by David Schnarch
Betty, a designer in a high-powered advertising firm, and Donald, a college professor bucking for tenure, had been married for 15 years. They spent the first 10 minutes in my office invoking the standard litany of our times as an explanation for their lousy sex life they were both just too busy. Not that this focus precluded blaming each other for their difficulties.
"Betty gets home from work so late that we barely see each other anymore, let alone have sex," said Donald resentfully. "We're collaborators in child raising and mortgage paying, but we're hardly lovers anymore. I've taken over a lot of the household chores, but she often doesn't get home until 9 p.m. and most nights, she says she's just 'too tired' for sex."
Betty sighed in exasperation. "Sometimes I think Donald wants me to leap from the front door to the bedroom and take care of him," she said. "But I'm being swallowed up by a sea of obligations my boss, the kids, the house, the dog, Donald, everybody wants a big chunk of me. Right now, I feel there's nothing left of me for me, let alone for him. He just doesn't get it that I need more time for myself before I'm interested in sex."
I asked them to be specific about how the stress from their very demanding lives revealed itself in bed exactly what happened, and in what order, when they had sex. Several moments of awkward silence and a number of false starts ensued before another, much more intimate, level of their marital landscape revealed itself.
Betty looked hard at Donald, then at me. "The fact of the matter is, he doesn't even know how to kiss me!" she said grimly.
"How would you know? It's been so long since you let me kiss you!" hissed Donald.
When I asked them to describe their foreplay, Betty looked embarrassed and Donald sounded frustrated. "During sex, she turns her face to the side and I end up kissing her cheek. She won't kiss me on the mouth. I think she just wants to get sex over with as fast as possible. Not that we have much sex." Betty shook her head in distaste. "He always just rams his tongue halfway down my throat I feel like I can't breathe. Besides, why would I want to kiss him when I can't even talk to him! We don't communicate at all."
Over the years, I've worked with many couples who complain bitterly that the other kisses or touches, fondles, caresses, strokes the "wrong" way. I used to take these complaints at face value, trying to help the couple solve their problems through various forms of marital bargaining and forbearance listen empathically, give a little to get a little, do something for me and I'll do something for you teach them the finer points of sexual technique and send them home with detailed prescriptions (which they usually didn't follow) until I realized that their sexual dissatisfactions did not stem from ignorance, ineptitude or a "failure to communicate." On the contrary, "communicating" is exactly what Donald and Betty were already doing very well, only neither much liked the "message" the other was sending. The way this couple kissed each other, indeed their "vocabulary" of foreplay, constituted a very rich and purposeful dialogue, replete with symbolic meanings. Through this finely nuanced, but unmistakable language, both partners expressed their feelings about themselves and each other and negotiated what the entire sexual encounter would be like the degree and quality of eroticism, connection and intimacy, or their virtual absence.
Donald and Betty had tried marital therapy before, but their therapist had taken the usual approach of dealing with each complaint individually job demands, parenting responsibilities, housework division and sexual difficulties as if they were all separate but equal situational problems. Typically, the clinician had tried to help Donald and Betty resolve their difficulties through a skill-building course on compromise, setting priorities, time management and "mirroring" each other for mutual validation, acceptance and, of course, better communication. The net result of all this work was that they felt even worse than before, even more incompetent, inadequate and neurotic, when sex didn't improve.
Knowing that Betty and Donald were most certainly communicating something via their gridlocked sexual styles, I asked them, "Even if you are not talking, what do you think you might actually be 'saying' to each other when you kiss?" After a minute, Donald said resentfully, "She's telling me I'm inadequate, that I'm not a good lover, I can't make her happy and she doesn't want me anyway." Betty defensively countered, "He's saying he wants me to do everything exactly his way and if I don't just cave in, he'll go ahead and do what he likes, whether /like it or not!" I asked her why she was willing to have intercourse at all if she didn't even want to kiss him. "Because he is such a sullen pain in the ass if I don't have sex," Betty replied without hesitation. "Besides, I like having orgasms."
Donald and Betty perfectly illustrated the almost universal, but widely unrecognized, reality that sex does not merely constitute a "part" of a relationship, but literally and metaphorically embodies the depth and quality of the couple's entire emotional connection. We think of fore-play as a way couples establish connection, but more often it's a means of establishing (^connection. Betty was a living rebuttal of the common gender stereotype that all women always want more foreplay; she cut it short so they could get sex done with as quickly as possible and Donald understood. Donald returned the compliment by "telling" Betty he knew she didn't like him much, but he was going to get something out of her anyway with or without her presence, so to speak.
Clearly, foreplay for this couple was not simply a mechanical technique for arousal, amenable to the engineering, skill-building approach still dictated by popular sex manuals. Nor were they likely to improve sex just by being more "open" with each other, "asking for what they wanted" another popular remedy in self-help guides and among marital therapists as if they weren't already "telling" each other what each did and did not want, and what each was or was not willing to give. Instead of trying to spackle over these normal and typical "dysfunctional" sexual patterns with a heavy coat of how-to lessons, I have learned that it makes much more sense to help the couple analyze their behavior, to look for the meaning of what they were already doing before they focused on changing the mechanics.
Rather than "work on their relationship" as if it were some sort of hobby or home-building project, Betty and Donald, like every other couple I have seen, needed to understand that what they did in bed was a remarkably salient and authentic expression of themselves and their feeling for each other. The nuances of their kissing style may have seemed trivial compared to the screaming fights they had about money or the long days of injured silence, but in fact it was an open window into their deepest human experience who they were as people, what they really felt about each other, how much intimacy they were willing to risk with each other and how much growing up they still had to do.
As in any elaborate and nuanced language, the small details of sex carry a wealth of meaning, so while Donald and Betty were surprised that I focused on a "little thing" like kissing, rather than the main event frequency of intercourse, for example they were startled to find how truly revealing it was, about their personal histories as well as their marriage. I told Betty I thought she had probably come from an intrusive and dominating family that never dealt openly or successfully with anxiety and conflict. "So now, you have a hard time using your mouth to tell Donald not to be so overbearing, rather than turning it away to keep him from getting inside it. You've become very good at taking evasive action to avoid being overwhelmed," I said. "You're right about my family," Betty said softly, "we kids didn't have any privacy or freedom in my family, and we were never allowed to complain openly about anything just do what we were told, and keep our mouths shut."
On the other hand, I said, I imagined Donald had never felt worthwhile in his family's eyes. He had spent a lot of time trying to please his parents without knowing what he was supposed to do, but he got so little response that he never learned how to read other people's cues he just forged blindly ahead, trying to force his way into people's good graces and prove himself without waiting to see how he was coming across. "Come back here and give me a chance to prove myself!" his behavior screamed. "Are you so used to being out of contact with the people you love that you can successfully ignore how out of sync you are with them?" I asked. To Donald's credit, he didn't dodge the question, though he seemed dazed by the speed with which we'd zoomed in on such a core issue.
Nevertheless, Donald and Betty discovered that their discomfort in describing, in exact detail, what was done by whom, when, how and where, was outweighed by their fascination at what they were finding out about themselves far more than was remotely possible from a seminar on sex skills. Betty, for example, had suggested that once kissing had stopped and intercourse had started, her sexual life was just fine after all, she had orgasms and she "liked" them. But when I asked her to describe her experience of rear-entry intercourse a common practice with this couple she did not make it sound like a richly sensual, erotic or even particular-pleasant
encounter. During the act, she positioned herself on elbows and knees, her torso held tense and rigidly parallel to the mattress while she protectively braced her body for a painful battering. Instead of moving into each thrust from Donald, she kept moving away from him, as if trying to escape. He, on the other hand, clasped her hips and kept trying to pull her to him, but never got a feeling of solid physical or emotional connection.
In spite of the fact that both were able to reach orgasm widely considered the only significant measurement of successful sex- Betty and Donald's minute-by-minute description of what they did made it obvious that a lot more was happening than a technically proficient sex act. I told Betty I was glad she had told me these details, which all suggested that she thought it was pretty hopeless trying to work out conflicts with people she loved. "I suspect you've gotten used to swallowing your disappointment and sadness without telling anybody, and just getting along by yourself as best you can," I said. "It sounds very lonely." At that point, much to Donald's shock, Betty burst into tears. I said to Donald that he still seemed resigned to chase after people he loved to get them to love and accept him. "I guess you just don't believe they could possibly love you without being pressured into it. In fact, I think both of you use sex to confirm the negative beliefs you already have about yourselves."
For several seconds Donald looked at his lap, while Betty quietly cried in the next chair. "I suppose we must be pretty screwed up, huh?" Betty snuffled. "Nope," I said. "Much of what's going on between you is not only understandable, it's predictable, normal and even healthy although it doesn't look or feel that way right now." They were describing the inevitable struggle involved in seeking individual growth and self-development within the context of marriage.
Betty said she used to enjoy sex until she became overinvolved with her job, but I suggested that the case was more likely the reverse that the demands of her job gave her a needed emotional distance from Donald. Her conscious desire to "escape" from Donald stemmed from emotional fusion with him she found herself invaded by his worries, his anxieties, his insecurities
and his needs as if she had contracted a virus from him. 'You may feel that you don't have enough inside you to satisfy his needs and still remain a separate, whole person yourself," I said. 'Your work is a way of keeping some 'self for yourself, to prevent being absorbed by him. That's the same reason you turn your head away when he tries to kiss you."
I suggested that Donald's problem was a complementary version of the same thing: in order to forestall the conviction that he had no worthwhile self at all, he felt he had to pressure Betty, or anybody he loved, to demonstrate they loved him over and over. Donald, of course, did not see that he was as important to Betty as she-was to him, but their mutual need for each other was really a function of two fragile and insecure selves shoring each other up.
Like most of us, neither Betty nor Donald was very mature when they married; neither had really learned the grownup ability to soothe their own emotional anxieties or find their own internal equilibrium during the inevitable conflicts and contretemps of marriage. And, like most couples after a few years of marriage, they made up for their own insecurities by demanding that the other provide constant, unconditional acceptance, empathy, reciprocity and validation to help them each sustain a desired self-image. "I'm okay if, but only if, you think I'm okay," they said, in effect, to each other, and worked doubly hard both to please and be pleased, hide and adapt, shuffle and dance, smile and agree. The more time passes, the more frightened either partner is of letting the other know who he or she really is.
This joint back-patting compact works for a while to keep each partner feeling secure, taut eventually the game becomes too exhausting to play. Gradually, partners become less inclined to please each other, more resentful of the cost of continually selling themselves out for ersatz peace and tranquility, less willing to put out or give in. To the extent that neither partner has really grown up and is willing to confront his or her own contribution to this growing impasse, however, both would prefer to fight with or avoid the other. It's less frightening to blame our mates than to face ourselves. The ensuing "symptoms" low sexual desire, sexual boredom, control battles, heavy silences often take on the coloring of a deathly struggle for selfhood, fought on the implicit assumption that there is only room for one whole self in the marriage. "It's going to be my way or no way, my self or no self!" partners say in effect, in bed and out leading to a kind of classic standoff.
Far from being signs of a deeply "pathological" marital breakdown, however, as Donald and Betty were convinced, this stalemate is a normal and inevitable process of growth built into every marriage, as well as a golden opportunity. Like grains of sand inexorably funneling toward the "narrows" of an hourglass, marriage predictably forces couples into a vortex of emotional struggle, where each dares to hold onto himself or herself in the context of each other, in order to grow tip. At the narrowest, most constricting part of the funnel where alienation, stagnation, infidelity, separation and divorce typically occur couples can begin not only to find their individual selves, but in the process acquire a far greater capacity for love, passion and intimacy with each other than they ever thought possible.
At this excruciating point in a marriage, every couple has four options: each partner can try to control the other (Donald's initial ploy, which did not succeed), accommodate even more (Betty had done so to the limits of her tolerance), withdraw physically or emotionally (Betty's job helped her to do this) or learn to soothe his or her own anxiety and not get hijacked by the anxiety of the other. In other words, they could work on growing up, using their marriage as a kind of differentiation fitness center par excellence.
Differentiation is a lifelong process by which we become more uniquely ourselves by maintaining ourselves in relationship with those we love. It allows us to have our cake and eat it too, to experience fully our biologically based drives for both emotional connection and individual self 1 direction. The more differentiated we are the stronger our sense of self-definition and the better we can hold ourselves together during conflicts with our partners the more intimacy we can tolerate with someone we love without fear of losing our sense of who we are as separate beings. This uniquely human balancing act is summed up in the striking paradox of our species, that we are famously willing both to die for others, and to die rather than be controlled by others.
Of all the many schools of hard experience life has to offer, perhaps none but marriage is so perfectly calibrated to help us differentiate if we can steel ourselves to take advantage of its rigorous lessons, and not be prematurely defeated by what feels at first like abject failure. Furthermore, a couple's sexual struggle what I call the sexual crucible is the most powerful route both to individual maturity and the capacity for intimate relationship, because it evokes people's deepest vulnerabilities and fears, and also taps into their potential for profound love, passion, even spiritual transcendence.
In the typically constricted sexuality of the mid-marriage blues, Betty and Donald's sexual repertoire consisted of "leftovers" whatever was left over after eliminating every practice that made one or the other nervous or uncomfortable. The less differentiated a couple, the less they can tolerate the anxiety of possibly "offending" one another, the more anxiety they experience during sex and the more inhibited, rigid and inflexible their sexual style becomes: people have sex only up to the limits of their sexual and emotional development. Unsurprisingly, Donald and Betty's sexual routine had become as predictable, repetitious, unadventurous and boring as a weekly hamburger at McDonald's. This is why the standard advice to improve sex by negotiating and compromising is doomed to failure most normally anxious couples have already long since negotiated and compromised themselves out of any excitement, variety or sexual passion, anyway.
And yet, it would have been pointless and counterproductive to march Donald and Betty through a variety of new sexual techniques. Using sex as a vehicle for personal and relational growth is not the same as just doing something new that raises anxieties. Rather, it depends on maintaining a high level of personal connection with someone known and loved during sex allowing ourselves to really see and be seen by our partners, feel and be felt, know and be known by them. Most couples have spent years trying not to truly reveal themselves to each other in order to maintain the illusion of complete togetherness, thus effectively smothering any true emotional connection, with predictably disastrous effects on sex.
