easily lose your balance and crash to earth, especially if you fail to stay focused. I learned this lesson the hard way.
A few years ago, my client Ronald was angry with me because I was leaving town for a few weeks. He was so full of fury that, for the first hour of a double session, he wouldn't talk at all. He sat half-facing away from me, tense and seething. From time to time, his eyes would fill with tears. Repeatedly, I tried to make verbal contact with him, using such standard gambits as "You seem very angry" and "This looks very difficult for you." But I had the unmistakable feeling that my words projected about a foot from my mouth, and then thudded heavily to the floor.
Finally, I decided to hold my tongue and let Ronald work it out himself. With my mind emptied of fix-it schemes and nothing much else to do, I began to consciously copy my client's hypertense posture. I clenched my jaw, clasped my hands tightly in my lap, and scrunched my shoulders forward.
Two things happened. The first was that within a minute or so, Ronald's posture began to loosen up a little and he began to talk about his feelings of impending abandonment. (I've since learned that mimicking another's posture can nonverbally convey understanding.) As he aired his rage and hurt, I was able to acknowledge his feelings and let him know that I could understand and accept his anger. By the end of the session, he reported feeling somewhat calmer.
But not me. After Ronald closed the door behind him, I realized that I was very uncomfortable. Actually, that's an understatement: I was practically unhinged with fury. But why? Was I angry at Ronald? Had the session triggered something from my own life? I tossed around a half-dozen possibilities in my mind, but nothing seemed to fit. Only later, when I talked it over with a colleague, did I remember: I'd copied Ronald's infuriated posture! My mirror neurons had done their job too well. Once I made this crucial connection, the "infection" began to drain--I could almost feel the fury leaking out of me. I returned to myself again in a matter of seconds.
To some therapists, what happened between Ronald and me may look like a textbook case of projective identification--a case of Ronald's "putting" his uncomfortable feelings into me and thereby "inducing" my fury. I couldn't disagree more. I was a full participant in the process: only after I actively mirrored Ronald did I begin to feel angry. But while my mimicry was entirely conscious--if later forgotten--I believe that this kind of brain-to-brain communication occurs at an unconscious level between clients and therapists all the time. The next time you feel that you may be suffering from the impact of a projective identification, you may need to look no further than your own body to discover whether you've mimicked your client's posture, facial expression, or breathing pattern. Routinely adding such a simple step could eliminate the blaming of clients for feelings that are, in fact, rooted in our own, naturally responsive, neural circuitry.
There's liberation here, particularly for therapists who often find themselves on the edge of emotional overload. Active awareness of your own neurally-mediated role in absorbing clients' feelings can help you control the contagion. Once you become aware of your mimicry, any behavior that brings you back to the sensations and feelings of your own body, and out of synchronization with the client, will help you to apply the "empathy brakes." You might stretch, take a drink of water, get up to fetch a pen, or write some notes. These steps won't short-circuit empathy, but rather will allow you to return to yourself--to a place of clarity, presence, and helpful attunement to your client.
When a Client Feels Your Pain
Empathy, of course, is a two-way street. Our clients often unconsciously mimic our body patterns and take on our corresponding emotional states. Many therapists instinctively foster this process. When, for example, you slow your own breathing and your anxious client subsequently slows his, you're engaging his mirror neurons. No words need be exchanged for the client to gradually match your slower respiration and begin to calm down.
But if clinicians' serenity is contagious, so, too, is their agitation. One morning, upon returning to Copenhagen (my then home) after a long visit to the United States, I was suffering from a particularly nasty case of jet lag. Though exhausted and headachy, I jumped right into my usual work schedule. At the end of my afternoon session with Helle, I asked her, as usual, "How are you feeling?" Helle proceeded to describe my jet lag in precise detail. "I feel very tired, and there's a feeling of pressure in my forehead," she said, rubbing her eyebrows. "I also feel an odd heaviness in my chest. And I'm hungry, though I shouldn't be: I ate a good lunch just before I came."
I suggested to Helle that she stand up and walk around the room, hoping that the physical activity would move her out of my somatic sphere of influence and back into her own body. After pacing for a minute or two, she returned to her chair, noticeably more energetic. "My exhaustion and hunger have disappeared!" she reported. I then told her how I was feeling, that she'd described my sensations precisely.
Since consciousness is an important part of the process of controlling the neuronal dance, we spent a few minutes tracking how Helle had "caught" my state. In retracing her postures, she realized she'd rested her head on her hand as I'd tiredly done. That ordinary act of unconscious mimicry was enough to make her vulnerable to feeling my jet lag and the untimely hunger that accompanied it.
Psychiatrist and early attachment expert Daniel Stern calls the moments of true meeting in therapy a "shared feeling voyage." Though each voyage may last but a few seconds, we've all experienced its potent rush--the sudden throb of feeling not just for but with a client, a sensation of jolting connectedness that can be both exhilarating and fearsome in its intensity. What we've always imagined to be a resonance born of voice, smile, tears, or touch is encoded in us, it turns out, far more deeply and inexorably than we ever knew. It may be that our mirror neurons, those tiny and inescapable vessels of empathy, encapsulate one of the most exciting challenges of psychotherapy--that of attuning two brains, and two hearts, so that they warmly vibrate together without melting into one.
Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles and gives professional trainings worldwide. She's the author of The Body Remembers:The Psychophysiologyy of Trauma and Trauma Treatment and The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. Website: www.trauma.cc. E-mails to the author may be sent to: firstname.lastname@example.org.
Gallese, Vittorio. "The Roots of Empathy: The Shared Manifold Hypothesis and the Neural Basis of Intersubjectivity." Psychopathology 36 (2003): 171-80.Hatfield, Elaine, John T. Cacioppo, and Richard L. Rapson. Emotional Contagion: Studies in Emotion and Social Interaction. Cambridge, England: Cambridge University Press, 1994.
Rothschild, Babette, and M. L. Rand. Help for the Helper: The Mind and Body of Compassion Fatigue, Vicarious Trauma, and Burnout. New York: W. W. Norton, forthcoming.
by Yvonne Dolan
It was a completely full morning flight to Los Angeles. Despite the post 9-11 security procedures, our United Airlines flight was actually leaving on time. Everyone, passengers and crew alike, seemed in pretty good spirits. Then I noticed the man seated across the aisle. He was hunched over, his face in his hands, the muscles in his back shaking. He nodded almost imperceptibly when the attendant gently touched his shoulder and reminded him to fasten his seat belt in preparation for takeoff.
A few minutes into the flight, I heard the muffled sound of sobbing. After a few minutes, I leaned across the aisle and asked, "Are you okay?" He shook his head. "Is there anything I can do?" Again, he shook his head.
A little later, a flight attendant walked down theÂ aisle, noticed the man's sobbing, and asked, "Do you need anything?" He shook his head and cleared his throat.
"My wife and all four of my kids were killed last night in a car accident. I'm on my way back to Hawaii to make the funeral arrangements. I moved over here [the flight had originated in Chicago] for my work." His voice broke. "They were going to join me when the school term ended. "
"I don't know what to say, sir," the attendant said gently. "I'm so sorry. Are you sure there isn't anything I can get you?" Again, he shook his head. "I just need to get through the next two flights, so I can do what needs to be done. Our family is all flying over from the mainland for the funeral and I'm going to have to pick them up and make arrangements. I was up all night last night after they called me, so I'm going to try to get some sleep."
"Ring the call bell if you need anything, sir, "the attendant murmured. As she walked away, the man looked across the aisle at me. "I just need to focus on what needs to be done. That's the only way I can get through this." Then he folded the airline blanket across his chest and closed his eyes.
To most people, this man would hardly qualify as "hopeful." His misery and his story make it easy to conclude that he was, literally, without hope. Easy, but wrong. True, he undoubtedly felt hopeless, but he was not hopeless, he had not succumbed to despair. Even in the face of his catastrophe, he was taking small, tentative but active, steps back toward the realm of life. By focusing on what he needed to do in the immediate future--get some sleep, pick up his relatives, and begin making arrangements--he was assuming a future, a time for which plans needed to be made, people contacted, tasks met, even if, for now, that future encompassed only the next few hours or days. Despite his acute grief, he was saying, in effect, "this is impossible, but I'll find a way to get through it."
Making his plans didn't change what had happened or his feelings about it, but it gave him some small measure of control in otherwise uncontrollable circumstances. It also provided him with a rough map for what would undoubtedly be a brutal journey through a wilderness of suffering. For the time being, he was alive and coping; he hadn't been defeated by despair, and that in itself was a harbinger of hope to come.
There's Hope in Activity
As therapists, we've been trained to think that we should focus primarily on emotions. We often elicit negative emotions, believing that they must be purged before there'll be room for hope and other positive emotions. We're particularly anxious to assuage trauma survivors, whose desperate, unbearable pain seems to demand immediate relief. We frequently assume that all clients must feel hopeful and believe that life is meaningful before they'll make much progress in therapy or in life.
But the fact is that in the wake of catastrophe, it's often impossible to summon up the least glimmer of hope or faith or sense of life's meaning. How, for example, can you suggest to someone whose child has been shot in a schoolyard, who has lost a home to a hurricane, or who's been raped as a child by family members that there's hope for the future, that they'll feel "better" someday? To clients who have suffered such profound trauma, it's ludicrous to suggest that they can be coaxed into feeling hopeful about the future.
In these cases, the trauma therapist may be in something of a bind. Trying to "drain off" negative emotions by focusing on the pain--asking clients to rehash what happened or to speak repeatedly about their terrible feelings--is likely to make them feel worse. Just asking such clients an open-ended question about their emotional state--"How do you feel today?"--may exacerbate already terrible feelings or call forth a sense of numbness and apathy.
But favoring positive emotions and subtly trying to subdue negative ones can backfire. Asking these clients to imagine a time when they won't feel suicidal or reframing their trauma as an opportunity to "grow" can trivialize their suffering and inadvertently insult them. These efforts may also strike them as manipulative, as though the therapist is trying to maneuver them into a hopeful response they're not ready for.
How do we get beyond this impasse? We can begin by looking again at the ways people have found consolation and support in the thousands of yearsÂ Â before psychotherapy was developed. Throughout history, human beings have found rough relief and a modicum of comfort in the immediate obligations and habits of ordinary, daily life. The greatest incentive to go on coping lies in their relationships with other people, not only those who comfort and support them, but those who depend upon them. Sometimes, the simplest act can have profound power. I learned recently of a Red Cross survey given to disaster survivors, asking them to name the most helpful "intervention" they'd experienced right after the disaster. Many said they most appreciated being given a cup of coffee by an aid worker. It wasn't fancy trauma therapy, but I suspect the familiarity and ordinary helpfulness of the act implied to survivors that, in spite of catastrophe, normal life was still going on. In receiving a cup of coffee lay some small kernel of hope for the future.
In my 25 years of treating traumatized people, I've found that in these crisis situations dissecting negative emotions or trying to rev up positive ones isn't the most useful step we can take. This isn't to say we should avoid discussions about how clients feel--far from it. But talking with clients about what they're doing and how they're coping provides not only a framework for them to talk about how they feel, but a real-life scaffolding for the eventual construction of more positive emotions. Hope follows action, rather than the other way around. Helping clients become aware that what they're doing--even if it's "merely" coping and "just" getting by--can be the first step toward rebuilding their sense of agency and control.
I first began thinking about the healing power of activity and its "hope-implicit" quality when I was a young therapist-in-training, working in a shelter for abused and runaway teenagers. Every one of these kids had experienced severe and prolonged abuse, and virtually all suffered from acute post-traumatic stress. As an all-night staff person, my job was to help them get to sleep--an almost impossible task because for my charges sleep was a realm of nightmares and flashbacks. Talking with them about their traumas just heightened their distress, and asking them "positive" questions--about what they wanted to do with their lives, what they liked, what would make them feel safer--didn't engage them.
