by Michael Ventura
Till change hath broken down
All things save Beauty alone.
-- Ezra Pound
In Brooklyn, circa 1957--when doctors still smoked cigarettes while examining their patients in small stuffy rooms--I was in a hospital, 12 years old, dying. If I hadn't been fever crazed I might have known I was dying, for we were poor, we lived in what was then called "slums" and what was I doing in a private room? In those days, before health insurance as we know it now, and before federal programs, my family had no possibility of paying the bill. I was a "charity case," and, with true charity, the hospital had given me a private room to die in. My diagnosis had something to do with "acute malnutrition"--in other words, hunger--complicated by a seemingly untreatable fever. Though nobody told me what was going on, I should have known I was dying when my aunts (my father's sisters) visited. For my aunts to be in the same room as my mother was an event; they did not often speak. In a Sicilian family, grudges go deep, so when my aunts and my mother treated each other tenderly . . . well, I must have been dying. But my family and the doctors, and even my skinny fever-wracked body, all seemed then, and in memory seem now, like figures in a dream. What was most real to me, and what remains vivid even now, was the window.
For several days and nights, too weak to lift my head, all my attention was fixed on that window. It was . . . just a window. Nothing remarkable about it. But pigeons would alight on the sill, suddenly, as though out of nowhere. They would make their clucking and cooing sounds. Occasionally, one would simply sit very still for a long time. Then, just as inexplicably, fly off. Through that window I would watch the changing light of the sky, and the clouds--I had never noticed how many shades of light inhabited the sky. And sometimes a flock of pigeons would sail across my field of vision, high up and far away; I would wait for that, wish for that. Sometimes, too, their wings would catch the sun as they banked all together at some unseen mutual signal, and that flash of many- winged light thrilled my heart.
I think I remember that window so well because it was my first consciousness of beauty--that is, my first independent, deeply inner meeting between the beauty of the world and my own soul. All my former contexts had been shattered, I could hardly even move, I was in a sense utterly on my own, yet even in this state (or because of this state?) I was being touched directly by a sweet and transforming force, or feeling, for which I know no other word but beauty. I was many years away from the concepts of contemplation and meditation, but I believe now that those were the fundamental elements, or activities, of my enthrallment, my rapt attention, as I focused upon that window. It's impossible to prove, but I believe that my intake, my inspiration (literally, my breathing in) of the elegance, the beauty, of the birds and the sky, gave me strength and saved my life. This, at least, is sure: from that time on I have been extraordinarily, gratefully susceptible to, and conscious of, the beauty of the physical world, even in the bleakest of places--like Brooklyn.
I do remember one fragment of conversation from that hospital bed. My Aunt Anna, in a way that was hardly typical of her, commented to my mother that I had "pretty hands." My mother said in response, "He has an artist's hands." This was the first time it occurred to me that anything about me might be beautiful. After they said this, when alone in that room, I often looked at my hands, and, yes, thought them beautiful--as though, like the pigeons and sky, and unlike anything else about me or my life, they were a part of the beautiful world. I can still hear the soft proud way my mother spoke those words. I believe now that she somehow sensed or grasped what was going on; for it's clear to me, 40-odd years later, that in that hospital bed, my soul took its first, wondering and gloriously unselfconscious steps (steps more unselfconscious than they would ever be again) toward being an artist--for not very long after I left the hospital I began to write. By the age of 14, writing became, consciously, all that I wanted to do with my life--became, that is, my devotion, the calling to which I intended to devote my life.
The illness had stripped me down to the core of my being, which, like the core of anyone's being, feels itself most intensely when at the meeting-point of life and death.
And the window--the window!--had poured beauty into me at just that terribly vulnerable moment. And everything changed; or, to put it more accurately and less dramatically, many disparate and not-yet-coherent elements in me coalesced and found their focus.
Many walk into the therapist's consulting room exactly at the moment, and because of the moment, that they have been stripped to the core of their being. While not at the physical meeting-point of life and death, they are often at its emotional and spiritual equivalent. One element they seek and are desperate for, one element they usually feel they've lost, is beauty; they present a situation that's cut them off from experiencing beauty. They may not articulate it that way, but that's what's going on. Yet, beauty has not still been sufficiently recognized as both a healing balm and a necessity--something without which we may die, and through which we may live.
In Carl Jung's Memories, Dreams, and Reflections, he relates a dream in which he went into the center of a darkened city--Liverpool. It does not take an analyst of Jung's caliber to know that a dream that takes you to the center of your liver (an organ that cleanses the blood of toxins) is a journey to where your innermost self deals with the poisons you've ingested from the world. Jung's "Liverpool" was very dark except for its centermost point, where a tree glowed all on its own. "A single tree, a magnolia, in a shower of reddish blossoms. It was as though the tree stood in the sunlight and was at the same time the source of light." That tree was one of the most beautiful things Jung had ever seen. He wrote, "I had had a vision of unearthly beauty, and that was why I was able to live at all."
He had found in a dream what I had found in a window. His movement toward the sustenance of beauty was from the inner (his dream, his soul) to the outer (his life); mine was from the outer to the inner; but the result was the same: "that was why I was able to live at all." Every day these movements of beauty happen in many small ways to many people; and almost everyone, except the most severely damaged, remembers at least a few events that, whether dramatic or everyday, are startling in that they suddenly open the soul, the self, the psyche, to beauty. While it is difficult to define what beauty is, because different people find so many different beauties, the experience of beauty is not as hard to define: one's soul and one's world are connected in an engagement of wonder. Sometimes we experience this with others--while listening to music, perhaps, or in an intimate moment with someone we love. Sometimes the experience is solitary, and can even come in a dream. But the singular quality, however fleeting, is an awakening of, and a connection to, wonder. The experience of beauty is always one of expansion, of opening, of inclusion--a moment of connection, often mysterious, that extends the possibilities of all connection.
So beauty isn't merely decorative; its primary function is to connect--beauty connects our innermost being to the world. It is precisely this lack of connection that afflicts so many. And while suffering usually has its source in the personal life, it's reinforced by the ugliness we live amidst. Much depression is a symptom (James Hillman might call it a healthy symptom) of resistance to ugliness--a holding-back of the spirit from an aggressively ugly environment. In most urban neighborhoods, there is only an immense and slowly deteriorating sameness of brick, building after building, street after street--a relentless and unforgiving sameness, a dull labyrinth in which to struggle for the basics. The suburbs are only slightly more benign; they have become a culture of malls, the same franchises and signs and structures everywhere, and houses built without distinction, without excitement, without inspiration. Millions go from dull ugly rooms on dull ugly streets, on clogged roads, to dull ugly workplaces where they do work that has little or nothing of the saving grace of beauty. It's impossible to overestimate how Americans have come to take this extent and degree of dull ugliness for granted; but it is not surprising that, taking it for granted, we have become too dulled as a culture to ask what this ugliness does to us.
As beauty opens us, ugliness closes us. We shut down. We blunt our perceptions, our sensitivities. We stop seeing, because seeing gives us no sustenance. We enclose ourselves in our own bodies, the personal circle of our own bodies, because it is unpleasant, unrewarding, to see, feel, scent, and touch what's around us. We become resigned. That is what ugliness, or a continual lack of beauty, conditions us to do. I have seen, more than once, a magnificent rainbow over a city, with thick bands of brilliant color, and no one on the crowded street was looking at it, no one else seemed to notice it. Not because they were insensitive dolts, but because they were so accustomed to the absence of beauty that they'd conditioned themselves not to see anything but what was directly in front of them, not to see anything they didn't have to deal with directly. So much shutting down, done so automatically and done by so many that it's taken for "normal," can't help but have consequences. It makes a certain dullness-of-spirit, a certain boredom-of-perception, seem commonplace and therefore "right" and "normal." So it is no surprise that when we try to address problems in our intimate lives, whether in our homes or in the consulting room, the insensitivity we've conditioned ourselves to accept and practice is an invisible but potent factor. How can people so conditioned to dullness-of-perception by the absence of beauty in their world--how can they ever really see each other? It is crucial to realize that this insensitivity, this reluctance to see, cannot be attributed only to a childhood or familial situation, and still less to a genetic or otherwise "natural" lack of intelligence; whatever our personal situation, for many of us, the reluctance to see, to feel, has literally been "built in" to our environment, and is reinforced every day by that dull ugliness, the attack on beauty, that is the environment for so many.
The result is that an assumption of dullness and ugliness has become an unconscious psychic foundation for many of our feelings, thoughts, perceptions. Only this can explain America's need for continually more sensational entertainments--ever louder music, ever cruder sexual depictions and the loutish popularity of wrestling, shouting-matches on political "discussion" programs, effusive and argumentative talk shows where people willingly give up dignity to get attention and nothing gaining wide public notice unless it is extreme. The root of these phenomena is in large part aesthetic: an ugly dull environment in which brutish behavior becomes a positive value because it at least has the force to cut through, momentarily, our shielded, blocked ability to perceive.
All of which leaves us, each of us, facing one piercing question: What is beautiful in your life?
The therapist-client relationship is just about the last functioning shared space in this country where this question can be asked and, more important, heard. Which is why it's so crucial that therapists find a way to ask it. Directly or by implication, that question leads to others, questions that would make any of us squirm--and so they need to be asked all the more. Questions such as: Your children, your friends--do you find them beautiful? But what, exactly, is beautiful about them, and do you contemplate it much, does it shine in your behavior? In theirs? Your wife, husband, lover, what is their beauty in your eyes? But how does it play in your life, how does it nourish or inspire or challenge you? How do you acknowledge, salute, and cherish their beauty? And if you don't, why don't you? Your home, your city, your town, are they beautiful? How do you enter and celebrate and preserve their beauty, or do you? And if your surroundings are not beautiful or, more to the point, if you can find no beauty in them--what is there to do about this? What is the beauty in your work? And if this question stops you in your tracks, what does that say about your work--and about what your work gives to you and to others? And: What is your beauty? And does that question embarrass, frighten, annoy, or depress you? Why?
In an ugly world, beauty is a revolutionary idea. Which is why these questions strip us of comfortable and/or evasive language, cut through our technical professional language, and demand responses that are specific, concrete, immediate. Psychotherapy is in a unique position to ask these questions, to introduce these questions into our cultural life once more, for people seek therapy in that state of vulnerability in which the discovery of beauty is desperately needed--especially the beauty of relationship. Psychotherapy has forged a precise and immensely useful language for dealing with the negative and problematic aspects of relationship, but it has no corresponding language for the beauty of relationship. This is because problems between people are reducible; we can break them into pieces, concepts, and deal with them. But beauty between people is irreducibly itself. A rose is a rose is a rose. Jose Ortega y Gasset said, "Why do I love this woman? Because she is this woman." We can't be abstract about the beauty of one another, or that beauty flees. My wife Hannah has a marvelous laugh. When I feel and hear and see the beauty of her laughter, I experience as natural a beauty as the flash of sunlight on the wings of those birds I first noticed in that hospital, or the changing light upon the clouds that I learned to watch for in the sky. When I look into her eyes, I see a depth, a glow, a presence, to which I cannot give a name, not even hers. "I had had a vision of unearthly beauty, and that was why I was able to live at all." A psychology of beauty must somehow grope its way toward experiencing the Other as part of the beauty of the natural world--a beauty to which, in relationship, we have privileged access.
So the question, "What is beautiful in your life?" goes beyond analysis and into what was always intended as the end result of analysis: experience. Beauty doesn't matter much as an idea, it only matters, it only gains force, as an experience. A psychology of beauty is a psychology of experience, a psychology that appreciates and teaches an aesthetics of experience. For our very lives depend upon the beauty that we are capable of experiencing in each other and ourselves.
Another hospital, some 40 years after my view from that window: In my father's 81st year he was on a gurney about to be wheeled into the OR for a serious operation, a procedure that might well kill him. I held his hands, and their grip was still strong--his small, thick, deft peasant hands, that had earned his living all his life, hands that had an intelligence of their own, so precise were they in work. He looked up at me, and I was astounded by his eyes. I had never seen such eyes. So deep and calm, so full of an all-encompassing love--so unlike him! Had he been waiting all his life to muster the incredible focus of love with which he now looked at me? But not just at me. It was as though I were a representative for all of life, in that moment, in his eyes. In that moment we were all we had both been, and far more than we had ever been--the love in his eyes, for me and for life itself, was that overwhelming. It was, and remains, the most beautiful face I have ever seen. That it was my father's face is almost incidental. It was a face of humanity, looking upon the world with unalloyed adoration. You'll have to trust that I am not exaggerating--for, believe me, no one could have been more surprised than I that this man had that look in him. His beauty, and the beauty he could see, had been his best-kept secret, revealed only now at the end of his life. If this bitter, failed, enraged human being could achieve that look--then perhaps it was a gaze inherent and waiting in all of us. As they wheeled him away to what might be death, I stood in that bleak hospital hall stunned with joy. I had seen nothing less than pure human beauty--a beauty within, reaching out to bless and beautify all it saw. How can we leave beauty unaddressed, when so many long for beauty and are withering for the lack of it; and when so many keep the beauty they feel secret, and never reveal it, or reveal it only in extreme situations, perhaps at the very end?
Beauty is specific, personal, intimate--for it is experienced, in tiny but crucial ways. In dreams, in a child looking out a window, in hearing a lover laugh, in an old man taking what could be his last look at life. Which is precisely why beauty is in the terrain of psychotherapy--an as-yet-undiscovered country at the center of psychotherapy. "What is beautiful in your life?" is a question psychotropic drugs can't answer.
Our eyes go dead for want of a connection with beauty. And deadness, dullness, of the eyes is the very death that psychotherapy is dedicated to resurrecting.
I remember my very first therapist. I was about 13, and New York City had instituted some sort of program--through the schools? I don't remember--enabling emotionally disturbed street kids like me to receive help from "uptown" shrinks on an individual basis. His name was Dr. B.T. Lassar or Lasser. He was a portly, very dignified gent with deeply serious yet sweet eyes. His office on Central Park West was the most well-appointed, monied room I had, at that point in my life, entered--a plush room, not very well lit, full of portent and shadow, but I found the dimness appealing. The strange thing was . . . I was comfortable in that room. Lasser couldn't have been more different from the adults I'd known--for one thing, he was quiet and patient, and I hadn't seen much of that in the adults of my family. Perhaps because I was a child, he was careful to speak in words I understood, though now I remember almost nothing of what he said. What I remember most was the long subway ride from my tenement to his office--for the ride had the quality, going and coming, of a passage into and out of another world, a world that valued what my world didn't or couldn't. And that, I know now, was the healing power of his therapy for me: he put a value on qualities in me that my world mostly didn't notice, didn't want to notice. On the subway, I journeyed to and from a space where different things were valued, cherished, nurtured--which meant that there was such a space to be journeyed to, even if it was only one dim room in which sat one attentive person, attending to what the world devalued and ignored.
The consulting room has the power to be such a space--in it, value can be placed on what one's world will not or cannot consider. And in that space, that value can grow and become strong. In that space, in addition to dealing concretely with dilemmas, it is possible to value beauty--it is possible to make that space a place where the maligned and attacked beauty of the world and of humanity is emphasized, explored and made more real to whoever seeks that space. If the question "What is beautiful in your life?" can root itself in that space, then from that space, beauty will radiate, exert itself, find itself in the only way that beauty finally matters: in the experience of a soul that is, by degrees, less and less afraid to ask that question of itself.
Michael Ventura's biweekly column appears in the Austin Chronicle .
by Karen Smith
I'm sitting on a metal folding chair in the corner of a large, open room watching my son misbehave. I'm trying not to interfere. He is being tested by Rebecca, an occupational therapist, but he is not cooperating. She asks him to imitate a simple sequence of hand movements: she taps the child-size table where they are sitting with her right hand once, then with her left hand, then with her right hand once again. Evan flashes her a beautiful 5-year-old's grin, but then beats out his own rhythm on the table. She calmly repeats the instructions and tries again, with no success.
Next, she demonstrates a sequence of foot stomps. He ignores her and asks if he can play on the mats in the center of the room. I wonder, "Does he understand what he is supposed to do?" I suggest that I show him how to do it. Rebecca indulges me and I carefully copy her alternating foot movements. Evan just laughs at us both and runs off.
I cringe. This is exactly why we're here: He won't follow directions. For weeks now, Susan, his Montessori preschool teacher, has been greeting me with a furrowed brow when I arrive to pick him up each afternoon. She catches me on the playground and, with increasing agitation, catalogues the ways in which Evan refuses to follow the routine, respond to direction or make any apparent attempt to stay out of trouble.
He bumps into other children, steps on their work, makes loud noises, jumps and wanders aimlessly around the room, refuses to stand in line or join the group at circle time. He talks about poop and penises, obsesses about Scooby-Doo, generally acts the fool. When told to choose among the array of activities lining the shelves of the classroom, he rejects all of the options. When asked to sit on the back porch of the school building where his noise making won't disturb other children, he explodes. When forced to talk about his misbehavior, he shows little remorse and avoids looking Susan in the eye.
I am struck silent by these descriptions of Evan. As a child psychologist, I've heard parents of so-called oppositional children describe similar behavior, and I've made scores of recommendations about how to handle these kids at home and at school--how to set limits, define boundaries, support change. My practice is full of parents and children burdened by their individual and shared failures; and I have based my efforts to help them on the unspoken belief that good parents raise good children, despite the inevitable problems that come their way. But, now my child is failing. Now, I'm questioning whether I know how to be a good parent. What can I tell Susan? I'm not the expert here. I have no suggestions to offer about how to entice or coerce my own son to cooperate.
For months, I have been feeling helpless as a mother and utterly without grounding as a psychologist and family therapist. I watch myself get tangled up in power struggles with Evan. I hear myself bully him in ways that I could never admit, let alone recommend, to my patients. I ask myself how I can expect a preschooler to control himself when I'm so out of control. I joke, half-heartedly, that the day is coming when I will have nothing more to offer families than a sympathetic ear and a sad story of my own.
At home, my husband and I constantly argue with Evan about the simplest everyday things: getting dressed, washing his hands, picking up his toys, turning off the TV, taking a bath, brushing his teeth, going to sleep. He ignores us, then complains, whines, resists, falls on the floor, cries, screams. Really screams. We try being firm, we try being playful, we repeat ourselves over and over again. Then we give warnings, threaten, yell.
Nothing is easy at our house. Everything is hard.
Now as I watch Evan with Rebecca, I recognize the battle lines that are being drawn. She reminds him of the rules. He insists that he needs a snack. She bargains with him and promises a break after he does more work. He falls out of his chair onto the floor. I roll my eyes. She asks, "Does it feel good to fall?" He doesn't answer, but the question intrigues me.
I'm reminded that six months ago Evan rolled around on the floor at the Parents' Breakfast while his classmates stood in two neat rows singing Woody Guthrie favorites. At the time, Mr. Warren, the director of his school, characterized Evan as a "contrarian." He meant this in a vaguely complimentary way, and I actually took some comfort in his description. I could imagine a contrarian growing up to be a social activist, an artist, even a Pulitzer Prize winner.
But in the fall of Evan's second year of preschool, Mr. Warren's view of my son's future took a turn. He began describing him as "disruptive," "aggressive" and, on one occasion, "violent." He hinted that his school might not be the right place for Evan and suggested that we get a "behavioral analysis" at the university psychology clinic. I was furious--and grateful--that he didn't seem to remember that I analyze behavior for a living.
In our culture, we don't take kindly to children who refuse to do what they are told. We label them with euphemisms, such as difficult, willful or spirited. When these kids show up in my office as early as age 3 or 4, their parents--often tearful, angry, guilt ridden--want quick advice about how to win the battles they are losing. In single-minded pursuit of control, they contort themselves and try to twist their offspring into whatever shape fits their idealized notion of how parents and children should behave.
Sometimes these families don't seek help until the children run into trouble at school. There, where the rules don't bend, kids who push against the system are punished for their resistance. And parents are held culpable if they can't, or won't, make their kids knuckle under.
If their defiance persists, we call these kids maladjusted, antisocial or delinquent. We send them to the principal, to the school counselor, to a therapist--perhaps to their physician and a pharmacist. When these efforts fail, we send them to the judge, to the parole officer, to the warden.
I remember clearly the day my father asked me if Evan might need to see a psychiatrist. His well-intended suggestion landed on me like a slap in the face. From his point of view, Evan's misbehavior seemed pathological. But, as I saw it, the standard psychiatric tools were unlikely to be helpful. I knew the DSM-IV forward and backward, and our situation didn't fit into any of those boxes. This was not Depression, nor was it Anxiety. It was not Post-Traumatic Stress Disorder, Pervasive Developmental Disorder or Attention-Deficit/Hyperactivity Disorder. Maybe it was Oppositional Defiant Disorder, but what was a psychiatrist going to do about that?
One day as I was driving Evan to school, he said, "I wish Maria Montessori was in my class." I looked at him quizzically and asked why. "Because then maybe I could have a good day," he explained. As he saw it, only the benevolent spirit of the founder of his preschool could help him. The rest of us were clueless.
A week later he was sent home from school for slapping Susan in the face. I held him in my lap and tried to comfort him as he cried hysterically.
"We have to take down the school," he sobbed. "We have to, Mom. All the boards and all the nails. We have to take it down."
"Why?" I asked.
"Because I'm always bad there," he insisted.
These conversations--and many more just like them--devastated me. Every night, I fell into bed, exhausted by the day's failures, by my confusion, by the unrelenting struggle. And Evan was unhappy. "I wish God didn't make me to do bad things," he lamented one night just before he drifted off to sleep. As I groped in the dark for a reply, he added, "I think God feels sorry for me."
I imagined that my life would be spent clearing a path for my son in this world. A path where he would not be penalized for his obstinance. But I didn't feel up to the job. I was tired of pushing him through each day, trying to keep him on track, telling him every step to take and then arguing with him about why he had to take it. How could I expect his teacher or anyone else to tolerate his constant resistance?
Near desperation, I followed a friend's suggestion and called her son, a newly licensed neuropsychologist with a small practice and time to talk. That conversation led me to a murky netherworld outside the DSM-IV, where I discovered alternative diagnoses such as nonverbal learning disabilities, regulatory disorders and sensory integrative dysfunction. I wasn't sure where we were headed, but I knew that the map I had been using for years as an expert on children and families couldn't get us to where we needed to go.
This is how we came to Rebecca. Cautiously. Skeptically, even. I knew that occupational therapists sometimes worked collaboratively with psychologists; yet, in five years as a staff psychologist at one of the leading pediatric hospitals in the country and eight years in private practice, I had never met an OT. I had a vague notion that they helped babies with feeding problems, children with fine-motor delays and survivors of traumatic injury. What was an OT going to do for my precocious, uncooperative son?
In my first conversation with her, I sensed that Rebecca knew something about Evan that I didn't know. She was the first person who suggested that he wanted to please me, but couldn't. That in most situations he was doing his best. That many things that seemed simple and reasonable to me were, in fact, impossible for him. That there might be reasons for everything he did--and didn't do. That there was help.