Donald and Betty were so obsessed with sexual behavior, so caught up in their anxieties about who was doing or failing to do what to whom in bed, that they were not really emotionally or even physically aware of each other when they touched. Like people "air kissing" on social occasions, they were going through the motions while keeping a kind of emotional cordon sanitaire between them. Their sex was more like the parallel play of young children than an adult interaction except that they each watched the other's "play" with resentment and hurt feelings. Betty complained that Donald touched her too roughly "He's crude and selfish!" she said, "and just uses me to please himself." Her complaint undercut Donald's sense of self, and he defensively accused her of being a demanding bitch, never satisfied and fundamentally unpleasable thereby undermining her sense of self.
In order to help them each find a self and each other, I had to redirect their gaze away from their obsession with mutually disappointing sexual behavior, and encourage them to "follow the connection" rediscover or establish some vital physical and emotional link as a first building block to greater intimacy. To consciously "follow the connection," however, requires the full presence and consent of both partners, each purposely slowing down and giving full attention to the other, feeling and experiencing the other's reality. For example, I suggested that Betty and Donald, who couldn't come up with even one way in which they made some sort of vital contact, might simply caress each other's hands and faces while attending to what they were doing and feeling.
The next session, Donald reported that he now understood why Betty felt he was too "rough"; he said the experience made him realize that he usually touched her with about as much care and sensitivity as if he was scouring a frying pan! But slowing down to really become conscious of what he was doing made him experience a sudden jolt of emotional connection with Betty. This awareness was an unnerving sensation for someone who had spent his life performing for other people (including his wife rather than actually being with them.
Betty, too, was shaken by the jarring reality of their connection. She hadn't liked being touched roughly, but the concentration and attention in Donald's hands as he really felt and got to know her body was deeply disturbing; she found herself suddenly and unexpectedly sobbing with grief and deprivation for the warmth and love she'd missed as a child, and that she had both craved and feared in her marriage. Donald managed to keep his own anxiety in check during Betty's unexpected reaction, holding her hand while she cried her eyes out and gradually calmed down on her own. Later that night, they had the best sex they had experienced in a very long time.
Buoyed by this first success, more hopeful about their future together, they both wanted to know how they could enhance this new and still tentative sense of connection. I suggested they try something called "hugging till relaxed," a powerful method for increasing intimacy that harnesses the language and dynamics of sex without requiring either nudity or sexual contact. Hugging, one of the most ordinary, least threatening gestures of affection and closeness, is also one of the most telling. When they hugged, Betty complained that Donald always leaned on her making her stagger backward while Donald accused Betty of pulling away from him, letting go "too soon," and leaving him "hugging air."
I suggested that Betty and Donald each stand firmly on their own two feet, loosely put their arms around each other, focus on their own individual experience and concentrate on quieting themselves down while in the embrace neither clutching nor pulling away from or leaning on each other. I never tell clients how long to hug, but few initially can take more than four or five seconds before they experience a kind of emotional "jolt" when the connection threatens to become too intimate for comfort. Once both partners can learn to soothe themselves and maintain their individual equilibrium, shifting their own positions when necessary for comfort, they get a brief, physical experience of intimate connection without fusion, a sense of stability and security without overdependency.
While practicing hugging until relaxed with Donald, Betty found that as she learned to quiet her own anxiety, she could allow herself to be held longer by Donald without feeling claustrophobic. Just relaxing in the hug also made her realize that she normally carried chronic anxiety like a kind of body armor. As Betty calmed down and began to melt peacefully into the hug, not pulling away from fear that Donald would, literally, invade her space, he noticed his own impulse to break it off before she wanted to. After they had spent several weeks working on hugging till relaxed, they began to feel more centered within themselves when they did it; each no longer anxiously watched for the least little twitch in the other, or wondered what the other was thinking, or worried about doing it "wrong." When they each could settle down in the hug, they discovered that together they eventually would enter a space of great peace and tranquility, deeply connected and in touch with each other but secure in their self.
Soon, they could experience some of the same kind of deep peace during sex, which not only eliminated much of the anxiety, resentment and disappointment they had felt before, but vastly increased the eroticism of the encounter. Now that they knew what they were looking for, they could tell when it was absent. It was as if each had let slip away a hard, tough carapace, and allowed something tender and vulnerable to emerge. Later, in my office, while Betty gently stroked his arm, Donald teared up as he told me about the new sense of quiet but electric connection he felt with her. "I just had no idea what we were missing; she seemed so precious to me that it almost hurt to touch her," he said, his voice thick with emotion.
This leap in personal development didn't simply occur through behavioral desensitization. Sometimes, Betty and Donald got more anxious as their unresolved issues surfaced in their physical embrace. At times, when Betty dared to shift to a more comfortable position, Donald felt she was squirming to avoid him. It was my job to help them see how this reflected the same emotional dynamics present in other aspects of their marriage. Betty was attempting to "hold onto herself while remaining close to someone she loved, and likewise, Donald was refusing to chase after a loved one to get himself accepted. Insight alone didn't help much; a lot of self-soothing was required. Ultimately, they stopped taking each other's experience and reaction as a reflection on themselves and recognized that two separate realities existed even during their most profound physical union.
Building on their new stockpiles of courage earned in these experiments with each other, I suggested that Donald and Betty consider eyes-open sex, the thought of which leaves many couples aghast. Indeed, Donald's first response to the suggestion was that if he and Betty tried opening their eyes during sex, they wouldn't need birth control because the very thought made him so anxious he could feel his testicles retreating up into his windpipe! But eyes-open sex is a powerful way of revealing the chasm between sensation-focused sex and real intimacy. Most couples close their eyes in order to better tune out their partners so that they can concentrate on their physical feelings; it is a shocking revelation that to reach orgasm supposedly the most intimate human act most people cannot tolerate too much intimacy with their partners, so they block the emotional connection and concentrate on body parts.
Eyes-open sex is not simply a matter of two pairs of eyeballs staring at each other (indeed, people can hide behind a blank stare), but a way to intensify the mutual awareness and connection begun during foreplay; to really "see" and "be seen" is an extension of feeling and being felt when touching one another. But if allowing oneself to be known by touch is threatening, actually being seen can be positively terrifying. Bravely pursuing eyes-open sex in spite of these misgivings helps couples not only learn to tolerate more intimacy, it increases differentiation it requires a degree of inner calm and independent selfhood to let somebody see what's inside your head without freaking out. "It scares me," said Betty, speaking many people's experience. "I don't like my body much, and I don't like a lot else about myself, and I don't really expect him to, either."
But the experience was also exhilarating. As Donald and Betty progressed from shy, little, peekaboo glimpses into each other's faces to long, warm gazes and soft smiles, each found their encounters more deeply moving. Betty slowly realized that whereas before she had wanted to escape from Donald, now she yearned to see all of him, and for him to see all of her. "I felt so vulnerable, as if he could see all my inadequacies, but the way he looked at me and smiled made all that unimportant." Donald gradually relinquished the self-image of a needy loser; he no longer needed to pursue Betty for reassurance and found, to his delight, that she wanted him a breathtaking experience. "Her eyes are so big and deep, I feel I could dive into them," he said in wonder.
Both began to experience an increasing sense of self-acceptance and personal security. "We're having better sex now than we've ever had in our lives," Betty reported, "And I thought we were getting to be too old and far too married for exciting sex." Donald agreed. Betty and Donald, like society at large, were confusing genital prime the peak years of physical reproductive maturity with sexual prime the specifically human capacity for adult eroticism and emotional connection. "Are you better in bed or worse now than you were as an adolescent?" I asked them. "Most people definitely get better as they get older, at least potentially. No 17-year-old boy is sufficiently mature to be capable of profound intimacy he's too preoccupied with proving his manhood; and a young woman is too worried about being 'used' or too hung up about romance and reputation to really experience her own eroticism. Most 50-year-olds, on the other hand, have a much better developed sense of who they are, and more inner resources to bring to sex. You could say that cellulite and sexual potential are highly correlated."
"So that's why I have such incredible erotic talents!" said Betty.
As far as issues of gender equality are concerned, both men and women become more similar as they age and approach their sexual potential. Men are not as frightened of letting their partners take the lead in making love to them, and they develop far greater capacity and appreciation for emotional connection and tenderness than they had as young men. Women, on the other hand, become more comfortable with their own sexuality, more likely to enjoy sex for its own sake and less inclined to apologize for their eroticism or hide behind the ingenue's mask of modesty. As they age, women feel less obligated to protect their mate's sexual self-esteem at the cost of their own sexual pleasure.
Once a couple's sexual potential has been tapped, partners are no longer afraid to let their fantasies run free with each other. Donald, for example, let Betty know that he dreamed of her tying him up and "ravishing" him sexually so one day, she bought four long, silk scarves and that night, wearing three-inch high heels and a little black lace, she trussed him to the bed and gave him what he asked for, astounding him and surprising herself with her own dramatic flair. Betty had always secretly cherished a fantasy of being a dangerous, sexually powerful femme fatale, but Donald's clingy neediness had dampened her enthusiasm for trying out the dream also she had been afraid it would make him even more demanding. But now, knowing he was capable of being himself regardless of what she did or did not do, Betty felt much more comfortable expressing her own sense of erotic play.
The Sexual Crucible Approach encourages people to make use of the opportunity offered by marriage to become more married and better married, by becoming more grown-up and better at staking out their own selfhood. But the lessons learned by Betty and Donald, or any couple, extend far beyond sex. The same emotional development that makes for more mature and passionate sexuality also helps couples negotiate the other potential shoals of marriage money issues, childrearing questions, career decisions because differentiation is not confined to sex. In every trouble spot, each partner has the same four options: dominate, submit, withdraw or differentiate. Differentiation does not guarantee that spouses can always have things their own individual way and an unfailingly harmonious marriage besides. Marriage is full of hard, unpleasant choices, including the choice between safety, security and sexual boredom, on the one hand, and challenge, anxiety and sexual passion, on the other.
But spouses who have learned to stand on their own two feet within marriage are not as likely to force their own choices on the other or give in or give up entirely just to keep their anxiety in check and shore up their own frail sense of self. Learning to soothe ourselves in the middle of a fight with a spouse over, say, the choice of schools for our child or a decision to move, not only helps keep the discussion more rational, but makes us more capable of mutuality, of hearing our partner, of putting his or her agenda on a par with our own. The fight stops being, for example, a struggle between your personal needs and your spouse's personal needs, often regarded by each as my "good idea" and her/his "selfishness," but which is really often my fragile, undeveloped self versus his/her equally fragile, undeveloped self. Instead, we can begin to see that the struggle is inside each of us individually, between wanting what we want for ourselves personally, and wanting for our beloved partner what he or she wants for himself or herself. Becoming more differentiated is possibly the most loving thing you can do in your lifetime for those you love as well as yourself. Someone once said that if you're going to "give yourself to your partner like a bouquet of flowers, you should at least first arrange the gift!
There is no way this process can be foreshortened into a technical quick-fix, no matter how infatuated our culture is with speed, efficiency and cost containment. Courage, commitment, a willingness to forgo obvious "solutions," tolerating the anxiety of living without a clear, prewritten script, as well as the patience to take the time to grow up are all necessary conditions, not only for a good marriage, but for a good life. At the same time, reducing all marital problems to the fallout from our miserable childhoods or to gender differences not only badly underestimates our own ability to develop far beyond the limitations of our circumstances, but misjudges the inherent power of emotionally committed relationships to bring us (drag us, actually, often kicking and screaming) more deeply and fully into our own being. Marriage is a magnificent system, not only for humanizing us, maturing us and teaching us how to love, but also perhaps for bringing us closer to what is divine in our natures.
David Schnarch, Ph.D., is the founder of the Sexual Crucible Approach and director of the Marriage and Family Health Center in Evergreen, Colorado. His books include Passionate Marriage: Sex, Love, and Intimacy in Emotionally Committed Relationship and Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy. Address: 2922 Evergreen Parkway, Suite 310, Evergreen, CO 80439. Website: www.passionatemarriage. com
by William Doherty
I want to propose a new competition for therapists: awards for the worst experiences doing couples therapy. My own entry would be in the category of a worst experience as a new couples therapist in the first session. It was 26 years ago, but as they say, it feels like yesterday. As a graduate student, I'd done individual counseling before, and had worked with parents and kids, but had never worked with a couple. Thirty minutes into the first session, when I was lost in the midst of a meandering series of questions, the husband leaned forward and said, "I don't think you know what you are doing." Alas, he was right. Naked came the new couples therapist.
Since then, as we say in Lake Wobegon, I like to think I've become an above-average couples therapist, but that might not be much of a distinction. A dirty little secret in the therapy field is that couples therapy may be the hardest form of therapy, and most therapists aren't good at it. Of course, this wouldn't be a public health problem if most therapists stayed away from couples work, but they don't. Surveys indicate that about 80 percent of therapists in private practice do couples therapy. Where they got their training is a mystery, because most therapists practicing today never took a course in couples therapy and never did their internships under supervision from someone who'd mastered the art. From a consumer's point of view, going in for couples therapy is like having your broken leg set by a doctor who skipped orthopedics in medical school.
What's my evidence for these assertions? Most therapists today trained as psychologists, social workers, professional counselors, or psychiatrists. None of these professions requires a course in marital therapy. At best, some programs offer an elective in "family therapy," which usually focuses on parent-child work. Only the professional specialty of marriage and family therapy, which constitutes about 12 percent of psychotherapy practitioners in the United States, requires coursework in couples therapy, but even there you can get a license after working only with parents and kids. After coursework, few internship settings in any field give systematic training in couples therapy, which isn't ordinarily a reimbursable service.
The result is that most therapists learn couples therapy after they get licensed--through workshops and by trial and error. Most specialize in individual therapy, and work with couples on the side. Most have never had anyone observe or critique their couples work. So it's not surprising that the only form of therapy that received low ratings in a famous national survey of therapy clients, published in 1996 by Consumer Reports, was couples therapy. The state of the art in couples therapy isn't very artful.
Why is couples therapy a uniquely difficult form of practice? For starters, there's an ever-present risk of winning one spouse's allegiance at the expense of the other spouse's. All your wonderful joining skills from individual therapy can backfire within seconds with a couple. A brilliant therapeutic observation can blow up in your face when one spouse thinks you're genius and the other thinks you're clueless--or worse, allied with the enemy. After all, one spouse who agrees with you too vociferously can dramatically undercut your effectiveness.
Couples sessions can be scenes of rapid escalation uncommon in individual therapy, and even in family therapy. Lose control over the process for 15 seconds and you can have spouses screaming at each other and wondering why they're paying you to watch them mix it up. In individual therapy, you can always say, "Tell me more about that," and take a few minutes to figure out what to do next. In couples therapy, the emotional intensity of the couple's dynamics doesn't give you this luxury.