Desperately casting around for a solution, I began to ask more specific questions about the immediate future. "What would you like to do tomorrow? What do you need to get that done? How will you know tomorrow night that you had a decent day?" Several said they wanted to contact brothers, mothers, or friends to find out if they were okay. Others said they wanted to go outdoors; they'd been cooped up inside for too long. Still others said they wanted to wash their hair, take a bath, get clean clothes. This doesn't sound like therapy, nor does it provide much in the way of emotional breakthroughs. But it worked. Talking about practical, immediate plans calmed them down and helped them sleep. I believe that the practical details of their lives reminded them that they were more than their traumas, and gave them concrete realities that, at least momentarily, jostled them out of their inner turmoil.
Drawing on my shelter experience, I work with trauma clients to help them identify actions they can take to keep going. But sometimes trauma clients no longer have a sense of who they are and why they should continue living--except that they feel they have to go on for the sake of their kids, their grandchildren, their spouses, or even the person they've lost. Many clients who cannot imagine going forward for themselves can summon up some last ounce of strength on behalf of those they love.
Focusing on Day-to-Day
Germaine, came to see me after her adolescent son had been killed in a gang-related shooting. She'd just lost her job, was drinking heavily, and was almost paralyzed with grief. She entered therapy not to make herself feel better, but so that she could go on living for the sake of her other two children.
At that point, nothing I could say would make her feel better. I told her how sorry I was for what happened to her son, and how painful I imagined this must be for her whole family. "How have you managed up until now?" I asked. This focused her on what she was doing and offered her an indirect opportunity to express her feelings. Germaine said she'd been going to a support group, and while it helped to get dressed, get out of the house, and be with others, the overall experience wasn't particularly useful. "I feel like I'm being swallowed up by how much it hurts, like I could, literally, drown in the pain."
Germaine was a former crack addict, but had been clean for six years. She'd resisted taking drugs again, but she was drinking heavily. "These feelings aren't ever going to go away," she said. "And just talking about it isn't going to cut it. I have to have some sort of concrete plan of what I'm going to do to fill up the time or I'll die of grief. What am I going to do?"
Of course, I didn't know the answer. But clients often have within themselves the budding solutions to their own dilemmas, though they may not recognize it at the time. Germaine had come up with a potential way out of her hell when she said she needed a "concrete plan" of action. I thought we should try to construct one. I asked her if there had been anything at all that had helped to make these past few months a little bit more bearable. She was silent for several minutes, staring at the floor.
"It helps when I make a list," she said finally. "Some days, when I get up in the morning, I make a list of what I need to do and, somehow, those days seem to go a little bit easier--maybe because I have a plan, sort of like a map for getting through the next few hours. When I don't have my list, it's a lot worse. I can just sit and cry all day."
I asked her how the list helped. She said that it wasn't so much the list itself that helped, but that the act of making it put her completely in the present. Listing the most mundane chores--"go to grocery store," "pick up Michael's shoes from repair shop," "make kids' lunches for tomorrow"--and then doing them helped her "get back to living, at least for the time being," she said. In a sense, she could do hope before she could feel hope. This focus reflects a great human wisdom found in many major spiritual traditions: that being consciously mindful, maintaining full awareness of what's going on in the present can bring some solace and peace when all else fails.
It struck me that concentrating on her list-making and following through with the tasks when she felt so terrible must have taken extraordinary effort. "How did you do it?" I asked.
"I guess I just made up my mind."
"But just how did you make yourself get up in the morning?"
"I told myself I had to do it."
"What did you do to convince yourself?"
"Well, I gave myself a lot of shit, as I lay there, telling myself it was a lousy thing to do to my kids--just let them fend for themselves while I wallowed in bed."
This pursuit of minutiae can have a powerful impact on the client. In answering the questions, Germaine acknowledged her own agency and strength. If I were to praise her, no matter how sincerely, for managing to get up every morning, it might have sounded condescending. Focusing her attention on what she was doing for herself helped her to recognize her own strength and her ability to keep going despite her pain.
I saw Germaine weekly for a year and a half, keeping the focus on her own efforts. One of the most powerful and respectful ways to help clients actively find new meaning for their lives is to ask them to imagine someone who loves them telling them what they're accomplishing. When I asked Germaine what she was doing right, she responded like many depressed and grieving people that she wasn't doing anything right. So, I rephrased the question, "Well, imagine that your kids are remembering what you did during this past week. What would they say you'd done right?" After a pause, she said, "I guess they would say that I'd put a meal on the table every night, and that I took them to church on Sunday, and that we went to the movies one evening." Once, I asked her what a favorite aunt, who was deceased, might have said to her. For the first time, she smiled softly and said in a small voice, "She would tell me I was doing good, taking care of the kids and all, and that she was proud of me for not hitting the bottle at the end of the day."
Session by session, Germaine gradually began to immerse herself in the mundane stuff of daily life, and her despair seemed to lessen over time. ButÂ she seemed to grow more anxious about her children. She worried that she hadn't been a good enough mother, expressing guilt for neglecting them while addicted to crack. She wondered if she'd been responsible for her son's death. Now, though still grieving for the one she'd lost, she felt increasingly frightened for the other three, and anxious about her own capacity to guide them through childhood.
"Suppose that you dream that many years have passed and your children--who are now adults--are sitting around the kitchen table with you, telling you that you did a great job as a mother and describing all the things you did completely right while raising them," I said. "Now, suppose you wake up and can't remember the dream, but find yourself doing all the things they said made you a great mother. What would be the first things your kids would notice you doing?"
Germaine closed her eyes and smiled. "I would go to every parent-teacher meeting. And I would make sure they told me where they were going to be every hour of the day--even if they fought me on it. And I would help them with their homework. And I would push them to finish school. I would keep on loving them, and let them know how much I loved them every day." Because she was already beginning to do some of these things, it slowly dawned on her that she was already becoming the kind of mother her kids needed.
By asking this type of question, the therapist makes a kind of hypnotic suggestion that communicates--indirectly, without ever denying the client's ongoing pain--that there is something significant to hope for. If the question is worded right, the client will answer it not by expressing a wish for the impossible, but by setting out realizable goals. I didn't ask Germaine the kind of question that would provoke her to wish for her son to be alive again. Instead, she could wish for something entirely achievable, through her own efforts--something that would help her become the mother she wanted to be.
Starting with Baby Steps
Though focusing on mundane tasks in the present can seem impossibly beside the point for someone who has suffered a life-shattering event, it can help build, inch by inch and then yard by yard, a pathway out of despair and into the fullness of life. A Japanese doctor told me a story about how powerful this kind of mindfulness can be. Mr. Tanaka, a recently retired patient of his, had been admitted to a hospital after trying to commit suicide. For nearly 50 years, Mr. Tanaka had suffered from severe back pain as a result of tubercular meningitis he'd contacted at 15. He'd endured 30 operations, to no avail. Every treatment--physical therapies, nerve-blocks, drugs--had failed. Indeed, the pain was getting worse and he was now confined to a wheelchair. Stuck at home and in constant pain, he'd lost all hope and had attempted suicide. The doctor asked him how he'd managed to get through his painful life to that point.
"Well, I'm a very optimistic man at heart, and that has helped me," Mr. Tanaka answered. "While the pain was awful, I just buried myself in work, which relieved it a tiny bit. I also believed the pain would become much less some day--and that made me optimistic. But now that I know I'll never have relief, I feel there is no hope."
Not knowing what else to offer, the doctor grabbed at this lifeline. "Could you do something for me?" he asked Mr. Tanaka. "When you feel even a little bit more comfortable, please notice and remember the occasion, and notice why and how it occurs."
Each time he saw Mr. Tanaka over the next few weeks, the doctor encouraged him to notice when his pain was less severe. For six weeks, nothing. But one day, Mr. Tanaka came in smiling. "Since you began asking me to notice times I feel better, I've been thinking about it. A couple of days ago, on the way home from the dentist, I stopped in the park by the riverside. I ate sandwiches and fed the crumbs to the pigeons. They started going after the crumbs, and I really enjoyed watching them. In fact, I became so absorbed in watching them that I didn't have any pain at all while I was there!"
The doctor encouraged him to continue noticing other times he became so involved he didn't notice the pain. Gradually, Mr. Tanaka noted more and more activities during which the pain disappeared. He also noticed that the pain didn't seem to be getting any worse. He began gardening and fishing and even took a short trip with his wife. Seven years later, the doctor told me, Mr. Tanaka was still improving.
Strangely enough, the "distraction" of living fully in the present seems to be the only real cure for the terrible things life can do to us, the only real source of hope in hopeless situations. As therapists and healers, we can't make people feel hopeful, nor can we reverse the tragedies that make them feel hopeless. But we can help them slowly begin building, out of life's own materials, a place in which hope can nest.
Yvonne Dolan, M.A., specializes in trauma treatment. She is the author or coauthor of 5 books, including Resolving Sexual Abuse. Address: 7137 Knickerbocker Pkwy., Hammond, IN 46323. E-mails to the author may be sent to email@example.com. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by Richard Schwartz
Mark and Stacey, an attractive couple in their early thirties, have only been married two years and they're already knotted in conflict. In our first session, Mark, an intense, athletically built man, gets to the point, "I hate it that we're such a stereotype, but it's the typical scenario of me wanting more sex than she does. We're down to once every two weeks--if I'm lucky--and it's driving me crazy. I have a strong sex drive, so if it were up to me, we'd do it every day, the way we used to when we were dating. Now, not only do I not get my sexual needs met, but I feel rejected because most of the time I get shot down when I initiate."
Stacey, slim, darkhaired, sits rigidly in her chair. "I know we don't have sex as much as Mark likes," she says, with an edge in her voice, "but for me to want to make love, I have to feel emotionally connected to him and, to be honest, most of the time, I just don't. He seems so obsessed about this issue. I constantly feel pressure to satisfy him. It's like raw sex is the only thing he wants from me. It's gotten to the point where any time he touches me I freeze up--I'm afraid to respond even affectionately because if I do, he thinks it's an invitation to sex."
"Yeah, in some ways that's the hardest part of it for me," Mark interrupts, "the way she sees me now. She looks at me like I'm one of those guys on The Sopranos. I like sex, but I'm no drooling animal. I can be romantic and I do try to help her feel close, but whatever I do does no good," he says despondently. "No matter how sensitive I try to be, it's like she has this view of me as a sex-crazed gorilla."
I ask each of them to describe what typically happens when they do have sex. Stacey says, "After some time goes by when we haven't had sex, Mark gets more and more sulky, and I begin to feel I'm like a bad, unloving wife. So I hug him or pat his shoulder or maybe just smile at him or something and, oh boy! That's all it takes--he's off to the races. I feel I can't say no again, and so we'll get in bed and start kissing. I try to be as warm as I can get myself to be; I don't want to just lie there like a dead fish. And, usually, at a certain point, I can work myself up so that I'm into it, sort of. Afterwards, I feel relieved because I know he feels happier and not so angry at me and, also, he'll back off and I won't have to do it for a while."
Mark seems not to have heard the many negative qualifiers in Stacey's description of their sex life. "That's what I don't get," he exclaims with exasperation. "In the middle of it, she comes alive and seems to like what I'm doing, but the next day she's uninterested again. If you like it, why not want more? Also, I don't enjoy the beginnings that much because I want to feel wanted by her, not like I have to kick start her engine every time. I'm not one of these guys who just wants to satisfy himself. I'm good at foreplay and I've learned what she likes."
Mark and Stacey are caught in a classic struggle, and most couples therapists have responded with a now-classic technique: get him to back off by issuing a moratorium on sex and assigning exercises that allow them to show affection to each other without any sexual expectation. Trained as a problem-solving, strategic therapist, I used to give that directive to couples and often found that it had the desired effect. It probably would've worked with Mark and Stacey, too. As he contained himself so she felt less under seige and more cared for, eventually they could've found a frequency that felt okay to each, checked off this particular glitch on their list of relationship issues, and left therapy reasonably satisfied.
I once felt an outcome like that meant I'd done my job. Not anymore. Through the years, I've come to see that this kind of technical fix, however immediately useful, is unequal to the inner complexity of people and their potential to know each other intimately.