She tested him on 17 different tasks that measured visual skills, coordination between the right and left sides of his body, balance, sensitivity to touch, accurate positioning of his body in space, imitation of movement and the ability to follow a sequence of instructions. Initially, the tasks were nonverbal but highly visual, like recognizing a picture embedded within another picture or copying geometric designs. Then she asked him to do things like move his finger from one spot on a map to another--without looking at the map--or to stand on one foot with his eyes closed. At first, he seemed to do pretty well, despite his reluctance to participate. But when he was forced to rely on touch, balance and sensory information coming from his muscles and joints rather than from his eyes and his ears, he flat out failed. For example, when Rebecca lightly touched one of his fingers without allowing him to look at his hand and then asked him to identify which finger she had touched, he couldn't do it. In most instances, he chose the wrong finger.
I was shocked. Evan was a creative, vivacious character who could talk circles around anyone on almost any subject. I had never thought of him as anything other than gifted. "He escapes into language," Rebecca explained. "He uses it as a distraction from tasks that are too difficult." Tasks too difficult? For Evan? With that comment, my understanding of my son began to change dramatically.
Several days later, my husband and I sat with Rebecca in her clinic. She reminded us that she had not evaluated Evan's intelligence, only his ability to process sensory information. And she confirmed that she had, in fact, found evidence of sensory processing problems. He was extremely sensitive to touch, but he often couldn't tell where he was being touched. As a result, he responded to tactile sensation defensively. His balance was shaky and his upper body was weak, so he often held his left arm bent and close to his body to stabilize himself. Because of this, he didn't use the right and left sides of his body in a coordinated manner. He also had a great deal of difficulty with what Rebecca called motor planning--the ability to plan, organize and carry out new or unfamiliar movements. She explained that these weaknesses interfered with his ability to pay attention, follow basic directions, participate in group activities and engage in purposeful, independent activity. They were also likely explanations for his emotional reactivity, his resistance and his sense of helplessness.
According to Rebecca, Evan was not oppositional by nature. (And he had not been poorly parented.) He was at the end of his rope, trying to meet the behavioral expectations of a typical preschooler's world without the neurological equipment required. Trying--but failing--to please his parents, who were dragging him through his life oblivious to the challenges he faced every day.
For most of us, the delicate interaction between the brain and body known as sensory integration (SI) is nothing short of marvelous. It allows us to move purposefully through the world without being driven to distraction by the cacophony of sensory experience that bombards us each minute we are awake. It is how we can sit at a computer, concentrating on abstract ideas without thinking about how to position our body in the chair so that we don't fall on the floor, or where to move our fingers on the keyboard without looking at them or when to ignore the sounds of the wind at the window and the barking dog and when to tune in to the ringing telephone or the crying child.
Rebecca talked to us about "sensory integrative dysfunction," a malfunction in the brain's translation of sensation into meaning and action. For example, the brain might not automatically recognize that pressure on the skin and muscles of the abdomen is coming from a too-tight waistband. It may not judge accurately whether the sensation is important or trivial, dangerous or benign and, therefore, may not respond logically or efficiently. It's like there is a traffic jam in the lower brain. Important information that needs four-lane access to the thinking centers of the brain--like the awareness that you're about to lose your balance--can't get through. Other information that should be diverted into a parking lot--like the feeling of a shirt tag rubbing against your neck--gets full attention, creating havoc and confusion.
When brain-body connections are intact, the lower brain constantly interprets input from sensory receptors all over the body and responds with motor reactions. Those actions create more sensory feedback, which provides self-correcting information to the brain in a never-ending cycle. Thankfully, this occurs outside of our awareness in most instances. We are free to focus on conscious thoughts, while our subcortical brain and its agents, literally, keep us from bumping into walls.
Children like Evan are not so fortunate. They vacillate between states of over- and under-stimulation and, as a result, often act in ways that are erratic and inconsistent. Everyday tasks--washing their hair or brushing their teeth--quickly overwhelm them. Complex tasks--learning to ride a bike or cleaning up a messy room--totally confound them. They become discouraged, irritable, whiny, explosive.
Because we assume that these children are neurologically and physiologically capable of doing what we ask them to do, we may describe them as inattentive, hyperactive or clumsy and complain that they are stubborn, angry or oppositional. In fact, they are all of those things--but for a reason. That reason is faulty sensory processing. Sensory integrative dysfunction is not a diagnosis like AD/HD, which is merely a list of symptoms that can be identified reliably. Rather, it is a conceptual framework for understanding what is causing some of the symptoms on that list (and others).
I was flooded with sadness and relief as I listened to Rebecca's descriptions of Evan. Through her eyes, I saw a boy who couldn't-- absolutely couldn't --stop thinking about the seam of his sock, or the waistband of his underwear or the tag on the back of his shirt. A boy who didn't yet button his pants, zip his jacket or fasten his seatbelt because he wasn't able to determine which of his fingers were touching the things he was handling. A boy who constantly made noise in order to screen out noise. A boy who had to bump into things or keep moving in order to maintain his balance. A boy who felt under attack by his skin, by smells, by noises. By his friends. By his father. By me. No wonder he was pushing back. His body was in a constant state of alert--and he was putting out tremendous effort just to get through each day.
It was the first explanation of Evan's behavior that made sense.
We quickly learned to recognize the obvious examples of sensory interference in his life. His consistent, adamant refusal to hug his grandparents because of his fear of losing his balance and the confusion and discomfort that light pressure on his skin created. His extreme reaction to the least little bump, scrape or cut. With Rebecca's guidance, we learned to detect the more subtle clues: the times he was driven under the dining room table by the smell of a fish stew, collard greens or even fresh bay leaves. The severe meltdown following a friend's crowded, noisy birthday party. The way he avoided schoolwork that involved tracing or writing because he couldn't discriminate between his fingers and couldn't control a pencil.
We started taking him to Rebecca for twice-a-week therapy sessions, but I would have taken him once a day if she would have agreed to it. She predicted that he would respond well to treatment, but that it would take time--at least a year. This was not magic: it was hands-on, developmentally oriented therapy based on the notion that the brain is shaped by experience. Through play, Rebecca provided Evan with sensorimotor challenges difficult enough to be appealing, but easy enough to be attainable. She said that these experiences would build upon one another, gradually laying the neural pathways between body and brain that were necessary for more efficient sensory processing.
Watching Evan and Rebecca together, I had to remind myself that they were shaping his brain. To my untrained eye, it looked like they were just having fun--crawling through tunnels, spinning in tire swings, diving into bean bags, tooting on horns, jumping through hoops. But surreptitiously, she was working him. Decreasing tactile sensitivity. Increasing upper body strength and postural stability. Encouraging bilateral coordination. Practicing motor planning. Building self-confidence. Developing a sense of mastery.
Meanwhile, life at our house was still hard. Power struggles persisted and temper tantrums were a regular occurrence, usually just before dinner, when the accumulation of the day's irritations crashed in on us all. Even though we couldn't always figure out what was causing him to crumble, we no longer blamed Evan for his frustration. We eased up and tried to listen.
With encouragement, he began to describe the peculiarities of how his body worked. Over a peanut butter snack one morning, he said, "Andrew is allergic to peanut butter, but I'm allergic to things on my skin." After we gave in to his request to wear the same pair of soft cotton shorts day after day, he happily said, "I love smooth. It's my favorite thing." When I asked him what happened when kids at school accidentally bumped into him, he replied, "Oh, I have to fall down to get away from them."
One of the children I wished he could get away from was a boy in his class named Jack. I didn't like Jack. He was loud and disruptive and annoying--and Evan was drawn to him like a pig to mud. Each morning, just as Evan was settling into some methodical Montessori-style activity, Jack would cavort by, chanting some nonsensical rap, tapping him on the head, knocking over his carefully arranged work. And Evan would be off in a flash. The two of them would bound around the classroom together, working each other into a frenzy that would usually get them both sent to time-out.
I was fighting my unfriendly feelings one afternoon as Jack stood in front of me in a new hooded sweatshirt. I dug deep to find something nice to say. "That's a great red jacket," I offered lamely. His mom, Terre, overheard me.
"Jack has just started treatment for sensory integration problems and we've discovered that he's very sensitive to noise," she explained. "He likes to wear jackets that he can pull up over his ears, even when he's inside."
I was stunned. I had dismissed Jack as a troublemaker, but now I could see that I had been wrong. He and Evan had the same fundamental problem. No wonder they couldn't resist each other.
Terre told me that Jack had been a difficult child from early on. As an infant, he didn't sleep, he couldn't breast-feed, he was restless, hyperactive, difficult to settle. From the first moment that he could crawl, he sought out small, enclosed spaces where he could hide. Even though she had raised two older children, Terre didn't know what to make of Jack's unusual behavior. Before she knew about sensory integrative dysfunction, she had gone to see a family therapist, who had recommended a behavior modification program to decrease Jack's "aggressive behavior." It hadn't worked (just like a sticker chart I'd designed for Evan hadn't worked). "I felt desperate," she said. "I didn't know what to do. I had this underlying fear that if we didn't do something, we were headed for medication."
Jack was 5 years old when a family friend who was the director of an OT training program told Terre about sensory integrative dysfunction. She had Jack evaluated and immediately started him in therapy with Rebecca. For the first time since her son was born, Terre felt hopeful.
Fortunately for both Jack and Evan, their teacher, Susan, was interested in learning about sensory integration. She read everything that I downloaded off the Internet about school-based interventions for SI kids. She created work spaces away from the noise and activity of the busy, open classroom. She allowed us to set up an old refrigerator box as a sensory shelter, which we decorated and called the "chill zone." She consulted with Rebecca whenever their opposition to a task puzzled her. Most important, she maintained her composure in the face of their sensitivities.
Within a few months, Evan stopped hating school. He started to recognize his own weaknesses, which made it easier for him to calm himself when he got upset, rather than exploding or disintegrating into a crying heap. When the din of the classroom became too intense and he started to get jumpy and loud, he asked for permission to go into the refrigerator box for a break. As his sensory processing became more efficient, he was able to focus on learning and enjoy its natural rewards.
"I'm so busy doing work at school that I don't have to try to be a good boy," I heard him tell his grandmother one afternoon.
His body was now working for him rather than against him, and he gradually developed the ability to ignore little discomforts. Because he was less sensitive to touch, getting dressed was no longer a painful chore. One morning, with wonder in his voice, he told me, "Mom, when I put on my underpants, they were too tight. But by the time I got downstairs, they were just the right size." Habituation--the brain's automatic modulation of sensory awareness--is no small miracle, when you think about it.
Emotionally, a vulnerable side of him emerged. "I don't want anyone to be mad at me," he said when he heard even the slightest irritation in my voice. This was the boy I had so recently thought of as impervious to my wishes. It was now painfully obvious that he had always wanted to do the right thing.
One night at dinner I found myself repeatedly correcting him: Lower your voice. Don't lean back in your chair. Stop teasing your sister. You know you can't have dessert until you eat your food. No singing at the table. Don't interrupt me. Suddenly, my patience ran out and I yelled at him before I could stop myself. He cried inconsolably, a wellspring of discouragement and self-doubt.
"Oh, I just hate it when this happens," he wailed. "What if it starts happening all the time? What if all my nights are bad nights? What if I never have a good night again?"
In my therapy office, I began to recognize children who were similarly misunderstood. Children described as angry now sounded hopeless; kids whose parents complained that they were stubborn seemed stuck. Defiance became a red flag for me--as did explosiveness and even hyperactivity. My map was changing: perhaps being out of control was a survival strategy for some kids.
Now I frequently hear myself defending kids' best intentions to their exasperated parents: Nothing would make your son happier than to please you. He wants to, but he can't-- and it's up to us to figure out why. I find myself comforting parents who blame themselves for not being in charge of their children: It's not your fault. You have not caused this. I tell them honestly that I know how it feels to say things to your child that you deeply regret. I give them permission to ease up: It's okay to give in. Love is more powerful than control.
Parents willing to accept alternative explanations for what appears to be misbehavior respond eagerly to my suggestion that these problems are not evidence of personal failure. "I'm hoping you'll tell me I'm not the worst mother in the world," the mother of an uncontrollable 4-year-old boy with significant sensory integration problems recently said to me. Once she and her husband recognized the source of their son's difficult behavior, they were able to appreciate his predicament, alter their expectations and rethink their ideas about how to discipline him. I encouraged them to accept and support him as he was , and to adopt a lifestyle that would accommodate his many needs. In consultation with their son's OT, they learned to control his environment in order to prevent sensory overload as much as possible.
But I'm still learning myself, and I'm not always certain when sensory integration is a reasonable framework for understanding behavior problems. When kids persist in everyday battles, I routinely inquire about their over- and under-sensitivity to sensory experience. I recommend an OT evaluation before a medication consultation for most hyperactive children. I don't want to overidentify sensory integration problems; on the other hand, I don't want to ignore the possibility that some kids cannot follow the rules, earn the points or honor the family contract despite considerable effort on their part.
I've discussed the possible connection between oppositional behavior and sensory integrative dysfunction with physicians, teachers and therapists--many of whom are considered authorities on the topic of disruptive behavior. Not one of them has been well informed about sensory integration theory. Most of them dismiss it out of hand because it has not been empirically validated. I find their closed-mindedness puzzling.
Therapists forced to appease managed care administrators are understandably hesitant to embrace alternative diagnoses. "Unproved" treatments are unlikely to be authorized. However, our track record for treating angry, defiant kids is not impressive. What I am discovering is that many difficult, oppositional kids can be helped. Not all of them have sensory integration problems, certainly, but a large number of them may. If they could be identified and treated early--before they get labeled as "behavior disordered," before peer problems develop, before they alienate their teachers, before their relationships with their parents get tangled up in guilt and rage and shame, before they lose faith in themselves--they might be spared the social, emotional and psychological repercussions of repeatedly failing to meet the expectations of adults.
Evan is a different child today than he was 18 months ago, when I first sat on that chair in Rebecca's clinic watching him fail. Collaboration between a talented occupational therapist, a sensitive teacher and parents who were willing to be flexible opened up new possibilities for him. He is a happy, successful first grader in a public school. He makes it through most days without a serious problem. He is kind and funny and affectionate. He is still clumsy, and he will probably never be athletic; but he has developed an astonishing talent for art. Best of all, he believes in himself.
The other morning as I drove him to school, we were talking about all the things he can do now. "I just might be the best person there ever was," he said dreamily. I smiled at him through a sudden mist of tears and kept driving, convinced that we're heading in the right direction.
Karen Smith, Ph.D., is a clinical psychologist in private practice in Athens, Georgia. She is currently writing a book about the possible connections between disruptive behavior and sensory integrative dysfunction. Address: 892 Prince Avenue, Athens, GA 30606; e-mail address: email@example.com
Sensory Integration: A Primer
The theory of sensory integration (SI) attempts to explain a process so integral to our experience that few of us are aware of it--the organization, interpretation and utilization of the continuous stream of input from our eyes, ears, skin, tendons, muscles and joints. As Evan recently commented: "Your brain is all over your body." Once we understand that, we are on our way to appreciating the many ways children's lives can be disrupted by sensory integrative dysfunction.
SI theory is the life work of the late Jean Ayres, an occupational therapist and educational psychologist whose observations of neurologically impaired children caused her to wonder about the contribution of the senses to behavior. She was particularly interested in the "hidden senses"--those that provide information about balance, the position of our bodies in space, touch, pain and temperature. Her work at UCLA's Brain Research Institute in the 1960s convinced her that irregularities in sensory processing, which she called sensory integrative dysfunction, could lead to a vast array of problems, such as inattention and poor self-regulation, over- or under-sensitivity to sensory input, disturbances in activity level, floppy muscle tone and lack of motor coordination, emotional reactivity, speech and language problems and oppositional behavior.
Ayres developed a battery of tests (the Sensory Integration and Praxis Tests or SIPT) to assess the fundamental components of sensory integration: touch reception, balance, processing of input from the muscles and joints, form and space perception, visuomotor coordination, bilateral integration, sequencing and motor planning. Results from the SIPT, which was recently standardized on a large sample of American children, provide a profile of a child's strengths and weaknesses and can be used to set specific treatment goals.
The SI framework suggests an explanation for many of the symptoms associated with an assortment of behavioral, emotional and academic conditions, including specific learning disabilities, Developmental Coordination Disorder, Reactive Attachment Disorder, Fetal Alcohol Syndrome, Schizophrenia, Pervasive Developmental Disorders and Attention-Deficit/Hyperactivity Disorder. It offers promise for understanding difficult children without a specific diagnosis, like Evan and Jack.
SI treatment is based on the concept of neuroplasticity, the nervous system's capacity to modify its structure and function in response to environmental demands. There is increasing scientific evidence of the brain's capacity for reorganization throughout the life span. SI therapists believe that purposeful activities that stimulate sensory receptors in the inner ear, skin, muscles and joints enhance the nervous system's ability to process and integrate sensory information, which in turn make higher levels of functional behavior possible.
Does SI treatment actually lay new neural pathways and reorganize sensory processing circuitry? Because we can't map or measure the complexity of neuronal connections, we can only infer neurological changes by observing a child's behavior. There is a great deal of anecdotal, clinical evidence of dramatic improvements in kids' emotional, social and academic functioning following SI treatment. What has caused those changes is unclear. Was it a natural process of maturation that would have occurred with or without occupational therapy? Was it the unconditional positive regard of the therapist? Was it the change in family dynamics once the parents understood the child's problem? Was it the SI treatment?
These are empirical questions and, admittedly, the empirical literature on sensory integration is limited. Occupational therapy is still a "young" discipline without a solid scientific foundation. Findings from studies of SI treatment outcome range from negative, to contradictory to positive; but many of those studies fail to meet the rigorous standards of scientific methodology. Nevertheless, a growing number of OT researchers are focusing on basic questions, such as how to reliably identify and classify children with SI problems, how to define SI treatment and how to select reasonable outcome measures. Until these questions are addressed with well-designed research, we will not have clear guidelines about when to recommend SI treatment and what to expect from it.
The fact that more progress has not been made in the 30 years since Jean Ayres first proposed her ideas about sensory integration is no reason to reject them outright. It wasn't so long ago that the empirical and theoretical underpinnings of psychotherapy were similarly shaky. SI theory could be a diamond in the rough, an unpolished gem with great potential value, a dream come true for many unhappy, unsuccessful children who are not receiving the help they need.
To consult with an occupational therapist who has a solid background in sensory integration, start by contacting local hospitals, pediatric rehabilitation clinics or early childhood intervention programs and asking for a pediatric OT with expertise in SI treatment. To refer a child for an SI evaluation, contact Sensory Integration International at www.sensoryint.com or call (310)320-2335 for a list of SIPT-certified occupational therapists in your geographical area. This organization also offers courses for parents, OTs and other professionals about SI theory and treatment. Another good source of information about SI research, clinical work and treatment resources is the website www.sinetwork.org, which is sponsored by the KID Foundation in Littleton, Colorado.
For more information about occupational therapy in general, refer to the American Occupational Therapy Association's website at www.aota.org .
by David Treadway
The sky had gone dark and ominous. The halyards kept banging on the mast as the wind picked up. I was in an exposed anchorage and had to get out of there before the blow hit. Unfortunately, this was my last writing day on my boat, and I had barely started winnowing down my list of most challenging cases. I wondered what criteria I should use to select the best one to write about. Was it the most complex cases, like those in which I have been the marriage, family and individual therapist to many different members of three generations? Or, maybe, the most dangerous, like the time when I was inadvertently locked in with a violently psychotic kid and the staff forgot about me for six hours? Perhaps, I'd talk about the most unusual, like the group I ran for three teenage transvestite male prostitutes.
I had finally narrowed the list to six clients who were culled from 30 years of clinical practice. I wondered what those last six cases had in common? As I shut down the computer, it was suddenly obvious why I had chosen them. The cases I had listed were really different, except for one thing: they all had been emotionally devastating for me. It was then that I knew I had to write about Amy.
I went up on deck and put a double reef in the main before raising the anchor. Better safe than sorry, I thought to myself. I wish I had been so wise when I started working with Amy a long time ago.
1978 --After 22 years, I can still see Amy sitting there, cross-legged, with her arms folded across her chest and her dirty blond hair falling down over her face. She was perched on the hood of my car. It was 9:00 p.m., and I was just leaving my office. Amy glared at me as I approached. Our therapy session had ended five hours earlier.
"Don't you think your Moms will be worried? You better head on home."
She took a long, studied drag on her cigarette and then flicked the butt away. "I'm not going home. I'm headed for the mountains of Montana. I just wanted to say goodbye. Do you have a problem with that? Or do you shrinks only care what happens when your victim's in your office and you're getting paid to be nice."
"Oh shit," I thought to myself, "here we go again." And I was dumb enough to think that we had had a good session earlier. Amy was one of my first private practice patients, and I was too embarrassed by the case to admit to myself what a mess it had become. It hadn't started out that way.
Amy's mother and her same-sex partner had asked me to see 16-year-old Amy in individual therapy because they thought she was depressed and possibly had an eating disorder. They also described her as increasingly combative and hostile. They had heard that I was good with adolescents, and even thought that my being a male might help a little, since she had no relationship with her father.
Since I was primarily a family therapist, I met the whole family at the first interview. Amy wore baggy clothes and looked a little like a war refugee, but she wasn't overtly hostile. She just stared at the ground and spoke in a barely audible whisper. Amy's mom seemed engaged and concerned. The stepmom seemed to understand the importance of not being too parental. Amy hardly spoke, but she did mumble agreement when asked if she wanted to have a few sessions alone.
Our work started off well. Amy was basically a good kid who was terribly lonely and very self-conscious. After a month or so of pretty benign how-to-deal-with-high-school sessions, Amy began to hint at the need to tell things she had never said to anyone. I was as gentle and reassuring as I knew how to be. After several false starts, she whispered haltingly about being little and her dad in the middle of the night; the smell of his breath, the weight of his body. Despite my never having done trauma work with an incest survivor, I felt I could help. I hoped that my bearing witness to her darkness and shame would allow her to risk opening herself back up to the world around her. She soon asked to come for more frequent sessions because she felt they were so helpful. I was pleased. Then she confided in me that she sometimes cut her wrists and often thought of killing herself. "I never thought I would ever be able to tell anyone," she said. I felt like her knight in shining armor. I should have known then that I was headed for trouble.
Amy began calling me at home. When I tried to help her understand that it wasn't okay to call me there, she was devastated. That's when she accused me of just being a rent-a-friend. Then she began making hang-up phone calls, started cutting her wrists again and threatened suicide. I utterly believed her when she promised to kill herself if I told anyone how suicidal she was. She told me that I was the only one who could possibly save her life. I remember her saying to me, "If you quit on me, Treadway, I'll be dead before you get home." And I was arrogant, foolish and scared enough to believe her.
My mother had killed herself seven years earlier, and both my father and older sister had had nervous breakdowns. I had been the de facto head of my family for years and was fairly entrenched in my role as codependent rescuer. Because I had been in my own therapy and believed that I had dealt with my issues, I didn't see how much my work with Amy had become a reprise of my desperate desire to save my mom and protect my sister.
Finally, I got so distraught over the hang-up phone calls, her suicidal threats and her desperate pleas for help that my wife insisted that I get some kind of help. I recognized that my heroic efforts might be doing more harm than good and that it was time to invite her mother to a session. Amy tried to make good on her threat and slashed her wrists, took an overdose of Valium and drank a bottle of wine. She was rushed to the hospital. The staff there concluded that Amy was a Borderline, that she was overly dependent on me and that it would be better for her to stop seeing me. I felt both relieved and terribly guilty. I knew Amy would be deeply hurt by my withdrawing from the case, but I didn't stand up to the clinicians. I was too afraid that they already felt I had bungled the case and was way too enmeshed with Amy.