Even more unnerving is the fact that couples therapy often begins with the threat that the couple will split up. Often, one spouse is coming just to drop off his or her partner at a therapist's doorstep before exiting. Others are so demoralized that they need an intense infusion of hope before agreeing to a second session. Therapists who prefer to take their time doing their favorite lengthy assessment instead of intervening immediately may lose couples who arrive in crisis and need a rapid response to stop the bleeding. A laid-back or timid therapist can doom a marriage that requires quick CPR. If couples therapy were a sport, it would resemble wrestling, not baseball--because it can be over in a flash if you don't have your wits about you.
As in any sport or art form, there are beginners' mistakes and advanced practitioners' mistakes. Inexperienced and untrained couples therapists don't manage sessions well. They struggle with the techniques of couples therapy, and clients often sense that these therapists aren't skillful. More advanced therapists can manage sessions well with challenging couples, but they make subtler mistakes, of which neither they nor their clients may be aware. I'll start with beginners' mistakes and then describe how couples therapy can go south, even in the hands of experienced therapists.
Mistake No. 1--Lack of Structure: The most common mistake made by inexperienced couples therapists is providing too little structure for the sessions. These therapists let spouses interrupt each other and talk over each other. They watch and observe as spouses speak for each other and read each other's minds, making attacks and counterattacks. Sessions generate a lot of energetic conversation, but little learning or change. The partners simply reproduce their familiar patterns in the office. The therapist may end the session with something blandly reassuring like, "Well, we've gotten a number of the issues on the table," but the couple leaves demoralized.
Screenwriters are onto this fundamental clinical mistake. In the movie The Ref, Kevin Spacey and Judy Davis are a warring couple in a therapist's office. At one point, they turn to the therapist, almost pleading for him to intervene in their bickering. He says reflexively, "What I can say is that communication is good." Later, he adds, "I'm not here to give advice or to take sides," whereupon Davis shoots back, "Then what good are you anyway?" When the therapist loses control completely and begs the couple to lower their voices, they shout back, "Fuck you!" in unison--the first time they've agreed on anything in the session.
Sometimes a therapist who doesn't create a clear structure for the sessions will conclude that some clients aren't good candidates for couples therapy because they're too reactive in each other's presence. The upshot is a referral, splitting up the partners for individual therapy, which might further erode the marriage. I once saw a tape of an inexperienced couples therapist who announced that the sessions didn't seem "safe enough" for the angry spouses. (There was no evidence of physical violence or emotional cruelty in the relationship.) The real issue wasn't the couple's ability to handle the joint sessions--it was the therapist's ability. She was the one who didn't feel safe.
I remember when I first realized that I had to ratchet up my structuring skills. I was working with a couple in which the husband was Israeli and the wife American. David was opinionated and assertive, but loving and committed. The challenge I faced in the early sessions was his tendency to interrupt his wife, Sarah. I tried to keep him at bay with my standard armamentarium of diplomatically crafted "I-statements." "David," I'd say, "I'm concerned about your interrupting Maria, which means she can't finish her thought. I'd like to reinforce the ground rule that neither of you interrupts the other. Is that something you're willing to commit to?" He'd agree, be cooperative for a while, and then start interrupting again when she got his goat. Finally, I fell back on my working-class Philadelphia roots, bluntly instructing him, "David, stop interrupting your wife. Let her finish." He looked as though he was taking in my message for the first time. "Okay," he replied meekly. Thereafter, when he'd start to interrupt, I'd keep looking at Sarah while waving my arm in his direction, shooing his comments away. He cut it out, the therapy progressed, and I realized I'd reclaimed a piece of my Philly street past that I could use when the occasion required.
Mistake No. 2--No Plan for Change: After lack of structure, the most common complaint I hear is that many therapists don't recommend changes in the couple's day-to-day relationship. Some therapists act as if insight alone is enough to help couples change intractable patterns of thinking and acting. But we all know that certain dynamics within a relationship have a life of their own. I start emotional, you start rational, I get angrier, and you get more controlled. Then I mention your mother and you blow up, which pleases me immensely. Just pointing out this dynamic isn't enough to change it. All empirically supported forms of couples therapy require active interventions aimed at teaching couples new ways to interact. Most involve homework assignments. Of course, just making interventions isn't enough if they're too global or generic. If my wife and I are fighting continually over her mother, saying to us, "Remember to paraphrase and use your other communication skills" won't take us very far. Good therapy addresses the way couples actually do their own particular dance, both during the session and back at home.
Mistake No. 3--Giving Up: The third common mistake of inexperienced therapists is giving up on the relationship because the therapist feels overwhelmed with the couple's problems. I've heard enough stories about therapists who abandoned ship too soon to be confident that this is a common mistake. In one case, the therapist did an assessment during the first session, and in the second session pronounced that the couple was incompatible and weren't candidates for couples therapy--without ever trying to help them. In another case, a woman whose husband was becoming emotionally abusive as his Parkinson's disease progressed told me that, at the end of the first session, the therapist had said, "Your husband will never change, so you have to accept what he's doing or get out." Translation: "I don't have a clue about Parkinson's disease or how to help an elderly couple with serious marital problems, so I'm pronouncing yours a hopeless case." This also kept the therapist's average length of treatment in favorable territory with his managed-care employer.
Some therapists survive the early sessions but get frustrated later and actively advise couples to separate. When deciding that the couple isn't amenable to treatment, they don't seem to factor in their own skill level. They may further reduce their own sense of responsibility by making a delayed diagnosis that one of the spouses has a personality disorder. This often means nothing more than "I can't work with this person." Giving up this way is akin to a primary care physician's pronouncing a patient incurable without referring the patient to a specialist in his or her life-threatening condition. I once worked with a young family physician who had a rule that no one should be allowed to die without a consultation from a specialist in what is killing them. I would argue the same for couples: treatment failures, especially those that lead to divorce, shouldn't be accepted without a consultation or referral to a competent, experienced therapist who specializes in working with couples.
Experienced Therapists' Mistakes
Mistake No. 1--Thinking All Couples Are Equal: Advanced practitioners' mistakes are more about strategy than technique, more about missing the context than specific relational dynamics, and more about unacknowledged values than lack of knowledge. I'll focus on two areas of poor couples therapy by experienced therapists: working with remarried couples and working with couples deciding whether to work on their marriage or divorce.
Remarried couples with stepchildren are a minefield, even for experienced therapists, because the partners almost always come with parenting issues, not just couples problems, and because many therapists miss the nuances of stepfamily dynamics. Therapists who specialize in adult relational work but aren't skilled at parent-child therapy will fail with these families. Experienced therapists who treat remarried couples like first-marrieds usually manage the individual sessions well, but use the wrong overall strategy.
I remember my own awakening on therapy with remarried couples almost as clearly as I remember my first session of couples therapy. It was in the spring of 1985, and I'd been trying to get Dave and Diane to reduce conflict in their two-year-old marriage by being equal parents with Kevin, Diane's challenging, 14-year-old son from a previous marriage. It was a familiar coparenting problem. Dave thought that Diane was too soft on the boy, and Diane thought Dave was too strict. They'd sometimesÂ reach a "compromise," but Diane wouldn't follow through on it. I'd helped many couples with this kind of bread-and-butter problem in family therapy, but I was stuck here. I can feel the chair I was sitting on when I said to myself something like, Bill, why are you insisting that this woman share parenting authority equally with this man? He didn't raise Kevin, Kevin doesn't see him as a father, and Dave doesn't have the same investment as Diane does. She can't treat Dave as an equal here, so stop beating up on her for not succeeding.
I realized that I was misapplying a norm about coresponsibility in biological coparenting to a family structure where it didn't apply in the same way. I then told the couple that I could understand why Diane couldn't give Dave equal say in disciplining her son--the fact was that Diane was the parent. With so many years invested in her son and Dave's relationship with Kevin so new, she couldn't share authority 50-50. I introduced a metaphor that I would come to use often with stepfamilies: in the parenting domain with her child, Diane was the "first violinist" and Dave "second violinist." Diane immediately was relieved, and Dave immediately was alarmed. There was a lot of work ahead, but they did achieve a workable coparenting relationship based on Diane's leadership with her son. Shortly thereafter, I read Betty Carter's work on stepfamilies in which she argued for treating the spouses as having different roles with the children, and then I came across new research by Mavis Hetherington making the same point. Stepfamilies are a different species, and couples in these families have to be treated with different approaches. Many experienced couples therapists still don't know this--or even if they do know it, still lack a viable treatment model.
Beyond coparenting leadership issues, couples in stepfamilies swim in a sea of divided loyalties, which even experienced therapists sometimes miss. I once consulted on a case of a recently married couple in which the wife had three children and the husband none. One thorny issue was that the husband felt left out of the wife's emotional world because they had little time alone together. The wife agreed, and she told the therapist how torn she felt about this. She loved her husband and wanted the marriage to work, but her three school-age children required nearly all of her time after work and in the evenings. She helped them with their homework every night, and they had the kind of extracurricular activity schedules that render contemporary parents part-time chauffeurs and full-time activity directors on the family cruise ship. Weekends were spent doing errands and driving the kids to their traveling soccer games.
In one of the early sessions, the therapist, who was highly experienced in couples work, empathized with the wife's feeling caught between the needs of her husband and those of her children, and supported the wife's decision to prioritize the children. The therapist explained that these years of raising school-age children are ones in which the children's time demands are huge, and the marital relationship inevitably has to take a back seat. She said that, as a wife and mother, she herself knew about these demands, which ease when children get older. In other words, the therapist normalized the marital gap in terms of the family life cycle, recognizing especially the unique strain on a wife who couldn't meet everyone's needs. The wife burst into tears at feeling so deeply understood and accepted. The therapist then turned to the husband and gently asked him for his feelings and thoughts as he'd followed the conversation and seen his wife's pain and tears. The husband, a "good guy," who didn't like conflict, owned that he'd been selfish and pledged to back off on his demands for more time with his wife, promising he'd be more understanding in the future.
The session ended with a warm glow. The couple agreed to continue working on other issues that had brought them to therapy. The therapist was pleased at how she'd been able to combine her clinical skills and her own experience as a wife and mother to help this couple. A few days later, the husband called to end the therapy, saying tersely that they'd decided to continue to work on things by themselves.
The therapist was stunned and consulted with me. I helped her see that she'd missed that there were two distinct family developmental stages at work in this case. Yes, the parent-child development stage was one of intense time demands (leaving aside for the moment the overscheduling supported by the wider culture), but the marital-developmental stage had its own pacing needs: a puppy marriage needs time for play and nurturing. To put aside their new marriage for years on end is dangerous. Of course, it's dangerous even in long-term relationships, but at least there may be a strong foundation and memories of good years. The husband was appropriately worried about the viability of a neglected new marriage. What struck me was how even a skilled, experienced couples therapist had misunderstood the special needs of a remarried couple.
Mistake No. 2--Not Standing by Marriage: If beginners give up on couple relationships because of lack of skill, experienced therapists sometimes give up on couples because of the values they hold about commitment in a troubled marriage. I've heard experienced therapists announce proudly, "I'm not here to save marriages; I'm here to help people." This split between people and their permanent, committed, intimate relationships (which is how I'm defining marriage ) has a superficial appeal. No one wants to save a marriage at the cost of great damage to a spouse or the children. But the statement reflects a troubling--and usually unacknowledged--tendency to value a client's current happiness over everything else.
One highly regarded therapist in my local community describes his approach to working with couples in this way: "I tell them that the point is to have a good life together. If they think they can have a good life together, then let's give it a try. But if they conclude that they can't have a good life together, then I tell them maybe they should move on." Again, at one level, this sounds like practical advice, but as a philosophy of working with marital commitment, it's lame. How does it differ from counseling someone about a job decision? If you think that your frustrating accounting job can eventually work out for you, then try to improve the situation; if not, move on. Most of us didn't stand up in front of our family, our friends (and maybe our God) and declare our undying loyalty and commitment to Arthur Andersen LLP, but we did so with our spouse.
In this way, the ethic of market capitalism can invade the consulting room without anyone's seeing it. Do what works for you as an autonomous individual as long as it meets your needs, and be prepared to cut your losses if the futures market in your marriage looks grim. There are legitimate reasons to divorce, but given the hopes and dreams that nearly everyone brings to a marriage, divorce is a wrenching, often tragic, event. I see divorce more like amputation than like cosmetic surgery. That's a different value orientation than that of one prominent family therapist who sees his job as helping people decide on their best option. "The good marriage or the good divorce," he told a journalist, "it matters not."
A lesbian therapist told me of how her own therapist wouldn't permit her to bring the children's needs into the therapy conversation when she was contemplating whether to stay with her partner. "This isn't about the kids," the therapist insisted. "It's about what you need and want." When the client objected that she had to weigh the kids' needs in her decision, and wanted to talk about it, the therapist balked, insisting that the client was avoiding dealing with her real issues. Finally, the client fired the therapist. Later, she told me that she and her partner had found a way to stay committed, improve their relationship, and raise their children together. The therapist in this case was a highly regarded professional, a "therapist's therapist" in the community.
It was an experience that happened to a couple who are close to my family that radicalized me about how today's therapists deal with commitment. It's a story like many others I've heard from clients, colleagues, and friends. Monica's life was thrown into chaos the day that Rob, her husband of 18 years, announced that he was having an affair with her best friend and wanted an "open marriage." When Monica refused, Rob bolted from the house and was found the next day wandering around aimlessly in a nearby woods. After two weeks in a mental hospital, diagnosed with an acute, psychotic depression, he was released to outpatient treatment. Though he claimed during his hospitalization that he wanted a divorce, his therapist had the good sense to urge him to not make any major decisions until he was feeling better.
Meanwhile, Monica was beside herself. She had two young children at home, held a demanding job, and was struggling with a serious chronic illness diagnosed a year before. Indeed, Rob had never been able to cope with her diagnosis, or with his own job loss six months later. (He was now working again.) In addition, the family had just recently moved to a new city.
Clearly, this couple had been through a lot of stress. For a former straight-arrow man with strong religious and moral values, Rob was acting in a completely uncharacteristic way. Monica was depressed, agitated, and confused. Being an intelligent consumer, she sought out recommendations and found a highly regarded clinical psychologist. Rob continued in individual outpatient psychotherapy, while living alone in an apartment. He still wanted a divorce.
As Monica recounted, her therapist, after two sessions of assessment and crisis intervention, suggested that she pursue the divorce. She resisted, affirming her hope that the real Rob would reemerge from his mid-life crisis. She suspected that the affair with her friend would be short-lived (as it was). She was angry and hurt, she said, but determined not to give up on an 18-year marriage after only one month of hell. The therapist, according to Monica, interpreted her resistance to "moving on with her life" as stemming from an inability to "grieve the end of her marriage." He then connected this inability to the loss of her mother when Monica was a small child. Monica's difficulty in letting go of a failed marriage, he claimed, stemmed from unfinished mourning over her mother's death.