Know Your Selves
No other area of a couple's life holds as much promise for achieving intimacy as sex. Indeed, the promise of intimacy may be as important as lust for drawing human beings toward sex in the first place. My goal now is to help partners reach the kind of soul-deep connectedness in their sexual encounters that can transform their lives and their relationship with each other.
The Latin adjective intimus means "inmost, deepest." So real intimacy means, first of all, that both partners listen deep inside--i.e., get to know their inner worlds of emotion, desire, and vulnerability--and then reveal what they've learned to each other in an atmosphere of loving acceptance. The couples I've helped reach that level of resonance report tremendous rewards for themselves and their relationships. However, as rewarding as that state is, it's also quite rare--both because of the risks involved in being that vulnerable and because knowing yourself isn't a simple task.
When people listen deeply inside, they encounter a host of feelings, fantasies, thoughts, impulses, and sensations that comprise that background noise of our everyday experience of being in the world. When they remain focused on and ask questions of one of those inner experiences, they find that it's more than merely a transient thought or emotion. Within each of us is a complex family of subpersonalities, which is why we can have so many contradictory and confusing needs simultaneously, especially around sex. American poet Walt Whitman got it right in "Song of Myself": "Do I contradict myself? Very well then I contradict myself, (I am large, I contain multitudes.)" So do we all contain multitudes.
Thus, the Oracle of Delphi's admonition to "know thyself" should really have been to "know your selves." I call these subpersonalities "parts" because, when I first started doing this kind of work, that's how my clients referred to them. "Part of me wants to stay married and faithful, but another part wants to be free to get laid every night of the week with a different woman," a client might say. "I know I'm successful at my job, but there's a part of me that says it's only a matter of time until everybody else finds out how stupid and incompetent I really am," another would report. While people like parts of themselves that make them feel powerful, competent, and in control, they tend to dislike and even despise what they feel are their less attractive, more troublesome, parts. In one session, Stacey said spontaneously "I hate the part of me that's so scared to have sex with Mark." But hating and trying to get rid of parts that we don't like doesn't work. We only feel more polarized inside, and the despised part gets stronger.
Getting to know ourselves in all our multiplicity isn't an easy stroll through a familiar neighborhood. When our inner parts meet our partner's parts, the complexity is compounded, which is why couples therapy can be so difficult. Despite the fact that, like Mark and Stacey, most partners want me to get the other to change, I try to help each listen inside to discover why they respond to their mates in such extreme, and often damaging, ways.
I've found that, if I establish a safe, accepting atmosphere in our sessions, clients can have inner discussions with their parts. In a trancelike state of internal focus, they can dialogue with their parts about what motivates them to react in irrational or self-defeating ways. In listening to their parts' stories, their behaviors or beliefs become comprehensible.
As clients learn to separate from their extreme emotions and thoughts (their parts) in this way, I find that they spontaneously tap into a calm, centered state that I call their Self. When this happens in a session, it feels as if the very molecules in the atmosphere have radically shifted. My clients' faces and voices grow softer and more tranquil; they become more open and tender, able to explore their parts without anger, defensiveness, or dislike. When accessing this state of Self, clients are tapping into something deeper than all these conflicting inner warriors, something that spiritual traditions call "soul."
Now imagine what it can mean for a relationship when each partner connects to such a Self. If intimacy means being able to truly know and reveal all our parts to a beloved other, then the presence of Self makes doing so possible. When they make a Self-to-Self connection, people sense at a very deep level that they aren't alone and that even their most shameful facets are loved. When, during sex, each partner can dive beneath the surface where their contending parts are creating stormy waves and into the calm depths of Self-to-Self connectedness, their bodies and souls meet and sense a oneness that's delicious and profoundly satisfying. For me, then, intimacy has two components: the knowing and revealing of one's secret parts and also the sense of awe and belonging that comes with Self-to-Self connectedness.
The first step toward that kind of intimacy involves helping each partner get to know the parts that are triggered by their problems. Because Mark and Stacey were polarized around their sexual relationship, I thought they'd feel safer doing this exploration in private. I suggested that I meet with each of them separately for a session or two. To help people find their parts, I usually begin by asking them what they think or feel about the problem they bring me. When I saw Stacey individually, for example, I asked her what she said to herself when Mark approached her for sex. "Oh no, here we go again!" she replied contemptuously. "I feel angry and helpless and just yuck! But then, I tell myself, 'God, I suppose I've got to do it or he'll make me pay.'"
I then asked her to focus on the disdainful voice. She said she sensed it in the back of her head. As she focused there, I suggested she ask it why it felt such revulsion for Mark and for sex? Putting her hands up as if to push the entire subject away, she said the voice was really disgusted by the whole thing--sweaty, naked bodies, ugly, hairy genitals, revolting fluids, and ridiculous animal noises. Stacey's face was scrunched up in a look of loathing as she spoke, when suddenly she stopped cold and put her hands over her eyes."Oh my God, it's my mother!" she cried out. "It's my mother's voice in me!"
As we explored this revelation, Stacey recalled that her mother had conveyed her own deep revulsion with all things having to do with the body and sexuality. Some schools of therapy consider a voice like that a "parental introject" or a "schema" of learned cognitions (i.e., the internalized attitudes of Stacey's mother), and would encourage Stacey to ignore or argue with it. While there's no doubt that this part absorbed aspects of Stacey's mother, I find that such parts intend to protect rather than torment. These aversive, controlling voices belong to a category of parts I call the Managers, which act to protect people from hurt and trauma suffered in the past--usually when they were very young and unable to defend themselves emotionally or even physically. There are all kinds of Managers. Some are inner critics who drive people to perform perfectly so they'll never reexperience old feelings of failure and inadequacy. Other managers, like Stacey's, are early-warning systems that operate to prevent the person from even getting near an experience that might cause harm. Sex is perhaps the area of life most prone to the meddling of overzealous managers.
Managers like Stacey's bring new meaning to the phrase "safe sex." They have to be in control of the action. They see spontaneous expression as dangerous. They don't want anyone to know about, much less witness, certain parts of you. They also don't want you to be rejected or exploited, so they keep your heart closed to others. Managers monitor the passion, affection, play, and spontaneity you express in sex. If you begin to get carried away, they might interrupt the action with distracting thoughts, suddenly erase sensation or inject pain, or make you tense and uncooperative. Managers are the ultimate control freaks.
The Return of the Exiles
If you think of Stacey's voice as an introject or a cluster of thoughts, it makes sense to try to get her to challenge or eliminate it. If, in contrast, you view it as an inner personality, you get curious about why it's in the role of puritanical mother. Rather than try to shut down this "manager-mother," I wanted to know why she had this role in Stacey's inner drama. I've found that when we approach our Managers with respect, instead of resentment and dislike, they often have good reasons for what they do. I asked Stacey to sit quietly, breathe evenly, and go inside. "Ask the mother part what it's afraid will happen if it doesn't keep you so repulsed by sex," I said.
After a moment, Stacey had a vivid image of herself as a 6-year-old girl in the bathroom. Her father was helping her undress to take a bath, and as she watched the scene play out, she could see something wrong about it. Her father was looking at her in a funny way, once she was naked, his voice sounded different, and he trembled slightly. She sensed again the fear and confusion she'd felt then--the feeling that something bad was happening, and that it had something to do with her being naked.
The 6-year-old was one of Stacey's Exiles. Exiles are often childlike parts of ourselves that carry the memories and sensations from times when we were hurt, terrified, abandoned, or shamed. Because we want to forget those experiences, we exile these parts, and our Managers do their best to keep them from ever being triggered. Whenever Mark became amorous, it began to scare Stacey's little girl, so her manager-mother went into action, damping down any sexual feelings. Unfortunately, by keeping the Exile deep underground, Stacey not only missed unpleasant memories and sensations, she also missed the most sensitive, innocent, and open aspects of herself. If Exiles carry our most rending pain, they also can give us our capacity for joy, love, passion, creativity, imagination, playfulness, and sheer zest for life. If we shut away the Exiles, we also shut away much of what gives sex, and life in general, pleasure and adventure and meaning.
Mark, too, had parts that influenced the patterns between him and Stacey. When I saw him alone, I asked him to relax and focus on the feeling of frustration he felt whenever Stacey "shot him down." He closed his eyes and said he noticed a voice saying that he needed and deserved lots of sex. I told him to ask the voice about itself. Mark smiled and said that that voice called itself "The Stud," and it looked like a very buff, very macho, very tan version of himself. Mark said The Stud bombarded him with images of himself having sex in numerous hot and ingenious ways with his wife and other women, who panted and moaned in lusty abandon. Mark said he liked The Stud and that it had a powerful influence on him. He basically agreed with The Stud that his life should be more like those images. Many men have parts like Mark's stud, but not many are so open about it so early in therapy.
"Ask The Stud," I said, "what it's afraid would happen if you don't get to have sex all the time." He soon became quiet. After a long silence during which his face betrayed intense emotion, Mark said he'd felt waves of shame as he watched an image of himself as a 13-year-old in the boys' locker room. Talking in a bare whisper, he said that, at that age, he'd had small protuberances at his nipples. The other boys had ridiculed him mercilessly, calling him "Tits," asking him when he was going to buy a bra, and telling him he was really a girl. At such a vulnerable age, this kind of abuse was deeply traumatic to a young boy's developing sense of his own manhood. It was then that The Stud stepped into its role and the devastated 13-year-old was exiled. Never again, vowed The Stud, would he let anybody doubt Mark's masculinity, and it pushed him to seduce as many girls as he could.
Since he'd married Stacey, The Stud constantly pressured him to have affairs, especially after Stacey started rejecting him. So far, he'd resisted--he loved Stacey and wanted their marriage to succeed--but he was afraid that, if their sex life didn't improve, he'd succumb.
Firefighters to the Rescue
Mark's stud is characteristic of a third category of parts that I call the firefighters.
Like the Managers, the Firefighters want to protect the Exiles, but where Managers are cautious and often very rational in their attempts to protect Exiles, Firefighters leap into action after the Exile's feelings have been triggered. Firefighters are emergency responders who come out, hoses on full blast, when we feel so bad we have to drown the flames of emotion before they destroy us. These Firefighter parts manifest as urges to binge on food, alcohol, drugs, sex, work, or anything else that offers quick relief from pain.
Firefighter sex is one way to stave off intolerable feelings. Only while having or fantasizing about sex can people like Mark feel they have value, strength, or personal agency. Furthermore, a sexual Firefighter's obsession with power, dominance, and high-voltage sensation, can make us oblivious to the human being we're having sex with. Indeed, Stacey complained that she felt that Mark wasn't really there with her during sex; he didn't seem to care who was there, as long as a compliant body shared his bed. As is true for most Firefighter activity, the irony is that this part's efforts to help the exiled 13-year-old didn't work: ultimately they backfired. Stacey repeatedly rejected Mark for his sexual boorishness, only making Mark's exiled teen more ashamed and his stud more desperate.
When we uncover the dance of parts within and between members of a couple, we see many vicious cycles. The aggressiveness of Mark's stud triggered Stacey's Manager, which further triggered his stud, and so on, with disastrous results for their sex life. An Indian proverb says when the water buffalo battle in the marsh, it's the frogs who suffer. As Mark and Stacey's protective parts became increasingly extreme, the Exiles in each of them were increasingly wounded. My experience is that until each partner can care for and heal their own Exiles, these battles will continue. So I asked Mark how he felt about his young teen, and Stacey about her 6-year-old girl. Predictably, Mark was ashamed of the boy and didn't want to remember what he'd felt like. "That was all a long time ago," he said with a dismissive wave of his hand, "and I can't see any point in talking about that now." Similarly, Stacey was irrationally critical of the little girl. "She must've done something to make my father change like that," she said stubbornly.
It's very common for people to fear or dislike their Exiles initially. So I ask a client to find the rejecting or fearful voice that dislikes the Exile and politely ask it to just step back or relax for a bit. Sometimes it takes several requests for it to step back, but when it happens, the client's feelings toward the Exiles change dramatically from disdain and anger to curiosity or compassion, from fear to a sense of peace and confidence. When I ask clients what this calm, compassionate part is, they often reply withÂ something like, "This isn't a part like those other voices. This feels more like who I really am, like my real self." It seems that as people separate from their parts, their Self spontaneously emerges.