The last session was harsh. Amy sat curled up in a fetal position, while the psychiatrist, social worker, her mother and I all tried to engage her. She wouldn't look at me or talk to me. I tried to tell her how sorry I was that our work had to stop and that I hadn't been able to help her enough. "Amy, it's not your fault. I just didn't know enough about how to work with you. I am so sorry." "So, Dr. Rat gets to leave the sinking ship," she spat out. "Good for the rat, bad for the fucking ship."
The psychiatrist motioned for me to leave. I closed the door of the office. I felt like ripping my face off.
1996--The phone rang during dinner one summer evening. "Just don't hang up. I'm okay now. Please let me talk to you. Just for a minute. Please."
After 17 years, I still recognized that voice. Through the years, I had assumed that Amy had either continued to struggle in and out of hospitals or had finally killed herself. Instead, she sounded great. She had actually moved to Montana and become a dental hygienist. She also reported that she was happily married and had a 2-year-old baby girl. She said she just wanted to bring me up-to-date on her success and thank me for being there for her during her tough times. I was delighted for her.
A couple of months later, Amy called again. This time, she confided that she had been to many therapists since seeing me and that no one had ever been able to help her as well as I had. She asked if I would please be willing to consider doing a few phone sessions with her about parenting, because she was having a little difficulty with her daughter.
Incredibly, I agreed. I thought I knew what I was doing. I had written a therapy book and many articles, had directed a family therapy training institute for a decade and had traveled the country giving workshops. More important, I had some decent training in treating trauma survivors. Surely I could help Amy appropriately within safe boundaries in a carefully managed short-term contract. I thought that, if I set it up carefully, I might be a bridge for her into a healthy therapeutic alliance in her own community. Part of me worried that once again I was falling into my knight in shining armor role, but I felt like I was being careful and avoiding the obvious pitfalls.
First, I talked with her and her husband together. He had heard all about me and, apparently, I had been placed back on the pedestal in the intervening years. So he thought it was a great idea. I warned her that the work had to be short term, and encouraged her to join a parenting group and find a local family therapist. I also contracted with her for safety, even though she laughingly said that I didn't have anything to worry about on that score, after all, she had her daughter, Heather, to worry about. She and I even talked about transference issues and how difficult it might be for her to work with me again even on a short-term basis. We both seemed to understand the risks.
Unfortunately, within the first month of seemingly benign phone sessions, Amy's secrets began tumbling out again. She had been stealing pain killers from the dentist's office and drinking wine. She confessed that she sometimes raged at Heather, which would made her feel terrible, which led to cutting and suicidal fantasies.
She was caught in the vortex once more and, like a complete fool, so was I. I even wondered if I had caused all this. But at least I knew that I couldn't be her therapist over the phone. Like many trauma survivors, Amy was desperately seeking gentle, loving compassion. But our therapeutic relationship seems to have provided a dollop of caring that invariably stimulated an insatiable hunger in Amy that she couldn't manage. It was almost as if she had a kind of lactose intolerance to nurturing. And I hadn't been able to manage my anxiety and grandiose codependency well enough to maintain the stringent boundaries that might allow Amy to tolerate our relationship and grow through our work together.
When I insisted that Amy find a therapist locally, she went into crisis again, and there were hang-up phone calls, another suicide attempt and an emergency hospitalization. Fortunately, a gifted therapist at the hospital was willing to take her case. On a conference call with her new therapist, I terminated with Amy. Once again, she was furious. Once again, I felt that, somehow, I had let her down. I realized I had gotten caught in my own grandiosity. I tried to reassure myself that as messy as it was, at least Amy had found a good person and maybe it would still turn out alright. I felt sad for her, and for me. And I also felt relieved.
1999--Once again, the sound of Amy's voice on the line was a jolt. "Joe was killed in a car accident. I didn't know who else to call. This time, I'm not going to make it," she said in a flat monotone.
Three years had passed, but it seemed like a day. I can imagine your thoughts, gentle readers, "No, Treadway, you didn't do it again! How arrogant and dumb can you be?"
At least, this time, I knew that I couldn't be her therapist, even temporarily. That was progress. But I couldn't turn my back on Amy when she was in such desperate straits. I'd known her since she was 16, and I couldn't just refer her to her local emergency room. So I told Amy that I would talk with her if she went back to her therapist and the three of us worked out a plan. Although I was essentially using myself as a bribe, at least it got her back to therapy. Amy acknowledged that it wouldn't work for me to be her therapist, but pleaded with me not to just dump her again. Given what she was going through, both her therapist and I thought it was a reasonable request. Even though it was highly unconventional, we agreed that Amy could have a once-a-month, half-hour, check-in call with me, if she was willing to recommit to her therapy out there. I volunteered to be a support person for her as long as she and her therapist thought her contact with me was helpful and that she was making progress. Although I had never done it before with a client, I decided to offer this contact without charging a fee, because I wanted to make my limited role with her absolutely clear.
Many of you may feel this latest arrangement was also highly suspect and that Treadway and his lifetime client were just remixing the same old brew in a different bowl. I hoped, for both Amy's and my sake, that this wasn't true. Despite my best efforts through the years, I may have done Amy more harm than good. Certainly, if I had to do it all over again, I would have insisted on family therapy and groups as the two main treatment modalities as soon as she acknowledged her suicidality. I also should have sought intensive consultation early on. I might have gotten some therapy around my intense countertransference vulnerability to suicidality. I never should have tried to do long-distance phone therapy. Would'ves, could'ves and should'ves. However, although there was nothing I could do to change the past, I wanted to support her through the loss of her husband and help her slowly find a way to rebuild her life.
Was I still playing the knight in shining armor after all these years? Probably. But I had turned my back on Amy twice, and I simply decided that I was going to hang in there and hope for the best. The role we three defined for me felt like a balance between my being overly involved and simply disconnecting from her. I hope it was the right choice.
2000--"Heather looked so cute in her life preserver, holding her paddle. I just wish Joe could see her." Amy said wistfully.
I just listened.
It's been more than a year since Joe died. She has absolutely kept to the rules of our contract and, to the best of my knowledge, is no longer cutting herself and drinking. Although she still thinks about suicide, she also has a part-time job and a good relationship with her daughter. Her therapist has been as steady as a heartbeat and feels that Amy's making slow, but substantive, progress. Our monthly talks are just support calls. She gives me honest and painful updates on her struggles, and I don't offer much advice. I commiserate and bear witness. I don't know that it's making any difference. I hope it is. We both know that, someday, she still might kill herself, but we don't talk about it much anymore. One day, I hope to say goodbye to Amy and see her on her way. But I don't know if we will have a good ending. I am still scared for her. Her life is truly in her hands. I pray for her.
It's been embarrassing to write about Amy's and my story, because it seems clear that I made a lot of mistakes throughout, and maybe I am continuing to make a mistake. This is what makes it my most challenging case. I don't know to this day if it's a success or a failure. If Amy ultimately kills herself, does that mean my involvement in her life was wrong. If she makes it, do I deserve the credit for a job well done? Am I still acting out some ancient rescue fantasies? Probably. But it's unclear whether the impact of my efforts is ultimately positive for her or not. I don't know, nor do I think I ever will. I do know that, in the end, I have to live with my choices, and I'd rather have risked caring too much than too little. I pray for me, too.
David Treadway, Ph.D., is a family therapist in private practice. He is 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 02193.
by Barry Duncan and Scott Miller
There was a time when therapists, and much of our larger culture, saw depression and other human troubles as complex conditions of mind and heart, influenced by many subtle inner and outer forces. But in the last decade, a vast intellectual and emotional sea change has taken place. We now inhabit a culture where many people hold the view that their emotional pain is "biochemical" and can be cured by simply taking a pill.
Emotional suffering, according to this new view, is a genetic glitch, successfully treatable by drugs. Depression is no longer thought to be shaped by such diverse forces as a sedentary, lonely or impoverished life;
the loss of love, health or community; "learned helplessness" or feelings of powerlessness arising from unsatisfying work or an abusive relationship. Its resolution no longer requires anyone to get meaningful support from others, to establish a collaborative relationship with a good psychotherapist, to draw on community resources, or for communities to address conditions that breed depression. No, depression is now publicly defined as a purely biological illness, treatable--thank heaven--by the miracle antidepressants.
Consider, for example, this interview, which ran on the CBS news program 60 Minutes in 1991, three years after Prozac began its meteoric rise to therapeutic dominance:
Lesley Stahl: [voice-over]... For 10 years, Maria Romero has been suffering from depression, a serious illness. Sometimes she spends weeks on an unmade bed, in a filthy apartment. She told us that she didn't care about anything, and she often thought of suicide. . . . Most doctors believe chronic depression like Romero's is caused by a chemical imbalance in the brain. To correct it, the doctor prescribed Prozac . . . and two and a half weeks later, we paid her another visit.
Stahl: I can't get over it. You're smiling.
Romero: Thank you. Yeah.
Stahl: How do you feel?
Romero: Great. I feel great. I feel like--like I'm a different person, somebody else. Somebody--something left my body and another person came in.
Stahl: She no longer spends her days in a filthy apartment. So two weeks after you started on this drug, whammo? . . . You stopped being depressed?
Romero: I stopped being depressed.
Stahl: Got out of bed . . . fixed your apartment, fixed yourself, and are losing--
Romero: --Fixed my life --
Romero: Yeah. Mmm-hmm. Yep. I'm happy about it. I think it's great.
In the eight years since this segment was broadcast, hundreds of stories like Romero's have been whispered between close friends, described by journalists and repeated in books like Peter Kramer's bestseller, Listening to Prozac. They have become our culture's conventional wisdom. The grinding despair and helplessness of depression is, these stories imply, just a "chemical imbalance" somewhat like diabetes or high blood pressure. The treatment of choice, we are told, is always a drug: Prozac, another Selective Serotonin Reuptake Inhibitor (SSRI) like Zoloft or Paxil, or perhaps another, newer antidepressant like Wellbutrin or Serzone. These miraculous drugs, the story goes, are effective with 75 to 85 percent of the people who take them. In this prevailing cultural script, therapy, like an old character actor, is sometimes ignored altogether, and never given more than a minor supporting role. Only one solution, apparently, is needed, and only one is offered: the passive consumption of a pill.
These views have taken on the luster of scientific truths. But they are not truths. They are myths. They have not been confirmed by the latest discoveries of neuroscience, nor are they supported by outcome research. They seem true because they have been repeated and reinforced by mass-market advertising intended to make taking antidepressants seem as normal and pervasive as swallowing aspirin: Zoloft's logo smiles from long-distance calling cards, coffee mugs, luggage tags and complimentary pens and pencils. A commercial during the World Series trumpets Paxil's power to cure social anxiety disorder. And the sides of colorful tissue boxes in physicians' offices proclaim: "Sue's playing with her kids again," "Walter's fishing again" and "Just like normal--thanks to Prozac!" SSRIs, these advertising campaigns imply, are simply the best first choice for treating depression.
The message is seductive and it works: if these drugs were books, they would be runaway bestsellers. More than 130 million prescriptions were written for them last year alone, and more than $8.58 billion was spent on them. And while most mental health professionals would acknowledge that the explanation given to clients is a gross oversimplification of actual brain functioning, few reject the biochemical model altogether. Fewer still question the effectiveness of the drugs, and virtually no one challenges the idea that combining medication with therapy is the best of all treatment options. At least it includes what talk therapists have to offer. The problem with these common beliefs and practices emerges, however, when they are examined in the light of scientific research.
On a level playing field, antidepressants would be regarded as one valid therapeutic choice among many--one with risks far more grave than those usually attendant on therapy. The awareness of many side effects is just beginning to make it into mainstream consciousness, and the future may reveal further unanticipated consequences: witness the silent epidemics of drug addiction among American women in the 1950s, produced by the widespread prescribing of "mother's little helpers"--amphetamine diet pills and Librium.
Not only are side effects underrated and underreported, outcome research does not confirm the miracle status these drugs have been accorded in the popular imagination. Our culture's exaggerated faith in these psychiatric medications rests not on science, but on brilliant marketing by a profit-driven industry. Outcome research--even outcome research funded by the companies that manufacture pharmaceuticals--has not found these drugs to be any better than therapy, and only marginally better than placebos. Knowing what the research really says will empower therapists to challenge the myths our culture holds about psychoactive medications, reinvigorate their belief in therapy and offer their clients choices based on fact, not superstition masquerading as science.
The first and perhaps most pervasive myth about SSRIs and other newer antidepressants is that their effectiveness is a matter of scientific record, conclusively demonstrated in strict, controlled, double-blind, placebo studies--the gold standard in medical research. According to this myth, the development of SSRIs was a pharmaceutical watershed and the drugs are "magic bullets" far more effective than the older tricyclic antidepressants like Elavil. This message is not only retailed by drug companies, but by the mass media and professional journals: in October 1995, for instance, the American Association for Marriage and Family Therapy's (AAMFT) Family Therapy News cited "overwhelming evidence" in support of antidepressants and their undisputed effectiveness with all but 25 percent of people suffering from unipolar depression.
This is a gross overstatement. Last year, a federal research review of hundreds of clinical trials found that the newer antidepressants were effective with only half of the depressed people who took them and outperformed placebos by only 18 percent. The finding came from the federal Agency for Health Care Policy and Research (AHCPR), a branch of the Public Health Service that promotes "evidence based" health care practices. The AHCPR reviewed all 338 relevant clinical trials of antidepressants conducted between 1980 and 1998, including 206 that directly compared SSRIs and other new antidepressants with older tricyclic antidepressants like Elavil. It found "no difference in overall efficacy" between SSRIs (costing about $66.41 a month) and tricyclic antidepressants (costing less than a tenth as much, or about $5.50). About 50 percent of trial subjects responded well to either drug, while 32 percent responded equally well to placebos; thus, all drugs helped only 18 percent more people than did sugar pills (plus hope and regular contact with a researcher or clinician).
Even at the anecdotal level, miracle stories like Maria Romero's are more rare than we have been led to believe: an online survey of 1,400 depressed people by the National Depressive and Manic-Depressive Association (NDMDA) in November 1999 found that 25 percent reported that antidepressants had no effect on their symptoms, 40 percent reported no improvement in fatigue and loss of energy and 35 percent reported no increase in their ability to experience pleasure.
Leaving aside the question of effectiveness, we turn to another major myth about Prozac and other newer antidepressants: that clients are more likely to tolerate them because their side effects are relatively mild compared with older tricyclic antidepressants like Elavil. In reality, the SSRIs' advantages are marginal; it's more a question of picking your poison. According to the AHCPR review, takers of tricyclics complained more of dry mouth, constipation, dizziness, blurred vision and tremors. SSRIs and other new antidepressants, on the other hand, produced more diarrhea, nausea, insomnia and headaches. Another side effect well known to clinicians went unmentioned by the AHCPR: SSRIs cause sexual problems, including pain during intercourse and difficulty reaching orgasm, in somewhere between 30 and 70 percent of the men and women who take them. SSRIs are also associated with rarer, but much graver, side effects, including bleeding, liver damage, seizures and akasthisia, an almost unbearable jitteriness that can escalate into suicidal thoughts and violent impulses: more than 200 lawsuits have been filed against pharmaceutical companies contending that SSRIs helped precipitate murders and suicides (see the Networker, September/ October 1999).
A third widely held myth is that tolerating even severe sexual side effects is worthwhile, because SSRIs are so much more effective than therapy for depressed people. This myth, too, is junk science, and is not supported by any large-scale methodologically sound study. According to the AHCPR review, the only known, well-controlled research study directly comparing antidepressants and therapy gave a slight edge to therapy. The 1996 study, involving 31 subjects and published in the journal Â Depression, found that Prozac and cognitive therapy were both effective, with no statistically significant differences between them. But a full third of the Prozac group dropped out of treatment or were unavailable for a final assessment, while only 3 of the 13 who received cognitive therapy dropped out.
The myth that SSRIs have proven their superiority to therapy echoes the belief held earlier about tricyclic antidepressants, which were also, in their heyday, thought to be a therapeutic watershed. But in 1989, another large federal study found that therapy was just as effective in the short run, and more effective in the long run, than tricyclics. This finding came from the landmark Treatment of Depression Collaborative Research Project (TDCRP), a National Institute of Mental Health (NIMH) study led by psychologist Irene Elkin. The four-month project involved psychiatrists and psychologists in Washington, D.C., Pittsburgh and Oklahoma City who treated 239 patients diagnosed with major depression. Patients were randomly assigned to one of four groups: Aaron Beck's cognitive therapy; Gerald Klerman and Myrna Weissman's interpersonal therapy; treatment with the tricyclic antidepressant imipramine; and, finally, treatment by placebo. After four months of treatment, the talk therapies had narrowly outperformed the drug: 39 percent of those receiving cognitive therapy, 34 percent of those receiving interpersonal therapy and 32 percent of those receiving drug therapy were rated as recovered. (In the placebo group, 16 percent had recovered.)
In the 18 months following the conclusion of the study, however, the people who had taken part in talk therapy did much better than those who had been given drug treatment. Psychologist Tracie Shea, of Brown University, and her colleagues found that about 24 percent of the therapy clients had recovered without a subsequent major depressive relapse, compared with only 16 percent of the pharmacotherapy clients and an equal percentage of the placebo group. Those receiving the antidepressants did worse on practically every outcome measure: they sought treatment more often during the follow-up period, were more likely to relapse and experienced fewer weeks of minimal or no symptoms than members of either of the two therapy groups. Shea did not speculate on why this was so. But her provocative findings dovetail with the findings reported by outcome researchers Michael Lambert and Allan Bergin in 1994, that clients who attribute change to their own efforts are more likely to maintain positive changes. One plausible hypothesis is that the therapy clients gained the tools and confidence to draw on when other life problems arose, while those who had been given drugs had nothing new to draw on.
But wouldn't the best of all possible worlds be one in which medications were combined with therapy, giving clients enough stability to make use of therapy and creating a sort of double-whammy treatment effect? The idea that both together must be better than either one alone for treating depression has become the newest orthodoxy among many professional groups. In fact, this sensible-sounding "compromise" solution actually promotes the use of medications, by implicitly suggesting that virtually anybody who enters therapy for any reason could usefully take them. Many managed care funded practices now routinely require all therapy clients to undergo medical evaluations as a prerequisite to reimbursement for treatment. But neither outcome studies nor clients themselves offer much support for applying this two-is-better-than-one approach.
In one of the broadest surveys ever conducted of therapy under real-life conditions, Consumer Reports in 1995 tabulated the responses of 4,000 members who filled out a questionnaire on their experiences with therapy. On the whole, their self-reports of both therapy and drug treatment were positive: 54 percent of those who said their state of mind had been "very poor" said treatment made things "a lot better." But people who received only psychotherapy reported as much improvement, on the whole, as people who tried drugs-plus-therapy. Given the additional expense of medication and the risks of side effects, we think therapy alone should be the treatment of first resort rather than drugs-plus-therapy.
The Consumer Reports survey has obvious limitations: those who filled it out had sought therapy for many problems besides depression; the results were based on self-reports by a self-selected group of members willing to discuss therapy on a questionnaire; and the sample was not randomized or demographically balanced. But its conclusions echo those of a research metareview by Yale University psychiatrist Bruce Wexler published in the Journal of Nervous and Mental Diseases in 1992. Wexler examined seven well-controlled outcome studies of 513 patients treated for depression. Therapy alone, he found, helped as many people as therapy-plus-drugs, with fewer dropping out of treatment. The review concluded with this simple summary: out of 100 patients with major depression, 29 would be expected to recover if given drugs alone, compared to 47 given therapy alone and 47 given combined treatment. On the other hand, 52 drug-only patients would be expected to drop out or have a poor response to treatment, compared to 30 therapy-only patients and 34 patients getting therapy-plus-drugs.
Â In all of the healing arts, there is no single explanation or simple, infallible remedy for any of the problems that beset humankind. Yet the growing power of the biological perspective in mental health discourse and practice suggests not only that there are solely biological explanations, but perfect, fail-safe biological solutions as well--simple pills that mark finis to everything from mild depression and nervous tension to panic attacks, bipolar disorder and full-blown psychosis and schizophrenia. How did this scientifically anomalous, weirdly simplistic point of view come about? If the science behind the advertised superiority of psychotropic drugs is so lacking, how did medications come to hold almost unchallenged sway over both public and professional opinion?
In the days of the Watergate investigation, the government informant known as "Deep Throat" met with Washington Post reporters Carl Bernstein and Bob Woodward in an underground garage and advised them to "follow the money" if they wanted to find who was really behind the break-in at Democratic National Committee Headquarters. The same advice can help explain why psychiatric medications have permeated every aspect of our culture. Follow the money, and you will begin to understand the growth of the pharmaceutical behemoth.
In March 1992, Consumer Reports estimated that the $63 billion drug industry spent $5 billion a year on promotion and publicity, and it spends at least as much today: advertising in medical journals, on television and in women's magazines; helping fund "public awareness" efforts like the National Depression Awareness Day; giving grants to organizations like the Anxiety Disorder Association of America (ADAA), the National Depressive and Manic Depressive Association (NDMDA) and even the American Association for Marriage and Family Therapy (AAMFT.) The American Psychiatric Association confirms that at least 30 percent of its budget is now underwritten by drug companies through grants, glossy paid advertisements in its journals and paid exhibits at professional conferences. Psychotherapy organizations cannot begin to compete with this billion-dollar promotional machine, even though the data upholding the value of therapy are clear.
Drug companies also fund much of the drug research that supports, however weakly, the myths that have taken hold of almost everyone from psychiatrists and journalists to therapists and the average client in the street. Because of the shrinking of federal grants and the privatization of research funding that began in the Reagan years, pharmaceutical companies now pay for the majority of clinical trials of drugs. The AHCPR metareview, for example, noted that out of 315 published clinical trials of 29 antidepressant drugs, every study that identified a sponsor had been funded by a drug company. The ubiquity of drug company funding may also help account for the dearth of research comparing the effectiveness of therapy and medication: why would drug companies fund research that might prove a competing product (such as therapy) was equally or more effective?
In the broader field of nonpsychiatric medical research, those who pay the piper tend to enjoy the tune: researchers with financial ties to drug companies usually publish results friendly to their funders, and friendly researchers, likewise, tend to get funded. An October 1999 study of 44 journal articles on anticancer drugs, for instance, published in The Journal of the American Medical Association ( JAMA ), reported that only 5 percent of drug-company funded research found that the drugs were not cost-effective, while 38 percent of the research sponsored by universities, foundations and other nonprofit organizations found the drugs not cost-effective. A study in the January 1998 New England Journal of Medicine produced similar results: of researchers whose published studies supported the use of calcium channel blockers to treat high blood pressure and angina, 96 percent had financial relationships with the manufacturers; only 37 percent of researchers whose work did not support the use of calcium channel blockers, on the other hand, had received drug company funding. Thus, like a flower opening itself to the sun, published research results tend to be skewed in the direction of the money source.
Our exaggerated sense of the efficacy of psychiatric drugs may also be colored by the fact that drug companies are under no obligation to publish the results of failed clinical trials. Thomas J. Moore, a health policy analyst at George Washington University, for example, recently found, in a search of FDA files, the results of two identical trials of the antidepressant Serzone. The one showing a marginally positive result was published, but Moore found no indication that the other trial, showing no measurable drug effect, was ever published.