Fortunately, Monica had the strength to fire the therapist. Not many clients would be able to do that, especially in the face of such expert pathologizing of their moral commitment. It was equally fortunate that Monica and Rob found a good marital therapist, who saw them through their crisis and onward to an ultimately healthier marriage. When I last saw them, Rob was more emotionally available than I'd ever seen him before. He and Monica had survived an intervention that I call therapist-assisted marital suicide.
The therapist's blundering in this case stemmed not from clinical incompetence in knowledge and technique, but from his values and beliefs. He simply didn't recognize the importance of a commitment made "for better or worse." Like attorneys who automatically fight their clients' opponents, some therapists encourage clients to rid themselves of currently toxic spouses, rather than working hard to see what can be salvaged and restored. This approach may be wrongheaded, even when it comes to individual well-being. Recent research by sociologist Linda Waite has found that the great majority of unhappy spouses who persevere in their (nonviolent) marriages for five years report marked improvements in their marriages, and that divorce, on average, doesn't make people in unhappy marriages any better off in personal well-being.
Ultimately, clinical skills aren't enough in couples therapy, because here, more than in any other form of therapy, our clinical skills and values intersect. Treating a client's depression or anxiety doesn't involve the kind of value judgments that working with couples does. Feminists were among the first to point out the inevitability of moral positions in couples work. You can't work with heterosexual couples without a framework that addresses justice and equality in gender relations. If you claim to be neutral, you'll enact whatever traditional value orientation you have about women and men and how they should make a life together. The same is true for race and sexual orientation. Not to have a moral framework is to have an unacknowledged one, and in mainstream American culture, that will probably be individualistic rather than relational or communitarian.
Just as clients who value gender equality won't be well served by therapists with traditional value orientations about gender, clients who cherish their moral commitment to their marriage, as Monica did, won't be safe in the hands of clinically skilled couples therapists who have individualistic orientations. Such clients need therapists who understand the wisdom of Thornton Wilder when he wrote: "I didn't marry you because you were perfect. I didn't even marry you because I loved you. I married you because you gave me a promise. That promise made up for your faults. And the promise I gave you made up for mine. Two imperfect people got married and it was the promise that made the marriage. And when our children were growing up, it wasn't a house that protected them; and it wasn't our love that protected them--it was that promise."
The biggest problem in couples therapy, beyond the raw incompetence that sadly abounds, is the myth of therapist neutrality, which keeps us from talking about our values with one another and our clients. If you think you're neutral, you can't frame clinical decisions in moral terms, let alone make your values known to your clients. That's partly why stepfamilies and fragile couples get such bad treatment from even good therapists. Stepfamily life is like a morality play with conflicting claims for justice, loyalty, and preferential treatment. You can't work with remarried couples without a moral compass. Fragile couples are caught in a moral crucible, trying to discern whether their personal suffering is enough to cancel their lifetime commitment, and whether their dreams for a better life outweigh their children's needs for a stable family. The therapist's moral values are writ large on these clinical landscapes, but we can't talk about them without violating the neutrality taboo. And for clients, there's the scary fact that what therapists can't talk about may be decisive in the process and outcome of their therapy.
In the end, we need to cultivate wise couples therapists, not just competent ones. Wise therapists see the whole context of people's lives, and can reflect openly and deeply on values and broader social forces influencing the profession. My wisdom won't be the same as yours, but we have to engage one another on the big questions, instead of hiding behind the wizard's veil of clinical neutrality. The philosopher Alasdair MacIntrye wrote that, in a world that seduces professionals into seeing their work as the delivery of technical services stripped of larger social context and moral meaning, the hallmark of a true profession is a never-ending argument about whether it's being true to its fundamental values, principles, and practices. In other words, becoming a competent couples therapist is just the first step in becoming a good one.
William Doherty, Ph.D., is professor and director of the marriage and family therapy program at the University of Minnesota. Address: Family Social Science, University of Minnesota, 290 McNeal Hall, St. Paul, MN 55108. E-mails to the author may be sent to firstname.lastname@example.org.
by Michele Weiner-Davis
In our first session, Lynn, a sullen looking 27-year-old, had plenty to complain about. Her husband, Jeff, had been extremely critical of late and seemed emotionally distant from both Lynn and their 18-month-old son, Jason. Lynn felt that Jeff spent too much time with friends after work and on the weekends, and when he was home, he constantly picked on her. With little help around the house, no assistance on the parenting front and virtually no affection from Jeff, Lynn felt desperately unhappy, Lynn longed ' for things to be the way they had once been. "We were better friends back then," she recalled. "We spent a lot of time together and it really didn't matter what we were doing, as long as we were together." I asked, "Lynn, when your relationship was more loving, how was Jeff different?" Without hesitation, she replied, "He was thoughtful and very sensitive to my needs. He had a great sense of humor and was lots of fun to be with." "And how were you different, Lynn?" 1 asked. "I was a much happier person back then, no doubt about it."
"When you were a happier person, how were you different with Jeff?"
Lynn admitted that, because she was so unhappy, she was "crabbier" than she had been in the past. "I guess I used to be a lot nicer to him." She offered a long list of endearing acts of kindness, like putting love notes in Jeff's lunches or calling him at work just to let him know that she was thinking of him. She often used to initiate lovemaking, something she never did anymore. After thinking about the "old Lynn," she wistfully admitted that she liked herself more back then and disliked the angry, resentful person she had become much of the time.
As Lynn described the problems in her marriage, the circular nature of her interactions with Jeff became apparent. Were Lynn's crabbiness and standoffishness a result of Jeff's long absences from home and/or his criticisms of her, or were Jeff's absences and critical tone a result of Lynn's moodiness and withdrawal from him? Knowing that the correct answer was probably "both," I suggested an escape route out of their marital merry-go-round. "Starting tonight, no matter what you're thinking or feeling about Jeff, act like the old Lynn. Do the things you used to do when you liked yourself more, and watch Jeff very closely to see how he responds."
When she returned for our next appointment two weeks later, Lynn was eager to tell me about her experiment with Jeff. Right after our session, he had come home in a grouchy mood and made a critical comment during dinner. But instead of getting angry and defensive, Lynn simply agreed. She said that Jeff actually looked up at her in amazement and that the rest of the meal went without incident. In fact, Jeff discussed a situation at work that had been troubling him, something he hadn't done in months. When Lynn offered her opinion, he seemed unusually receptive. Lynn felt encouraged.
Later that week, Lynn realized that they hadn't spent time alone for months and reminded herself that she used to be a "social coordinator" of sorts in their marriage, and that Jeff seemed to appreciate this quality in her. So, despite the fact that she wasn't completely certain of how things would turn out, she arranged for a babysitter and made dinner reservations at one of Jeff favorite restaurants. Their evening went extremely well and when they got home, they stayed up late talking.
In the days that followed, Jeff seemed more relaxed and less critical of Lynn.
Nevertheless, the time between sessions was not without its rough spots. On a couple of occasions when Jeff made inflammatory comments, Lynn responded in kind and the tension between them escalated. Although Lynn felt discouraged when this happened, she was beginning to understand how her actions during these tension-filled times impacted on Jeff's when she allowed her buttons to get pushed, their unpleasant interactions got even more unpleasant.
She also recognized that no matter what Jeff did or said, no matter how his comments or actions "made her" feel, she was still in control of how she responded. She felt empowered by this realization, and in tense situations asked herself, "What's my goal here? What do I want to have happen?" and then quickly assessed whether what she was about to do would achieve those ends.
I asked Lynn to rate how well things were going in her relationship on a 1 to 10 scale, with 10 being great and 1 being the pits. She replied, "Four weeks ago I would have told you 2. In these last two weeks, I'd have to say 7. Then I asked, "Where on the scale would you need to be to feel satisfied?" She said 8 or 9. So I asked "What would be one or two things that could happen in your relationship that would bring you up to an 8?" and she said, "He would have to say, 'I love you' again and we'd have to make love." I urged her to keep being the "old Lynn," and take note of Jeff's reactions. We scheduled a third meeting and she left.
Two weeks later a very happy Lynn greeted me at the door. "Well, it happened. We made love and right after we were done, he turned to me and said, 'Lynn, I really love you.' It felt great because he hasn't said that in a long time. I can't believe he's changed so much so quickly." Lynn described quite a few things she had done to maintain the changes and divert unnecessary arguments in the last few weeks. As she spoke, I felt confident that she understood the "magic" behind the "new Jeff." To help her plan for future challenges, I said, "You will undoubtedly hit bumps in the road in the future. If things between you and Jeff start to go downhill, what will you do to get back on track?" With a huge smile on her face Lynn replied, "I'd remember everything we talked about here that I got things on track all by myself the first time, and that I can do that again." Lynn's look of confidence was striking. That was the last I saw of her.
From my perspective, there is nothing remarkable about this case. I helped Lynn figure out what she needed to do differently to spark a change in Jeff and in their relationship, and assumed that a positive change in Jeff would be so reinforcing that it would be the beginning of a solution avalanche. It was Systems Theory 101 "A change in one part of the system leads to changes in other parts of the system." Yet, when I discuss Lynn's case and others like it in the workshops I give on solution-oriented therapy, working with one partner to elicit relationship change isn't as mainstream a practice as I once believed. Many therapists question whether Lynn's reports of change were real. Some worry whether, since Jeff hadn't participated in therapy, the changes will stick. Others argue that the burden for relationship change should not have been left solely on Lynn's shoulders. But the most burning question turns out to be the most basic "How is it possible to do couples therapy with just one partner?"
This question stems from the fact that many therapists define the type of therapy they practice by taking a head count: if one person is present, they're practicing individual therapy; if two or more people are present, it's couples or family therapy. I believe this is misguided the key to determining which brand of therapy is in use at any given point lies in the therapist's orientation and focus, not the number of people occupying space in the room.
Individual therapy and couples therapy are based on very different premises and require completely different clinical skills. Individual therapists delve into intrapsychic processes. They help clients gain insight into themselves, their family of origin and how these childhood experiences have impacted on their present behavior, attitudes and feelings. It is the individual therapist's belief that insight is the vehicle for change; that is, once clients understand why they do what they do, they will then be able to change.
Couples/family therapists, on the other hand, are focused on the observable connections between people in the here and now. They're interested in patterns of interaction what people say and do with one another. According to this theoretical orientation, change is brought about not by going inward, but by changing observable interactions among people.
Another reason some therapists can't fathom doing couples therapy with individuals is that they are trained to believe that relationship problems are best resolved by helping people identify, process and express their feelings to one another. With this perspective as a starting point, it's easy to see why one would be skeptical about the possibilities for positive relationship change when only one partner is present. Teaching active listening skills to just one person in the relationship is like listening to the sound of one hand clapping.
But couples therapy with individuals is based on different premises. Although good communication skills go a long way toward creating healthy relationships, talking things out isn't the only, nor necessarily the best, way to resolve recurring problems. While we are affected by what our partners say to us, we are also greatly affected by what they do. For instance, although Lynn had tried for months to convince Jeff to be more loving toward her, nothing she said ever made a difference. It wasn't until she stopped talking and started changing her actions that Jeff became more responsive.
There might be a familiar ring to Jeff's tuning out Lynn's words, but not her actions. During the last few years, we've learned a lot about gender differences. In particular, we've become aware that women, in general, are more verbal than men, who tend to favor action over words. That's why when women tell me, "I talk until I'm blue in the face" or "I've told him a million times," instead of teaching them new and better ways to express themselves, I encourage them to say less and do more. And, since women are much more likely to come in to therapy solo, teaching action-oriented techniques should be tops on therapists' lists of things to do.
The fact that action-oriented techniques may work better with women under certain circumstances is no consolation to therapists who feel that doing couples therapy with women is a bad idea because it places all the burden of improving relationships on women's shoulders. "Why should women have to dream up ways of approaching men? Why can't men take responsibility for finding more creative ways of reaching women?" This position, in my opinion, stems from a lack of understanding of the systemic laws governing change. Change is like a chain reaction. She tips over the first domino, then he changes. When a woman who is dissatisfied in her relationship decides to change her method of getting through to her partner, she isn't doing "all the work." Assuming responsibility for creating positive change in life isn't working harder, it's working smarter.
Despite my emphasis on the merits of this approach with women, it's important to point out that I practice couples therapy with men, with similar results. Even when the marriage teeters dangerously on the brink of divorce, there is much therapists can do when the man is willing to change.
For example, Ben's wife had asked him to leave the house a week before she filed for divorce. When he scheduled an appointment, he had moved out and was desperately unhappy. He didn't want their 20-year marriage to end and wanted to know if there was anything he could do to make her change her mind.
I asked Ben, "If your wife were here now, what would she say you've been doing recently in regard to your marriage?" He said, "She would tell you that I've been pressuring her all the time and that she can't stand it anymore. I've been calling her several times every day and begging her to change her mind. I've been reminding her about all the good times we've shared and have sent her flowers four times. I leave Hallmark cards for her around the house." I asked if this was working, and he said, "No, I've been making things worse."
I explained to Ben that relationships are like seesaws the more of something one person does, the less the other person does of it. "If you do all the longing for your marriage, it allows her to focus only on the bad points. If you are the emotional one, it gives her room to be cold and withdrawing. So, if you want her to stop pulling away from you, you're going to have to stop pushing her."
I then asked him, "What could you do or say that would make Lois sit up and take notice?" Ben responded, "I guess I should stop calling her every day. I should stop saying 'I love you,' because I know it only makes her mad. I should stop asking her if she's changed her mind." I told Ben that he was on the right track and wondered what else he could think of to turn things around. He said, "I'm always so depressed around her. I guess that's not too attractive. If I were more upbeat, and even somewhat enthusiastic about anything in my life, she would really be shocked. That would be noticeable instantly."
I sent Ben home with the following-instructions. "Start experimenting by changing how you act when you are in Lois's presence. Do all the things you discussed here today. When you do, one of two things might happen. The first is nothing. When you change, it might not make a difference at all. That's a real possibility. Or she might be intrigued by your changes and start to show some interest in being with you. But I'm warning you, if you get overly enthusiastic and try to get her to move along quickly, she will definitely back off. You must move slowly. Don't discuss the future of your marriage at all for now. And don't move back home until the issues that separated you have been worked out."