Once a client shows more qualities of Self, I ask him or her to enter the scene that an Exile is stuck in. "Can you go into that locker room and be there in the way that boy needed someone to be there at the time?" I asked Mark. Even after 20 years of doing this kind of work, I'm still awed by the way people unerringly know just what to do to heal these wounded inner parts. Mark said that as he approached the 13-year-old, the boy looked up with fear and embarrassment, thinking that this strong, athletic man would also make fun of him. Instead, as Mark played the scene, he sat down on the bench a few feet from the boy. He gently told the boy that there was nothing wrong with him or his body, that the appearance of his breasts was due to hormonal changes and they'd soon look perfectly normal. Other boys were also insecure about their bodies, Mark pointed out. "And anyway, I love you," he said to the boy. At this, the boy dropped his guard and burst into tears. Mark put his arm around the boy and took him out of the locker room, to a safe and pleasant place in the present--Mark visualized taking the boy canoeing on a nearby lake that he and Stacey often visited.
Meanwhile, Stacey went through a similar process. She helped the little girl out of the tub, carefully folded her in a fluffy, warm towel, and, embracing the girl, told her that she'd done nothing wrong. Whatever happened was her father's problem, not hers. Stacey, too, brought the girl into a safe and comfortable setting--to the living room couch--where she folded her arms around the little girl as she read her a story, while the sun streamed through the window.
After people compassionately witness their past in this way and retrieve the Exiles that are frozen there, they feel far less vulnerable. Consequently, the parts that guarded those Exiles are freed from their protective roles. The inner, reactive voices--explosive anger, self-hatred, anxious vigilance, compulsive behavior--transform into valuable helpers. A chronically suspicious, distrustful inner voice, for example, becomes an accurate intuition, helping the person sense who's safe to open up to, but no longer automatically closing off to everyone or keeping him in a fog of paranoia. A carping inner critic becomes a supportive voice urging the person to keep trying rather than constantly beating her down. After rescuing his 13-year-old, Mark focused back on The Stud, who was relaxed and smaller, less musclebound. Similarly, when Stacey returned to her manager-mother, the part was willing to reconsider the beliefs it had taken on from her mother, now that it didn't need to keep the little girl safe. These are the beginning steps in the process of transforming inner parts.
The Exiles of both Stacey and Mark carried feelings of worthlessness and self-loathing, and believed that they were fundamentally flawed and unlovable. Stacey's little girl craved the tender affection and protection that a father is supposed to provide--and, in fact, that's what she wanted from sex with Mark. She was drawn to him in the first place because of his strength, competence, and apparent self-confidence--his take-charge personality seemed to promise perpetual safety. Stacey's Exiles would only let her enjoy sex that was cozy, warm, adoring, and not terribly erotic; they were frightened by insensitivity, crudeness, or, often, even unashamed lust.
Mark's Exiles, meanwhile, couldn't at first believe that a woman as pretty and vivacious as Stacey would find him--a weak, "effeminate," 13-year-old--attractive. Because of the Exiles' own fears and anxieties about his manhood, he only let another person have access to him through sex--but sex was also the way he reassured himself that he was really a man. As a result, men like Mark become highly attached to and possessive of their current lover while constantly looking around for another. Since Mark and Stacey had Exiles that were extremely needy and full of impossible expectations of the other, and Managers and Firefighters that strongly provoked the other's protectors, their sex life was doomed from the start.
After Mark and Stacey made peace with their inner exiles in private sessions and, consequently, were each less vulnerable and reactive to the other, I brought them together for a joint session. I told Mark and Stacey, "No wonder you feel so hopeless. You never had a chance for real intimacy. As you heal these parts we've found, you'll finally have a chance."
In the joint session, my role is to help them remain Self-led as they speak to each other. When I notice that either of them has been hijacked by a part, I encourage them to focus inside briefly and then come back and speak for their parts rather than from them. When a partner speaks from the Self about its parts, the other partner is less likely to be triggered and more likely to hear the message.
Mark and Stacey nervously shared with each other what they'd learned in individual sessions. It was extraordinarily touching--as it often is when embattled couples begin to thaw out--to see Stacey tell Mark with unfeigned emotion how sad she felt for that young boy who had been so cruelly humiliated. "I can understand now why you feel so driven, and why my rejection hurts you so much," she said, looking him deeply in the eyes. Mark said he'd never known about the old incident with her father, and now it made complete sense that she'd cringe when he pursued her. He knew what it felt like to be hounded. The quality of the conversation between the two of them was soft and hesitant, but direct.
Stacey asked Mark if he was willing to be patient around sex while she continued to work with her own inner parts--several other Managers had surfaced in therapy. Mark said that he'd really try to let her be in control of that arena, which would be easier now that he knew himself and his stud better. Both sighed as they began to understand that this was only the beginning of a long process. This was different from any conversation they'd ever had. They'd felt closer and more real to each other than any other time during their marriage.
Once couples get a taste of what real Self-to-Self connection feels like, they're eager to keep going, particularly when they see the barriers to their own freedom fall away. Over the course of a year, working with their parts, sometimes individually, more often in front of each other, Mark and Stacey reported continuing changes in their sexual and nonsexual lives together. Each was becoming a different person with the other; in fact, they were becoming a lot of different people with each other in ways that increasingly energized, touched, and delighted them both.
As the polarization between parts diminishes within a person, so it diminishes between partners. Stacey was no longer afraid of Mark's stud. In fact, she was surprised to discover a formerly hidden "hot babe" part of herself that could sometimes meet or even exceed the energy of Mark's stud. Mark said that whereas all his previous sexual experience had been dominated by his stud's frenzied aggressiveness, now he'd come to also enjoy the softer, slower kind of sex that Stacey preferred. His stud was less agitated and more sensual. It no longer hijacked him and took him away into fantasy worlds, so he was more responsive to Stacey's moods.
What most surprised this couple was discovering how moving and powerful sex was when they allowed their more vulnerable parts to be present--those parts that they'd previously barricaded behind various protectors. No longer terrified, wounded victims, the Exiles began to exhibit their capacity for openness, innocence, sensitivity, and childlike pleasure. "You know," Mark said, "sometimes when Stacey and I are together, I feel like that embarrassed 13-year-old kid I used to be. I even let myself act as if I'm more like I'm 8 or 10, or even younger--all bouncy and eager the way I was then." To his wonder, when he let himself feel young, vulnerable, and a little awkward, rather than cleaving to the old image of a technically perfect sexual operator--Stacey responded with loving warmth and laughter, kissing and stroking him as if he were her beloved child. While feeling highly charged sexually, he also felt, for the first time in his life, utterly cherished and nurtured.
It took longer for Stacey to let herself feel that vulnerable--her distrust was very intense. Eventually, however, she could let the little girl out in a nonsexual context during sessions, becoming playful in a funny, slightly silly, way. Later, the little girl began to spontaneously show up in their bed. As the little girl took part in sex, Stacey said she felt the same kind of total love and acceptance from Mark that he'd reported from her when his boy was present. They both found humor and playfulness moving seamlessly from their nonsexual to sexual lives and back again. They teased each other during the day, which often became a prelude to sex.
One of the enormous advantages of this kind of free-flowing give-and-take of parts between a couple is the variety and richness it brings to their lives. Stacey remarked one day toward the end of therapy that what she loved most about their new sexuality was the unpredictability of it. For the first time in her life, she was no longer trying to control every aspect of their sexual encounters and, instead, could let any part of herself spontaneously emerge in her body during their lovemaking. The appearance of a part in her often elicited a new part in Mark, so sex, which had been a predictable deployment of stereotyped parts, became an improvised and often astonishing dance in which neither one knew in advance who would show up. This meant for Stacey that she'd suddenly find herself moving in ways she'd never moved before and saying words she'd never said, and all the different parts seemed to find great joy in finally expressing themselves as openly and physically as they wanted. She constantly expected to berate herself for acting so brazenly, but the torrent of criticism from her Managers seemed to have dried up. She still occasionally felt embarrassed the morning after, but that didn't last long, since Mark seemed so happy about it all.
Mark and Stacey were also experiencing more and more Self-to-Self intimacy, although they'd have been puzzled by what I meant, if I'd told them this. I don't talk very much about the Self with clients; before they've done much work with their parts, it might sound incomprehensible to them. Afterward, they know and experience Self-to-Self connection without having to name it. Clients still in thrall to their parts, manifesting in extreme and polarized form, or couples who mostly see only angry, resentful, dependent, jealous, self-pitying parts in each other, may not know there's anything like a Self within them. But the simple process of learning to help a part "step back" before they talk to each other allows the couple to experience a few minutes of agenda-free, open-hearted curiosity about the other. Fleeting as they are, such moments inevitably create an almost palpable sense of connection that wasn't there before and can carry them through ensuing "parts wars."
Enough of these moments and a couple begins to know that, whatever stormy melodrama roils the waters of their relationship, it cannot interrupt a deeper, more enduring current flowing between them. When your partners hold Self-to-Self connection, parts can come and go spontaneously within both, without eliciting the old fears, angers and misunderstandings, because each of them senses the calm, abiding presence of an essential "I" in the storm. That connection forms a loving backdrop to a couple's sexual experience that makes it safe and wonderful for any part to come out. It's the safety of the Self-to-Self connection that allows the delicious surrender to the sexual process.
Once a couple has tasted Self-to-Self intimacy, they know that whatever tempests they find themselves in aren't the essential reality of their connection. No matter what the parts are saying during these inevitably rough times, the couple knows that sooner or later they'll again speak to each other in their true voices. And when that happens, each loses a sense of lonely separateness, and, at some level, experiences a state of union and oneness. They sense that both of them are part of the deep ocean, not the isolated waves. Both are home.
Richard Schwartz, Ph.D., is the director of the Center for Self Leadership (website: selfleadership.org). He is the originator of the Internal Family Systems Model and author or coauthor of five books, including Internal Family Systems Therapy . Address: 217 North Lombard Street, Oak Park, IL 60302; e-mail address: firstname.lastname@example.org. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by Jenny Newsome
When I was young and only three years out of graduate school, one of my first private clients came into a session carrying a small package simply wrapped in brown paper and string. The memory of that package and how I reacted to it haunts me still.
The client--Katy--was a businesswoman who had come to me six months earlier, dumbfounded by a depression so deep that she was fighting the impulse to drive her car off a bridge. In cognitive-behavioral therapy, she'd improved steadily, returning to activities she had previously enjoyed and finding the strength to let go of unfixable situations she'd badly wanted to fix.
She was dressing more casually, laughing easily and entertaining ways to broaden her already full life. She'd decided to leave her present employer, expand her private consulting business and enroll in a Ph.D. program. Even though her depression was resolved, she had continued in therapy in order to solidify her changes and stay in touch with her long-term goals. All in all, I couldn't have been more pleased about the progress of her therapy.
Then came the fall day when, much to my surprise and horror, Katy came into her session and gave me the little brown-paper package. I unwrapped it and found a small, black velvet box. Inside, was a necklace, and not just any necklace: a gold chain with a diamond pendant that she had designed herself, worth about $500.
I took a breath. I was out of my depth.
Katy knew that giving a gift to one's psychologist could be tricky, so she was also armed with a persuasive list of reasons why I should not refuse her gift. She told me earnestly that it gave her great joy to thank me in a special way. Given her high income, the necklace was comparable to a holiday box of chocolates from a middle-class patient she insisted. She wanted to celebrate her therapy success, and this was a way of making it tangible. The choice of a diamond held great significance: it was analogous to her experience of the transformative power of therapy. The earth, she explained, takes a dark substance (carbon) and subjects it to great pressures that make it clearer and better than it was before.
Being young and new and the good ethical psychologist that I was trained to be, I did just what she feared: I refused her gift. I thanked her for the thought and said it was against my professional code of ethics to accept.
Katy looked pale and shaken and said she felt dizzy. I had to suggest she take some deep breaths. I tried other cognitive-behavioral strategies, but this was not a simple panic attack.