While drug-neutral and drug-negative research is underplayed, drug-friendly research is sometimes overplayed and made to serve the purposes of marketing. In February 1999, for example, JAMA published a study showing that as many as 40 percent of American women and 30 percent of men suffered from some form of sexual dysfunction. "I think it gives us a base for explaining why we had this enormous response to Viagra," one of the coauthors, sociologist Edward Laumann, told The New York Times at the time. The article, widely reported in the popular media, was actually a recalculation of data first published in 1994. The JAMA article did not disclose that two of the coauthors, Laumann and Raymond Rosen, had served as paid consultants to Pfizer, the makers of Viagra.
Closer to home, the American Association for Marriage and Family Therapy (AAMFT) recently took part in a major public relations campaign focusing on depression, intimacy and antidepressants. The campaign was primarily funded by Glaxo-Wellcome,Â makers of Wellbutrin, an antidepressant notable for its lack of sexual side effects. With the help of a $50,000 grant from Glaxo-Wellcome,Â the AAMFT 1998 national conference in Dallas featured a panel on intimacy and depression at its opening plenary--a session historically reserved for one of the real movers of the family therapy field. The slick, Oprah-style session featured clips from the television series Party of Five Â and a five-member panel that included three speakers with financial relationships with Glaxo-Wellcome: psychologist Martha Manning; her husband, social worker Brian Depenbrock; and psychiatrist Anita Clayton, associate professor in the University of Virginia's Department of Psychiatric Medicine.
Over the next hour and a half, the audience of 2,000 therapists was reminded 11 times of the tragic sexual side effects of some antidepressants. Although Wellbutrin was never mentioned by name, Clayton mentioned several times that someÂ antidepressants don't deprive clients of a sex life. She did not disclose that she is a member of Glaxo-Wellcome's advisory board and speakers bureau, nor that Glaxo-Wellcome has funded her research. Nor didÂ Manning, who has written widely about her own depression, disclose that she has sometimes acted as a paid consultant to Glaxo-Wellcome and has cowritten a brochure for them on intimacy and depression.
The plenary was part of a larger public relations effort funded by Glaxo-Wellcome and cosponsored by AAMFT and the National Depressive and Manic Depressive Association (NDMDA)Â a private non-profit "public education" organization that gets the bulk of its funding from pharmaceutical companies. The campaign included a brochure for the public on intimacy and depression, bearing the AAMFT and NDMDA logos, but copyrighted by Glaxo-Wellcome and written from the point of view that drugs are the treatment of choice for depression. Nearly four full pages are devoted to the nuances of antidepressants, while individual and couples therapy rate a few sentences. ("Antidepressants are usually effective . . . psychotherapies developed specifically for the treatment of depression can be useful. . . .") Wellbutrin is not mentioned by name, but the point is prominently made that consumers should consult their physicians about medications free of sexual side effects. The campaign also took a panel that included two AAMFT officials, plus Manning and her husband (and on occasion, actors from Party of Five and John Gray of Men Are from Mars, Women Are from Venus fame) to three well-publicized and advertised "town hall meetings" on intimacy and depression held in New York, San Francisco and Seattle.
Psychiatrist Anita Clayton told the Networker that her airfare and lodging expenses for her participation inÂ the AAMFT 1998 plenary had been paid, but she had not receivedÂ an honorarium. She also noted that she has received research funding from, and is on the speakers' bureaus of, other pharmaceutical companies beside Glaxo-Wellcome.
We the authors were so concerned about AAMFT's involvement in the depression and intimacy campaign that we organized an e-mail protest to AAMFT before the plenary, leafleted the event and spoke in opposition to it at an AAMFTÂ "town meeting." Although AAMFT did not violate the ethical standards of any group with which it is affiliated, the failure to prominently disclose the speakers' relationships to Glaxo-Wellcome at an event presented for continuing education credit would violate the standards of other professional groups, including the American Psychiatric Association and the Accreditation Council for Continuing Medical Education.
Manning says that she routinely discloses that she is sometimes a paid consultant to Glaxo-Wellcome, but was never asked by the AAMFT to do so for the 1998 plenary; her involvement with the drug company's campaign, she says, resulted in far more focus on therapeutic and relational issues. "We cannot afford to isolate ourselves from the medical approach to depression, which has been enormously useful in my own experience, as has psychotherapy," she said. "Depression is such a horrible thing that we have got to be involved in all kinds of cross-fertilization." We do not argue that her views, and those of other consultants, aren't sincerely held. But what therapeutic school can afford to fund its advocates to put on an equivalent national public-relations road show?
This magazine, likewise, has never routinely asked its authors to disclose financial ties to pharmaceutical companies. In March 1999, the Networker published "Rx for Passion: Antidepressants Needn't Depress the Libido," about the sexual side effects of antidepressants, by Valerie Davis-Raskin, M.D, in which she recommended Wellbutrin. The editors were not aware that Davis-Raskin was also a member of Glaxo-Wellcome's speaker's bureau. The ubiquity of nondisclosure of financial ties, like these, makes it impossible for the general public, including therapists, to critically evaluate the objectivity of so called medical experts.
Marketing masquerades not only as research, but as public education. Take National Depression Screening Day, for example, a public relations and marketing extravaganza riding on the back of a public service campaign. On October 7 every year, volunteer mental health workers offer simple screening tests for depression (as well as counseling and referrals), at more than 3,000 hospitals, mental health clinics, doctors' offices, libraries, grocery stores and shopping malls across the country. Public service radio spots publicize the day. The American Psychiatric Association and the National Institute of Mental Health (NIMH) lend their names to the event, which is administered by a private, not-for-profit organization called the National Mental Illness Screening Project (NMISP) of Wellesley Hills, Massachusetts.Â NMISP also sponsors screening days for other mental illnesses.
According to information provided by NMISP to the IRS, Eli Lilly, the makers of Prozac, gave the group $1.75 million between 1993 and 1997--nearly half of the organization's $3.6 million income for those years. Almost all of Depression Day's largest funders (giving $50,000 or more) are pharmaceutical companies, as are six of the seven major funders named on the web site for the event. The director of NMISP told the Networker that revenue from other sources has since increased, and that only 25 to 30 percent of Depression Day's funding now comes from pharmaceutical companies.
Some marketing connected with Depression Day has been directed specifically at children. In 1995, for example, The Washington Post reported that several students at Walter Johnson High School in Bethesda, Maryland, complained after sales representatives of Eli Lilly spoke at a school assembly on Depression Day and then passed out free pens, pads and brochures touting Prozac. One student said she had been forced to listen to "a 45 minute plug for Prozac," and her mother told the Post that no other alternative treatment for depression, such as counseling, had been presented. These campaigns have a predictable effect: more than 453,000 prescriptions for Prozac alone were written last year for kids under the age of 18. Another recent Depression Day initiative focused on primary care physicians, teaching them how easily their patients could take screening tests in the waiting room, to be later scored by staff without imposing on the doctor's time.
Adrift in this cultural sea of overprescription and overpromotion, what is the responsible therapist to do? The solution is not to dismiss SSRIs and other antidepressants out of hand, but to put them in their place. Therapists should stop kowtowing to their supposedly superior powers and think of them as one choice among many--and certainly not as the treatment of first resort.
In our own practices, we never suggest medication as the treatment of first resort. Instead, we begin therapy on the assumption that if we follow the client's lead, ask about the client's own theory of how change takes place and strengthen the therapeutic bond, we will enhance therapeutic outcomes of all kinds--with and without medication. When clients believe that medication will help and are "in the driver's seat" in making an informed choice, we have found that SSRIs can be helpful at times. Whatever approach evolves from the dynamic, moment to moment synthesis of ideas, it is the client who judges its helpfulness. Finding something that fits is facilitated by routinely inviting each client's feedback about the treatment he or she is receiving. Whether the approach is medication or one of the 400 available therapy methods and techniques, we think therapy should be a partnership that involves the client's voice at every juncture and in every decision. And if talk therapy has not produced results in three to six weeks, we brainstorm options with our clients; one of them may be antidepressants, while others include switching to another therapist or another approach. But SSRIs are never our first choice unless the client suggests them.
Guidelines like these don't make the treatment of depression simple. Nor can guidelines--or any drug--fully prepare any of us for those horrible moments when we sit face to face with the smothering despair of our clients. Not long ago, one therapist at our clinic at Nova Southeastern University worked with a weeping, financially desperate woman named Alina. The therapist listened with growing concern as Alina talked about her inability to leave her emotionally abusive husband, her worry about her four children and her humiliation at her new job, where her boss mocked her Spanish accent in front of customers. "I can hardly get up in the morning. If I had the guts, I'd just crash my car into a tree and be done with it," she said. Her tears, anguish, and despair were so palpable during the session that the therapist found herself having to fight her own feelings of hopelessness and fear for Alina.
It was this painful resonance that permitted the therapist to connect with her client, and that helped create the possibility that Alina and she could be part of some kind of change together.
But this very resonance also made the therapist vulnerable to finding herself, like Alina, in momentary despair. For many therapists, this is the moment when the voice of bad research and great marketing emerges, whispering of the superiority of "modern science" over primitive "talk therapy." It leads many therapists to reach for what looks like a sure thing to give their clients (and themselves) hope and relief. The medication solution is like fast food: it takes the work, time and anxiety out of answering "What's for supper?" But the introduction of the topic of medication in therapy carries numerous messages, among them, "Your problem is so severe, and you are so biologically damaged, that we have to look at something other than what we are doing together, or what you can do on your own." These messages serve to abort most clients' naturally occurring search for solutions and to block access to their own innate resourcefulness that lies at the heart of good therapy.
Reaching for that sure thing, the therapist thought as she faced Alina, would have predictable results. She would refer Alina to a physician who could prescribe drugs, and he or she would inevitably focus on Alina's mental state, her fragility and her potential for suicide. The therapist also considered the implications of the fact that 70 percent of all antidepressants are prescribed to women. Other paths were far more uncertain. As the therapist struggled internally, Alina volunteered that she didn't like pills, and wanted to solve her problems herself. Knowing that other options could be introduced at any time, the therapist trusted in Alina's direction and in the power of the therapeutic relationship.
At the end of the first visit, the therapist pointed out Alina's strengths and all she had done to extricate herself and her children from unbearable situations. Alina concluded the session by emphatically stating that she had no plans to hurt herself. Over two months of therapy, the therapist met with Alina every week, encouraging her concrete efforts to deal with the circumstances that were distressing her, and Alina's life and mood slowly improved. When federal funding for the therapy program ended, Alina was no longer desperate, validating the therapist's faith in her client's innate resourcefulness. Alina was going out with girlfriends more, she had conquered her job and was getting praise there and she had much more confidence in herself. She had even begun saving money for an independent future without her abusive husband. She and the therapist had weathered the storm together, with Alina, not medication or the therapist, at the helm.
Some people, like Alina, struggle with despair and oppressive life circumstances over time; others, including the severely depressed, sometimes make stunning turnarounds within the course of a single therapy hour. If the option to try something different is not at least as attractive as the medical option, the magic pill will win every time. What is required is a reconnection to what good therapists already know: that most people can and will develop solutions to even the most daunting dilemmas, given support and encouragement.
At the core of this approach is our faith that change occurs naturally and almost universally: the human organism, shaped by millennia of evolution and survival, tends to heal and to find a way, even out of the heart of darkness. When we hang on to this belief in our hearts, we level the playing field and can compete with the noisy medical ideologies promoted by profit-making drug companies and championed by factions within our own professions.
Every good therapist knows that each case is as different as the faces we greet each hour. Each experience of depression will take its own course. Rather than being hostage to the notion that "it's all biochemical," we can remind ourselves that every emotional human experience--including hope, reassurance, trust, love, faith and rapport--affects the body's chemistry and has neurochemical correlates in the brain. Rather than turning to the magic pill, therapists can access the real magic: the connection created by listening to and exploring their clients' stories, experiences and interpretations of their problems. That rapport, as the sustained power of the much misunderstood and underrated "placebo effect" suggests, can positively affect not only clients' bodies and brain chemistries, but their willingness to act and their sense of who they are and who they can become. A mountain of outcome studies conducted over the last 40 years has shown that forming a therapeutic alliance is not a prerequisite to successful treatment--it is Â the real treatment. In study after study, therapies in which the client perceives a helpful therapeutic bond and a mutual agreement on goals are the most successful. Finally realizing that psychiatric drug therapy is a profit-driven industry, built on flimsy science, may be the bad tasting medicine we've needed. Although it may be hard to swallow, empowered with the knowledge, therapists can regain their voices, trusting what they have known all along about depression and other human travails: there is no better medicine than a good therapeutic relationship.
Barry Duncan Psy.D., is an associate professor at the School of Social and Systemic Studies at Nova Southeastern University in Fort Lauderdale, Florida, and Scott Miller, Ph.D., is a therapist and an international workshop presenter based in Chicago, Illinois. They are cofounders of the Institute for the Study of Therapeutic Change (ISTC). Jacqueline Sparks is a member of ISTC and a doctoral candidate at Nova Southeastern University. This article is adapted from Duncan and Miller's latest book, The Heroic Client: Doing Client Directed Outcome Informed Therapy . The authors can be reached at: www.talkingcure.com
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Murlow, Cynthia D., et al. Treatment of Depression: New Pharmacotherapies. Evidence Report/Technology Assessment Number 7. AHCPR Publication No. 99-E014. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, February 1999.
Shea, M. Tracie, et al. "Course of Depressive Symptoms Over Follow-up: Findings From the National Institute of Mental Health Treatment of Depression Collaborative Research Program." Archives of General Psychiatry 49, no. 10 (October 1992): 782-87.
Wexler, Bruce E., and Domenic V. Cicchetti. "The Outpatient Treatment of Depression: Implications of Outcome Research for Clinical Practice." Journal of Nervous and Mental Disease 180, no. 5 (May 1992): 277-86.
by Pat Love
Late on a chilly spring night several years ago, my husband inquired when I would be coming to bed. "Mmm, a little later," I replied. Translation: "Do you want to make love?" Answer: "Not a chance." The dialogue was familiar, but this time it was edged with a quality of brooding tension that distinguished it from the hundreds of similar invitation-and-refusal scenes we'd enacted before. When I finally came to bed that night, my husband was still awake, bristling with outrage and hurt. "Every night, it's the same routine," he stormed. "Aren't we ever going to have sex?"
I began to marshal my usual arguments about being exhausted after a day of chasing two small kids when, suddenly, I felt myself go limp with dejection. I felt bone-weary of the years of conflict, guilt and crushing sense of inadequacy that pervaded my lack of interest in lovemaking. Turning my face to the wall, I said softly but entirely audibly: "I don't care if I ever do it again."
From the other side of the bed, there was silence.
How had it come to this? When I first began dating my husband, a rangy, dark-haired college athlete with a chiseled physique and a talent for making me feel like the only woman on the planet, I was plenty attracted. Saving sex for our wedding night only heightened my desire. But even after our marriage, we made love frequently, passionately and often for hours at a time. If, during those early years, he wanted sex slightly more than I did, the difference in our sexual setpoints seemed negligible. On the erotic front, we seemed about as perfectly matched as any couple could hope to be.
Until it all ended. Two years into our marriage, my libido began to wilt; after giving birth to our first child, it went permanently AWOL. Truth to tell, I didn't much care about the demise of our sexual synchrony. Furiously busy with the demands of an infant son, homemaking and church work, I rarely even thought about sex, much less craved it. My husband's desire for me, however, had dimmed not one iota. One evening he arrived home, full of hope, bearing a book on sensual massage for couples. When I glanced through the photos of smiling, nude women pleasuring their partners, I felt my inadequacy like a physical attack and threw the book into the trash.
Silently, I blamed my husband for being inconsiderate enough to desire me when the feeling wasn't mutual, and while he never explicitly said so, he must have felt profoundly unwanted. For years, we coped by simply repressing all of our anger and sorrow--each of us fearful to say out loud how desperately unhappy we had become in our marriage.Â Then, on the night I finally spoke the unspeakable--"I don't care if I ever do it again"--our mutual disenchantment bottomed out into despair. Like many people, my husband and I equated sexual passion with love, so we concluded that if I had lost all interest in sex, I must no longer love him. At the very least, it seemed that each of us was trapped in an unbearably incompatible marriage, a union that doomed one partner to everlasting sexual frustration and rejection, and the other to feeling perpetually invaded and, at the same time, somehow defective. These convictions led to an action that remains the deepest regret of my life--an unnecessary divorce from a thoroughly decent, loving man and the father of my two children.
I say "unnecessary" not because we didn't try to work things out. We sought therapy and got the best that was available. But the intensity of shame and hopelessness that permeated our mutual sense of sexual failure was beyond the usual therapeutic jump-starts. Rather, I believe our divorce was unnecessary because we did not understand then that our desire gap was rooted, to a large degree, in powerful, automatic, biochemical processes that had little to do with how attractive I found my husband or how much I actually cared for him. In fact, I did love him; the problem was that my body didn't know it.
If the idea that desire is orchestrated by our body chemistry hasn't yet found its way into the clinical conversation, it may be because the evidence is still largely buried in scientific journals, primarily from the emerging fields of behavioral endocrinology and psychophysiology. The provocative core of the new research is this: Each of us approaches our erotic encounters already primed by a premixed neurochemical and hormonal "cocktail" that influences both the strength and staying power of sexual passion. Having delved into this new biological evidence and observed its impact in my own couples therapy practice, I am convinced that as long as our clients remain unaware of these bodily processes, they are at high risk for making disastrous decisions about their intimate commitments. Some clients will misread their clashing desire levels as the death of love and lose faith in basically sound marriages, as my husband and I did. Others will choose badly to begin with, making lifelong commitments while under the influence of short-lived, highly irrational brain states.
But I believe that both catastrophes are largely preventable. The emergent data on the biology of desire offers therapists a potent new tool for helping troubled couples--a genuinely new kind of sex psychoeducation. This form of "desire ed," which I now use routinely in my work with couples, doesn't dwell on the usual sex therapy instruction about performance anxiety or the search for the elusive G spot. Instead, its objective is to help clients understand how their hidden neurobiological agendas may operate in the bedroom, so that they can make conscious, thoughtful decisions about their intimate relationships rather than ones that misinterpret the critical messages of the body.
But let me be clear: I am not proposing that the complexities of sexual desire can be reduced to Chemistry l0l. There is no question that problems of passion also can be influenced by relationship conflicts and a long list of other factors, from depression, stress and past sexual trauma to certain medications and a host of medical disorders. Likewise, it goes without saying that chronic sexual problems can contribute hugely to relationship difficulties. Nonetheless, the biochemical action of the human brain--the organ that nature writer Diane Ackerman calls our "three pounds of blood, dream and electricity"--may influence how often and how badly each of us wants sex more than we ever imagined.
To begin to understand the biology of desire, think back to the last time you fell fiercely, feverishly in love. He, or she, merely walked into the room and your body was zapped by a thousand-watt current, transforming you from a reasonably rational, functional adult into a trembling, mushy puddle of pure yearning. When the two of you were together, the most mundane activity--say, going to Wal-Mart for poultry scissors--became an exhilarating, deeply rewarding event. Not to mention the sex. Remember? The sex was amazing .
Most of us who have spent any time in infatuation's clutches also remember the sense of pure, utter helplessness that permeates this state. In the throes of new romance, there is something strangely involuntary about one's behavior--the workaholic misses deadlines; the penny-pincher blows his paycheck on plane tickets for two to Paris; the solidly married woman finds herself whispering on the phone, making furtive, high-risk plans with her paramour. Our culture speaks of "falling" in love. Other societies have compared infatuation to divine revelation, and to psychosis. We often say, in jest, that this experience of hurricane-force passion is "like a drug."
But that oft-quipped analogy may turn out to be no joke. Some scientists now believe that the frenzied euphoria of romantic love may well be a bona fide, altered state of consciousness, primarily brought on by the action of phenylethylamine (PEA), a naturally occurring, amphetamine-like neurotransmitter. Michael Liebowitz, a research psychiatrist at the New York State Psychiatric Institute, believes that when we come into contact with a person who highly attracts us, our brains become saturated with a "love cocktail" comprised of PEA and several other excitatory neurotransmitters, including dopamine. This chemical brain-bath theory explains why new lovers can talk till dawn, make love for hours on end, lose weight without trying and feel so outrageously, unquenchably optimistic. Their neurons are soaking in natural speed.
Thus far, much of what we know about PEA's action comes from animal studies. When mice are injected with PEA, they cavort and squeal in displays of rodent rapture, while rhesus monkeys dosed with PEA-like chemicals make pleasure calls and smack their lips, a courting gesture. While the brains of romance-besotted humans have yet to be directly studied, Theresa Crenshaw, a sexual medicine researcher and author of Sexual Pharmacology , reports that elevated levels of PEA have been found in the bloodstreams of lovers. Crenshaw also has found that women's PEA levels tend to rise at ovulation, which suggests a role for this potent molecule in the survival of the species.
Still, speed-spiked blood and the antics of small animals hardly prove a pivotal role for PEA in firing human passion. To date, the most compelling evidence comes from studies on a group of people suffering from a disorder known as hysteroid dysphoria, characterized by a desperate, boundless craving for attention and admiration, coupled with an acute hypersensitivity to rejection. Unlike most adults, who succumb to infatuation upon occasion, the hysteroid dysphoric is a kind of "romance junkie," falling in love constantly, violently and often with unsuitable partners. This person's usual pattern is to enjoy a brief, thrilling infatuation, followed by a traumatic breakup, often precipitated by his or her anxious, seemingly bottomless need for displays of love and affection. Upon rejection, the romance-hooked person predictably plunges into deep depression, which he or she tries to cure by falling in love all over again.
Research psychiatrist Liebowitz and his colleague Donald Klein suspected that such "infatuation junkies" might suffer from some kind of biochemical imbalance--perhaps abnormally low PEA levels. They wondered: Was it possible that these individuals jumped compulsively from lover to lover in order to keep their PEA sufficiently revved up to feel normal? To find out, Liebowitz and Klein treated a group of hysteroid dysphorics with the class of antidepressants known as monoamine oxidase (MAO) inhibitors, which block the action of brain enzymes that break down PEA. MAO inhibitors, therefore, act to boost PEA levels. Within weeks of starting their medication regimen, some of the lovesick subjects began to choose partners more judiciously, while others reported feeling reasonably comfortable without any love interest in their lives at all. Apparently, these individuals no longer craved the PEA jolt they once got from their euphoric, disastrous romances.
But one doesn't have to have a diagnosable love disorder to be influenced by PEA. Researchers propose that in the presence of a sufficiently intense sexual and emotional attraction, virtually everyone's neural lattices become marinated in natural speed. Given some of the dangerously delusionary thinking that accompanies new romance, the concept of an overstimulated brain makes compelling sense. If the frenzied action of lovers' neurons tends to render them maniacally optimistic, it is no wonder that they tend to discount patently alarming qualities in their sweethearts. You may gently remind a love-struck client: "Have you really considered the fact that she is a practicing alcoholic, has lost three jobs in a row and has been divorced only two months?" Your client sweetly responds: "We can work it out." Indeed, in a study of 400 men and women involved in a new romance, psychologist Dorothy Tennov found that while infatuated individuals had no trouble identifying shortcomings in their lovers, they tended to recast even the most serious liabilities as trivial, tractable and even charming.