Ben was lucky. When he gave Lois some breathing room, she did show interest in revitalizing their relationship. It was a slow process and required a lot of support on my part to keep Ben from becoming impatient. But in the end, without having Lois ever come in for therapy, they resolved some long-standing issues and he did return home. As far as I know, they are still living happily ever after.
My couples work. With individuals can be broken down into three simple steps. First, I help clients figure out what they really want from their partners by establishing clear, concrete goals that always remain in our peripheral vision. I urge clients to talk about what their partners will be doing differently when the relationship is more satisfying. I help clients picture a new, more positive relationship by asking questions such as, "When you start to feel closer and more connected to your husband, what will he be doing differently?" and "If I were a fly on the wall, what would I see the two of you doing differently when your relationship improves?" I emphasize observable actions rather than subjective feelings, to help clients develop clearer signposts for change.
The next item of business is to help my clients become "solution detectives." I want people to view their relationships as a trial-and-error process: when there's a problem, they do something to solve it. They then should watch closely for the results. If what they do is working, they should keep doing it. If not, they should switch gears.
Although simple in theory, this is not so simple in practice. People get glued to their favorite problem-solving strategies, believing that whatever they're doing to improve their relationships is the right thing to do. In fact, they think miserable results often signal the need to crank the particular strategy up a notch, i.e., do it one more time, with feeling.
Once we establish goals, the third step is to investigate what my clients have done in the past to accomplish these goals. I want to access what's worked and what hasn't. A trademark of the solution-focused therapy approach is to ask clients about problem-free times or periods that are the exceptions. For example, I might say to a client, "Tell me, I know you've been fighting a lot lately, but there must be times when you get along better. What's different about the times the two of you are more at peace with each other? What does he do differently then? What do you do differently then?" We begin to weed through the frustration and anger provoked by the problems in their relationships and discover what can be learned from the times they get along well. As clients identify what's different about the times things go well, the solution comes into view. My clients can then begin to do what works the moment they leave my office.
Although analyzing the good times is uplifting and informative, I also want to know what hasn't been working. To help clients ascertain dead-end strategies, I ask, "If your partner were here now and you weren't, and I asked, 'What does she do that drives you nuts,' what would he say?" I show them how their actions, no matter how effective they "should" have been in theory, have, in reality, caused their partners to dig in their heels even further. In other words, I train clients to pay attention to "what is" as opposed to "how things should be." Once we identify what would constitute a new and different approach to the ongoing problem, I send clients home to experiment.
In contrast to therapists who question the value of doing couples therapy with individuals, this approach is often my method of choice for a variety of reasons. I find it can empower people by showing them that they no longer have to play the waiting game of "I'll change if you change first."
Instead, they find themselves back in the driver's seat of their own lives. This is no small feat, given the helplessness arid hopelessness people feel when their partners present impenetrable walls.
Secondly, working with only one partner allows me to both join with arid confront that person in ways that wouldn't be possible if the other partner were present. For example, I can let my client know how well I understand what he or she is feeling about the relationship or about the other partner. It allows me to connect with the person without alienating the partner. On the other hand, because I'm perceived as an ally, I am at liberty to be bolder, more challenging and, at times, less balanced than would be the case if the other partner were present.
Furthermore, working with only one partner can avoid the unfortunate "ping-pong effect" in therapy, whereby one partner escalates his point of view, triggering the other partner to do the same and so on, until they're completely polarized. It has been my experience that when seen alone, many people are quite willing to take a closer look at their partners' points of view, since they don't feel coerced or that they're losing face. Once they put themselves into their partners' shoes, they're usually more conciliatory. Working with one partner doesn't work all the time, even in less challenging situations. This method is not a therapeutic panacea. There are times when one person changes and the other doesn't notice or, worse yet, doesn't care. Sometimes the relationship changes aren't in the desired direction or of the hoped-for magnitude. Occasionally, your client won't stop blaming his or her partner long enough to switch gears. But nothing works all the time. When my clients and 1 aren't getting positive results, we try something else. Working with one partner is only a good strategy if it works.
In the spirit of sharing what's worked for me, I want to encourage the skeptics I've encountered, and those I have not, to do a few things. First of all, stop telling clients, "Unless he/she joins us, therapy won't work" or, "If your husband isn't willing to come in, it means he's not committed to working on your relationship." Some people who are totally committed to their partners wouldn't dream of stepping into a therapist's office. (My own husband of 20-something years happens to be one of them.) Ascribing negative intent to those who prefer to steer clear of therapy is unfair, often incorrect and almost always hurtful to those who wish their partners would share their enthusiasm about the benefits of therapy. They end up blaming their partners even more intensely.
Furthermore, make a commitment to temporarily suspend judgment about the viability of working with individuals on relationship issues. Therapists who agree to work with individuals whose partners won't come in, but see it as a second-rate approach, worry me. We clinicians communicate our presuppositions about people and how they change when we do our work. If we begin therapy with a "this is better than nothing" attitude, we undoubtedly broadcast a pessimistic message about the possibilities for change.
Instead, the next time you hear, "My partner won't come in," try viewing the situation as an opportunity rather than a relationship death-sentence. Act as if you expect your work with your client to be successful. The results might be surprising! A change in you might just be a powerful catalyst for change in your clients.
Michele Weiner-Davis, M.S.W., is in private practice in Woodstock, Illinois. Her books include In Search of Solutions, Divorce Busting and most recently A Woman's Guide to Changing Her Man. Address: The Divorce Rusting Center, P. O. Box 197, Woodstock, Illinois, 60098; web site: www.weiner-davis.com; e-mail: Dbusting@aol.com
by Bill O'Hanlon
Nearly a decade ago, I treated a man named Abel, who was severely obsessive. He taught in a college communications program and loved words, but he'd become so obsessed with how human beings communicate that he could no longer put together words and meanings. He loved to read, but he could no longer concentrate because he obsessed about page margins and typefaces. He obsessed about art, sex, and his own writing. If one obsession went away, another took its place, from the moment he woke up till the moment he went to sleep. Nothing he tried brought any relief.
I thought hypnosis might help with his symptoms, but Abel, who'd unsuccessfully tried practically every form of therapy, including hypnosis, didn't think so. I assured him that I used a different approach to hypnosis, and he agreed to give it a try. During our second hypnosis session, he was symptom-free for about 15 minutes, and he continued to be for about 2 hours afterward. Even though he didn't entirely believe he'd been in trance, he was impressed and happy that something finally had helped.
In the third session, I began once more with hypnosis: "Okay, you can keep your eyes open, or you can close them, or they might open and close on their own," I said. Abel closed his eyes. "And as you're sitting there, you may be thinking you're not going to be able to go into trance. You can have that thought--that's okay. You may be thinking that this trance isn't going to work. You can think that--that's okay. You may be distracted by one of your symptoms, maybe by the tension in your jaw or your neck. You may even think you're too tense to go into trance--that's okay. You can be tense and you can still go into trance and you might relax as the moments go on. You don't have to relax to go into trance. You may be obsessing--that's okay. You can just let yourself feel what you feel, think what you think, experience what you're experiencing, and not think what you don't think, not experience what you don't experience, not feel what you don't feel, and you can still go into trance."
At that point Abel's eyes popped open. "That's it," he said. "Do more of that. That's what helped me last time."
"You mean do more trance?" I asked.
"No, no. I don't think I'm going into trance. But what you're doing now is exactly what I need. Do more of that."
"What do you mean?" I asked again.
"The way you're talking now is what's helping me. Because, somehow, when you talk that way, I get the sense I can't do anything wrong. It's the only time in my life when I can't do anything wrong. I long for that sense."
While Abel's symptoms didn't completely disappear, from this point on, he began to make progress in therapy. For the first time in years, he could relax his obsessive vigilance and begin to live his life instead of endlessly worrying about the details around life's edges.
Erickson and Not-Doing
I first learned this permissive approach watching Milton Erickson's work in the late 1970s, particularly the way Erickson used hypnosis and challenged standard ideas about hypnotic techniques and affects. Many considered hypnosis a rigid procedure, which could be effective only if certain exacting conditions were met: a person had to be physically and mentally relaxed to go into a trance; once in a trance, the person was supposed to be unaware of his or her surroundings except for the hypnotist's voice. So rigid were the requirements for succeeding at being hypnotized that many people believed they didn't have the ability to "go under" the hypnotist's spell.
Erickson's view was different. For him, trance was more of a not-doing than a doing. He understood that the hypnotist had to take the pressure off people, and make them realize that they didn't have to experience specific mental and physical stages in a particular order to go into trance. He invited people to just allow their own experiences to happen as they happened, without having to force anything. He used language that neutralized the mind's tendency to break experience down into dualistic opposites--this or that, right or wrong, correct or incorrect.
In a sense, he gave his clients permission to experience simultaneously or in rapid succession contradictory emotions and states of mind and body, emphasizing that no reaction excluded any other, and that all were "right." From Erickson, I learned to make statements like: "You can listen to and hear everything I say and you don't have to. You may remember what I say and you may not. You don't have to believe anything about this."
Abel's response to this approach--that it made him feel he couldn't do anything wrong--crystallized something for me. Here was a way to break up unconscious logjams; permissions enabled clients to experience two seemingly contradictory states simultaneously. The structure of hypnotic language freed people from the tyranny of having to choose, and choose correctly, what to feel and how to proceed. I began to appreciate the extraordinary power of permission, with or without hypnosis, particularly with my most challenging cases.
So I began focusing on how to most productively include the good, the bad, the ugly, and the in-between of my clients' experience to help them expand their sense of possibilities in life. But this was the mid-1980s, the height of the popularity of various forms of solution-based therapy, and people would sometimes come up to me at my workshops and say, "I really like your positive approach," thinking they were complimenting me, in spite of the fact that I wasn't particularly interested in accentuating the positive.
Around the same time, therapist David Nylund told me that the staff at his clinic had noticed a problem with therapists who were too focused on highlighting the positive. As they watched from behind the one-way mirror, they were struck by how often they saw therapists straining relentlessly to keep clients focused on solutions and solution-talk. Often, the effect was that clients became more and more frustrated and alienated, while the oblivious therapists continued asking about what was going better. Nylund and his colleagues named this phenomenon solution-forced therapy.
So, in my training workshops, I began emphasizing the importance of not excluding those thoughts and feelings that didn't look like solutions to anything. As valuable as it is to help people focus on solving their problems, it's equally important to validate people's experiences, however negative. The essence of good therapy is to be able to descend with people into their hell and at the same time keep one foot in the land of hope and possibility. I once heard a radio interview about research conducted with people who'd survived jumping off the Golden Gate Bridge. The only common factor among them seemed to be that on the way down each of them had had more or less the same thought: Hmmm. Maybe this wasn't such a good idea.
As therapists, we must recognize the complexity and ambivalence at the core of human experience. Inevitably our therapy theories invite us to oversimplify, and solution-focused therapists aren't the only ones guilty of that: the client's problem is "cathected introjects"; she needs to "express her feelings"; he needs to "take responsibility for his life"; clients have to "reexperience their abuse to heal from it." Whatever ideas we therapists get are going to be helpful in some situations with some clients, but they necessarily diminish and impoverish our clients' inner realities. Recognizing this, we need to remind ourselves that whatever conclusions we come to about our clients, it's always more complicated than that.
The Power of Permission
People run into problems when their lives are dictated by rigid beliefs that make the stories they're living out too restrictive. One common set of beliefs is about what you must or should do. For example: "I must always be perfect," or "I should always smile and be happy," or "Females should take care of others' needs." Another common set of beliefs is about what you can't or shouldn't do: "I can't be angry," or "Big boys don't cry."
Permission counters these commands and prohibitions. The therapist who offers permission goes beyond accepting clients as they are and moves into encouraging them to expand their life stories and their sense of themselves. In effect, the therapist who offers permission is saying, "There's more to you than this story you've lived out up to this point." Permissions can introduce choice and possibilities into circumstances that have been limited by necessity and impossibility.
How do permissions work in practice? Some years ago, I worked with a woman who'd been sexually abused by a cousin in childhood. He routinely brought her to orgasm, which she liked and felt bad about--because she didn't like him and felt manipulated and coerced by him. As an adult, she never got sexually excited or had orgasms until she became involved in S&M in her early twenties. After a frightening experience in which she was almost killed, she left the S&M scene.
Now, after many years of therapy, she lived with her fiance and was still unresponsive sexually. She'd begin to get sexually excited, and then get frightened and go numb. She'd accepted that this was the way things were with her. Once, at a professional conference, she'd started chatting with a fellow attendee and had gone into an elevator with him. As the doors closed, sparks seemed to jump between them and they had sex in the elevator. She was surprised that she was doing this wild thing, and even more surprised to have an orgasm during the short encounter.
In our therapy, she realized she was operating under two beliefs: "You shouldn't enjoy sex, because it's bad," or, "You're bad if you're sexually excited or have an orgasm." Because she'd been coerced to be sexually aroused, she'd developed the idea that she had to be sexually aroused and have orgasms in any sexual situation, whether she felt like it or not. I gave her two permissions: "It's okay to have sexual pleasure and not be punished. It's also okay not to be sexually aroused and okay not to have sex." I started interspersing into our conversations permissions such as, "You can be a good person and be sexual." And "You don't have to be bad to be aroused." But also, "You don't have to have sex, if you don't feel like it." And, "You don't have to have orgasms when you have sex."
How did she begin putting these permissions into practice? She decided to let her partner know she became afraid or numb when they were having sex. She'd tell him she needed to stop and talk, or not have sex right then. He was understanding and appreciated that she was honest with him, rather than just forcing herself to go through the motions. The fact that he responded so well confirmed for her that she did not have to have sex or have an orgasm. Her new freedom actually enabled her to have orgasms with her fiance more often.
Although you can give the permission to or the permission not to, giving both permissions at the same is often most effective: "It's okay to be sexual, and you don't have to be sexual." If you give only one permission for one type of response, clients may feel pressured to experience only one part of the equation, or they may find the other side emerging in a more compelling and disturbing way.
In certain situations, it's important to give permission for feelings, not actions. For instance, "It's okay to feel like cutting yourself, and you don't have to feel like cutting yourself." Needless to say, never give permission for harmful, destructive behavior.
Other times, it's helpful to give a client permission to do two things at once. Such was the case with Josie, whom I'd seen for a few sessions when she came in very agitated. She said she had something to tell me, but was terrified to talk about it. I told her it was okay not to tell me until she was comfortable enough to do so. Josie responded that she had to tell me, or she felt she'd be wasting her time and money in therapy. I told her to go ahead and tell me in whatever way felt right.