I asked her if this was a transference issue in which she was confusing aspects of our relationship with other significant people and events from her past? No. Was she trying to bribe me into having a non-therapy relationship? No again. Did she have trouble receiving help without reciprocating? She said that although she liked to reciprocate kindnesses, she did not feel "driven" to do so.
Then she told me she felt insulted that ethical rules designed to protect vulnerable patients were being applied to her, even though her depression was in remission. Would she now always be classified in such a way that her own judgment could be questioned? Didn't I trust her to make good decisions? And isn't a cigar sometimes just a cigar?
Finally, terrified and exhausted, I told her flatly that accepting something so expensive was against the ethical rules of my profession and I did not want to place myself at legal risk. Katy got so upset that, again, I thought she might faint. I agreed to hold onto the necklace for 10 days and talk about it again at our next session.
I put the black velvet box in my desk drawer.
Meanwhile, I talked to close colleagues, called the American Psychological Association ethics board, my state ethics board and a lawyer-psychologist who specialized in ethics law. I took the train to Philadelphia and New York to consult with two of my mentors, one of whom had supervised me in graduate school. (In the end, I spent more money on consultations than the dollar value of the necklace.)
My mentors told me I was running the risk of dehumanizing Katy and jeopardizing our therapy relationship by being so scared and rigid. The ethics boards and lawyer both told me that it was in Katy's interest that I accept her gift.
But that was not the reaction I got closer to home. One of my closest colleagues suggested that Katy must be a "borderline" and secretly in love with me. Another recommended I accept the gift but never talk about it.
With much anguish, after 10 days, I accepted the necklace, thanked Katy and brought the black velvet box home. Katy and I continued therapy for several more months before terminating, but something had changed. The sense of a "dirty little secret" had leaked into our sessions.
I had consulted with everybody I could think of and tried to please them all. Losing touch with my own best instincts, I'd gotten enmeshed in our profession's confusion over how to respond to a client's gratitude while safeguarding her from exploitation. In the process, the beautiful necklace Katy had given me had become tainted--not the celebration of growth and gratitude she had meant it to be. I'd allowed other voices into the sanctuary of our therapy and once they were there, I couldn't get them out.
"Jenny Newsome" is the pseudonym of an experienced cognitive-behavioral therapist on the Eastern Seaboard. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by William Doherty
I want to propose a new competition for therapists: awards for the worst experiences doing couples therapy. My own entry would be in the category of a worst experience as a new couples therapist in the first session. It was 26 years ago, but as they say, it feels like yesterday. As a graduate student, I'd done individual counseling before, and had worked with parents and kids, but had never worked with a couple. Thirty minutes into the first session, when I was lost in the midst of a meandering series of questions, the husband leaned forward and said, "I don't think you know what you are doing." Alas, he was right. Naked came the new couples therapist.
Since then, as we say in Lake Wobegon, I like to think I've become an above-average couples therapist, but that might not be much of a distinction. A dirty little secret in the therapy field is that couples therapy may be the hardest form of therapy, and most therapists aren't good at it. Of course, this wouldn't be a public health problem if most therapists stayed away from couples work, but they don't. Surveys indicate that about 80 percent of therapists in private practice do couples therapy. Where they got their training is a mystery, because most therapists practicing today never took a course in couples therapy and never did their internships under supervision from someone who'd mastered the art. From a consumer's point of view, going in for couples therapy is like having your broken leg set by a doctor who skipped orthopedics in medical school.
What's my evidence for these assertions? Most therapists today trained as psychologists, social workers, professional counselors, or psychiatrists. None of these professions requires a course in marital therapy. At best, some programs offer an elective in "family therapy," which usually focuses on parent-child work. Only the professional specialty of marriage and family therapy, which constitutes about 12 percent of psychotherapy practitioners in the United States, requires coursework in couples therapy, but even there you can get a license after working only with parents and kids. After coursework, few internship settings in any field give systematic training in couples therapy, which isn't ordinarily a reimbursable service.
The result is that most therapists learn couples therapy after they get licensed--through workshops and by trial and error. Most specialize in individual therapy, and work with couples on the side. Most have never had anyone observe or critique their couples work. So it's not surprising that the only form of therapy that received low ratings in a famous national survey of therapy clients, published in 1996 by Consumer Reports, was couples therapy. The state of the art in couples therapy isn't very artful.
Why is couples therapy a uniquely difficult form of practice? For starters, there's an ever-present risk of winning one spouse's allegiance at the expense of the other spouse's. All your wonderful joining skills from individual therapy can backfire within seconds with a couple. A brilliant therapeutic observation can blow up in your face when one spouse thinks you're genius and the other thinks you're clueless--or worse, allied with the enemy. After all, one spouse who agrees with you too vociferously can dramatically undercut your effectiveness.
Couples sessions can be scenes of rapid escalation uncommon in individual therapy, and even in family therapy. Lose control over the process for 15 seconds and you can have spouses screaming at each other and wondering why they're paying you to watch them mix it up. In individual therapy, you can always say, "Tell me more about that," and take a few minutes to figure out what to do next. In couples therapy, the emotional intensity of the couple's dynamics doesn't give you this luxury.
Even more unnerving is the fact that couples therapy often begins with the threat that the couple will split up. Often, one spouse is coming just to drop off his or her partner at a therapist's doorstep before exiting. Others are so demoralized that they need an intense infusion of hope before agreeing to a second session. Therapists who prefer to take their time doing their favorite lengthy assessment instead of intervening immediately may lose couples who arrive in crisis and need a rapid response to stop the bleeding. A laid-back or timid therapist can doom a marriage that requires quick CPR. If couples therapy were a sport, it would resemble wrestling, not baseball--because it can be over in a flash if you don't have your wits about you.
As in any sport or art form, there are beginners' mistakes and advanced practitioners' mistakes. Inexperienced and untrained couples therapists don't manage sessions well. They struggle with the techniques of couples therapy, and clients often sense that these therapists aren't skillful. More advanced therapists can manage sessions well with challenging couples, but they make subtler mistakes, of which neither they nor their clients may be aware. I'll start with beginners' mistakes and then describe how couples therapy can go south, even in the hands of experienced therapists.
Mistake No. 1--Lack of Structure: The most common mistake made by inexperienced couples therapists is providing too little structure for the sessions. These therapists let spouses interrupt each other and talk over each other. They watch and observe as spouses speak for each other and read each other's minds, making attacks and counterattacks. Sessions generate a lot of energetic conversation, but little learning or change. The partners simply reproduce their familiar patterns in the office. The therapist may end the session with something blandly reassuring like, "Well, we've gotten a number of the issues on the table," but the couple leaves demoralized.
Screenwriters are onto this fundamental clinical mistake. In the movie The Ref, Kevin Spacey and Judy Davis are a warring couple in a therapist's office. At one point, they turn to the therapist, almost pleading for him to intervene in their bickering. He says reflexively, "What I can say is that communication is good." Later, he adds, "I'm not here to give advice or to take sides," whereupon Davis shoots back, "Then what good are you anyway?" When the therapist loses control completely and begs the couple to lower their voices, they shout back, "Fuck you!" in unison--the first time they've agreed on anything in the session.
Sometimes a therapist who doesn't create a clear structure for the sessions will conclude that some clients aren't good candidates for couples therapy because they're too reactive in each other's presence. The upshot is a referral, splitting up the partners for individual therapy, which might further erode the marriage. I once saw a tape of an inexperienced couples therapist who announced that the sessions didn't seem "safe enough" for the angry spouses. (There was no evidence of physical violence or emotional cruelty in the relationship.) The real issue wasn't the couple's ability to handle the joint sessions--it was the therapist's ability. She was the one who didn't feel safe.
I remember when I first realized that I had to ratchet up my structuring skills. I was working with a couple in which the husband was Israeli and the wife American. David was opinionated and assertive, but loving and committed. The challenge I faced in the early sessions was his tendency to interrupt his wife, Sarah. I tried to keep him at bay with my standard armamentarium of diplomatically crafted "I-statements." "David," I'd say, "I'm concerned about your interrupting Maria, which means she can't finish her thought. I'd like to reinforce the ground rule that neither of you interrupts the other. Is that something you're willing to commit to?" He'd agree, be cooperative for a while, and then start interrupting again when she got his goat. Finally, I fell back on my working-class Philadelphia roots, bluntly instructing him, "David, stop interrupting your wife. Let her finish." He looked as though he was taking in my message for the first time. "Okay," he replied meekly. Thereafter, when he'd start to interrupt, I'd keep looking at Sarah while waving my arm in his direction, shooing his comments away. He cut it out, the therapy progressed, and I realized I'd reclaimed a piece of my Philly street past that I could use when the occasion required.
Mistake No. 2--No Plan for Change: After lack of structure, the most common complaint I hear is that many therapists don't recommend changes in the couple's day-to-day relationship. Some therapists act as if insight alone is enough to help couples change intractable patterns of thinking and acting. But we all know that certain dynamics within a relationship have a life of their own. I start emotional, you start rational, I get angrier, and you get more controlled. Then I mention your mother and you blow up, which pleases me immensely. Just pointing out this dynamic isn't enough to change it. All empirically supported forms of couples therapy require active interventions aimed at teaching couples new ways to interact. Most involve homework assignments. Of course, just making interventions isn't enough if they're too global or generic. If my wife and I are fighting continually over her mother, saying to us, "Remember to paraphrase and use your other communication skills" won't take us very far. Good therapy addresses the way couples actually do their own particular dance, both during the session and back at home.
Mistake No. 3--Giving Up: The third common mistake of inexperienced therapists is giving up on the relationship because the therapist feels overwhelmed with the couple's problems. I've heard enough stories about therapists who abandoned ship too soon to be confident that this is a common mistake. In one case, the therapist did an assessment during the first session, and in the second session pronounced that the couple was incompatible and weren't candidates for couples therapy--without ever trying to help them. In another case, a woman whose husband was becoming emotionally abusive as his Parkinson's disease progressed told me that, at the end of the first session, the therapist had said, "Your husband will never change, so you have to accept what he's doing or get out." Translation: "I don't have a clue about Parkinson's disease or how to help an elderly couple with serious marital problems, so I'm pronouncing yours a hopeless case." This also kept the therapist's average length of treatment in favorable territory with his managed-care employer.
Some therapists survive the early sessions but get frustrated later and actively advise couples to separate. When deciding that the couple isn't amenable to treatment, they don't seem to factor in their own skill level. They may further reduce their own sense of responsibility by making a delayed diagnosis that one of the spouses has a personality disorder. This often means nothing more than "I can't work with this person." Giving up this way is akin to a primary care physician's pronouncing a patient incurable without referring the patient to a specialist in his or her life-threatening condition. I once worked with a young family physician who had a rule that no one should be allowed to die without a consultation from a specialist in what is killing them. I would argue the same for couples: treatment failures, especially those that lead to divorce, shouldn't be accepted without a consultation or referral to a competent, experienced therapist who specializes in working with couples.
Experienced Therapists' Mistakes
Mistake No. 1--Thinking All Couples Are Equal: Advanced practitioners' mistakes are more about strategy than technique, more about missing the context than specific relational dynamics, and more about unacknowledged values than lack of knowledge. I'll focus on two areas of poor couples therapy by experienced therapists: working with remarried couples and working with couples deciding whether to work on their marriage or divorce.
Remarried couples with stepchildren are a minefield, even for experienced therapists, because the partners almost always come with parenting issues, not just couples problems, and because many therapists miss the nuances of stepfamily dynamics. Therapists who specialize in adult relational work but aren't skilled at parent-child therapy will fail with these families. Experienced therapists who treat remarried couples like first-marrieds usually manage the individual sessions well, but use the wrong overall strategy.