What about sex? We don't need a slew of studies to convince us that with a new lover, sex is the Mount Everest of romantic peak experiences. Some neuropsychologists now think that the sexual euphoria that accompanies infatuation issues from brain secretions of both PEA and dopamine, a neurotransmitter that both stimulates libido and mobilizes people to actively pursue the pleasure of lovemaking. With two potent brain molecules working overtime, it's as though our erotic thermostat gets overwhelmed--we want scads of sex with our beloved, we get our fill, then in short order we're ready for more. It must be love.
Until it's not. For the universal and much-denied truth is this: Romance has no legs. Numerous studies that have measured the duration of infatuation--from the first moment of stuttering euphoria to the first feeling of neutrality for one's love object--have found that the state of romantic rapture predictably burns out after 18 to 36 months. And while the demise of infatuation certainly encompasses emotional components, such as the resentment that attends the inevitable discovery that our lover has other priorities besides keeping us happy, our wilting desire is also likely to be grounded in brain physiology. Liebowitz and others theorize that the brain cannot eternally maintain its revved-up, lust-crazed state of romantic bliss, either because the nerve endings become habituated to the brain's natural stimulants or because levels of PEA and related substances begin to drop. It certainly makes sense that if infatuation is a "high" that is chemically analogous to an amphetamine jolt, lovers would develop a tolerance for each other over a period of time. Whatever the precise mechanism involved, all of us have experienced this downshift in desire--slowly but predictably, euphoria sneaks out the back door while reality, that perpetually unwelcome houseguest, makes its sullen entrance.
If the sexual reality facing postinfatuation couples were limited to plummeting desire, it would be tough enough to cope with. But the dilemma of many disillusioned lovers is made far more difficult by a substantial desire gap between partners. To fully understand this element of a couple's sexual struggle, we need to introduce a second biological factor--testosterone. When most of us think of this steroid hormone, we reflexively think "male," and a pumped-up, perpetually horny one at that. We almost never think about the ways in which testosterone influences women--and consequently, we may be missing one of the biggest clues to the desire difficulties of many couples.
Scientists have known for decades that both sexes produce testosterone: men manufacture gobs of the stuff in their testes and adrenals, while women pump out smaller quantities from their ovaries and adrenals. But while testosterone has been conclusively shown to highly correlate with male libido, it was long dismissed as a nonfactor in the sex drive of women. Then, in 1987, Barbara Sherwin, a psychologist and psychoendocrinology researcher at McGill University in Montreal, published her now-classic study on the impact of hormone replacement therapy on women's sex lives. Sherwin divided her 43 subjects, all of whom had undergone surgical removal of their ovaries, into three groups, giving one group estrogen medication, a second group a regimen of estrogen and testosterone and a third group a placebo.
The results were swift and dramatic. The women who received the testosterone-estrogen cocktail reported a greater upsurge in sexual arousal, more lustful fantasies, a stronger desire for sex, more frequent intercourse and higher rates of orgasm than the women in either of the two other groups. Sherwin replicated these findings in several other carefully conducted, double-blind studies.
Subsequent research on women's naturally produced testosterone has yielded similar results. In the absence of infatuation, women with high baseline levels of testosterone--so-called "high-T" women-- tend to be significantly more sexually interested and responsive than "low-T" women. This now-substantial body of psychoendocrinological research has exploded decades of mythology about female sexuality by establishing that libido requires a goodly supply of testosterone in women as well as in men. But herein lies a key source of the postinfatuation desire gap. Both genders rely on testosterone for a robust sex drive, yet on average, men have 10 times more of the stuff circulating in their systems as women do. This doesn't mean that women are typically only one-tenth as lusty as men; many endocrinologists suspect that because women are exposed to lower levels of testosterone, they are more sensitive than men to a given amount. Nor does it mean that all men are the sexual equivalents of the Energizer Bunny. Testosterone levels drop gradually with age, and at any stage of life, the genetically determined sensitivity of androgen receptors in the genitals and brain influences how strongly testosterone pumps up male libido.
Nonetheless, the biological reality remains that, on average, men tend to be hornier than women--by quite a bit. Surveys show that, among both heterosexuals and homosexuals, men think about sex more frequently, masturbate more often and rank sex as more important in their lives than women do. Of course, there are millions of exceptions to this gender-typed scenario. I worked with one young couple in which the woman wanted daily lovemaking, while her husband felt the urge maybe once a week. Sharing a bed with him aroused her to such a pitch that she had taken to sleeping alone in a back bedroom. I also have worked with many lesbian and gay couples on problems of mismatched desire, indicating that passion quotients vary within as well as across gender lines.
Whatever the gender positions of this lust gap, it is a commonplace phenomenon: A survey of 289 sex therapists found "desire discrepancy" to be the single most common presenting problem of clients. Yet couples might be able to cope more sanely with their divergent desire levels were it not for the biochemical blinders they wear in the early stages of their relationship. It is during the infatuation stage that the two major components of the biology of desire--the time-limited PEA factor and T-level mismatches--collide to create sexual catastrophe for many couples. If the brains and bloodstreams of new lovers are awash in the aphrodisiac properties of PEA and other brain molecules, any disparity in libido is, at first, likely to go blissfully unnoticed.
Let us say, for argument's sake, that you are a "low-T" woman who has fallen fervently in love with a "high-T" man. You, a person whose needle on the sex meter usually points close to zero, suddenly find yourself fantasizing about sex in graphic, Omnivision detail, and approaching lovemaking with a level of gusto bordering on zeal. You think to yourself: "I am a sexual person--I just needed the right partner." Your naturally highly sexed new lover, meanwhile, finds himself in a state of erotic nirvana: "Finally, I've found someone as hot as me!" Over and over again, I have heard clients recall their mingled sense of exhilaration and relief at having finally found their "perfect" lover. Even if they had experienced a similar sense of sexual harmony in the early months of a past romance, infatuated people tend to discount history: It is this lover, at this moment, who satisfies me more deeply than any other. That is, until the tide of PEA begins to recede and preexisting T-levels emerge, unveiling for each person his or her "real" sexual partner.
At this juncture, the "high-T" person is apt to feel bitterly disappointed, even betrayed. For even though his or her brain may no longer be drenched in a PEA-dopamine cocktail, he or she typically has sufficiently high T-levels to still want plenty of action in the bedroom. The "low-T" partner, meanwhile, is likely to feel bewildered by the loss of his or her temporarily turbocharged libido, as well as sexually pressured by what now seems like an insensitive, even predatory, partner. A downward spiral of mutual anger, bad sex, more anger and still worse sex--or none at all--finally leads many couples into therapists' consulting rooms, raging with sorrow, shame and profound doubts about the future of their disappointing marriages.
At first glance, the proposal that something as fluffy-sounding as "desire education" could make any difference to dispirited couples sounds inflated, if not preposterous. As University of Washington psychologist John Gottman's research indicates, on average, couples straggle into therapy a full six years after their troubles first erupt. If anything is going to help at this late date, it seems as though it would have to be an intervention that does something fairly dramatic--something that packs a real emotional wallop or teaches potent relationship skills or both. Faced with the typical couple's end-of-their-rope discouragement, how is dispensing a bunch of facts on body chemistry going to make any difference?
In my experience, the difference is as profound as hope. For beneath the "dry" facts on neuronal and hormonal processes lies a radically normalizing, shame-reducing message: Sexual passion is rooted in our natural body rhythms. That means that if the thrill is gone or if the thrill is different for you than it is for me, I have not failed and you have not failed. Nor has our relationship failed. There may be plenty of emotional junk that is also mucking up our sexual connection, but that's not all that's going on. If our desire problems are at least partly innate--mirroring neither messed-up psyches nor a bankrupt relationship, but rather the pulse and flow of ordinary bodily processes--then maybe we don't need to feel quite so ashamed and despairing about the muddle we're in. Maybe each of us, and the embattled, fragile relationship we're trying to sustain, are even fundamentally okay. Maybe we've got a chance.
Of course, every therapeutic approach tries to engender hope. The particular potency of desire education is its capacity to plant seeds of optimism so early in therapy--sometimes as soon as the first session. Every clinician who works with discouraged couples understands that there is no time to waste: You need a way to show them, quickly and compellingly, that what they view as a sorry excuse for a relationship is even worth expending further energy on. The problem here is that the palpable rewards of most couples work--the profound emotional breakthroughs, the fruits of well-learned relationship skills, the mastery of new sexual techniques--take time to emerge. By contrast, the matter-of-fact, calming information of "desire ed" can be dispensed almost immediately to interrupt the furious, toxic, blame-shame cycle that sabotages so many sexually polarized couples at the very outset of therapy. As a potent, front-end couples intervention, desire education can make the difference between a willingness to plunge into relationship work with a measure of motivation and the decision to prematurely quit in despair.
When Eddie and Joyce, a couple in their mid-thirties, arrived for their first session with me, it quickly became clear that their sexual standoff was already calcifying into a kind of listless bitterness. Slumped in his chair, Eddie complained that Joyce was his "wife in name only"--that is, she had avoided sex with him as much as possible duringÂ the past five years. "Your basic ice queen," he quipped grimly. Joyce countered that Eddie made her feel ugly and invisible by openly flirting with other women, to which she often responded by collapsing into tears, panic stricken that she was losing her husband. Eddie made clear that this was a real possibility. "Do you know what it feels like to get down on your knees and beg for sex?" he asked me. Joyce snapped, "It's more like being cornered by a dog in heat." Twice before, they had tried therapy, which had focused on improving communication and injecting more novelty into their erotic repertoire, to little effect. In a last-ditch attempt to stave off separation, Joyce had dragged Eddie to see me.
In the past, I would have begun therapy with a couple like Joyce and Eddie by focusing immediately on communication about relationship issues, such as Joyce's anger and "withholding" of sex and Eddie's motives for his blatant attentions to other women. But my experience has been that sexually struggling couples can rarely focus on such efforts at relationship repair at the outset, because they feel too deeply flawed and full of shame to believe that genuine change is even possible.
Instead, I began by empathizing with each of them about how painful it must be to live in a relationship in which one partner wants sex more than the other. Then, gently probing about their desire history, I learned that both partners had experienced their particular passion level over time, with several different partners. This suggested to me that Eddie and Joyce's sexual problem wasn't purely relationship-driven, but probably also had a hormonal component. So I introduced some information about T-levels and the consequent normality, even near inevitability, of their desire gap.Â As I spoke, Eddie and Joyce became quiet and attentive. Neither of them had had the slightest idea that testosterone--or the relative lack of it--was such a major player in female desire. I concluded with my core message: "What all of this means is that it's entirely possible to love someone a lot, but still not be very sexually turned on by him or her." Joyce and Eddie remained silent for a moment. Finally, Joyce spoke up. "So what you're saying," she said slowly, "is that I'm not just trying to punish my husband."
She glanced quickly at Eddie, who seemed lost in thought. "Well," he finally said, "I guess the good news is that maybe I don't have to feel like such a jerk when I get turned down." I sat quietly with them for a few minutes, letting the deeper message of my mini-primer soak in. I wasn't expecting any big epiphanies or tearful embraces, nor did they materialize. All I wanted was to give this couple sufficient relief from their mutual sense of sexual failure to commit to the work ahead. I wanted time. Eddie gave me my opening. "I like the idea that the trouble we're having maybe isn't all personal," he began. "But, not to be rude, so what? If I'm some kind of hormone factory and she's not, what the hell are we supposed to do now?" I responded that even if their hormonal makeup contributed to a natural difference in libido, it was entirely possible, with sufficient time and effort on their part, to develop a satisfying sexual connection. When, in the last few minutes of the session, they agreed to try, I felt a small jolt of elation.
Having now worked with scores of couples who suffer a substantial desire gap, I understand more about the private hell that couples like Joyce and Eddie inhabit. In our sex-saturated culture, the woman or man who is "low-T" is already, by definition, defective. But if you are that person, imagine then the experience of living with a "high-T" partner, who comes to you for sex again and again and again, when you truly feel you have little to give. The screws of inadequacy get turned still tighter as you experience your many varieties of unworthiness--unworthiness for not matching the "normal" sex drive of your partner, unworthiness for failing to live up to a fundamental expectation of a committed relationship, unworthiness for repeatedly turning your back on your partner's helpless, fervent desire for you.
And the inescapable truth is that your partner is hurting. How could it be otherwise, when he or she inhabits a reality of constantly slamming doors? Because of the raw exposure of self that attends sexual intimacy, this more ardent partner may experience chronic sexual rejection as an existential wound. Again and again, I have heard the more sexually desirous partner say to the other: "I've shown you myself--the real me. And you don't want it."
As I worked with Joyce and Eddie in the succeeding months, my goal was never to transform them into the hot couple of the month; nor was it theirs. Using other strands of "desire ed" that I wove into our therapy sessions, they understood that they had long since spent their allowance of PEA-spiked passion; from now on, whatever sexual intimacy they might experience would have to be consciously created.
To begin this process, I asked each partner to share with each other what kind of sexual-emotional activity would feel most loving and satisfying to them. For Eddie, it was what this couple jokingly came to call a "marital"--a periodic, 15-minute session of sex that gave him both a measure of physical release and, more important, the feeling that Joyce cared for him. For Joyce, it was receivingÂ regular, leisurely massages from her husband, which might or might not culminate in intercourse, depending on her wishes. Haltingly at first, each tried to respond to the other's requests for behavior that seemed, initially, alien to his or her own impulses. But as they gradually deepened their understanding that their partner's experience of passion was both different from their own and entirely valid, they became more generous in their capacity to stretch to respond to it. The result wasn't blood-boiling sexual fireworks, but rather a budding sense of mutual intimacy and trust that began to energize both their erotic and emotional connection. Slowly but perseveringly, they began to feel their way toward a state of marital grace that I call mature love.
I am not arguing here for any particular therapeutic approach to sexual desire problems. My observation is that a number of useful ones already exist, from the skill-building orientation of traditional sex therapy to the more emotion-centered approaches of numerous schools of couples therapy. Many therapists, no doubt, pick and choose from several models. My point is that whatever overall approach you favor will almost certainly be rendered more potent and effective by integrating some basic education on the biology of passion. By the same token, if you omit desire education, you risk giving your clients a hazardously incomplete understanding of their situation.
For example, if Eddie and Joyce had taken their dilemma to a mainstream sex therapy clinic, their problem would likely have been diagnosed as "hypoactive sexual desire" on Joyce's part, with a program of sensate focus exercises prescribed. There is much to be said for sensate focus, in which partners are taught to hold and stroke each other while attending to the sensations that emerge, to help each discover what kind of touch is pleasurable. The limitation of traditional sex therapy antidotes is that they are typically taught in the absence of context: They rarely give unhappy couples a way to feel less flawed and freakish about the sexual afflictions they have laid bare. In fact, a couple's shame may even be deepened by sex therapy's habitual use of such pathology-laden labels as "hypoactive sexual desire" or "retarded ejaculation." Desire education, by contrast, avoidsÂ the medicalization of sex in favor of a gentle, humanizing context. It conveys the idea that nobody here is inherently damaged or inherently unlovable. Desire differences are natural and normal. Relax.
Desire education also has a key role to play in couples therapies that focus explicitly on the emotional aspects of sexual desire dilemmas. The hazard of purely relationship-centered sex therapies is that by focusing solely on the interpersonal factors that fuel passion problems, a therapist may convey the message that once partners resolve these emotional conflicts, they will become, once again, the effortlessly synchronized sexual match of their courting days. But by judicious melding of information on the psychology and the biology of desire--especially about the experience of red-hot sex as a short-lived, PEA phenomenon--a therapist can convey reasonable optimism about a couple's sexual future without raising erotic expectations to untenable levels. For the reality is that when a substantial, hormonally mediated desire gap exists between partners, their ultimate erotic satisfaction will depend on a steady, vigilant effort to sustain their sexual connection. Even when two people love each other deeply, postinfatuation passion is rarely a free ride.
Even as I write this, I am confronting this challenge in my own life. I am still a classic "low-T" woman who, just three months ago, married an unmistakably "high-T" man. Fortunately, this time I knew--and so did he--that the exquisite tango of brand-new love would downshift, inevitably, into the reality of differing sexual setpoints. We know, now, that our work together for the long term will encompass much stretching beyond our respective sexual comfort zones--stretching to understand, to empathize with and to accommodate the other's unique experience of passion. Neither of us expects this process to be easy; at times, it may well be excruciating. Our hope is that during the toughest moments, when even our best efforts cannot bridge our differences, we can hold fast to the conviction that our desire dissonances are rooted in nature, not in an insufficiency of love.
For clinicians, perhaps the most invigorating potential of the emerging science of passion is the challenge it poses to radically reenvision our concept of human sexual relationships. Up to now, therapists have been offered two divergent, even diametrically opposed, ways of looking at clients' sexual problems: Either they are a direct reflection of the troubled state of the relationship, requiring deep emotional work, or they are a set of physiological problems, requiring primarily technical intervention--usually through referral to a sex therapist. The biology of desire offers a more encompassing vision: Our sexual selves are mind-body creations in the deepest, most inclusive sense. To consider the influence of our neural and hormonal processes is neither to diminish the power of emotional factors nor to deny the usefulness of sexual skill-building; instead, therapists can use the lens of human biochemistry to enlarge clients' understanding of the entire spectrum of influences on human erotic connection.
All of us need to become active, knowledgeable sex educators in this new, more inclusive sense. While we may think of this realm as belonging to clinicians who somehow "specialize" in sexual difficulties, the reality is that virtually all therapists work with people who are struggling with problems of passion--the woman who wonders whether she should leave her boring husband for the new, more enthralling man she has met at the office; the love-struck, single man who is rushing to the altar far too precipitously; the couple on the verge of splitting up because she wants it and he doesn't. These are deeply emotional concerns, but they are also matters of raw, palpitating bodily desire, and our clients can ill afford to have us uninformed about them. The emerging science of passion, which has relevance for nearly every sexual-emotional event that transpires between two individuals, can help us explicate these dilemmas for clients with a new level of depth and authority.
Still, it can be tricky, demanding work. As we teach clients more about the biology of desire, the age-old, inexorably human tug-of-war between biological imperative and moral responsibility is likely to emerge with renewed force in the consulting room. If desire is tied to biological processes, how responsible are clients for their sexually motivated behavior? Under the influence of PEA, can a long-married man "help" having an affair with his sexy new law partner? Or, if a woman now comfortably accepts herself as a "low-T" person, is that a legitimate reason to abandon all efforts to revitalize a sexually stagnant, otherwise committed relationship?
These are the moments when therapy becomes a high-wire act, as we try to maintain a fragile balance between a generous acceptance of biological reality and a fierce, nonnegotiable allegiance to consciousness, the quality that makes us human and saves us from being utterly at the mercy of our molecules. If we are serious about trying to stem the tide of marital and family misery in this culture, our clients' most torturous questions about their intimate relationships--Do I stay? Do I bail? DoÂ I officially stay but just go through the motions?--will require arduous discussions about choice and responsibility, as well as about the proclivities of neurons and hormones. Our body chemistry counts--much more than we ever imagined. But in the end, biology is only backdrop.
Pat Love, Ed.D., a family life educator, trainer and lecturer, is the coauthor of Â Hot Monogamy. Â Address: 6705 Highway 290 West, Suite 502-291, Austin, TX 78735; e-mail address: Pat@patlove.com
Rx for Passion
Antidepressants needn't depress the libido
by Valerie Davis-Raskin
As a psychiatrist and couples therapist, some days it seems as if I never talk about anything but sex. And increasingly, I find myself educating my patients about the impact of the new selective serotonin reuptake inhibitors (SSRIs) on sexual interest and pleasure. Sure, I've had patients blush or change the topic, but most welcome the invitation to discuss problems in their sex lives, some related to medication, others not.
I didn't used to talk so much about sex and the sexual side effects of antidepressant medications. When I started practicing psychiatry a dozen years ago, we weren't yet in the better-sex-through-modern-chemistry era. Then the landscape changed. We began to live and practice in a culture that has come to consider pharmacology an acceptable (if not ideal) means of reducing depression. But until we had some ideas about how to counteract the sexual side effects of antidepressants, it still didn't much matter whether we talked about them or not.
Things are different now. We know that sexual side effects are among the most common and most troublesome difficulties experienced by antidepressant consumers. And more important, I know that I usually can help my patients recover from debilitating depression or anxiety without paying a sexual price.
When Prozac first came on the market, the medical profession didn't have a clue about how vital serotonin was to sexual pleasure and responsiveness. We didn't realize that Prozac and its two bestselling counterparts, Paxil and Zoloft, can and often do greatly reduce human suffering, but they also frequently kill sex drive, cause delayed ejaculation or completely eradicate orgasms. To this day, the Physician's Desk Reference (PDR) grossly underestimates the rate of sexual dysfunction caused by SSRIs. The PDR lists an incidence rate of medication-induced sexual dysfunction in the range of two percent or less. Would that this were true! In reality, between one third and one half of all individuals taking the most commonly prescribed antidepressants experience sexual side effects. And these three drugs--Prozac, Paxil and Zoloft--are among the top 10 most common prescriptions written in the United States for any condition--affecting, literally, millions of Americans.
The target of antidepressants are the neurotransmitters, our brains' chemical messengers. But neurotransmitters like serotonin are also found outside the brain wherever there are small blood vessels, a fact that accounts for many of the common side effects of SSRIs, such as nausea or jitteriness. Because serotonin is a sexually inhibitory neurotransmitter, increased serotonin in the brain may curtail the urge to have sex. Outside of the brain, serotonin may reduce genital sensation, somewhat like a mild anesthetic: what used to feel great feels good, what used to feel good feels okay, and what used to feel okay doesn't even register now. This means that arousal, both the psychological interest and physiological blood vessel reaction (blood flow to the clitoris, while less obvious, is as important for pleasure for females as blood flow to the penis is for males), may be suppressed by antidepressants that increase serotonin. Clinically, this translates into any combination of possibilities: lack of interest in sex, difficulty reaching an orgasm or outright absence of orgasm, inability to maintain an erection or prolonged erection. Some individuals experience a variety of side effects, while others experience only one, in an unpredictable fashion. And of course, it's just common sense that if you can't have an orgasm, eventually the libido falters as a consequence.
The chart below summarizes the degree of sexual side effects likely to be caused by the most frequently prescribed antidepressants.
Prevalence of Sexual Side Effects Caused by Antidepressants
Monoamine oxidase inhibitors (Nardil, Parnate)
One common intervention for any SSRI-induced sexual side effect is simply to lower the dose, as long as effective treatment for the psychiatric condition can be maintained. Since arousal, erection and orgasm changes are all dose-related phenomena, a substantial number of people will continue to benefit emotionally from smaller amounts of the offending SSRI. However, lowering the dose always carries the risk of a symptomatic relapse, and should symptoms exacerbate following dose reduction, other strategies are necessary.
Some people will benefit from a so-called "drug holiday" (an intervention that does not work for Prozac, due to the much longer time that Prozac remains in the bloodstream, compared with the shorter-acting SSRIs). A physician might recommend a regular drug holiday, in which the medication is taken on Thursday morning, skipped on Friday and Saturday, and resumed on Sunday morning. Ideally, a couple would opt to make love first thing Sunday morning, but many couples would find that a Saturday-night schedule is preferred.