She seemed to struggle for a while and then said, "I can't tell you. I'm too afraid." We went back and forth like that until I began to understand Josie's dilemma and said, "Okay, I know this may not make sense, but what I'm going to say can be understood somewhere deep inside. You can find a way to tell me and not tell me at the same time."
In response, Josie closed her eyes and her hands began to move in elaborate movements that reminded me of "hand dancing" I had seen done by Thai performers. After some time, she opened her eyes and smiled, obviously relieved. "There," she said, "you were right. I told you and didn't tell you at the same time. My hands told you the whole story of my abuse. Now I can tell you in words."
"That's good," I thought to myself, "because I didn't get the hand thing at all." Josie went on to tell me what had happened to her. Although she knew it was irrational, she'd feared that if she told me, she'd somehow be responsible if I had a car accident or a heart attack. Telling her story was a great relief to her. Once she could find a way out of her bind, she could embrace the possibility of breaking her "curse."
The Power of Inclusive Thinking
Sometimes the key to helping someone who seems hopelessly stuck is to invite them to experience two seemingly contradictory feelings or states without putting them in conflict. What's central is the use of the word and: "You can feel tense, and you could relax. You might think you can't change, and you might be surprised to discover that you're changing. You want to change, and you're so afraid to change." This contrasts with how most people unconsciously put things together: "I have to feel this or feel that. I feel this, but I should be feeling that." Instead of reinforcing one-dimensional definitions of ourselves, such permissions go beyond mere acceptance to actively encouraging clients to simultaneously experience thoughts and feelings that they consider irreconcilable. It's as if the therapist is saying, "Your story has become too small for you. Give yourself permission to begin to envision and live out a larger story."
I remember doing therapy with a woman who'd been severely and persistently abused as a child. She lived six hours away and we met every month or so for three-hour sessions. She'd struggled with suicidal impulses for years, and the work we were doing was leaving her emotionally raw. She called one day and told me she couldn't go on in the therapy. "You're getting too close, and I feel too vulnerable," she said. "Plus you're too far away, and I can't come easily for an emergency appointment if I need one."
"I understand," I replied, "and I think this isn't a good time to end treatment. So let's talk for a minute and see if we can get you through until the next appointment. You can find a way to be vulnerable and protected. And you can regulate the distance and closeness to make it work for you. I can be right there with you while I'm here. You can be right here with me while you're there. I can be as far away as you need me to be and as close as you need me to be. And I can be far away and close at the same time." I went on in a similar vein for a few minutes--trying to establish in her a direct feeling sense that she could have her cake and eat it, too. It seemed to work. "Okay. You're right," she said. "I can do that. I'll see you next appointment."
As therapists, we must always be sensitive to the enormous life-restricting pull of either/or thinking. This abused client believed she had to be either vulnerable or safe. But there were situations in which this particular client had been able to be both vulnerable and safe. She said she felt that I was getting too close. I suspected just the opposite as well: she felt that I was too far away, emotionally as well as physically. So I included both possibilities, instead of one or the other.
Typically, when people are stuck, it's like two people trying to go through a door at once. The two are present simultaneously: I want to change, and I'm afraid to change. Inclusion expands the doorway, leaving room for both--and perhaps more--aspects of self to move freely. Merely giving language to this double presence by inviting people to recast their life stories to match their expanded sense of themselves, is often enough to free them from the insidious internal demand to see themselves and their reactions monolithically.
Not long ago, I consulted at a hospital with a woman who was depressed, suicidal, self-mutilating, and defiant.
"How long have you been so depressed?" I asked.
"Since I was 8 years old," she said.
"That's a long time. I'm surprised you've lasted this long."
"Well, two times over the years I almost succeeded in killing myself."
I was curious about how she'd kept herself alive. She told me she'd struggled against the depression so long because in some ways she wanted to live and find a way out of depression. Nobody really understood that, she added, because she was always talking about killing herself.
A few weeks earlier, I'd seen Mike Wallace on 60 Minutes interviewing a woman with a degenerative illness, who was fighting through the courts for the right to die. Wallace asked her why she was suicidal. She replied, "I'm not suicidal. I just don't want to live like this, and I want the right to choose to die." Wallace insisted that, since she was fighting for the right to die, she must be suicidal. "No," she replied, "I love life. I just don't want to live like this. I love life."
I told the woman at the hospital the story and said, "You've lived all this time because you want to live. You've made it this far, by luck, or because the angels were watching over you, or because someone cared for you at times, but mostly because you just kept yourself going. You want to die and you want to live, but you definitely don't want to live like this."
"That's it exactly," she said. "No one has understood that. I'm suicidal and I'm not!"
Now you might say that these women really didn't want to die. But I think that's the cheap version of their reality. They did want to die in a certain way, and (there's that word again) they were still alive, which spoke powerfully for their desire to go on living. Only by recognizing the complex truth of the matter, taking it seriously, giving words to and accepting these dual realities can this permissive, inclusive method work. So clients really do want to live. And the reality that you must come to terms with is that they may really die.
Practicing What We Preach
If the approach I've been laying out here was purely a matter of logic, theory, and better clinical outcomes, its principles would be more widely demonstrated in therapists' consulting rooms. But embracing clients' multiple realities inevitably leads therapists to face emotional issues in their own lives, issues that make an inclusive approach much more than a merely intellectual exercise. At least that's what my own experience has taught me. It's been one thing to give clients permission to accept their ambivalence, but quite another to do that in my own life.
Some years ago, my wife Steffanie was stricken with a painful and life-threatening illness. By 1997, she was bedridden, gaunt, and in extreme physical pain. While the doctors could offer many diagnoses, they had no viable treatments. Many told her there was nothing more they could do. Others referred her for assessments or treatments she'd already tried. She was despondent and convinced she was going to die.
I would hear none of it and found it impossible to support her hopelessness. So I unswervingly emphasized the possibilities for treatments yet to be developed, and the need to keep a positive attitude to support her immune system. I thought, of course, that this would be helpful to her, but it often had the effect of sparking terrible arguments between us.
She would tell me, "You want me to feel better, and I don't feel better. What you're saying just makes me feel worse and more alone." But at some level, I felt that if I didn't expend all my energy in fighting her pain and hopelessness, I would be giving in to it, even making it worse. I was terrified that if I accepted her reality, she was doomed and I would lose her.
Finally, help came from an unusual quarter. We'd recently moved to Santa Fe, New Mexico, and rented a house out in the country. It turned out there were some problems with the well because of leaks and some toxic materials stored in the house. I called the landlady, explained the situation, and told her that we intended to move out. The landlady didn't want us to move and, in addition to making the needed repairs, had a suggestion that could only happen in Santa Fe (or perhaps Sedona): she proposed hiring a "house psychic" to do a reading on the house and deal with the problem at a more cosmic level. Skeptical and a bit bemused, Steffanie and I decided we had nothing to lose and agreed to let the house psychic do her thing.
After a few Feng Shui-type suggestions, the house psychic did a reading for us that revealed, she said, that in a previous life Steffanie and I had been a couple living on a large estate in ancient Italy. Steffanie was the heir and I, as the new husband, had taken over managing the estate. But because I had little experience in such things, I was running the estate into bankruptcy and stubbornly refusing to listen to Steffanie, who unsuccessfully kept trying to tell me what to do. In our past life, the psychic told us, our stalemate ultimately had led to tragedy for Steffanie and I'd spent the rest of my life regretting I hadn't listened to her.
I know, I know--only in Santa Fe! But whatever its value as a past-life story, the psychic's tale was so parallel to our situation that it had an electric effect on me. I realized that I hadn't been listening to Steffanie. However inclusive I'd tried to become as a therapist, at home, I'd been determined to screen out her "negativity." As I might have predicted had I had any distance from our situation, the more "positive" I got, the more desperate Steffanie became.
Something about the psychic's making me see how stubbornness can led to tragedy made me think about my own family story. I suddenly made the connection to growing up in a household in which the unwritten injunction was "don't get sick." We kids had to be essentially on our deathbeds to be allowed to stay home from school or work. If we did stay home, we were never coddled. There was no television or other distractions. My mother, a tough farm girl, would leave some 7-Up and soda crackers by the bedside and check back every few hours to make sure we were still alive. No doctors, no medications. It was as if sympathy would somehow reinforce the illness.
From fear that Steffanie might die, I'd been reenacting an old family drama. I saw that I had to quit trying so hard to make everything okay again. I needed to let myself just be with Steffanie in her hell. I remember going into our bedroom and just lying down and holding her for a long time, without saying much of anything. Then, we quietly spoke about the pain she was in. Later, she told me that it was the first time she hadn't felt left alone in her despair. From then on, something shifted between us. I realized that accepting her hopelessness didn't mean I had to give up my own hopes for our future. I could hold them both. Soon, Steffanie began to talk about future plans and other small dreams that indicated she hadn't given up. I could, in turn, speak to her about my fear of losing her and being left alone. She's still far from well, but the tension between us has been replaced by a sense of connection and an awareness of my tendency to "go positive."
It's relatively easy for most of us to think inclusively with our most functional clients, but much harder to do so with those who are difficult and demoralized, or when our own psychological hot buttons are being pushed. But being a therapist means taking the time to get all the pieces of people's reality, spoken and unspoken. At the most basic level, we must discover how to perform the balancing act of simultaneously giving up the need to see clients change while holding open the possibility of change. This attitude requires us to face our own fears (of lawsuits, suicide, failure) and be still with the client's pain, immobility, glaring absence of change, and , at the same time, we must be able to see the "and"--that something more, unrecognized and unspoken, happening beneath the dead calm of an apparently inert sea.
Bill O'Hanlon is a therapist, author, and workshop presenter. His latest books include Do One Thing Different; Try and Make Me; Collaborative, Competency-Based Counseling and Therapy; and Even From a Broken Web. His book A Guide to Inclusive Therapy is due in early 2003. Address: 551 West Cordova Road, Suite 715, Santa Fe, NM 87505. Website: www.brieftherapy.com.
by Frank Pittman
I've been in full-time private practice for almost 30 years. I've seen maybe 10,000 families (it certainly feels that way.) In that time, three patients in my practice killed themselves. Strangely enough, the three suicides were eerily similar. Each suicide has left me shell-shocked and questioning my therapeutic attitudes and methods.
I did not expect Adam to be one of my casualties. He reminded me of the guys I grew up with in rural Alabama. He was large, loud and rough, masking his intelligence behind a display of anti-intellectualism and cultural ignorance. I know these guys and I've had success at retraining them, since I'm not afraid of them or contemptuous of their fragile, hypermasculine pride and their awkwardness with emotion. Like so many of the scared, bullying men I see, Adam had been trained to fail at relationships.
Adam had grown up poor and fatherless. His mother divorced his violent father when he was 12. Adam never saw him again. He didn't drink, he went to church a lot and he was an active, hands-on father to his own children. He hovered protectively, though controllingly, over Angela, his quiet, compliant wife of almost 20 years, who was a nurse. He had made a great deal of money building houses, and was now building a gigantic dream house for their large family.
Six months before I saw them, Adam had slugged his hulking oldest son for quitting his high school football team. After being advised by a counselor at work, Angela threatened divorce. Adam, baffled that she would consider leaving him after such a (to him) minor incident, suspected her of having an affair and got first paranoid and then violent, breaking furniture and punching holes in the wall with his fist. Angela went for help to a therapist, who advised separate therapy for her and Adam, as the conventional wisdom in those years was to see violent couples separately and try to get them to divorce. Angela's therapist (who never met Adam) communicated both neutrality and pessimism about the marriage, and pushed for divorce.
Adam saw a psychiatrist, who put him on Prozac, which mixed badly with his two-pot-a-day coffee habit. He became toxically irritable and, as Angela pulled further and further away, increasingly violent. For the first time in all their years together, he actually hit her. Angela's therapist advised her to call the police (I would have given the same advice). They had Adam hospitalized for a few weeks in a special program for batterers. He went willingly and was a model patient. On discharge, he went home and found Angela and his kids had moved out. He stalked her, begged her to come back and, when she resisted, beat her up. At that point, Angela called me in. She had heard I was an expert with over-the-top men.
I saw Adam, Angela, the couple and the whole family in alternating combinations. She had a court order, which, while a good idea, offered no protection. I got Adam to promise us all there would be no more violence. And there wasn't, for the remaining few months of his life. Off caffeine and Prozac, he went into a clinging, dependent depression, but was stabilized on Stelazine for paranoia, Tegretol for explosiveness and Zoloft for depression.
Angela set up a separate home for herself and the children, and put Adam on notice that she was serious about getting a divorce. I did not question her intention or try to slow her down (a failure that continues to haunt me). Instead, I used the pressure of impending divorce to spur Adam on, as I tried to teach him some manners, some sensitivity to someone else's feelings besides his own. I hoped the changes in him would bring about a reversal of Angela's resolve to get away from him permanently. I saw him often by himself, developing what I thought was a great level of intimacy, full of personal revelations, shared experiences of the rural South and humor about the changing world around us. We talked about fishing and revivals. We talked about rattlesnakes, baseball, Hank Williams and the search for an exit from the swamps we grew up in. We talked most about the loss of his grandfather to bad homemade whiskey and his father to divorce. Then we talked about the difference between the father figures he had, the ones he imagined and the one he wanted to be. Once he was calmed and connected, I also put him in a group of non-batterers. I tried to be the gentle daddy he never had.
Adam felt in better control of himself, and redoubled his efforts to get his family back. He completed the dream house, begged Angela to move into it with him, was rebuffed and moved in alone. They had talked a lot, in my office and outside, about the terms of the separation. He was generous, sweet and apologetic with her, without control or bombast. Angela, aware of the drastic change in him, feared her longstanding tendency to pity and protect him. She held firm about divorce, but he (and I) saw her softening. I couldn't imagine him doing better than he was doing; I couldn't imagine that she would want anything better than the reprogrammed Adam. I thought I was doing a great job with Adam and that it was just a matter of time before Angela gave him another chance.
Throughout his adult life, Adam hadn't been connected to anyone else except Angela and the kids. So I thought it was imperative that he heal the longstanding rift between him and his mother. I sent him over to South Carolina for a weekend with her. While there, he also dropped by to apologize and make peace with Angela's family. On his return, I called him to postpone our next appointment for a day, as I had to go the funeral of an old childhood buddy. Adam and I talked for a long time on the phone. He told me how good he felt on his visit with his mother, especially learning the story behind the breakup of his family. He was proud of his new skill of apologizing. He had called Angela and was optimistic he could get her back. He sounded eager to see me a couple of days later.