I remember my own awakening on therapy with remarried couples almost as clearly as I remember my first session of couples therapy. It was in the spring of 1985, and I'd been trying to get Dave and Diane to reduce conflict in their two-year-old marriage by being equal parents with Kevin, Diane's challenging, 14-year-old son from a previous marriage. It was a familiar coparenting problem. Dave thought that Diane was too soft on the boy, and Diane thought Dave was too strict. They'd sometimesÂ reach a "compromise," but Diane wouldn't follow through on it. I'd helped many couples with this kind of bread-and-butter problem in family therapy, but I was stuck here. I can feel the chair I was sitting on when I said to myself something like, Bill, why are you insisting that this woman share parenting authority equally with this man? He didn't raise Kevin, Kevin doesn't see him as a father, and Dave doesn't have the same investment as Diane does. She can't treat Dave as an equal here, so stop beating up on her for not succeeding.
I realized that I was misapplying a norm about coresponsibility in biological coparenting to a family structure where it didn't apply in the same way. I then told the couple that I could understand why Diane couldn't give Dave equal say in disciplining her son--the fact was that Diane was the parent. With so many years invested in her son and Dave's relationship with Kevin so new, she couldn't share authority 50-50. I introduced a metaphor that I would come to use often with stepfamilies: in the parenting domain with her child, Diane was the "first violinist" and Dave "second violinist." Diane immediately was relieved, and Dave immediately was alarmed. There was a lot of work ahead, but they did achieve a workable coparenting relationship based on Diane's leadership with her son. Shortly thereafter, I read Betty Carter's work on stepfamilies in which she argued for treating the spouses as having different roles with the children, and then I came across new research by Mavis Hetherington making the same point. Stepfamilies are a different species, and couples in these families have to be treated with different approaches. Many experienced couples therapists still don't know this--or even if they do know it, still lack a viable treatment model.
Beyond coparenting leadership issues, couples in stepfamilies swim in a sea of divided loyalties, which even experienced therapists sometimes miss. I once consulted on a case of a recently married couple in which the wife had three children and the husband none. One thorny issue was that the husband felt left out of the wife's emotional world because they had little time alone together. The wife agreed, and she told the therapist how torn she felt about this. She loved her husband and wanted the marriage to work, but her three school-age children required nearly all of her time after work and in the evenings. She helped them with their homework every night, and they had the kind of extracurricular activity schedules that render contemporary parents part-time chauffeurs and full-time activity directors on the family cruise ship. Weekends were spent doing errands and driving the kids to their traveling soccer games.
In one of the early sessions, the therapist, who was highly experienced in couples work, empathized with the wife's feeling caught between the needs of her husband and those of her children, and supported the wife's decision to prioritize the children. The therapist explained that these years of raising school-age children are ones in which the children's time demands are huge, and the marital relationship inevitably has to take a back seat. She said that, as a wife and mother, she herself knew about these demands, which ease when children get older. In other words, the therapist normalized the marital gap in terms of the family life cycle, recognizing especially the unique strain on a wife who couldn't meet everyone's needs. The wife burst into tears at feeling so deeply understood and accepted. The therapist then turned to the husband and gently asked him for his feelings and thoughts as he'd followed the conversation and seen his wife's pain and tears. The husband, a "good guy," who didn't like conflict, owned that he'd been selfish and pledged to back off on his demands for more time with his wife, promising he'd be more understanding in the future.
The session ended with a warm glow. The couple agreed to continue working on other issues that had brought them to therapy. The therapist was pleased at how she'd been able to combine her clinical skills and her own experience as a wife and mother to help this couple. A few days later, the husband called to end the therapy, saying tersely that they'd decided to continue to work on things by themselves.
The therapist was stunned and consulted with me. I helped her see that she'd missed that there were two distinct family developmental stages at work in this case. Yes, the parent-child development stage was one of intense time demands (leaving aside for the moment the overscheduling supported by the wider culture), but the marital-developmental stage had its own pacing needs: a puppy marriage needs time for play and nurturing. To put aside their new marriage for years on end is dangerous. Of course, it's dangerous even in long-term relationships, but at least there may be a strong foundation and memories of good years. The husband was appropriately worried about the viability of a neglected new marriage. What struck me was how even a skilled, experienced couples therapist had misunderstood the special needs of a remarried couple.
Mistake No. 2--Not Standing by Marriage: If beginners give up on couple relationships because of lack of skill, experienced therapists sometimes give up on couples because of the values they hold about commitment in a troubled marriage. I've heard experienced therapists announce proudly, "I'm not here to save marriages; I'm here to help people." This split between people and their permanent, committed, intimate relationships (which is how I'm defining marriage ) has a superficial appeal. No one wants to save a marriage at the cost of great damage to a spouse or the children. But the statement reflects a troubling--and usually unacknowledged--tendency to value a client's current happiness over everything else.
One highly regarded therapist in my local community describes his approach to working with couples in this way: "I tell them that the point is to have a good life together. If they think they can have a good life together, then let's give it a try. But if they conclude that they can't have a good life together, then I tell them maybe they should move on." Again, at one level, this sounds like practical advice, but as a philosophy of working with marital commitment, it's lame. How does it differ from counseling someone about a job decision? If you think that your frustrating accounting job can eventually work out for you, then try to improve the situation; if not, move on. Most of us didn't stand up in front of our family, our friends (and maybe our God) and declare our undying loyalty and commitment to Arthur Andersen LLP, but we did so with our spouse.
In this way, the ethic of market capitalism can invade the consulting room without anyone's seeing it. Do what works for you as an autonomous individual as long as it meets your needs, and be prepared to cut your losses if the futures market in your marriage looks grim. There are legitimate reasons to divorce, but given the hopes and dreams that nearly everyone brings to a marriage, divorce is a wrenching, often tragic, event. I see divorce more like amputation than like cosmetic surgery. That's a different value orientation than that of one prominent family therapist who sees his job as helping people decide on their best option. "The good marriage or the good divorce," he told a journalist, "it matters not."
A lesbian therapist told me of how her own therapist wouldn't permit her to bring the children's needs into the therapy conversation when she was contemplating whether to stay with her partner. "This isn't about the kids," the therapist insisted. "It's about what you need and want." When the client objected that she had to weigh the kids' needs in her decision, and wanted to talk about it, the therapist balked, insisting that the client was avoiding dealing with her real issues. Finally, the client fired the therapist. Later, she told me that she and her partner had found a way to stay committed, improve their relationship, and raise their children together. The therapist in this case was a highly regarded professional, a "therapist's therapist" in the community.
It was an experience that happened to a couple who are close to my family that radicalized me about how today's therapists deal with commitment. It's a story like many others I've heard from clients, colleagues, and friends. Monica's life was thrown into chaos the day that Rob, her husband of 18 years, announced that he was having an affair with her best friend and wanted an "open marriage." When Monica refused, Rob bolted from the house and was found the next day wandering around aimlessly in a nearby woods. After two weeks in a mental hospital, diagnosed with an acute, psychotic depression, he was released to outpatient treatment. Though he claimed during his hospitalization that he wanted a divorce, his therapist had the good sense to urge him to not make any major decisions until he was feeling better.
Meanwhile, Monica was beside herself. She had two young children at home, held a demanding job, and was struggling with a serious chronic illness diagnosed a year before. Indeed, Rob had never been able to cope with her diagnosis, or with his own job loss six months later. (He was now working again.) In addition, the family had just recently moved to a new city.
Clearly, this couple had been through a lot of stress. For a former straight-arrow man with strong religious and moral values, Rob was acting in a completely uncharacteristic way. Monica was depressed, agitated, and confused. Being an intelligent consumer, she sought out recommendations and found a highly regarded clinical psychologist. Rob continued in individual outpatient psychotherapy, while living alone in an apartment. He still wanted a divorce.
As Monica recounted, her therapist, after two sessions of assessment and crisis intervention, suggested that she pursue the divorce. She resisted, affirming her hope that the real Rob would reemerge from his mid-life crisis. She suspected that the affair with her friend would be short-lived (as it was). She was angry and hurt, she said, but determined not to give up on an 18-year marriage after only one month of hell. The therapist, according to Monica, interpreted her resistance to "moving on with her life" as stemming from an inability to "grieve the end of her marriage." He then connected this inability to the loss of her mother when Monica was a small child. Monica's difficulty in letting go of a failed marriage, he claimed, stemmed from unfinished mourning over her mother's death.
Fortunately, Monica had the strength to fire the therapist. Not many clients would be able to do that, especially in the face of such expert pathologizing of their moral commitment. It was equally fortunate that Monica and Rob found a good marital therapist, who saw them through their crisis and onward to an ultimately healthier marriage. When I last saw them, Rob was more emotionally available than I'd ever seen him before. He and Monica had survived an intervention that I call therapist-assisted marital suicide.
The therapist's blundering in this case stemmed not from clinical incompetence in knowledge and technique, but from his values and beliefs. He simply didn't recognize the importance of a commitment made "for better or worse." Like attorneys who automatically fight their clients' opponents, some therapists encourage clients to rid themselves of currently toxic spouses, rather than working hard to see what can be salvaged and restored. This approach may be wrongheaded, even when it comes to individual well-being. Recent research by sociologist Linda Waite has found that the great majority of unhappy spouses who persevere in their (nonviolent) marriages for five years report marked improvements in their marriages, and that divorce, on average, doesn't make people in unhappy marriages any better off in personal well-being.
Ultimately, clinical skills aren't enough in couples therapy, because here, more than in any other form of therapy, our clinical skills and values intersect. Treating a client's depression or anxiety doesn't involve the kind of value judgments that working with couples does. Feminists were among the first to point out the inevitability of moral positions in couples work. You can't work with heterosexual couples without a framework that addresses justice and equality in gender relations. If you claim to be neutral, you'll enact whatever traditional value orientation you have about women and men and how they should make a life together. The same is true for race and sexual orientation. Not to have a moral framework is to have an unacknowledged one, and in mainstream American culture, that will probably be individualistic rather than relational or communitarian.
Just as clients who value gender equality won't be well served by therapists with traditional value orientations about gender, clients who cherish their moral commitment to their marriage, as Monica did, won't be safe in the hands of clinically skilled couples therapists who have individualistic orientations. Such clients need therapists who understand the wisdom of Thornton Wilder when he wrote: "I didn't marry you because you were perfect. I didn't even marry you because I loved you. I married you because you gave me a promise. That promise made up for your faults. And the promise I gave you made up for mine. Two imperfect people got married and it was the promise that made the marriage. And when our children were growing up, it wasn't a house that protected them; and it wasn't our love that protected them--it was that promise."
The biggest problem in couples therapy, beyond the raw incompetence that sadly abounds, is the myth of therapist neutrality, which keeps us from talking about our values with one another and our clients. If you think you're neutral, you can't frame clinical decisions in moral terms, let alone make your values known to your clients. That's partly why stepfamilies and fragile couples get such bad treatment from even good therapists. Stepfamily life is like a morality play with conflicting claims for justice, loyalty, and preferential treatment. You can't work with remarried couples without a moral compass. Fragile couples are caught in a moral crucible, trying to discern whether their personal suffering is enough to cancel their lifetime commitment, and whether their dreams for a better life outweigh their children's needs for a stable family. The therapist's moral values are writ large on these clinical landscapes, but we can't talk about them without violating the neutrality taboo. And for clients, there's the scary fact that what therapists can't talk about may be decisive in the process and outcome of their therapy.
In the end, we need to cultivate wise couples therapists, not just competent ones. Wise therapists see the whole context of people's lives, and can reflect openly and deeply on values and broader social forces influencing the profession. My wisdom won't be the same as yours, but we have to engage one another on the big questions, instead of hiding behind the wizard's veil of clinical neutrality. The philosopher Alasdair MacIntrye wrote that, in a world that seduces professionals into seeing their work as the delivery of technical services stripped of larger social context and moral meaning, the hallmark of a true profession is a never-ending argument about whether it's being true to its fundamental values, principles, and practices. In other words, becoming a competent couples therapist is just the first step in becoming a good one.