Should these more conservative measures fail (or be clinically inappropriate in the prescribing physician's or patient's view) there are other options. Three of the new antidepressants--Wellbutrin, Serzone and Remeron--have no sexual side effects at all. Wellbutrin is generally well tolerated, but may cause insomnia, headache, tremor or increased anxiety. Its major drawback is that it is only effective for depression and may exacerbate conditions such as panic disorder. Wellbutrin is pharmacologically distinct from the SSRIs in that it enhances the neurotransmitter dopamine rather than serotonin. As a result, while it has comparable efficacy for depressive disorders in general, any particular individual may respond preferentially to an SSRI (or vice versa).
Both Serzone and Remeron are very sedating, although this effect often wears off over time, especially for Remeron, which is taken at bedtime. However, Serzone must be taken in the morning as well, and sedation is a troublesome side effect for many. Remeron's major drawback is the high incidence of weight gain, a side effect far less tolerable in many cases than low libido.
The tricyclic antidepressants, such as Elavil, Norpramin, Pamelor and Tofranil, may cause sexual side effects, including erectile or arousal problems and anorgasmia. Nevertheless, the incidence is far lower than with the SSRIs. The major drawback to tricyclic antidepressants is their potentially negative cardiac effect, elevating the risk of suicide and overdose. Higher doses may cause sedation, constipation, dry mouth and weight gain. Tricyclics have a particular utility for panic disorder, since lower doses than those needed for depression may be effective, allowing a mid-range dose that causes neither sexual dysfunction nor other significant side effects. Antianxiety medications, such as Klonopin and Xanax, do not affect serotonin and do not have sexual side effects as a rule.
Finally, some physicians may recommend St. John's wort, which is not believed to cause sexual side effects, although this has not been systemically studied. Unfortunately, because St. John's wort is not regulated as a pharmaceutical substance, efficacy may vary widely among preparations, and even from one bottle of the same brand to the next. This, along with the fact that it has not been rigorously tested in head-to-head comparisons with traditional antidepressants (for efficacy and also for side effects), limits its use to mild cases of depression or anxiety. St. John's wort should be taken three times per day and many people have a problem remembering the midday dose.
If switching to an alternative medication is not clinically appropriate or effective, a physician might recommend adding another medication on a daily or as-needed basis. Taking a second medication may be problematic on several counts. Women often feel awkward about actively seeking sexual pleasure. Many people also are extremely hesitant to take anything for depression, let alone two drugs. For others, a second medication offers a wonderful antidote to the side effects of an otherwise helpful medication.
Most commonly, psychiatrists prefer a single low dose of Wellbutrin for patients complaining of sexual side effects from other antidepressants. It is prescribed initially only as needed, but daily if required. This comedication strategy employs lower doses of Wellbutrin than would be necessary to treat depression. Pharmacologically, Wellbutrin enhances dopamine, which has the opposite effect on libido and orgasm of serotonin. Small doses may restore the serotonin-dopamine balance, alleviating sexual side effects.
The list of agents used to comedicate for sexual side effects include stimulants such as Ritalin (methylphenidate), Urecholine (bethanechol), Yocan (yohimbine), Symmetrel (amantadine) and Periactin (cyproheptadine). Anecdotal evidence suggests that the botanical preparation ginkgo biloba may reverse libido, arousal and/or orgasm problems. Anecdotal reports also suggest that Viagra (sildenafil) is effective for SSRI-induced absence of orgasm--even in women--but its use may be limited by cost ($9 per pill).
At times, it's easy to distinguish whether sexual problems are a relationship issue or are caused by side effects. SSRI-induced sexual dysfunction follows a typical pattern: it begins within days or weeks of starting the new medication. For example, soon after she began takingÂ Prozac for obsessive-compulsive disorder, Maria found she could no longer reach climax with her husband, Steve. She did not volunteer this information, which is one reason I routinely ask women about inability to orgasm. My male patients can tell me that "things aren't working right sexually," without having to look me in the eye and complain that sex is no longer pleasurable. Many women, however, experience an ambivalence about whether nice girls are allowed to like sex or should just go along with it. And some women are terribly embarrassed to talk about orgasms. "He could stand on his head and nothing happens" is Maria's euphemistic description of her sexual difficulty. "It's like a switch turned off down there." Maria hasn't talked about this with Steve, and I suggest that she let him know that medication is the problem, since he may be wondering if it's his "fault." Maria looks horrified at the thought, so I give her some written information to hand him.
I invite Maria to bring her husband to a session so that we can talk this over together. In our joint session, I explain that she is on a high dose of an SSRI for Obsessive-Compulsive Disorder, an illness that only responds to serotonin enhancing antidepressants. Because an SSRI is the only reasonable medication, switching to something like Wellbutrin isn't an option. Further, I explain to her that since effective doses of SSRIs are typically higher for OCD than for depression or panic disorder, lowering the dose isn't a good idea. Likewise, the drug-holiday approach isn't appropriate for Maria. This leaves co-medication, an idea that Steve likes a lot more than does Maria.
Steve reveals that he feels so selfish since Maria stopped having orgasms, and he would like things to be the way they were before. He feels that he is imposing on Maria, because these days, he's the only one reaching a climax when they make love. Somewhat reluctantly, Maria agrees to try comedication and I review the alternatives. Does trying something just when needed prior to intercourse seem best, or would a regular daily comedication be better? I explain that the only-when-needed medication is like a diaphragm--you lose spontaneity, but you don't have to ingest it all the time. When I mention that the only "natural" remedy I know of that may alleviate inability to orgasm requires daily use, however, Maria jumps at this, stating that she'd rather take something natural even if it means taking it every day. I tell her about ginkgo bilboa, which she purchases at her health food store. Six weeks later, she reports that "it's not like fireworks or anything, but it's lots better. Steve says thank you."
Maria remains reluctant to "own" sexual pleasure, continuing to describe her medication-induced sexual side effects-- and return of orgasms--as Steve's issue. Until Prozac came into her bedroom, Maria's unexamined belief was that Steve mostly cared about his own pleasure, and that she was just there fulfilling her wifely duties. Now she's heard from Steve loud and clear that her sexual pleasure is an integral part of his pleasure. A seed has been planted. For the first time, she and her husband have discussed their sexual relationship openly, and she has an opportunity to reframe her sexual self-image.
Valerie Davis-Raskin, M.D., is the director of academic psychiatry at MacNeal Hospital in Berwyn, Illinois, and a clinical associate professor of psychiatry at the University of Chicago. She is the author of When Words Are Not Enough: The Women's Prescription for Depression and Anxiety Â and coauthor with Karen Kleiman, M.S.W., of Â This Isn't What I Expected: Overcoming Postpartum Depression.
by Lynne Stevens
A fee policy can clarify the therapeutic relationship
Money is an underdiscussed topic in graduate programs, supervision and peer groups, yet every therapist I know has felt the awkwardness of seeming mercenary when insisting to a client who has fallen behind that he or she needs to pay. Unfortunately, most therapists were never coached about how to reconcile the closeness of the therapeutic encounter with the fact that therapy is also a business. When I first started out, I made the mistake of letting my caretaker impulse overcome me and charging a certain client who was in crisis a lower fee for several sessions. When she didn't pay even that fee and later let it drop that she had gone on an extravagant vacation, I felt like a fool. It has taken me years to understand that therapy is not separate from the exchange of money. I am in this profession because I care and have skills and knowledge that can help, and I also need to make a living.
These days, I run into the problem of clients who don't pay far less frequently than I used to. I attribute this to two changes I've made. The first was convening a peer group to discuss money issues. We examined our family values and messages about both the importance of money and the secrecy that often surrounds money matters, while also looking at the impact of social messages about gender and earning potential. When I heard everyone's war stories about clients who owed hundreds of dollars or terminated therapy without paying, I realized that my discomfort with money wasn't a character flaw, but a deficit in my training. More than anything, doing this personal exploration is what prepared me to explore the topic with my clients. The second change I made was developing a few practical steps to make it more likely that my clients will pay on time: prevention, intervention and having a bottom line. Prevention involves setting clear boundaries up front about my expectations regarding payment. I give written guidelines to clients during the first session that explain how I run my business: I prefer to be paid weekly, but will accept payment monthly; I charge for missed sessions unless clients give me 24 hours' notice. My guidelines also extend to questions about sliding fee scales and how much notice I give before I raise my fee. I ask my clients to read and sign die guidelines while they are in my office. The next week, I follow up and ask them if they have any questions or thoughts about them. Even though it's not legally binding, the document signals a commitment to take the business side of therapy seriously. Later, if money issues come up, I show them the signed copy I keep on file.
Of course, having a signed piece of paper doesn't eliminate conflicts over money. When the client's checks keep bouncing or are never sent, I have to intervene. One client, Sherry, was four weeks behind in her payments, for which she offered a series of reasonable excuses. The next week, Sherry's session focused on a very intense description of an episode of childhood abuse. But when she got up to leave at the end of the session without paying me, I cleared my throat and said, "So, today is the day you need to settle up for the last few sessions, as we agreed." She was upset that I could care about money after she had just revealed her deepest pain. At that moment, thinking about money as a boundary made it easier to stick to my guns. Sherry's not paying was not only a violation of our contract, but a replication of old family patterns in which uncomfortable issues were not discussed and boundaries were regularly violated. My kind but insistent tone let Sherry know that I was not her mother or her best friend, and that money was a fact in our relationship as surely as the clock that told us when it was time to end the session. Although she was angry, she wrote me a check before she left.
At the beginning of the next session, Sherry talked about feeling humiliated that she had to pay someone to care about her. It gave us an excellent opportunity to talk about the therapeutic relationship, what she could expect from me and how I was different from a friend or parent. I saw this conversation as a deepening of the bond of trust between us. She admitted that my treating her like an adult by expecting her to pay had given her a positive sense of herself as being capable and mature even while she was exploring her childhood wounds.
Having a bottom line about our fees is hard for all of us in the helping professions. It doesn't mean cutting off anyone who doesn't pay like clockwork, but it does mean not being a doormat. I try to catch potentially disruptive money issues by dealing with clients' accrued balances in a timely way. I also address clients' resentment at being charged for a missed session that they forgot to cancel and explore their expectations of how "understanding" I will be when they tell me about financial hard times. With some clients, there has come a point at which I have had to recommend that they take a break for a few months until they can catch up on payments, or I've discussed options such as coming in less often to make therapy more affordable. There are very few cases in which I have had to say to clients, "No more therapy until you pay me for the sessions you owe." Sometimes, hearing that I am going to be that firm about payment jolts clients into action and a check appears in my mailbox. Other times, the client hears it as a rejection and leaves in anger. I try to leave the door open as much as I can, while at the same time holding to my bottom line. I am always on the lookout for creative options. One colleague who had past experience of clients who ; ended therapy without paying their balances now asks clients ending therapy to write postdated checks that she can ! cash throughout the year. It has cut I down on the amount of collections she ; has to do, and makes it easy for clients, who don't have to remember to send money every month.
The only way I can make sure that money issues don't harm the therapeutic relationship is to be self-aware enough about my own issues around money, and then be willing to raise the | subject with my clients when it comes | up between us. There is an old truism : that therapists are more comfortable discussing clients' most intimate sexual details than talking about money. This is no longer true in my practice. I now welcome the opportunity to examine the meaning of money with my clients. Our clients are not going to lead the way. When money issues come up in therapy, it's up to the therapist to blaze a trail of openness, honesty and healthy limit setting.
Lynne Stevens, C.S.W., B.C.D., has been a psychotherapist in private practice in New York for 20 years. Address: 159 West 95th Street, Apt. B, New York, NY 10025.
by Michael Yapko
IT WAS MID-MORNING ON THE FIRST DAY OF THE LARGE Psychotherapy conference when I first began noticing the small white buttons with their pithy little saying sprouting on the lapels of conference attendees: "DEPRESSION: IT'S AN ILLNESS, NOT A WEAKNESS." By late afternoon, the buttons, dispensed at an exhibit booth for a large pharmaceutical company, were everywhere. I glimpsed them affixed to collars, pockets, belt loops, purses, backpacks, folders, any spare inch of apparel or appurtenance. It was startling to see how quickly a slogan could capture the allegiance of so many of my colleagues, especially when so many of them shared a common preference for brief, solution-oriented psychotherapies. Why were they so willing to make a public endorsement of the saying? For one thing, the slogan is catchy. It seems to suggest that we've moved beyond an era of superstitious belief and finally uncovered depression's "true" nature. The idea that depression is a clear-cut illness, caused by a "chemical imbalance" that can be cleared up with a daily dose of Prozac or Zoloft, now threatens to become a widely accepted clinical mantra and a popular shibboleth, repeated in best-selling books, mass-circulation periodicals and morning TV talk shows.
Currently, the most common mental health disorder in America and one of the most costly depression racks up a staggering $54 billion a year in costs from work absenteeism, reduced productivity, lost earnings and treatment expenses, according to a 1995 study by the National Institute of Mental Health. Depression is also among the most medicalized of psychiatric diagnoses; indeed, family doctors, not psychiatrists, write up to 70 percent of antidepressant prescriptions, with a wide array of meds to choose from. With the lion's share of mental health research dollars going into psychopharmacology during the past 15 years, there are now five major classes of antidepressants on the market. Seven new medications have been introduced within the last 10 years alone, and about 15 more are now being tested by the pharmaceutical companies.
But does the wide prevalence of depression, the staggering popularity of drugs to treat it and the obvious zeal for medicalizing the whole problem constitute prima facie proof that it is a disease? Can we now reduce the complex phenomena of depression, with all its emotional, cognitive, relational, social and biological elements, to a simple neuro-chemical mistake? Or is it possible that most depressed people are not "sick," and that biology only represents one component in the reasons for their depression and the way they experience it?
While thesymptoms of depression, at least as officially described in the Diagnostic and Statistical Manual, may seem to many to be fairly clear-cut and predictable, its origins and antecedents are not. Genetics, childhood trauma, unconscious guilt, neurochemical imbalance, poor interpersonal skills, learned helplessness are all potential "ground zeroes" by one school of therapy or another. In fact, the way therapists regard and treat depression might be considered as a kind of professional Rorschach test, revealing far more about their theoretical allegiance than about the true condition of their depressed clients. Analysts are trained to think of depression as the consequence of unresolved childhood developmental losses; cognitive therapists look for errors in thinking and belief that reinforce negative emotions; behaviorists help clients extinguish habits that contribute to depression; and family therapists study systemic or interpersonal triggers for depressive symptoms. However different the methods and the philosophies of their proponents, all these models provide valuable insights into the hydra-headed entity of depression, and none can stand as the final, defining word. But of all of the methods for treating depressed clients, biological psychiatry is today in the ascendancy, due largely to the proliferation during the last 15 years of effective medications for treating depressive symptoms with fewer side effects than ever before.
The rising fascination with evolutionary psychology and biological determination has led some experts to proclaim, without much evidence, that all emotional states (including depression) are ultimately based on biology.
One study published in Psychological Science in 1990 by Robert Plomin, Robin Corley, John DeFries and David Fulker, for example, suggests that one's amount of television viewing may be genetically determined. A 1992 study in the same journal by Matt McGue and David Lykken indicates that the tendency to divorce is also biologically determined. Do we really have genes for TV and divorce? Where and how in human history would we have acquired such genes (that only seem to have been activated in the last 30 or so years)? Indeed, as psychologist Stanton Peele writes in Diseasing of America, it is currently fashionable to view all kinds of self-defeating personal behaviors, including eating disorders, excessive shopping and too much sex, as evidence of disease.
The push to redefine depression as a disease is aided and abetted by the managed care industry, which encourages the use of antidepressant medication as a treatment approach. According to psychiatrist Matthew Dumont, "It seems that if we so much as inquire whether a depression might be related to the stresses or losses of life before blasting it with a chemical, we are virtually guilty of malpractice."
But this devaluation of therapy that inevitably accompanies the new emphasis on biological approaches is wrong-headed on two fronts. In the first place, epidemiological, social and cultural data indicate that, for most people, depression is not a disease of biological origin. Increasing in prevalence among all age groups, it is growing most rapidly among late adolescents and young adults. The average age of onset for a first major depressive episode has been steadily decreasing and is now the mid-twenties. Since gene pools and biochemistry do not tend to change so markedly in so short a time, the evidence supports an argument for social and cultural causes for depression in most cases. Since 1945, when the first of the baby boomers, who suffer dis-proportionately from depression, were born, our cultural mores have changed profoundly. The breakup of the family, explosive technological growth, dwindling resources, violence, terrorism and the threat of nuclear disaster have undermined our sense of social stability and cast deep shadows over future expectations. Writing in the Archives of General Psychiatry in July 1985, psychiatrist Gerald Klerman and his colleagues identified some of the social stresses they believe account for the higher rates of depression. These include urbanization, changes in family structure, new gender roles and occupational shifts. All of these trends unsettle people, uproot them from traditional mores and meanings, confuse them about who they are and what is expected of them and create many new opportunities for experiencing inadequacy and failure. Psychology researcher Martin Seligman suggests that, as a people, we tend to be more self-absorbed than our forebears, and thus more hypersensitive to each transient mood. Seligman thinks that we may also have unrealistically high expectations of ourselves and others, even as we increasingly feel both more helpless and hopeless about controlling our lives.
This dichotomy is even more confounding for our own emotional well-being, Rates of depression and symptomatology vary widely from culture to culture and between genders, also lending support to the theory that the interplay of social, cultural and psychological factors is generally more important than biology. The Amish, for example, have considerably lower rates of depression than do other Americans. Their lower incidence of depression presumably relates to cultural factors, including vital religious beliefs, close-knit community ties and a reliance on their own labor rather than technology. Women in this country are two or three times more likely to be diagnosed as depressed than men, in part for biological reasons (reproductive events like postpartum depression and possibly premenstrual syndrome), but more likely because of systemic social inequities and cultural conditions.
There is no question that genetics and biochemistry play a part in depression, but the best data from identical-and fraternal-twin studies indicate that genetics can be identified as a cause of unipolar depression less than 20 percent of the time. But, if, as the evidence now shows, cultural and social forces contribute more to the onset of depression than does biology, medication is only a partial solution.
More important, there is now abundant evidence that therapy is as effective or more effective than drugs are for treating depression, with lower rates of relapse. In the January 1994 issue of American Psychologist, Ricardo Munoz, Steven Hollon et al. reviewed guidelines for treatment of depression developed by the Agency for Health Care Policy and Research (AHCPR) that compared thousands of treatment outcome studies using drugs alone, psychotherapy alone or a combination. Evaluating the guidelines, the authors concluded that psychotherapy was at least as efficient as drugs for relieving depression. And, on many measures, including treatment-dropout rate, social adjustment, symptomimprovement and relapse rate, psychotherapy performed better than meds. Several metanalyses of many controlled studies involving thousands of patients have reached the same conclusion. One is a recent review by David Antonuccio et al. of numerous studies comparing drugs to therapy and the value of both approaches combined, published in the December 1995 issue of Professional Psychology: Research and Practice, which reports substantial evidence for the superior effectiveness of therapy. There is "no stronger medicine" for depression than psychotherapy, writes Antonuccio in a recent issue of the American Psychologist. So, while medications can help relieve symptoms, and possibly help clients take better advantage of therapy, the reputation of Prozac or Zoloft as miracle cures for depression, rendering therapy obsolete, is simply not supported by research.
Late last year, the position of therapy was buttressed even more by the largest survey ever conducted of people who had undergone outpatient psychotherapy treatment, published in the November 1995 issue of Consumer Reports (See Around the Network, January/February 1996 Networker) and based on extensive reader-response questionnaires submitted by 4,000 subscribers. Unlike standard efficacy studies, with their random assignments of clients meeting rigid eligibility requirements to standardized treatments, the Consumer Reports survey caught the experience of therapy as it really is for most people with therapists who typically offer an eclectic mix of approaches and adjust their work to individual clients.
Of respondents to the survey, 87 percent said they felt better after treatment. There was no significant difference between psychotherapy alone and in combination with medication for any disorder, including depression. And social workers, psychologists and psychiatrists all had roughly the same rates of success. Most surprising, perhaps, to a field giving increased emphasis to brief therapy, respondents reported better results for longer treatment. Among those with similar levels of emotional difficulty, those who stayed in therapy more than six months said they made greater progress than those who left earlier. Not surprisingly, people whose choice of therapist or whose length of treatment was dictated by insurance coverage improved less than those who freely chose the clinician and modality.
Although the Consumer Reports study is not without problems low response rate to the questionnaire, lack of specificity to the depression diagnosis and other possibly distorting factors it broke new ground. By going directly to the mental health consumer, it produced the most naturalistic view of the actual experience of therapy of any study of the field ever conducted. According to psychology researcher Martin Seligman, principal consultant on the survey, writing in the December 1995 American Psychologist, "[The survey] is large-scale; it samples treatment as it is actually delivered in the field; it samples without obvious bias those who seek out treatment; it measures multiple outcomes . . .; it is statistically stringent and finds clinically meaningful results ... Its major advantage over the efficacy method for studying the effectiveness of psychotherapy and medications is that it captures how mid to whom treatment is actually delivered and toward what end. ... It provides a powerful addition to what we know about the effectiveness of psychotherapy and a pioneering way of finding out more."
While medications are often invaluable for symptom relief of depression, their effectiveness is not evidence for an underlying physical pathology. Medications work because they have a relevant chemical effect, indicating a correlation between their impact on specific neurotransmitters and mood. But while there are some cases in which medications may help depression sufferers without additional treatment, the consensus among most depression experts is that only prescribing medications is generally a disservice to the client. Most people require much more substantial psychotherapeutic help to learn the skills necessary for solving problems and avoiding future difficulties, if their medication-improved mood is to endure.
What is it about psychotherapy that makes it so vital to treatment, that gives depressed clients something they cannot obtain from medications? People become and stay depressed partly because they tend to explain life's ordinary defeats and disappointments in terms of their personal inadequacies and failures, and then believe their own negative opinion of themselves. Others have deeply pessimistic worldviews that influence their mood states and tend to engender self-fulfilling prophecies. A healing relationship with a therapist can provide the kind of personal support and teaching that can clear up the misperceptions that contribute to the negativistic view of life typical of depressed people. Therapy can help clients see life events from different perspectives and reattribute experience by assigning alternative explanations for life events that are less damaging to themselves than the typical depressive worldview. The ability to see and interpret events from new perspectives is critical to mental health.
As we become increasingly a nation of wanderers, our lack of steady and sustained social connections and consequent lack of competence in relationship skills provokes even higher rates of depression. Our ethos of extreme individuality and personal rights over collective responsibility and social accommodation increases the likelihood that we will be lonely and depressed, without the deep ties to family and friends that can immunize us against alienation and despair. But there is no disease here, just a way of responding to life that is proving ever more toxic to our individual and collective psyches.
As therapists, what can we do in the face of this rising tide of depression, which deeply implicates not the faulty biology of millions of people but the depressing nature of our civilization? And how can we counter the myth of pharmaceutical omnipotence that undermines our own confidence in therapy and our appreciation for its irreplaceable role? We must be aware that therapy works with depressed people because it draws on the clinical skills and adaptability required to understand a complex disorder skills no pill can mimic. Therapists also need to emphasize active, solution-oriented treatments over pathology-based passive ones. Rather than search the dim past for causes of presumed deficits, we need to actively teach clients the specific skills they need to manage their feelings and develop what author Daniel Goleman calls their "emotional intelligence."