Adam didn't show up for his next appointment and didn't answer his telephone. I called his secretary and he had not made it in to work, either. She and I both somehow knew what had happened, though suicide had never been mentioned before. She went out to the new house, where she found Adam in a chair with a shotgun in his mouth and his brains all over the living room wall. The divorce papers, which Angela unexpectedly had served on him, were on his lap.
I was stunned. It was not just a personal loss (I wanted to save this guy); it was not just a blow to my grandiosity (I kept telling myself in my newfound humility, this sort of thing doesn't happen to therapists who work as hard and care as much as I). I was sad over the loss of what Adam could, with time and effort, have become. His suicide was a dumb and preventable waste. His children were devastated. Angela felt many things, among them relief: when the abuse started the year before, a well-intentioned counselor had warned her that violent men never change. She had been fearful that she could not get herself and the kids out of the marriage alive.
I had been trying so hard to respect Angela's need to empower herself and feel in control of her life and the marriage, I had been non-directive and neutral with her, so much so that she didn't fathom that I had hopes not only for Adam, but for the marriage. I certainly foresaw a different outcome than this.
I met often with Angela and the kids during the next year or so, and occasionally still do, as they and I try to recover and understand. Adam didn't leave a note. We know he spent the day before his death shopping with a friend for kitchen appliances--not the actions of a man planning suicide. No matter how much he and I had talked about the possibility of divorce, Angela and I think the divorce papers came as a bewildering shock, snapping him out of his, and my, optimistic fantasy that a change in his behavior would get him his life back. To him, the divorce papers meant that there was no hope, no future. He wasn't ready yet for divorce; he didn't yet have a life apart and he was not a patient man.
As I played the case over and over in my mind, I saw clearly that I could have asked Angela to slow it down. And she would have. She was in no hurry and would have proceeded at whatever pace seemed safest for herself, her children and for Adam, whom she still loved. She had no way of knowing what I knew: that, in time, as long as his behavior was different, she would very likely feel safe with Adam. Those who have been abused cannot trust the ups and downs of their own feelings. Even as they track the abuser's behavior and react to the changes they see in the way they are being treated, they can't trust their sense of their own power in the relationship. And even though I had experience, expertise and wisdom about such matters, I didn't use it.
I don't know why I didn't know that those papers would be served that day. Clearly, I knew they were coming soon, but I was actively trying not to direct Angela's divorce process, or anything else she found empowering. I was optimistic in my ability to turn Adam around and, more important, in his ability to turn himself around if he had a different model of manhood. Beyond that, I was optimistic, after so many hundreds of cases in which it has happened, that Angela would take him back and the violence would not recur. So I acted neutral. I realize from this tragedy that it is as idiotic for me to be neutral about matters of marriage and divorce as about matters of life and death.
At the time I saw Adam, I had been so influenced by the feminist critique of family therapy that I'd gotten into the pattern of treating men as amateur human beings and coaching them on just what to do--of supervising them in relationships. It worked great. But at the same time, I'd become increasingly careful to validate women's feelings and avoid telling them what to do. The result, of course, was that many men changed their behavior quickly and many women were left nursing their hurts, feeling like victims and not noticing or responding to the changes in the men or the increases in their own levels of empowerment.
My pragmatically mechanistic approach toward relationships (i.e., ignore your feelings, do what will get the desired response from your partner and let the new interaction change the emotions) has a certain limitation. There are some offenses against marriage that feel unforgivable--at the moment and for a little while after. And no change in behavior can provide the necessary reassurance--at the moment and for a little while after. We all have grounds for divorce (or suicide), but we know that tomorrow is another day. I get so carried away with my belief that any change can be made and any offense can be overcome that I may leave behind some traumatized casualties of life's cruelties. Adam and I got ahead of Angela. After the offenses stopped, we needed to slow down long enough for the healing to take place.
I often think about my three suicides. All three of them were men who had done the unforgivable and couldn't get their families back quickly enough. I beat myself up about them and sift through them to find what I can do to keep it from happening again. People can make such a mess of their lives that they see no hope, but suicide is too hard on the survivors--including me. It threatens to make me cautious, pessimistic and risk-averse. To be truly helpful, I need my jaunty optimism about what can be survived in life and in marriage. Without it, I can't keep people afloat long enough for them to get their lives back. Did I give Adam too much hope? Did I give Angela too little? Did I fail to coordinate the trajectories of the changes the therapy was bringing about by being two different kinds of therapists--feminist for her, behaviorist for him? Did I go to the wrong funeral on that last day? If I'd known the papers were being served that day, I would have been with him, even if only by telephone. If he had just called me when the papers came--
Clearly, it will never be over for any of us.
Frank Pittman, M.D., is a contributing editor to The Family Therapy Networker and is in private practice. Address: 960 Johnson Ferry Road, N.E., Suite 543, Atlanta, GA 30342.
by Mary Pipher
I will never forget the Correys, who were referred to me by their family doctor in western Nebraska. As is not unusual in our vast, rural state, they flew to our sessions by private plane. Frank was a wealthy businessman and realtor. Donna was a housewife. They had a 16-year-old daughter. Every other week for a year, I saw them, during which time I tried pretty much every trick in my therapeutic arsenal. I spent hours discussing their case with trusted colleagues and read up on their particular problems. I don't know how many nights' sleep I lost worrying about how to get these folks on the right track. And in spite of all my efforts, the Correys were one of my most spectacular failures.
From the moment I met the Correys in my waiting room, I was baffled about why they were together. Frank was tall, good looking and suave; Donna dowdy and sullen. They were both in their mid-forties, although Frank looked younger than that and Donna older. She barely bothered to greet me, and stared resentfully at Frank. As soon as we were seated, Frank jumped in to complain about Donna's spending. He was clearly used to being in charge, confident and eager to explain their situation. And Donna was used to being passive and angry.
Frank explained that even though they lived in a town with only a grocery store and gas station, a town one hundred miles from the nearest mall, Donna used catalogs and the shopping channel to spend nearly $8,000 a month. I couldn't believe I heard him right, and actually asked him to repeat the figure. I tried to keep my expression mild and non-judgmental, but inside I was appalled. I can go months without buying anything but groceries, and have not spent $8,000 on consumer goods for myself in my entire life.
According to Frank, Donna tried to keep her spending secret. He only discovered the extent of her extravagance when he found credit card bills or his secretary noticed that his business accounts had been cleaned out. Ironically, even though Donna "owed" Frank more than $50,000 for unauthorized spending, she had little to show for it--no boats, fur coats or new cars, just boxes of shoes, clothes and household gadgets. Of all the questions and reactions I had to this case, my big question was--how could anyone stay married to such a loser wife?
I generally divide an intake into thirds: one-third for the presenting problem, one-third for some contextual information and one-third for a discussion of therapy. And I give each person a chance to explain the situation. Frank blamed Donna's spending on her depression and low self-esteem. He said he would be happy if only Donna would cook, clean and limit her spending to $1,000 a month. I thought to myself, "Climb a low mountain, Frank."
When her turn finally came, Donna pointed out that Frank was a millionaire and the sums she spent were insignificant. She complained that Frank was almost never home, and when he was home, he stayed in the basement managing his stock portfolio on his computer. She said, "Frank's moody and he takes no interest in us unless there is a crisis." She agreed she was depressed. She had once been active in her community, but in the last few years she had withdrawn from everyone but her daughter.
Ah-ha, I thought, now I get it. Her spending was functional. It kept Frank's attention. Frank worked all the time to keep Donna in dough, which she then spent rapidly to punish him for working. He worked to avoid a dull, depressed wife, while she spent to deal with her loneliness and sense of inadequacy, brought on partially by Frank's neglect. Still, even though I had a crisp intellectual formulation of the case, I suspected from the first that I wasn't quite on target. I couldn't get over Donna's spending and I was impatient with her stolid, stubborn demeanor. I felt sorry for Frank that he was stuck with such a lump.
At the end of that first session, I made a few recommendations to the Correys --that they tear up their credit cards, that Frank come home for dinner a couple nights a week and that they have a date as a couple. I suspected Donna was clinically depressed, so I encouraged her to exercise and to buy a copy of David Burns's Feeling Good. Neither one of them was happy with my suggestions. Frank insisted time demands made it impossible to spend more time with Donna. Meanwhile, Donna refused to cut up her credit cards. But they let me bully them into agreeing to try these assignments and we rescheduled for two weeks later. I sighed as they left.
Right after our first session, the cast of characters expanded. Donna scheduled an appointment with a psychiatrist, who prescribed antidepressants and wrote me a letter saying that she thought the real problem was Frank, who was invested in his wife's being labeled sick and was a mean son of a bitch, although she said this in medical jargon. The psychiatrist didn't see Donna's spending as any big deal, and what's more, she actually liked Donna, whom she described as having a keen sense of humor and good insight.
I was baffled by the psychiatrist's take on this case. I didn't see any meanness in Frank. How could the psychiatrist have missed his charm? And where was Donna's sense of humor when she was with me and Frank? I explained the discrepancies in views by recalling that the psychiatrist was recently divorced and perhaps angry at men. I knew she was a major consumer herself.
The Correys did have a few dates, mostly dinner at the nearest restaurant, a Pizza Hut 30 miles from their home. But the dates didn't generate any romance. Donna didn't exercise and hated Feeling Good . I found myself resenting the failure of bibliotherapy. After all, books always helped me. Donna eventually agreed to cut up her credit cards and to attend Debtor's Anonymous, which meant Frank flew her in for a group meeting once a week. They actually liked these meetings, although Donna didn't really reduce her spending. Somehow, no matter how carefully Frank and I tried to control her, Donna found ways to charge stuff or order junk over the Internet, Although she said the medication helped, Donna was still mildly depressed and still not cooking or going out in her community. Frank stayed mad about Donna's spending, although not that mad. Meanwhile, no matter how therapeutically neutral I tried to be, I remained appalled by her extravagance.
By now our sessions had lost any therapeutic momentum. Increasingly, I felt as if I were dragging a barge across the desert. The couple would fly in, report little change in Donna's symptoms, Frank's work habits or their relationship, and fly out. Both said they were dissatisfied with the relationship, but after 22 years of marriage, neither was considering divorce.
The less progress I saw in our sessions, the harder I tried. I utilized every technique I could think of. I tried paradoxical techniques and prescribing the symptom. Thud. I saw them alone and encouraged Frank to draw a line in the sand. Thud. I saw Donna alone and encouraged her to find women friends, go back to school, get a job, take walks or find a volunteer commitment she could enjoy. Thud. I recommended a vacation, which they half-heartedly tried and both hated. Thud. I encouraged them toÂ communicate their needs, set up a budget and work on their emotional relationship. Thud. Thud. Thud.
My exasperation and confusion peaked during one session in which, as Frank itemized her wasteful spending, Donna actually fell asleep. After I woke her, I asked Frank how he felt about Donna's sleeping. He insisted that he didn't mind that much. After all, Donna was tired. At that point, I almost jumped out my own office window.
How could I work with someone who was about as different from me as a woman could be? Donna was passive, preoccupied with consumer goods and she actively disliked exercise. She was bored by trees and prairies and had no interest in education. That boggled my mind. How could anyone not be interested in education? I knew I was being judgmental, but I was convinced that I knew how to be happy and she didn't. There was no question in my mind that my way of being in the universe was better than hers.
I felt more sympathy with Frank, who was at least a hard worker. Also he was a high-powered salesman and could sell me on his excuses, his interest in making things better. But I didn't really understand Frank either. He wasn't much more cooperative in therapy than Donna, especially with my insistence that he tell his wife what he would and wouldn't put up with and then hold that line. In fact, as I worked harder and harder to fix this couple, they seemed to become more locked into their original problem behaviors.
Finally, I had it with the Correys. When Frank found that Donna had opened a new line of credit and charged another $10,000 of purchases, I fired them. I can still see the three of us in our last session, me earnest and serious, trying to hide my anger and wishing them well with a different therapist, "who would offer them a fresh approach." There was Frank, not as unhappy at being fired as I would have hoped. In fact, he was a little rude to me, as if I were an employee who no longer mattered. And Donna, smiling for the first time since we had met. As they left my office, she said almost kindly, "Don't be too hard on yourself, we are nutty and we're hard nuts to crack." There, for the first time, was the sense of humor the psychiatrist saw.
I thought a lot about the Correys in the months after our termination. I'd ignored the wisdom that people only change when they feel deeply accepted for who they are. Instead, I'd let my own values about spending prejudice me against Donna. And I had other values conflicts as well--over reading, education, gardening and the importance of taking action.
A wise therapist once told me that our first task in any therapeutic encounter is to find something to respect in our clients. Without respect it's impossible to really help anyone. I realize I flunked Therapy 101. I didn't respect Donna and I let that important fact slide. I suspect Donna sensed my lack of respect and that's why she fell asleep in our sessions. She had no connection to lose with me. The big lesson from the Correys was that I need to find something I can truly and authentically respect or I need to get out. I can't pretend respect. And without it, there is nothing on which to build a therapeutic alliance.
Being a therapist is intellectually taxing, emotionally draining work, and respect is what fuels the process; it's what gives us a reason to care. Without it, the work is mechanical, for us and our clients. With no respect, there can be no connection, and without connection, therapy loses its meaning.
Mary Pipher, Ph.D., is author of the bestselling books Reviving Ophelia and Another Country: Navigating the Emotional Terrain of Our Elders. She is a clinical psychologist in private practice in Lincoln, Nebraska. Address: c/o Family Therapy Networker, 7705 13th Street, N.W., Washington, DC 20012.
by Brent Atkinson
In the 15 years that I've been following developments in neuroscience, the most compelling clinical lesson I've learned is likely to rub you the wrong way. An overwhelming body of research now suggests that we clinicians rely too much on insight and understanding--and too little on repetitive practice--in promoting lasting change.
This wasn't welcome news to me. I'm a couples therapist, and I got into this business because I loved transformative moments when intimate partners' defenses crumbled and their deep emotions emerged. That was what juiced me--not, getting couples to do the same things over and over again.
Yet, year after year, I watched couples let go of judgment and blame for an instant, only to show up for the next session as miserable, critical, or withdrawn as ever. They didn't even remember the profound insights they'd had that I felt sure were going to rock their worlds.
Then I encountered a series of studies published by neuroscientist Jaak Panksepp, from Bowling Green State University, and came to understand that when they were upset, my clients were in the grip of one of seven major body-brain mood states, which he calls "executive operating systems."