William Doherty, Ph.D., is professor and director of the marriage and family therapy program at the University of Minnesota. Address: Family Social Science, University of Minnesota, 290 McNeal Hall, St. Paul, MN 55108. E-mails to the author may be sent to email@example.com.
by Martha Manning
MY FAMILY IS HAUNTED BY DEPRESSION. MY MOTHER CAN trace it back in her family at least six generations and it's in my father's family, too. When it hits, it hits hard. We don't get "down in the dumps," we get lost in the pits. Some people find themselves or are found, others get lost forever. The melancholies, nerves and breakdowns of my ancestors landed them in sanitariums, rest homes or in upstairs rooms from which they never emerged. Treatment involved the state-of-the-art interventions of the time cold packs, electric current, sedating drugs. Sometimes people got better. Sometimes they didn't.
Six months into my own treatment for an episode of depression that scared me in its speed, severity and stubbornness, I had placed most of my emotional cards on the table, but was disappointed that my therapist still hadn't constructed some brilliant framework in which my difficulties and those of my family could be finally uncovered and our dysfunction excised. Since he never volunteered his opinion on the subject, I finally just demanded, "Why are there so many problems in my family?" He shrugged and replied calmly, "Because there are so many people in it."
My first reaction was, "I'm paying $100 an hour for this?" And yet, eight years later, his comment still stands firm among my list of top 10 therapeutic interventions of all time. The poet Mary Karr, author of the celebrated Liars' Club, a memoir of a colorful and tremendously chaotic family, recently echoed my therapist's comment when she wrote that her definition of a dysfunctional family is "a family with more than one person in it."
My therapist's comment looks naive sandwiched between some of the more elaborate observations other therapists and clinical supervisors have made to me over the years. But in addition to comforting me with its common sense about the variety of ways families suffer, his words have been an insistent caution whenever I am seduced too quickly into facile interpretations of psychopathology. There is, after all, a very thin line between theoretical elegance and bullshit. These days, the easier the explanation of something as complicated as the relationship between families and depression, the less I trust it.
For every connection we find between our favorite theories and what we see in our consulting rooms, there are probably a hundred such families whose members somehow muddle through in defiance of our ideas about how dysfunctional they and their families are. Understanding the legacy of depression in a family requires more than genetic mapping, family diagrams, or symptom checklists. Each of us is the product of a complex weaving of genes and expectations, biochemistry and family myths, and the configuration of our family's strengths, as well as its vulnerabilities. To truly appreciate the complexity of the weave, we have to sort out the contributions of individual threads to the overall design. Yet, in describing a weaving it would be ridiculous to say, "Well, there's a red thread and over there is a blue thread and here's a gold thread." While these separate observations yield pieces of information, they provide no overall view of the fabric. It is only when we see how red threads braided with blue threads influence the pattern in particular ways that we can even begin to grasp the design of the whole.
MY OWN MEMORY OF BEING haunted by depression extends back to my great-grandmother who lived into her nineties and died when I was about 10. As I began to put things together about the relationship between my grandmother and her mother, I started to wonder whether the dulling of self I sometimes experienced, and its power to contaminate energy and joy, played leap frog with the generations hopping over my great-grandmother and landing on my grandmother, leaping over my mother and crashing down on me.
My great-grandmother was either authoritative or controlling, depending on how negatively her behavior was affecting you at the time. When we made our annual family visit to my grandmother in Massachusetts, we knew our visit would include a pilgrimage to her mother, Grammy Hale. As young as 6 or 7, I knew that there was a whole lot more going on during those visits than I could grasp. My intuitions were confirmed whenever children were dismissed immediately following raised voices. I sensed something big happened during those dismissals. Something bad. Later I found out that these were the times my great-grandmother roundly castigated my grandmother. It didn't matter for what. It could have been my grandmother's break away from a middle-class Irish Catholic neighborhood after her marriage to reside in a big house on the Waspiest street in the town. Or it could have been the tone of a brief comment my grandmother had made weeks before. The crime didn't matter. The punishment was always the same: my great-grandmother's total and complete disgust.
After each visit, as we drove back from Salem, I noticed the way my grandmother deflated, remaining silent on the way back to her house. She was almost impossible to distract from her brooding, even with our most entertaining attempts. Even when we arrived back to her wonderful beach house and celebrated our freedom from creaking musty homes and strange old women, my grandmother was elusive. She stayed in her room, shades drawn against the sun and the ocean, windows shut tight against the clean salt air. It frustrated me to think that she was making herself oblivious to the most obvious ways to feel better.
When we kids asked what was wrong with Grandmother, grown-ups always told us the same things. Grandmother was "tired," Grandmother "needed some rest," Grandmother "wasn't well." And we were told that the only thing we could possibly do to make her feel better was nearly impossible: "Be quiet." Trays that were delivered to her room earlier in the day were retrieved untouched. She didn't even want to see me, her "golden girl" who could usually snap her out of anything. Sometimes, I'd sneak into her room and lie next to her when she was sleeping, matching my breathing to hers and stroking her hair and face. She didn't have a fever, she wasn't throwing up and I didn't see spots anywhere so she wasn't sick in any way I knew about. I wondered if sadness grew with age and actually made people sick. The reasons each siege of sadness finally ended were no clearer to me than the reasons it began. When I asked about these things, unlike other times when I knew information was intentionally withheld, I almost believed my mother when her smile flickered for a moment and she said she didn't know.
On her good days my grandmother was magic extravagant, energetic and always interested. She allowed my cousins and me to tag along with her on her many errands and activities. She let us know that we were all perfectly wonderful children, despite our parents' petty complaints about us. She was fun in a way my mother never was. But as I grew older, I learned about the other side. On her bad days, I could see my grandmother wilt before my eyes. There was nowhere to tag along, because she didn't go anywhere. She never got fully dressed and when she did, it wasn't worth it. She didn't laugh. She didn't think I was perfect anymore. The air felt heavy around her, very still and hard to breathe. My grandfather, a C.P.A., seemed always to be working. My grandmother went to bed early (many times before dark). For a woman who spent as much time in bed as she did, I was always puzzled by her daily complaint that she didn't get any sleep. My grandfather recedes in my memory as a major player when my grandmother was nursing her depressions and sulks. It's like he just disappeared at those times.
In early adolescence, my relationship with my grandmother changed. Now I felt some unspoken expectation that with my new maturity, I owed her something. Now she wanted me to listen to her complaints of how badly she slept or how my grandfather worked too much or how her children didn't understand her. I couldn't stand her laments. And, since I couldn't do anything about her complaints, I left each interaction frustrated and resentful. She scared me in a way I couldn't and didn't want to understand. I felt an uneasy resonance with her, a sonar that picked up on cues that predicted a shift in her mood.
My mother was not magic. She was practical, rational and smart. As a little kid, I knew that and I loved her for it, because to me it meant that she would always take care of me, that no matter what happened, she was a constant. As our personalities diverged, she seemed more formidable. My mother was in control of her feelings. Mine spilled out all over the place. To my mother, the fact that every day was a new day was a good thing. I was never so sure. I also learned that my own dark moods were best kept to myself. As the oldest of six, I, like my mother before me, was praised for being so responsible, so capable at such an early age. I loved the praise, but I hated the reasons for it.
My mother had a no-nonsense approach to unhappiness. Stay busy, think of someone worse off than yourself, offer it up for the souls in Purgatory. At the pediatrician's office when two or three of us lined up with our bare asses vulnerable to imminent medical intervention, one of us invariably burst into loud and contagious tears, protests and screams. I remember more than once my mother leaning over and whispering, "If you must cry, cry quietly."
I recall her curiosity and impatience at my unremitting despair following being dumped by a boy when I was 13. She was sympathetic to the pain of such an experience and allowed that there was nothing like a good, cleansing cry. It was the intensity and duration of it that proved problematic. My mother had about 15 minutes in mind, whereas I was planning to make a weekend out of it.
Early on, I considered myself flawed in a way that she wasn't. Unlike my mother, I had difficulty with what she calls "compartmentalizing." She could quickly extricate herself from awful feelings; I became mired in them. By my mid to late teens, I began to struggle with the variability of my moods, something that the steamroller approach to life I had learned from my mother could not control. I wondered which woman, my mother or my grandmother, was the preview of my future. My unspoken fear that increased with age was that I was destined to become my grandmother.
I UNDERSTOOD MORE ABOUT THE nature of my mother's strength when I saw her in the context of my grandmother's vulnerability. As I grew old enough to realize that my mother and I could experience diametrically opposed feelings on the same exact subject, I realized she hated visits to my grandmother the very same trips I loved. When I was 6, I looked at the calendar and cried out, "Two more days till vacation." My mother's face got as stormy as it ever gets. She clenched her teeth and spit out, "This is many things, but it is definitely not a vacation.
When my grandmother's mood changed, my mother's did, too. Upon our annual arrival at my grandparents' beach house, it seemed like my grandmother almost willfully fell backward into helplessness and depression. And, in response, my mother went into overdrive. After feeding her own six kids dinner in our adjoining cottage, she rushed up to the main house to feed my grandparents, who somehow made it through the other 50 weeks of the year just fine.
But cooking was the least of my mother's duties. She was my grandmother's personal cheerleader, her therapist, the person who got her up and going, who tried to shift my grandmother's automatic negative outlook at least to neutral. One of my most common memories of those visits is the way my mother and grandmother sat around the kitchen table. My mother always looked like she was sitting on tacks and my grandmother always looked likeÂ she was sinking in mud. The sheer exhaustion she conveyed in the act of stirring her tea made it look like she was mixing cement.
Their conversations always stopped short when I walked in the room, but my mother didn't look at all like she looked in the many kitchen-table conversations she shared with her friends. When I became a therapist, I realized that during those times my grandmother and mother were "in session." It was only once we were on our way home again that I could see my mother's shoulders relax. She started smiling again and tolerated our loud and stupid car games.
In retrospect, I sec how that pattern repeated itself with my therapist-husband when I was depressed, as we sat on the bed or at the table and he tried to get me to articulate what was wrong. Anyone who has ever been seriously depressed knows that that task is as daunting as asking a lame man to tap dance. In addition, it leads to mutual frustration, anger and, ultimately, helplessness. It was only when we both gave up the expectation that my husband could somehow "cure" me that we moved from pseudo therapy to true support. Instead of reaching out with well-intentioned "therapeutic" interventions, he shifted to questions like, "What would help right now?" My therapist was always willing to include Brian in our sessions and, even though they were not present, to recognize Brian and my daughter, Keara, not only as my support system but as people who were suffering also. This freed them from the responsibility of those awful sessions at the kitchen table, where the certainty is that if you stay with this depressed person for one minute longer, you will drown as well.
My grandmother constantly sighed, something my mother never did. It was not an "Oh well" kind of sigh or a "That's life" kind of sigh. Hers was an exhalation that sounded like it could possibly end in her demise. It was a sigh of surrender. But as I got older, I understood that it wasn't pure fatigue or sorrow or hopelessness. It was, in its essence, an angry sigh. It was a challenge: "Just you try and make me feel better. I dare you."
In my twenties, my mother began to tell me about her childhood. She recalled being very happy until she was a teenager. My grandmother was dynamic an energetic cleaner and planner. She loved children and was always wonderful with them. But in early adolescence, something changed. My mother began to return from school to a sink full of dirty dishes, her mother in bed for no obvious reason and no dinner planned. "My memory of ninth grade," she told me "is of gritting my teeth and thinking, 'Oh God, now I have that mess to face.'" But my mother did more than face it. She took care of it.
The expectation that she do it and keep on doing it was never articulated. It was assumed and rewarded with abundant praise, which totally hooked my mother in very short order.
As children, we believed all of my grandmother's promises that things would be better "if only" "If only you lived closer, I'd be happier." "If only your aunt was easier to deal with." "If only your grandfather didn't work so hard." When I was 10, my mother (who rarely said bad things about people) insinuated that we shouldn't count on those extravagant promises our grandmother had made. When we leapt to our poor grandmother's defense, my mother responded, "This is the truth. It's what goes on. I'm giving you the truth. I never got that from my mother. But you will always have it from me."
When I had my own child at the age of 25, my mother became much more open in expressing her frustration with my grandmother for not changing and with herself for not being able to make her. In my late twenties and thirties, the depressive fog that had shadowed me for a long time grew more difficult to override or outrun.