Martin Seligman, in his book, The Optimistic Child, writes that antidepressant skills for interpreting and responding intelligently to life events can be taught at a young age. We can prevent later misery by teaching children to be more flexible in their interactions and empower them to solve problems before they lead to entrenched, self-destructive patterns of behavior. Similarly, Robert Ornstein and Paul Ehrlich, in their book New World, New Mind, argue cogently that learning to think preventively acquiring a refined sense of the relationship between "this" course of action and "that" predictable consequence helps people avoid being sucked under by their own moods and emotional reactions. In short, therapists are badly needed to help people learn the tried-and-true skills that used to be considered the hallmark of adulthood. They include the ability to think ahead, critically consider alternatives, anticipate consequences, recognize when to give precedence to the heart or the head and, perhaps most of all, create and maintain solid and satisfying personal connections to other people.
Just as there is no single cause for depression, which is the personal and idiosyncratic response of individuals to a multitude of biological, psychological and social factors, so there can be no all-purpose panacea, like the simple act of taking a pill, that resolves life's difficulties. The idea that depression is a disease reflects, in part, the benign intention to destigmatize the suffering it causes and, less benevolently, the economic pressures to find a cheaper cure. Americans have a history of valuing quick-fix solutions to difficult problems. But this simplistic approach to depressive disorders underestimates the remarkable human capacity for self-transformation. We have the ability to use imagination and intelligence to change our life circumstances, our attitudes and emotions, even, to some extent, our personalities. It is the privilege of our profession to be able to help troubled people along this path, and though medications may make this journey less arduous, in the long run, therapists are indispensable for getting their clients to this destination.
So, for the sake of your profession and your integrity, watch out for facile explanations of depression and pluck off those buttons that reduce complex issues to catchy slogans. Your clients will thank you, and you'll feel better about your vital role in treatment.
Michael Yapko, Ph.D., is a clinical psychologist and marriage and family therapist in private practice in Solana Beach, California. He conducts workshops nationally and internationally in hypnosis and brief therapy methods, and is the author of the new book Breaking the Patterns of Depression (Doubleday). Address: 462 Stevens Avenue, Suite 309, Solana Beach, CA 92075.
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.
by Mary Sykes Wylie
ACCORDING TO AUSTRALIAN THERAPIST MICHAEL WHITE, a disconcerting effect of his new celebrity on the international therapy conference circuit is the recurrent experience of getting off a plane, being met by a workshop sponsor and told something like, "We sure have a real humdinger of a family for your live consultation. Oh, and by the way, about 500 people have signed up to watch." Whereupon White, the most visible representative of what is loosely called the "narrative method" of therapy, is plunked down in front of an impossible situation, while the audience waits breathlessly for a therapeutic miracle. White, who finds the hoopla attached to his new status puzzling, denies that there is anything magical about what he does. He says he is just very "thorough," very painstaking, and that "it's silly that people expect to get a good idea of this kind of work by setting me up in one meeting with the most complex situations they can find." Then he adds, "Certainly, the idea that I've got all the answers doesn't fit the spirit of the work."
Nonetheless, over the past decade, White has developed a worldwide following of both senior therapists and neophytes on several continents who insist he has something vitally important to say that the field needs to hear. But it can hardly be his therapeutic style that explains his elevation to the ranks of the illuminati. Watching him in session is a far cry from seeing one of the recognized lions of clinical performance sweep grandly into the middle of a dysfunctional family circle and in one session transform it into a little kingdom of love and harmony, while being wildly entertaining in the process. Far from it. His pace is measured, even monotonous some find it maddeningly slow the therapeutic persona respectful, solicitous, inquisitive, slightly donnish, almost deferential, the circuitous language an eccentric mix of the folksy and the politically correct. It is hard to imagine the following questions appearing in any psychotherapy textbook: "Do you know how you got recruited into these habits of thought that have been so capturing of your life?" "What skills have you developed as a couple that allowed you to hold on to your relationship in the face of adversity, and in spite of the politics of heterosexist dominance and ageism that marginalize your ways of being?" "What's it like for Anorexia Nervosa, which has been pulling the wool over your eyes, to witness these recent, more positive developments in your life?"
During sessions, White hunches down in his chair over his notes he seems almost to recede from view. He almost never asserts anything, rarely utters a declarative sentence, just patiently asks questions, hundreds of questions, often repeating back the answers and writing them down. Like an archaeologist, White sifts through the undifferentiated debris of experience for minuscule traces of meaning the tiny, precious shards of struggle, defeat and victory that reveal a life all the while doggedly taking notes, even occasionally requesting the speaker to slow down so he can take it all in.
At the same time, there is a startling tenacity about the process, a kind of polite but unshakable insistence on participation, a refusal to let people off the hook, even after hours and days of non-response long silences, embarrassed shrugs, parrot-like reiterations of "I don't know." White will not allow the people who consult him to slip away into the sad night of their misery. He simply will not give up.
In one session, for example, the parents of a deeply shy and isolated pre-adolescent girl, are trying to coax her away from her perch in front of the television and go walking with her father. But the girl's reluctance is such that even when she does consent, she dawdles so that her father says he must then take a second walk in order to get any exercise for himself. He is disheartened and wonders if the effort is worth it. In this segment, White tries to get a statement of feeling from the girl herself. It is uphill work. White asks, "Do you have different paces of walking? A snail's pace? A tortoise's pace?... Are you faster or slower when you go walking with your dad?" After a long pause, she murmurs, "Probably slower." "Probably slower," volleys White. "That means you do have more than one gear. [Do you walk more slowly] because you don't want to go walking with him?" "I don't want to do it," she says finally.
Ignoring this response, he asks her how she could help her dad work out what to do abandon their walks together or persist. She yawns hugely. Building on a microscopically tiny advance in the girl's life emerging earlier in the session (when he had elicited from her a barely spoken acknowledgement that she might like to be "taking more initiative in life, rather than being a passenger") White asks, "What would you like to do with your dad that would fit with this new direction of yours?" a "new direction" that would have been invisible to anyone but White. She mumbles "Go walking." "Going walking would that fit this new direction?" he pushes. "Fits," she barely murmurs. "It does fit," White continues enthusiastically, "So would you like him to keep on trying to go walking, or would you like him to stop?" "Hmmm, hmmm, hmmm," she replies. "You have to say what you'd like," says White the closest he comes to making a demand. "Keep on walking," she finally answers. It is an achievement, says White, because she has determined that the decision to keep on walking "fits more with self-care than self-neglect." By the end of a later session, while she doesn't exactly seem as "bright, open, chirpy, communicative, chatty" as White suggests to her, she is clearly much more engaged. She looks at him out of the corner of her eye and smiles shyly, and even produces some whole, unequivocal answers (short ones) to his questions, obviously delighting her parents. Their daughter, who had rarely been able to identify any of her own likes, dislikes, desires, interests, purposes, who had rarely even talked to anybody, has begun, however hesitantly and timidly, to say out loud what she wants for her life.
This kind of work may look to some practitioners like cutting grass blade by blade, but it is probably more like panning for gold in an overworked stream long since abandoned by other prospectors. Slowly, meticulously, steadfastly, White sifts through the sandy deposit, patiently extracting almost invisible flakes until, by imperceptible increments, he has amassed an astonishing mound of precious metal. Clearly, White's reputation rests less on therapeutic bravura than on the extraordinary, transfiguring moments that occur in his practice epiphanies that take place with people most therapists would write off as hopeless.
Mary, a young woman horribly abused as a child, appears in White's office anorexic and bulimic to the point of near death, suicidal, actively hallucinating, unable to leave her house or talk with anybody except her husband. Discharged from her last psychiatric hospital with the medical prognosis of death by starvation within a few weeks, she is brought in to therapy by Harry, her despairing husband, and spends the session curled up in a fetal position, rocking to and fro on the floor in the corner of White's office. "She would not answer any questions, and I did not get to see her face for the first three sessions," says White.
When Mary does not respond to his gentle, persistent probing, he asks her husband to pose the questions to her, and when she still remains silent, White wonders aloud if Harry would like to "speculate" on what her answers might be. At the end of the third session, after one of White's typical questions what did Harry think her answer might be if he asked her how she had been recruited into such self-hatred she moves a little and whispers something into her husband's ear. "For that one instant, hateful-ness did not speak to Mary the truths of her identity," says White, "and from then on, she began to speak more and more in a different voice for herself."
With time, this almost unbearably fragile woman has acquired a small puppy and talks about how sweetly the dog licks her chin in the morning at first, she had thought she was so hateful the dog would perish in her care. Once terrified into paralysis by the possibility of personal rejection, some months later she has organized an outing for herself, her husband and her in-laws. She has reestablished a relationship with her mother and, mir-abile dictu, she has gone, by herself on the train to a shopping mall, walked into a coffee shop, ordered a cappuccino and drunk the whole thing. When White asks what this event tells her about her life and her identity, this woman, who has believed she was worthy only of death, says in a small, frail, but unwavering voice, "I would like to do something for my own self."
In Mary's life, these ordinary events are miracles, of which nobody who views the tape can have the least doubt. Still mysterious, however, is what White has done that has made the difference. By now, the theories and methods that have given White and David Epston, his New Zealand colleague, an international following are well-known, and they clearly figure in Mary's case. Through "externalizing conversations," for example, White has helped Mary think about her anorexia nervosa and the attendant "self-hate" as hostile, outside forces in her life, not at all intrinsic to her nature and personality "When you were drinking the cappuccino," he asks her, "did you or Anorexia and Self-hate have the upper hand?" "I had the upper hand," she answers softly, but with something that sounds very like pride. When anorexia and self-hate are no longer inherent to her very being, she can fight them without fighting herself; she does not have to die in the act of resistance.
White and Epston also look for evidence of what they call the "unique outcomes" in people's lives and the "counterplots" associated with them seemingly ephemeral, often forgotten experiences that contradict the dominant story of abnormality, deficiency and failure. "There is always a history of struggle and protest always," says White. He finds the tiny, hidden spark of resistance within the heart of a person trapped in a socially sanctioned psychiatric diagnosis "anorexia nervosa," "schizophrenia," "manic-depression," "conduct disorder" that tends to consume all other claims to identity. White liberates little pockets of noncooperation, moments of personal courage and autonomy, self-respect and emotional vitality beneath the iron grid of lived misery and assigned pathology.
Even in Mary's history, for instance, in an almost unimaginably bleak and brutal childhood, he finds the saving remnant of another, untold story. "In her darkest hours," he says, "at a time when she was being sexually abused by several people, she used to run away into the woods to the same tree whose trunk she could just stretch her arms around she said she could hear the tree speak to her. She had found a living thing that didn't abuse her, a simply fantastic achievement." Such heartbreaking moments of spiritual valor are hints, in White's credo, of Mary's subtle, half-forgotten, almost unrecognized dissent from the dominant story of abuse and self-hatred, official psychiatric labeling and social ostracism. When people like Mary remember and speak about these tiny saving fragments of formerly lost experience, says White, they also relive and perform them as well transforming meaningless autobiographical aberrations into the palpable material of new stories, new lives.
IN EVERY KNOWN CULTURE, PEOPLE give meaning to their individual stories (what happened to me as a child that affects me now, how I met my husband, why I got sick and why I got well) by organizing them according to a time-line with a beginning, middle and (perhaps hypothesized) end. In this way, we create our personal history. White's therapeutic method may depend more on exploring people's history than any other current approach, barring psychoanalysis but with a profound difference. Whereas practitioners of the latter delve into personal history like surgeons looking for hidden tumors, a lump of pathology in the far distant past, White seeks out the healthy tissue, the protective antibodies, which he always finds. For White, people's present lives cannot be reduced to their diagnoses, which are much too tight, too confining to contain the capacious possibilities revealed in their histories.
And, unlike other therapists who may take history into account, but only as individual case histories, White both brings history with a capital 'H' into the lives of the people he sees and, in turn, brings them into the broad current of historical time and place. He might be described by an Eriksonian therapist as breaking the "trance" imposed on people by the powerful forces of history and culture, making visible the invisible pattern of ordinary humiliations and terrors, routine tyrannies and acts of violence that comprise much of "civilized" life.
John, for example, a therapist in training, came to see White because, says White, "he was a man who never cried" he had never been able to express his emotions and he felt isolated and cut off from his own family. As a child, John had been taught, both at home and at his Australian grammar school, that any show of gentleness or "softness" was unmanly and would be met with harsh punishment and brutal public humiliation. White asks John a series of questions that are at once political and personal, eliciting information about the man's "private" psychological suffering and linking it to the "public" cultural practices, rigidly sexist and aggressively macho, that dominated his youth. "How were you recruited into these thoughts and habits [of feeling inadequate, not sufficiently masculine, etc.]? What was the training ground for these feelings? Do you think the rituals of humiliation [public caning by school authorities, ridicule by teachers and students for not being good at sports or sufficiently hard and tough] alienated you from you own life? Were they disqualifications of you? Did these practices help or hinder you in recognizing a different way of being a male?"
Having clarified the social context of John's alienation from himself in the "dominant men's culture," White helps him acknowledge and appreciate his ability to resist it and "reclaim" the other stories of his life, the other selves and ways of being gentle, kind, loving that he had managed to keep alive, though hidden, in spite of his tormentors. White asks what it would have been like for John, as a young boy, to have himself as a father. That little boy would have loved it, John replies. It would have meant having a father who talked with him, who showed him love, gentleness, kindness; it would have meant being accepted for himself; it would have meant having more fun. "I try to do that with my kids, now," he says.
Then one of those White epiphanies occurs. While John is still in a kind of reverie about the little boy he had been and the father he had needed, thinking aloud about his own sons and the father he tries to be affectionate, emotionally open, warm, playful White asks him what is happening to him right then, in the session. A look of wonder comes over John's face, and he says, "It's okay . . . It's okay to be that way. It's alright," and for the first time in his adult life, he begins to cry. "Yeah. Wow. Whew," he says over and over, blowing his nose. "Yeah, thanks. That's really strong, that's really powerful. Yeah, I did resist it somehow. This is rare. Yeah." And it is rare, to see two trajectories meet the abstract knowledge about the power of cultural conditioning, and the gut realization of what that conditioning has meant in one's own life.
Even more striking is White's ability to cut through the maze of social opinion, psychiatric ideology and individual indoctrination that reinforces the very symptoms of people labeled "chronic" mental patients. Often, these people, particularly diagnosed schizophrenics, have what sociologist Erving Goffman referred to as "spoiled identity," and, says White, "perceive themselves to have failed rather spectacularly in their attempts to be persons," that is, in their attempts to force themselves to behave, feel and think along stereotyped lines considered "normal" and "healthy" in the dominant culture. The cost is often excruciatingly high for people already particularly vulnerable, for biological and/or psychological reasons, to emotional stress.
According to White, the hallucinatory voices heard by people diagnosed as schizophrenic, telling them they are sick, helpless, crazy, deranged outcasts, bear an uncanny resemblance to common negative cultural stereotypes. Men's voices, for example, tell them they are wimps and weaklings, while women's voices attack their sexuality calling them sluts and whores. In both cases they harp relentlessly on the hearer's stupidity, worthlessness, social unacceptability and failure to measure up to social norms and rules. All-knowing and opinionated, the disembodied, magisterial voices speak in tones of great authority the voices of correct opinion and unimpeachable judgment (one imagines a malevolent Dan Rather or Peter Jennings) that the hearer would have heard repeatedly in the "real" world.
What perplexes White isn't the odd parallelism between the "internal" voices and "external" social messages, but the difficulty most people have seeing the connection. "Although it seems relatively easy for us to entertain the idea that much of what we think and believe, and much of what we do, is informed by culture," he said in a recent interview, "for some reason it seems rather more difficult for us to entertain the idea that psychotic phenomena are similarly informed; that regardless of etiology, the content, form and expression of psychotic phenomena, such as auditory hallucinations, are shaped by culture."
In his own terms, White "deconstructs" the dominant authority by taking people's voices very seriously accepting their validity as hostile forces "out there" collaborating with the person to unmask them as the lying scoundrels they are and develop strategies that will undermine their power. "What is it that the voices are trying to convince you of?" he asks. "What are they trying to talk you into? Are these voices for you having your own opinion, knowing what you want, or are they against you having your own opinion? Does the confusion caused by the voices contribute to their goals for your life, or yours?"
Jane, for example, steadily regressing at home with a diagnosis of schizophrenia, heavily medicated, unable to leave her parents' house for years, has recently moved into her own home, after working with White. She says that the six hostile voices that used to harass her constantly have been reduced to one, which seems to be on the defensive. "They used to dominate my life totally," she remembers, "told me I had to stay in bed all the time, that I was queer, that nobody liked me, that I didn't deserve to have any company." As he does ordinarily with people who have experienced psychotic episodes and suffer hallucinations, White equipped Jane with transcripts of their sessions together, along with various other "documents of identity" (i.e. written "charters" celebrating the person's strengths, capacities and current progress and intended to be shared with family and friends), which protect her from her hostile auditory ensemble. Whenever one of the voices threatens to have a "tantrum" or otherwise attack her, she reads a transcript and "I get a picture of what I really am like ... a much better picture than the voices [give me] . . . and I'm not so scared. [I can see] that I'm a nice person, attractive, good personality, independent.. . [It] shows through." The action of reading the transcript makes the voices just "go away," says Jane, though they go with much grumbling, in ill grace and it is hard not to envision a swarm of evil, wrathful little trolls retreating before a determined woman wielding a particularly effective magic talisman. Together, Jane and White have transformed a hopeless story with a foreordained ending into a dramatic epic, in which Jane is not a victim, a defeated mental patient, a crazy lady, but a hero engaged in a valiant struggle against a formidable enemy.
White has been roundly criticized by the psychiatric profession for reinforcing hallucinations and failing to help people "own" and "integrate" the voices to recognize that they are part of themselves, and take responsibility for having, in effect, invented them. White rejects such criticism because he rejects the foundation on which it is based that every human being comes outfitted with a single, unitary, core-personality, the center and source of all human meaning. Those who admit to hearing tyrannical voices coming from "somewhere else" break all the rules of self-containment, self possession, self-definition, self-control, self-determination that are the earmarks of "healthy personality development" in our culture. This view, White contends, is far less an objective description of human nature than a culturally determined prescription for the way people should be, not to mention an implicit damnation of people who don't measure up. "This work is not about people discovering their 'true' nature, their 'real' voice," says White, "but about opening up possibilities for people to become other than who they are."
For White, the personal is, and must be, deeply embedded in the political. The stories of the people he sees John, Mary, Jane are of personal struggle and transcendence, no doubt, but in White's eyes they are also unmistakably tales of power politics, the "politics of local relationship," as well as the larger social politics of gender, class, professional and institutional dominance. Mary's anorexia is both the result and the expression of the damage done to her by the misuse of power by her family, by a society that countenances male domination of women and children, and also by the mental health establishment that defines her life, reducing her to a kind of psychiatric object a "case" of anorexia.
White's thinking is legions away from the clinical Zeitgeist suggested by the standard family therapy metaphors of cybernetics or systems theory, suggests Gene Combs, codirector of the Evanston Family Therapy Center in Evanston, Illinois. "You have to think more in anthropological, sociological metaphors; you need to have pictures and ideas in your mind about how social and moral values, political and intellectual practices are transmitted in a culture, and how they influence the way people are. When Michael talks about stories, he's not just talking about individual anecdotes, but the story of Western civilization and how it has already 'storied' our lives for us before we were born."
WORDS ARE SO IMPORTANT," White said in an interview with The Family Journal last January. "In so many ways, words are the world." Yes, but so are the people who utter them. And it is hard to avoid the sense that the White persona is a very powerful element in the therapeutic equation. He dislikes the terms "client" and "intervention," which suggest to him the sort of expert domination of people in therapy that reproduces the social control and disqualification they already experience outside. And yet, in spite of a distinctly unshowy clinical manner in sessions, he is clearly the director of the ongoing drama.
Sometimes, the stream of formulaic questions intended to elicit externalization and re-storying can seem relentless, almost conveying the impression of a benevolent salesman hammering away at a hesitating customer: "Come on, you know you are better than you think you are, more than this paltry story you've been given, so when are you going to get with the program, take the deal, sign the papers, buy the product?" It's as if he is trying to convince them not only to buy themselves but to consider the sale as good a deal as he does. He clearly believes in the people who consult him more than most others do more, probably, than many of the therapists observing and certainly more than they believe in themselves. In one live interview with the family of an 18-year-old boy involuntarily hospitalized by the legal system for setting fires, he spends a major part of the session following a line of questions apparently aimed at building a greater sense of personal agency in both the boy and his 12-year-old sister (herself hospitalized for suicide attempts), while helping the two of them get along better. It is not an easy job even getting the siblings, both following their own eccentric and antagonistic orbits, to respond to a line of questions about their accomplishments, much less focus on what they might have in common. Nonetheless, White pries from each (buttressed by appeals to the parents) admissions of small, but legitimate "new developments" related to their increasing maturity: Mike now takes a shower "at his own suggestion," and helps his mother with kitchen chores; Debbie keeps her room neater and can handle more school classes.
In a segment that looks like the equivalent of pulling seriously impacted wisdom teeth, White manages to get from brother and sister, syllable by syllable, grudging concessions that each notices the changes in the other, and approves of them, sort of. As usual, White is only asking questions not, presumably, "imposing expert knowledge" on the people he is interviewing. But, he is generating the lion's share of talk, energy and conviction, and it is hard not to see at least the shadow of an unflagging preacher cornering the town sinner and extracting from him an admission that, yes, he probably does feel an attack of salvation coming on.
In the question-and-answer period that followed this live interview, one observer said he had found White "directive" and "suggestive" in his questions and noticed that he had "blocked" Mike from saying things and "interrupted" him on several occasions. Was this an important part of the narrative method as White practiced it? White answered that what looked like direction, suggestion and interruption was, in fact, a form of differential attention. He was not "blocking" some material as much as he was "attending to" other material the "sparkling facts" and "unique outcomes" that had been totally ignored or quashed in the family's dominant story of sickness and failure. As powerful coauthors and coconstructors of the realities that people forge in the process of therapy, White suggested, clinicians have a rigorous responsibility for what they choose to select from the multitudinous possibilities given them in session, and for whether the stories they help create are newer, more helpful, more healing or just regurgitated chapters from an old chronicle of despair: "Old dominant, problem-saturated stories are not good for you there's not one old story that's good for you, despair is not good for you."
But old stories sometimes die hard people have been imprisoned in them too long. Coming into the light of a new story can be blinding at first It isn't likely, suggests White, that people will always be able to leap immediately to a new possibility, to instantly invest old, half-forgotten, devalued experiences with new meanings. If therapy with White is a process of coauthoring new stories, many of the people he sees could be said to suffer from paralyzing writer's block they sometimes need to be nudged out of their immobility, persuaded to fit those first awkward words to experience, embarking on the reflective reverie that begins with "Once upon a time . . ."