I MOVED TO BOSTON WITH MY husband and daughter to do a postdoctoral fellowship at McLean Hospital. We found a house several miles away from my grandmother, to her great delight. I was thoroughly unhappy with the fellowship, McLean and the move, especially as I realized why my mother had consciously put 500 miles between her mother and herself. It was so sad to see my grandmother's magic destroyed by something so insidious and powerful, that neither my love nor my training could change it. I knew she was in her own hell, yet there were times I wanted to coax her or kick her out of it, dismiss her complaints and sighs, but I couldn't. And I feared I was looking at my future. I didn't want anyone to feel that way about me.
My first cousin the firstborn in her family of seven was going through her own hell at the time from depression, a hell that culminated in suicide in her early twenties. My own deepening depression and my cousin's suicide catapulted me into psychotherapy with a psychiatrist referred by my health plan. I told him I was anxious. He told me I was depressed. Yeah, I admitted, I had my moods, but no way was I depressed in the way my cousin or grandmother was. As evidence against his diagnosis, I listed my accomplishments, the many responsibilities I fulfilled. But 30 minutes into my session with him I was convinced that I was indeed depressed. At the end of our first session, he turned to me solemnly and said, "You really believe that life is something to be endured, to be overcome." I looked back at him suspiciously, wondering if it was a trick question. "It isn't?" I asked. He told me we had our work cut out for us and scheduled a session for the next week.
Our work in the five months that remained in my fellowship was fairly structured and involved learning ways to manage my anxiety and set limits in the many areas in which I felt overwhelmed. Perhaps the most significant result of the work was that I decided not to accept a job at my fellowship and remain in the Boston area, but to return to Washington to accept an academic position there.
Not long after we moved back, I began to hear my grandmother's sighs in my own labored breathing. I, too, felt the weight of the spoon as I stirred my tea. I knew that making a peanut butter and jelly sandwich should be far less than a 30-minute operation. I entered individual psychotherapy, found it extremely helpful, particularly in quieting the loud voice of perfection that used to rule my expectations of myself, and the panic that had begun to sneak up from behind and immobilize me.
But my depression continued despite insight, despite a good marriage, despite a child I dearly loved. I finally agreed to try antidepressants and was horrified when my psychiatrist recommended imipramine, the same medicine my grandmother had used in her late seventies, with moderate success, but difficult side effects. My psychiatrist must have registered the horror on my face. He reassured me that he always chooses as the first antidepressant a drug that has worked with other family members.
He was right. The medicine helped quickly and dramatically. It lifted a lifelong weight off my back and made me wonder, "Is this how regular people feel?" But like many people who take psychotropic medications for significant periods of time, I struggled with questions like, "Why can't I do this on my own?" or, looking at the tiny pills, I wondered, "Is this all that stands between hell and me?"
Fortunately my psychiatrist and I already had a strong therapeutic relationship. Yet despite the benefits of the antidepressant, I still feared that I was destined to be my grandmother, a fear no drug could erase. I didn't want her resignation, her helplessness, her just-be-low-the-surface bubbling anger or her genuine and horrible suffering. I also didn't want to have the impact that she had on her family, particularly on my mother. I did not want my daughter to take on the yoke of responsibility and resent me for it. I had already watched three generational scenarios: My great-grandmother's influence on my grandmother, both of their influences on my mother and all three of their influences on me. The one that scared me most was the next one the weight of all four of us on my 11-year-old daughter.
In addition to support, the therapy focused on developing an understanding of the commonalities I shared with each woman, appreciating aspects of our shared legacies as some of the things I most valued in myself. I also had to articulate the differences between myself and each of them. I worked to understand that depression did not negate me, it just made my life different and difficult hopefully, for a limited amount of time, and that no one genetically, biologically or psychologically is the blueprint for anyone else. Being haunted is not the same as being cursed.
The fact that in little more than a year's time, I descended into a very serious depression does not negate the impact of the psychotherapy or the medicine. For reasons that were never clear, I began to metabolize my medications so rapidly that to keep a therapeutic dose in my blood, I required doses that became untenable. The benefits of each new medicine bottomed out within a matter of weeks.
My daughter tried to tease me, tempt me, annoy me, entertain me and soothe me all to no avail. Her constant question was, "Why are you so sad?" No wonder that I worried about the impact of my depression on her. The self-absorption caused by the acute pain of a severe depression makes being a good parent very difficult. I had difficulty following the rambling conversations in the car that I usually loved. Her new friends' names were hard to remember. Our 11-year-old bedtime ritual, with its whispers, soft songs and backrubs dwindled down to a quick goodnight.
She and my husband hovered and worried. In reaction to my early experience of whispered adult conversations, my husband and I tried to be straightforward with Keara. I remembered what my mother had wished for in her adolescence "Just some knowledge. What's going on and what's being done to help it."
Now, five years since my last serious depression, my daughter teases us that we went a bit overboard in providing the information my mother had wanted. She insists that the information we gave her about depression was a lot like the information we gave her about sex a lot of big words with little context. Her concerns had less to do with having a technical command of depression than about the continuity of her care and protection. Two years ago, at the age of 16, she spoke to an interviewer who was writing a story about my depression: "The thing about having someone close to you suffer from depression is that your feelings go from worried, to angrily impatient, to guilty. One of the worst things was seeing my mom in so much pain and being constantly reminded that it wasn't my fault and there was nothing I could do to make her feel better."
We tried to keep her life as stable as possible. Given my mother's experience, 1 definitely did not want my daughter to "rise to the occasion." In the interview, Keara said: "My mom worked hard to take care of me, to make sure I was taken care of, which I was. I was so lucky to have my father. My parents always shunned the value system where the mother would be the singular child raiser. I was always close to my dad, even closer at the time because I spent more time with him as my mom got worse. Anyway, the shift in my standard of living was not too dramatic."
Despite pills, therapy, love, professional expertise and faith, my symptoms worsened. I didn't sleep more than two hours a night. I stopped eating it was too hard to swallow. I thought about the wisecrack about someone who is "out of it": the lights are on, but nobody's home. In depression, the lights are off, but somebody's definitely home. She just can't make it to the door to let you in.
My ruminations turned to comforting thoughts of death. I had always thought of myself as living in a series of concentric circles that connected me to life. My outermost circles included my interests and acquaintances, my work and goals. Then came my friends. Then my parents and siblings. Then my husband and daughter. As the depression worsened, those connections dissolved. They were no longer reasons to stay in the game. Life could go on without me.
In the final days before my hospitalization, I was staying alive for my husband and my daughter. I never told them this. In the last clays, I kept going only for my daughter. My daughter and her songs. Every morning, Keara stumbles semi-conscious into the bathroom and turns on the shower. Within the space of 30 seconds, she starts to sing. She starts out humming so softly that her voice blends with the spray as it bounces off the wall. And then she chooses her song sometimes sweet and lyrical, sometimes loud and rocking. Each morning, when I had to face another day on two hours of sleep and no hope, I leaned against the bathroom door waiting for her to sing and let her voice invite me to try for one more day.
One morning, finally convinced that suicide was an act of love, not hate, I leaned for what I thought would be the last time against the door. I tried to memorize that voice, with all of its exuberance and hope. And then I realized that ending my life would silence that voice, perhaps forever. And I knew what I had to do. I would finally agree to electroconvulsive therapy (ECT), which had been recommended to me for several weeks. I had always said I'd step in front of a moving train for the sake of my child. Now it was time to prove it.
ECT was the tractor that pulled me out of the mud. Its power was hard to believe. Within several treatments, I was adding 20 to 30 minutes to my sleep per night. Having lost 30 pounds in three months, I began to look forward to meals. My face, which felt like a mask, regained its elasticity. It was as if several heavy backpacks had been taken from my shoulders. But it wasn't a magic cure. I still had to walk the whole way home a journey that took more than a year, assisted greatly by medicine, therapy and the support of many people.
FINDING MY PLACE AGAIN IN MY Family took some time. When her bedtime approached on my first night home from the hospital, Keara announced, "I don't need you to tuck me into bed anymore. I do it myself now." For several weeks, no one raised a voice or a broke a rule. I was being watched very carefully. At some point, my daughter must have experienced a critical mass of the old me. She started challenging me again, testing the limits of my authority and my capacity for following through.
Over the course of that year, I had to struggle with self-recriminations about the ways I had failed the people I loved. I was ashamed that I'd been unavailable to Keara and embarrassed that she had seen me so vulnerable. As a psychologist whose profession has historically enjoyed the sport of mother-bashing, it was easy to revert to it myself. Keara would be ruined for life and it would be all my fault.
For a long time after my hospitalization, my daughter dropped her middle name, Manning, and began making it clear that her name came only from my husband, Keara Depenbrock. I knew how important it was for her to see herself as separate from me currently but more important, in the future. It was helpful for my husband to point out to me that although some of it was due to my depression, it was also a normal function of adolescence. When she wrote, "While I have a lot in common with my mother, I have inherited my father's mental health," I was able to see it as a fact as well as a wish.
Over the next several years, I marveled at my child's blooming, despite the scarcity of light in our house at a critical point in her development. Keara later remembered: "My mom's depression was definitely an impediment to us being close at the time. Because she wasn't available to me, and because something so horrible was happening inside of her, it was really hard for her to have this great relationship with other people. I think that she spent all the time and energy she had with me and for me but it wasn't as much as I wanted. I don't blame her for that. She didn't make a choice to be that way. But sometimes I'd get really frustrated and impatient with her anyway."
I recalled psychoanalyst D.W. Winnicott, one of the less judgmental voices in the psychological wilderness, who disputed the necessity of a perfect mother for a child's healthy development, substituting the more attainable standard of "good-enough mother." My faith in Winnicott was confirmed the night my daughter invited me back into
her room for the nightly ritual that had taken so much effort only months before. Now, smoothing her rumpled sheets, straightening her comforter to her exact specifications and rubbing her back with the precise level of finger pressure were gifts, not burdens.
Depression and I are not finished with each other. Four years ago, two years after my first round of ECT, I started sliding in the same dangerous direction. This time, we all saw it coming. If I didn't improve quickly, we knew the plan. This time, I had more ECT treatments, on an outpatient basis. I left for the hospital in the morning, after I'd seen Keara off to school, and I was back before she returned home. Life was not business as usual, but we managed the details with the help of our families and friends.
With the addition of a mood stabilizer (lithium), which I had refused after my first ECT, I have since enjoyed the best years of my life. They have also been the best years of my relationship with my daughter. There was something in the combination of vulnerability and stability that protected us. She saw me go to hell. Exit she was there for the return trip as well. Her fears of depression invading our family again were confirmed so quickly that in some ironic way she got to really learn the drill and find comfort in the evidence that our plans worked. We both learned that lousy things can happen and that they can be so bad and so powerful that they stand good solid relationships on their heads.
The differences between Keara and me are clear. Temperamentally, she resembles my husband and my mother, not me. That knowledge frees her from having to deny the ways in which we are so alike. She can claim our similarities without the fear of turning into me. Several months ago, at the end of her senior year, she came home, leaned against the kitchen counter while I peeled carrots and described having to fill out a form with her name exactly as she wanted it on her high school diploma. "I was afraid it wouldn't all fit," she told me.
"Yeah, Keara Depenbrock is a mouthful," I replied.
"No, Mom," she laughed, "it's worse than that. My real name, Keara Manning Depenbrock."
Our children inhale our imperfections and failings as easily as our love. Perhaps they are meant to. How else will they ever learn to tolerate themselves? My goal is no longer to make a perfect impression. Now, I'm shooting for an imperfect impression and helping my daughter deal with it. I look ahead and hope that she is spared the torment of severe depression. I think she will be. But on the chance that she might get lost in it, or in any of the other ways life tests our faith and our patience and our endurance, I wish for her exactly what she gave to me: a sweet voice in the distance that penetrates her darkness and calls her gently toward home.
Martha Manning, Ph.D., is the author of Undercurrents: A Life Beneath the Surface and Chasing Grace: Reflections of a Catholic Girl, Grown Up, both published by HarperCollins San Francisco. Address: 716 S. George Mason Drive, Arlington, VA 22204.