The therapist who wishes to be coauthor, or creative agent and impresario, cannot hide behind passive silence or pretend neutrality. "There is no way of asking neutral questions," says White, "and you can't just drop a question when they don't answer right away and go on to something else. I'm very much the coauthor at first, but gradually, the person becomes far more active about articulating what these new developments mean in their lives. They become fascinated with neglected elements of their own stories, and as they step into that fascination, my role diminishes. I ask fewer questions, while they come up with ideas, notions, solutions I never would have imagined, unravel mysteries in a way I never could do." As the "alternative plot" gets rooted in people's own memory and imagination, says White, the story "runs away from me, it takes over, it has no end . . . and I can't know in advance whether the story will be beneficial or not. Only the people with whom I am working can determine this, and I keep encouraging them to do so."
Although White claims that Western ideals of individualism, self-determination, personal authenticity have become tyrannical measures of human worth in our society, he seems particularly good at producing these old-fashioned, perfectly unexceptional therapeutic outcomes. In fact, the people he sees seem to believe that his practice of nurturing a freer, more robust feeling of personal agency and individual identity is what distinguishes his therapy from the multitude of other treatments they have had.
Diane, for example, hospitalized several times for anorexia nervosa, compares the repressive, distrustful hospital environment with her experience of being treated by White. In the former, where food intake was rigidly watched, toilets were locked so that food couldn't be flushed away, rooms were searched if inmates didn't gain weight and therapists tried to extract from her admissions that she must have been sexually abused as a child, she felt degraded, brain-washed and rebellious "The way they treated you made you feel as if they had all the answers and you were nothing." White, on the other hand, "helps me along the way, but I'm the one who chooses what I want to eat; I'm the one who's got control. In the hospital I was forced to eat, and [when I gained weight] I wanted it off as quickly as possible, whereas with him, I did it myself, when / was ready, and it will stay on." If this isn't self-determination, what is? White words it differently, arguing that such responses "are the outcome of people stepping into ways of being and thinking that bring new options and possibilities for action." Still, a rose by any other name ...
Even people considered to be chronically psychiatrically ill and particularly at the mercy of the Western cult of individual selfhood, according to White, seem to emerge from his therapy with a much expanded sense of... individual selfhood! They also have a greater sense of community, White points out, because they have begun to engage family members, friends and others in the "renegotiation" of their life-stories making them witnesses, so to speak, to their changed realities. Still, White seems to have an inside grasp of the profound demoralization felt by people who are not only denied agency for their own lives, but told constantly that they are unworthy of having it so they become nonpersons to themselves. "I used to try to be everyone's [else's] person," says James, who holds a handful of diagnoses, including schizophrenia, schizo-affective disorder and manic-depression, and has suffered, as he puts it, from the judgmental, unrelenting "expectations" of others (including his own tyrannical voices) to get a job, to exercise, to give up smoking, to act "normal," to behave, to be the person others "expected" him to be. With White's help, he says, he could learn to say "no . . . Michael hands it over to me to decide what I want. He empowers me, he doesn't take over the reins for the management of my case. He's somehow very clever in allowing me the freedom to be the person I need to be, while also managing myself so I don't go overboard."
Gene Combs describes a tape in which a woman diagnosed as schizophrenic compares the hospital chart that had accompanied her for years on a mental ward with White's case notes based on his sessions with her. "When she read the hospital chart, she said she felt like a chronic, medicated schizophrenic, like someone stuck, with no hope, not worthwhile in the eyes of other people," says Combs. "When she read what Michael had documented, she saw clear movement in her life. She felt like a valuable person who lived a meaningful life that she was making even better. She said she felt respected." What really impressed Combs, however, was the difference on her face, in her voice and in her bearing when she talked about the hospital chart on the one hand, and White's notes, on the other. "When she talked about the former, she looked like a chronic mental patient; when she talked about Michael's story, she looked like a person."
This transfiguration seems at bottom a mystery, which challenges notions of the "unitary self" certainly, if that self is predetermined by culture and politics, and if it is a static, hard-wired entity of predictable operations and predilections. Is this newly transfigured "self" more "real," more "true" than the old one? Will this new self be more successful than the old? "I don't know what these stories are going to bring with them," says White. "I can't know whether they will be beneficial or not all I can do is keep on asking the person what the effects of the story are, asking him or her to judge it. I can't assume anything there are always lots of surprises."
In "The Power and Culture of Therapy," White quotes social philosopher Michel Foucault's words, which probably come close to White's own views on the issue of selfhood: " "The main interest in life and work is to become someone else that you were not in the beginning. If you knew when you began a book what you would say at the end, do you think that you would have the courage to write it? What is true for writing and for a love relationship is true also for life.'"
WHITE'S IMPACT ON THE PEOPLE he sees cannot be explained solely as the product of an interesting theoretical worldview that makes its way into some interesting new techniques. His work, perhaps like that of any gifted therapist, any inspirational spiritual leader, any talented artist, depends upon something like what 18th-century English evangelist John Wesley called "the heart strangely warmed." In White's case, there is no question that he is literally "warmed" by the people he sees, that there is a degree of devotion and loyalty to the people who consult him, a vital faith in them and their possibilities, and he insists upon their knowing it. When Mary tells him how she accomplished the triumph of her solo trip to the coffee shop she "took Michael and the team with her" in her mind, she says, when she boarded the train for the mall his own emotional response is as vivid as her narrative. "What do you think this does to my life, to know you have invited me and the team into your life this way, and to hear about you going to the coffee shop how do you think I'm feeling right now?" "Happy?" Mary asks faintly, after a pause. "More than happy," says White. "Joyful."
Probably all therapists worth the title feel privileged to be doing the work they are doing; many also feel gratitude, occasionally even awe, at the willingness of vulnerable and defensive people to trust their lives and sorrows to virtual strangers. Few, however, can have such a radical sense of solidarity with the people who seek their help, can consider the therapeutic relationship with them so profoundly sustaining and transformative of their own lives as does White, with every person he sees, regardless of how apparently unreachable and disturbed, how ground down by years in the psychiatric mill. "Inevitably, we change each other's lives, often in ways that are hard to speak of," White said in a recent interview. "These interactions are life changing for me ... In saying this, I am not talking of anything ingratiating,.. . And I am definitely not proposing something that has some strategic aim, like a one-down position for therapists, which I believe to be ingenuine, patronizing and disqualifying."
This attitude tends to raise skepticism, partly because it suggests an almost superhuman single-mindedness and integrity. Doesn't he ever fake it? No, according to colleagues who have worked closely with him. His vision of the people he helps, of the work he does, is apparently uncorrupted by the normal doubts, exasperation, weariness, disappointment and ordinary ill-temper about clients vented by even the most dedicated therapists from time to time. It is, for example, a point of deepest honor and professional integrity with him not to speak differently in private, entrenous with other therapists, about the people he sees than he will in front of them. This is part of the famous White "congruence" that his colleagues describe, which is not only a matter of political correctness undermining professional hierarchies, equalizing the relationship between therapist and client but a matter of utmost importance to the morality of the entire therapeutic enterprise.
"There is nothing about him that turns on and then turns off," says David Moltz, medical director at Shoreline Community Mental Health Services in Brunswick, Maine. Moltz recently attended a three-day workshop featuring White, who did a live consultation with a family in which the father, thought Moltz, was "completely impossible." But there was never a moment, Moltz said, when White indicated any remote difference between his apparent feelings about the family how he appeared to them and his "real" feelings; there was no moment afterward, says Moltz, when he let down his guard and said something like, "Oh, my God were they something else!" Says Moltz, "He has no guard to let down; there are no hidden corners or agendas ... no second order of business, no waiting for the family to leave before you say your real feelings." What you see is what you get.
A particularly revealing story about White and his work is one he tells himself. As a young man, before formally taking up the profession of social worker, he worked as a gardener for what was then politically incorrectly called an "old folks home." Paying no attention to official instructions from the institution's administrator, he collaborated with the elderly inhabitants to create the gardens they wanted in front of their units. "They would come out and tell me where they wanted to plant shrubs, and how they wanted things pruned," he recalls. "It was great because I didn't know much about gardening and they were teaching me." Eventually, White was fired for what might be called "client-centered gardening," but he remembers the experience as at least as important as other more personal or professional biographical tales.
In a sense, White has remained a gardener in the work he does now; doing therapy, like planting and tending a garden, is a matter of methodical attention, small steps and hard labor digging, spading, pruning, watering, mulching. Good gardeners are both practical and visionary. They don't expect to turn the desert into a Garden of Eden, at least not overnight, but they are optimistic enough to believe that with time and effort, and the blessings of rain and sun and decent soil, they can collaborate with nature to transform even quite desolate spots into little oases.
Good gardeners are forced to be modest. They can provoke and prompt and support nature in certain directions, but they can't control it they can't make anything happen. An acceptance of their own limitations is perhaps part of the ethic of gardeners, along with a renunciation of grandiosity and a respect for the self-created, self-sustaining rhythms of living things. In a sense, White's ethic of therapy is not dissimilar. It is an ethic that eschews the grand therapeutic gesture implicit in the myths of the one-session cure, the personality makeover, the eradication of mental "disease" through biochemical wizardry. Like a gardener who knows that even the most elaborate landscape must be tended step-by-step, plant-by-plant, square foot-by-square foot, White carefully nurtures the small triumphs in the lives of the people he sees, honors the transient moments of competency, initiative, resoluteness.
These marginal stories are usually neglected in the grand schemes of psycho-pathology as accidental, insignificant epiphenomena that are too small to count, but they are the seeds and the soil of human transformation. "People neglect the landscapes of their own lives they think they are uninteresting and dull," says White, "but I'm very curious about them, and I always find it interesting to hear people talk about themselves in ways they've never done before. I often find myself up against the limitations of my knowledge and vision, when I don't feel equal to the task, but the questions I'm faced with become the impetus for further explorations that extend the limits of what I know. I don't have any grand account of the work I do I don't think it is so fantastic, it's not heroic it just addresses a few things. We don't need to teach people anything new, just help them reach stuff that's already there."Mary Sykes Wylie, Ph.D., is senior editor of The Family Therapy Networker.
by Babette Rothschild
Much as we don't like to admit it publicly, it's an open secret among therapists that the road to recovery from trauma can be fraught with clinical missteps. In the past few years, I've frequently been consulted by highly competent colleagues who were dumbfounded by the speedy decline of clients contending with traumatic memories.
Eight of these clients included a nurse, a businesswoman, a salesman, a therapist, and other men and women who'd functioned relatively well prior to therapy. Yet after attempts to address their traumatic pasts (including rape, mugging, childhood abuse, and household fire), three were hospitalized, two went on disability, and the rest endured debilitating flashbacks, panic attacks, or other symptoms of dysfunction.
All the therapists involved were experienced and well trained. Each one favored a different, theoretically sound, therapeutic modality (psychodynamic psychotherapy, EMDR, body psychotherapy, and cognitive-behavioral). None was irresponsible. So what exactly went wrong?
In each instance, I eventually discovered, traumatic material was addressed before the client was equipped to manage it. These therapists were proceeding in a manner consistent with the usual aim of psychotherapy: helping a client open up. They knew very well how to call the genie of traumatic experience out of the bottle, but as is all too common, they didn't know how to get the genie back in.
My approach to trauma work, which is more cautious, is rooted in an experience I had in college. A friend asked me to teach her to drive--in a new car my father had just given me. Sitting in the passenger seat next to her as she prepared to turn on the ignition, I suddenly panicked. I quickly realized that before I taught her how to make that powerful machine go, I had to make sure that she knew how to put on the brakes.
I apply the same principle to therapy, especially trauma therapy. I never help clients call forth traumatic memories unless I and my clients are confident that the flow of their anxiety, emotion, memories, and body sensations can be contained at will. I never teach a client to hit the accelerator, in other words, before I know that he can find the brake.
Following this principle not only makes trauma therapy safer and easier to control, it also gives clients more courage as they approach this daunting material. Once they know they're in the driver's seat and can stop the flow of distress at any time, they can dare to go deeper. Developing "trauma brakes" makes it possible for clients, often for the first time, to have control over their traumatic memories, rather than feeling controlled by them.
My client Paula, for instance, first came to see me for problems in her marriage. She was in her mid-thirties and had three children under the age of 10. When she was a child, her mother had sometimes harshly beaten her. Paula still lived in fear of her mother's aggression, although now it took the form of yelling and criticism, rather than physical violence.
One morning, Paula came into her session pale, with her head bowed. Hardly looking up at me, she moved to her chair and crouched in it, shaking. I'd later learn that she'd just finished a searing telephone conversation with her mother.
Asking Paula about the source of her distress first thing would have let the genie of her traumatic past out of the bottle, increasing her distress. First I needed to help her calm down, to put her in charge of her somatic and emotional responses.
"You're really shaking, aren't you?" I said, drawing her attention to her body sensations. Sometimes this type of intervention is enough to help a client calm down, though for Paula it wasn't. "Y-y-ye-s," she replied with difficulty. "I s-sometimes s- shake a lot." A few seconds later, she was no longer able to speak and could only show me how fast her heart was beating by a rapid movement of her hand.
Paula was exhibiting symptoms of what neuroscientists call hyperarousal--a flood of adrenaline and other stress hormones that made her feel threatened and confused. The brain structures most involved in rational thought and memory were, practically speaking, out of commission. In neurophysiological terms, her sympathetic nervous system (which responds to situations of danger, threat, and stress) was in overdrive, giving her a pounding heart, a dry mouth, and muscle tremors.
To help a client when she comes as unglued as Paula was that day, it's useful to understand what's currently known about how the brain handles danger and emotion, especially in the limbic system and two of its major structures: the hippocampus and the amygdala.
The limbic system is survival central, the area of the mid-brain that initiates fight, flight, or freeze responses in the face of threat. (Paula was on the verge of freezing.) The amygdala and the hippocampus, part of the limbic system, are also deeply involved in responding to traumatic events.
The cortex, the more rational, outermost layer of the brain, is the seat of our thinking capacity and our ability to judge, deliberate, contrast, and compare. It's where most memory--traumatic and otherwise--is stored. The cool, rational cortex is in constant communication with the amygdala and the hippocampus.
The Early-Warning System
The amygdala is our early-warning system. It processes emotion before the cortex even gets the message that something has happened. When you smile at the sight or sound of someone you love even before you consciously recognize her, for instance, the amygdala is at work. Here's what happens: the sound of the loved one's voice is communicated to the amygdala via exteroceptive auditory nerves in the sensory nervous system. The amygdala then generates an emotional response to that information (pleasure or happiness, in this example) by releasing hormones that stimulate the visceral muscles of the autonomic nervous system and can be felt as pleasant sensations in the stomach and elsewhere. Lastly, the amygdala sets in motion an accompanying somatic nervous system (skeletal-muscle) response, in this case, tensing muscles at the sides of the mouth into a smile.
A similar process occurs with other types of stimuli, including trauma. When someone is threatened, the amygdala perceives danger through the exteroceptive senses (sight, hearing, touch, taste and/or smell) and sets in motion the series of hormone releases and other somatic reactions that quickly lead to the defensive responses of fight, flight, and freeze. Adrenaline stops digestive processes (hence the dry mouth) and increases heart rate and respiration to quickly increase oxygenation of the muscles necessary to meet the demands of self-defense.
The amygdala is immune to the effect of stress hormones and may even continue to sound an alarm inappropriately. In fact, that could be said to be the core of post-traumatic stress disorder (PTSD)--the amygdala's perpetuating alarms even after the actual danger has ceased. Unimpeded, the amygdala stimulates the same hormonal release as during actual threat, which leads to the same responses: preparation for fight, flight, or--as with Paula--freeze. In PTSD, this happens regularly, despite outward evidence that these responses are no longer needed. In sum, PTSD could be said to be a healthy survival response gone amok.
Why does the amygdala continue to perceive danger? What makes it possible for the whole body to repeatedly respond as if there is danger, when in fact the danger is past?
The Rational System
The hippocampus helps to process information and lends time and spatial context to memories of events. How well it functions determines the difference between normal and dysfunctional responses to trauma and normal versus traumatic memory. An example will help to explain.
In his book The Emotional Brain, Joseph LeDoux explains the survival response involved when encountering an object that looks like a snake. Naturally, the amygdala signals an alarm message, which sets in motion a series of reactions that culminate in the footstep halting in midair. The amygdala's communication travels at lightning speed. There's a second communication pathway that takes longer, eventually getting the message around to the cortex, where rational thought takes place. When the information "It's a snake!" reaches the cortex, it's then possible to evaluate the accuracy of the amygdala's perception. If the message was accurate and it is a snake, the halted step will freeze until the danger is passed, i.e., the snake slithers away. If, however, there's a discrepancy and what was thought to be a snake is discerned by the cortex to be a bent piece of wood, the cortex sends a new message to the amygdala, "Hey, it's only a stick," to stop the alarm immediately.
The hippocampus assists the transfer of the initial information--the image of stick or snake--to the cortex, where it's then possible to make sense of the situation. This is the normal way information is communicated, as long as the hippocampus is able to function.
The hippocampus, however, is highly vulnerable to stress hormones, particularly adrenaline and noradrenaline, released by the amygdala's alarm. When those hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function. Information that could make it possible to determine the difference between a snake and a stick (or, as in Paula's case, past danger and current safety) never reaches the cortex, and a rational evaluation of the situation isn't possible.
The hippocampus is also a key structure in facilitating resolution and integration of traumatic incidents and traumatic memory. It inscribes time context on events, giving each of them a beginning, middle, and--most important with regard to traumatic memory--an end. A well-functioning hippocampus makes it possible for the cortex to recognize when a trauma is over, perhaps even long past. Then it instructs the amygdala to stop sounding an alarm.
This has critical implications for therapy. Safe, successful trauma therapy must maintain stress hormone levels low enough to keep the hippocampus functioning. That's why it's so crucial for both client and therapist to know how to "apply the brakes" in therapy--to keep the hippocampus in commission and return it to action as promptly as possible when the system goes on overload.
When and How to Apply the Brakes
Knowing when to apply the brakes is as important as knowing how . Therapists can know when by watching for physical signals of autonomic system arousal, transmitted by the client's body, tone of voice, and physical movements. When a client turns pale, breathes in fast, panting breaths, has dilated pupils, and shivers or feels cold, her sympathetic nervous system (activated in states of stress) is aroused. Stress hormones are pouring into her body, threatening the hippocampus with shut-down. These symptoms mean it's time to calm the client down.
When, on the other hand, a client sighs, breathes more slowly, sobs deeply, sweats, or flushes, her parasympathetic nervous system (activated in states of rest and relaxation) has been activated, and her stress hormone levels are reducing. Recognizing these bodily signals is invaluable to the therapist. Likewise, a client who learns to recognize them often gains a greater sense of body awareness and self-control.
After identifying Paula's hyperaroused state, I asked her a few specific questions to narrow her focus. For some clients, paying attention to body sensations helps put on the brakes, but that wasn't the case with Paula, as I quickly found out. Her continued hyperarousal told me that her amygdala persisted in assessing danger. I needed to find another way to help her evaluate this situation, in this room with me.
I decided to see if I could directly engage her cortex using what I call dual awareness. If I could help her to accurately see where she was and whom she was with, she might be able to calm down. So I asked her, "Can you see me?" She replied with a nod of the head. "Clearly?" I could see her breathing slow a little and she managed to say, "Yes."
As Paula's arousal lessened, I asked for more information. "Tell me what you see. Describe me: What color are my eyes? What color is my hair? Am I having a good hair day or a bad hair day?"
Breathing slightly easier, Paula was now able to reply, "Your eyes and hair are brown. I think you're having a good hair day." We both laughed a little; laughter is great for calming the nervous system. I could see color returning to her face and she was shaking less.
To increase her body awareness and the connection between what we were doing and her emotional state, I asked, Paula to describe what happened to her shaking as she looked at and described me.
"It's less," she realized. But she was still shaking a bit, so we weren't through. On a hunch I asked if she felt threatened by me in any way.
"No," she said, "but don't come closer."
Her reply gave me a big clue. "Perhaps," I ventured, "I'm actually sitting too close to you. I'd like to try moving back a little. Would that be okay?"
She wanted me to move back a foot. When I complied, she exhaled sharply. I drew her attention to that response as well as another. "Something else changed. Do you know what?"
"I stopped shaking."
At this point Paula was much calmer, visibly to me and noticeably to her. Her cortex was beginning to discern that she was in a safe place, with a person who wouldn't harm her. It seemed that increasing the distance between us was useful for her, and I asked if she wanted to try increasing it more.
This time, she was more assertive, asking me to move back two feet. Then she was aware of physiological changes even before I asked. "I can breathe easier," she said. She also told me that her heart rate was much slower, nearly normal. But she complained that her legs felt rather weak, which is a common consequence of fear--that feeling of being "weak in the knees."
Increasing strength in her legs could help her feel more secure, so I instructed her to put weight on her feet and press them into the floor. "Do it as if you're going to tip your chair back, but don't actually do that. The point is to increase the tone in your thighs. When they begin to get tired, release the tension very, very slowly." That would insure that some of the tone remained.
As her thighs became stronger, Paula felt even calmer, and was able to think clearly. Her hippocampus was functioning now that stress hormones were no longer being released. To facilitate integration I asked, "What have you learned in the last few minutes since you arrived?" I wanted her to know what had helped, so she'd be able to use some of these same tools to combat hyperarousal and anxiety in her daily life.
Paula easily identified that she felt calmer when I sat farther away and that it was helpful when I asked her to describe me. "Looking at you, I stopped thinking about my mother. Just before I came, we had a big fight."
It became obvious to both of us that in her hyperaroused state, Paula had entered the session expecting me to act like her mother. "Actually, I expect everybody to act like her," she said.
That insight laid the groundwork for the rest of the session, in which we focused on helping Paula to differentiate who was a person to fear and who wasn't. That work wouldn't have been possible at the beginning of the session, when her hippocampus was overwhelmed.
Had I immediately begun questioning Paula on the causes of her distress instead of first attending to putting on the brakes, her overwhelmed hippocampus would have made it difficult for her to clearly separate me from her mother, and together we might have wandered into one of those anguished quagmires well known to trauma therapists. Putting on the brakes helped to avoid a potential transference disaster.
There's a common misconception among many trauma survivors and trauma therapists that working in states of high distress, including flashbacks, is the way to resolve traumatic memories. But being in the throes of hyperarousal and flashback indicates that the hippocampus isn't available to distinguish past from present, danger from safety. Under those conditions, working with traumatic images and the emotions they engender can risk a variety of negative experiences. Moreover, as Judith Herman has said, a trauma survivor's primary need is to feel safe, particularly in therapy. Applying the brakes to keep arousal low and the hippocampus functioning makes this goal much easier to achieve.
Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles. She's the author of The Body Remembers: The Psychophysiology of Trauma & Trauma Treatment , and the forthcoming The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. E-mails to the author can be sent to: firstname.lastname@example.org.
Damasio, Antonio R. Descartes' Error: Emotion, Reason, and the Human Brain New York: Putnam's Sons, 1994.
Herman, Judith L. Trauma and Recovery. New York: Basic Books, 1997.
Nadel, L., & Jacobs, W.J. "The Role of the Hippocampus in PTSD, Panic, and Phobia." In Nobumasa Kato, ed. Hippocampus: Functions and Clinical Relevance. Amsterdam: Elsevier, 1996.
van der Kolk, Bessel A., Alexander C. McFarlane, and Lars Weisaeth, eds. Traumatic Stress. New York: Guilford, 1996.