Our Brains' Executive Systems
Panksepp uses the terms rage, fear, seeking, lust, care, panic , and play to describe the signature emotion of each system. But they're more than passing moods. They're complex neurochemical cascades, in which hormones race through the body and brain and electrical impulses fly over familiar neural synapses, shaping what we feel, do, and think. When one of these systems becomes active, emotions, motivation, and thoughts take over in the service of the goals it's programmed to achieve. It's as though we've gotten on a plane to Paris, and no amount of fiddling with the seatbelt is going to change the plane's direction before the wheels touch down at Orly.
Four of the systems are wired for love: they draw us together. One of these is old-fashioned lust. Another promotes spontaneity and play. A third, the instinct to nurture others, which Panksepp calls care , is activated by the release of the hormone oxytocin into the bloodstream and brain. Another mood system Panksepp calls "panic" is experienced as yearning or even abandonment, when an intimate partner leaves on an unexpected business trip or storms out of the house during a fight.
Most of these mood states can help promote emotional bonding during couples therapy. But the states that therapists find the most frustrating in the consulting room--and often the most common--are two other body-brain mood states that used to be called fight or flight. Activated by the amygdala, they produce self-protective thinking and action. Fight, which Panksepp calls rage, quickens the breathing, sends blood to the muscles in preparation for striking out, and releases adrenaline and noradrenaline into the bloodstream and brain. It sharpens some mental functions and leads a person to think in decisive, impulsive, blaming, oversimplified ways. It's accompanied by the attitude "You're wrong, and I'm right."
This hormonal cascade can be lifesaving in the appropriate situation--in the face of a dangerous driver, say, or a possible mugger or rapist. But in intimate relationships, it's often toxic. In its grip, men (and some women) can become physically abusive; others yell, nag, blame, and complain. And as almost everyone knows, it's much easier to get on this particular tiger than to get off.
The second self-protective cascade, which Panksepp calls fear, produces feelings ranging from anxiety to intense fright, along with worried thoughts and the impulse to freeze, flee, withdraw, or hide. It, too, is accompanied by critical thoughts about the intimate partner. A man in the grip of this neurochemical cascade may exhibit sullen, disgusted, or spacey withdrawal in the face of a barrage of angry complaints from his wife.
Hence my frustration. I couldn't understand why couples continued in these patterns when they'd learned--in those magical moments of insight--that blaming or withdrawing didn't help them get what they wanted. It seemed so irrational. But when people are in the grip of these emotional takeovers, certain parts of the prefrontal cortex (the folded outer layer of the brain behind the forehead) are less active than when they're calm. The prefrontal cortex is the seat of free will and self-awareness. It allows us to plan, strategize, imagine the results of our actions, and choose to do one thing rather than another. When portions of it are inactive, as they appear to be when we're in the grip of one of our executive operating systems, our inner switchmaster is asleep: we simply can't shift from one state or course of action to another. So the wife keeps blaming, like a hamster on its treadmill, and the husband, in an equally mechanical state, keeps staring out the window.
Learning to Shift Mood States
When I first encountered this information in the early '90s, I worked at getting clients to shift out of these powerful mood states. When I got frustrated, I reminded myself that they were caught in neurochemical reactions beyond their control. I'd usually have one partner wait in the waiting room for a few minutes while I worked with the other, finding that a few minutes of concentrated empathy, validation, and acceptance would often calm someone down. Under these conditions, they could hear me say--in a soothing tone--that blaming would only stimulate the other's defensiveness and not get them what they wanted. We could then brainstorm more pragmatic, emotionally open, skillful ways of communicating. I was training them to reactivate the neocortex--the inner switchmaster--in the face of strong emotion.
I assumed the lessons would stick, but I was disappointed. I'd underestimated the hardwired nature of my clients' automatically activated, neural- response programs, ingrained through years of relating to each other. They needed far more practice than a weekly therapy session could provide.
It wasn't enough for my clients to rehearse new thoughts in calm moments. They needed to practice new ways of thinking under "game conditions"--when they were actually upset and least able to think clearly. And they'd have to do this over and over: most neuroscience researchers agree that the brain acquires new habits through repetition. One of the most enduring concepts in neuroscience is Hebb's Law, named after the pioneering McGill University neuroscientist Donald Hebb, who stated that brain processes that occur together over and over again become grafted together, and are more likely to occur in conjunction in the future. According to Hebb's Law, if my clients engaged in new thinking processes while they were upset, and did this enough times, the new thinking processes would begin happening spontaneously each time they became upset.
Then one of my clients, a registered nurse named Judy, who kept struggling to tame her tendency to get enraged with her husband, said to me, "If only I could take you home with me!" When she was furious, she was in the grip of the delusion that her anger was her empowering friend, only to find that her outbursts actually disempowered her. She asked me to make an audiotape for her to listen to precisely at the moments when she became upset with her husband. In this audiotape, I offered encouraging words and reminded her repeatedly that she was far more influential and powerful when she stood up for herself in ways that didn't put her husband down.
She loved the tape and listened to it not only when she was upset, but also when she was driving in her car and on a Walkman, while she was doing the laundry and cleaning house. Within three weeks, she experienced a dramatic shift in a lifelong destructive pattern.
I made more elaborate tapes for Maria and Tony, who trudged into my office one crisp October evening for their fourth session. Maria was so upset that she refused to speak to Tony. She'd had elective surgery the previous week, and had gone into rage mode when Tony left her alone in the hospital one night to go home and get some sleep. I asked Tony to stay in the waiting room while Maria told me how incredibly selfish he was for thinking of himself when she was in so much distress. In the grip of her amygdala-driven cascade, she couldn't see that her attack was sending Tony into disgusted withdrawal as usual. I sympathized with her feelings, and then simply suggested that although her attitude was perfectly understandable, she'd need to drop the idea that he'd done something wrong, and simply tell him how she felt. She struggled inside for a moment and then relaxed. Her eyes moistened and she said softly, "Okay, I think I can do it." When Tony joined us, Maria spoke from a different place inside, and Tony responded instantly with an apology.
I then made an audiotape that essentially repeated the words that had helped Maria shift during this session, and asked her to listen to it each time she became upset with Tony during the following week. The next day, she got off work early, pulled into the driveway, and saw her children playing at the neighbor's house, even though Tony had agreed that he wouldn't let the kids go out to play after school until they'd finished their homework. She felt a surge of anger, but as she reached for the car door, she remembered the audiotape in her purse. She paused for a split second, torn between the urge to vent and the desire to avoid going down the same old path.
Reluctantly, she plugged in the tape and listened in the car. After 10 minutes, she realized that she was in no frame of mind to talk to Tony, and decided to take a walk around the block. After 20 minutes, she felt calmer, and by the time she saw Tony, she was able to keep an open mind and simply ask him why the kids were playing, rather than accuse him of breaking their agreement.
What happened during Maria's walk around the block? Frankly, I don't know. In Maria's audiotape, I didn't tell her what to do or how to shift her attitude, I simply reminded her of a few reasons why she might want to try. The decision was hers. Clients often have difficulty describing how they get shifts to happen. Most report a willingness to let go of control and a momentary surrender to the fact that you can't make life go exactly according to your plans. The shift is usually accompanied by physical relaxation and a release from obsessive thinking. The client returns to the present moment, and is able to respond to what's actually happening, rather than what they fear is going to happen. The most important ingredient in getting an attitude shift to happen is desire. When clients decide they truly want to shift, they do.
What clients report helps them shift brain states has something in common with many repetitive religious practices--from praying "Thy will be done" to practicing mindfulness, kissing a St. Christopher medal before going up to bat, or making a list each night of things one is grateful for. All of these approaches help people create enough of a pause to free them from the grip of intense rage or fear and to generate states of generosity, acceptance, and trust. Like them, my audiotapes allow the body and brain to calm down, and they serve as timely reminders that it's in the client's best interest to try to shift.
Maria, for instance, used her tape as regularly as some people light candles at mass. She told me that she often could feel an attitude change beginning as soon as she heard my calm, confident tone. It reminded me of what attachment researchers speak of when securely attached children evoke images of their caregivers to soothe themselves. In her third week of using the tapes, Maria told me that she began to spontaneously hear my voice inside her head every time she got upset.
Some clients need little more than a verbal reminder. Others require vivid images or metaphors. Tony, for instance, once told me that when he reflexively defended himself, he felt like he was swatting Maria's complaints back at her with a baseball bat. In a minisession without Maria, I helped him imagine turning the bat into a pillow. The image worked, and when Maria returned, he was better able to absorb and digest what she had to say.
I put the pillow image on a tape for Tony. Then we got Maria to record a tape full of her complaints--a litany about how Tony didn't keep his word, didn't fix things around the house, and hadn't kept the kids quiet on Saturday morning after promising he'd let her sleep in. In a solo session, I had Tony listen. As soon as he began feeling defensive, we'd stop the tape and he'd focus on how his body felt; he'd tremble and go into a sort of disgusted shutdown. Then he'd practice trying to shift, seeing the pillows, relaxing physically, reminding himself that there might be some validity to her point of view. Then we'd start the tape up again and repeat the process. Tony used the tape regularly in his truck and became so adept at generating a state of acceptance and compassion that one of his employees remarked that he'd undergone what seemed like a spiritual shift.
I still love the drama of transformative experiences, and my favorite moments are still the tearful ones, when partners drop their defenses and exchange heartfelt expressions of love. But nowadays, I see these moments as just the beginning. They give clients the motivation for the real work of change, which is much less dramatic. I rarely get to see it because it doesn't happen in my office. It happens a little bit at a time, day in, day out, as clients practice letting go of the critical judgments that arise with the brain's self-protective mood states.
My happiest clients make shifting a daily practice, not unlike prayer. The tape recorder, and all my modern knowledge about neuroscience, have ended up supporting the practice of routine and ritual, largely ignored by modern psychotherapists, but intuitively known and practiced by sages since the beginning of time.
Brent Atkinson is the director of the family therapy program at Northern Illinois University, and is in private practice in Geneva, Illinois. Address: School of FCNS, Northern Illinois University, DeKalb, IL 60115. E-mails to the author may be sent to: Brent@thecouplesclinic.com.
by Babette Rothschild
Empathy is the connective tissue of good therapy. It's what enables us to establish bonds of trust with clients, and to meet them with our hearts as well as our minds. Empathy enhances our insights, sharpens our hunches, and, at times, seems to allow us to "read" a client's mind. Yet, vital as it is to our work, empathy has remained a rather fuzzy concept in psychotherapy. To many of us, it seems to arise from a kind of potluck stew of emotional resonance and insight, seasoned with lots of attuned presence and a generous dollop of luck.
Far from the therapy office, in the precisely measured environment of the research lab, brain scientists are discovering that a particular cluster of our neurons is specifically designed and primed to mirror another's bodily responses and emotions. We're hardwired, it appears, to feel each other's happiness and pain--more deeply than we ever knew. Moreover, the royal road to empathy is through the body, not the mind. Notwithstanding the river of words that flow through the therapy room, it's the sight of a client looking unhappy, or tense, or relieved, or enraged, that really gets our sympathetic synapses firing.
This news is both exhilarating and scary. The good news--for therapists, their clients, and the world at large--is that human beings may be more deeply capable of empathy than we ever imagined. If we're truly born to connect, perhaps there's hope for us all. The scarier news: if we're truly designed to mirror each other's feelings, we therapists may be exquisitely vulnerable to "catching" our clients' depression, rage, and anxiety, and succumbing to the ravages of "compassion fatigue." Given the hardwired nature of empathy, is it possible to say yea or nay to its effects on us? What steps might we take to harness and channel our natural-born empathy for the good of our clients--and ourselves?
I first recognized the physical force of empathy as a college student, with the help of my friend Nancy, who was studying to be a physical therapist. As we walked down a street together, she'd follow total strangers and subtly mimic their walking style. Copying a stranger's gait, and feeling it in her own body, gave her practice in identifying where one of her patients might be stiff, or in locating the source of a limp. Intrigued by this mysterious way of "knowing" someone, I asked her to teach me to do it, too. I began to surreptitiously mimic the walks of all manner of unsuspecting folk, from unsteady older people to cooler-than-thou teenage hipsters. What startled me was that not only did "walking in someone else's shoes" change the way I felt in my body, but it often altered my mood as well. When I copied the swaggering gait of a cocky young man, for example, I'd momentarily feel more confident--even happier--than before. I found this secret street life fascinating and fun, but I didn't think much about it until a few years later, when I started practicing clinical social work.
On my first job in the mid-1970s working in a family service agency, I began to notice peculiar things happening in my body when I sat in my office with clients. Some of my responses could be blamed on newbie jitters, but I strongly sensed that there was more to it than that. I particularly remember my bodily reactions to a young client named Allison. As she recounted the crises of her week in a spacey, disconnected way, she kept her body very still, and I had to lean forward to hear her whispery, almost inaudible, voice. As we worked together, I began to notice that I often felt lightheaded. When I began to pay attention to what was happening in my body, I found that my breathing had become very shallow--in fact, nearly undetectable. No wonder I was feeling lightheaded and spacey: I wasn't getting enough oxygen!
Turning my attention back to Allison, I noticed that her chest was barely moving. I was taken aback: we were breathing alike! I remembered then how my mimicry of walking patterns in college had often affected my bodily sensations and moods. Were my lightheadedness and general feelings of disconnectedness just the result of new-therapist nervousness, or the direct result of my imitation of Allison's breathing? If our breathing had actually become synchronized, I realized, it was totally unconscious on both our parts.
In all of my graduate-school discussions on the therapeutic relationship, including the fine points of transference and countertransference, I couldn't remember anyone who'd ever mentioned the possibility of "catching" bodily behaviors. Intrigued and a bit bewildered, I took my observations to my supervisor. I still remember her look of startled skepticism. "What an odd hypothesis," she finally remarked, her cool tone clearly implying that my experience wasn't to be taken seriously. I was dumbfounded by her lack of curiosity, but I never doubted my own sensations. On the contrary, increasingly fascinated with the role of the body in relational and emotional life, I began a serious study and practice of body psychotherapy.
In contrast to my suspicious supervisor, my body psychotherapy colleagues and teachers seemed to accept readily that their bodies were "in tune with" or "resonating with" those of their clients. Like actors, they regarded their bodies as essential, finely honed instruments of their craft. From these practitioners, I learned "postural mirroring," a technique instigated by dance therapists, wherein I'd attempt to get a reading on a client's emotional state by copying the way he sat, stood, or moved. There wasn't a lot of debate about the usefulness of such a technique: body psychotherapists simply assumed that "the body doesn't lie."
Tracking Down the Source
While I was heartened by the confirmation of my own observations, I was concerned about body psychotherapy's uncritical acceptance of a link between a therapist's and client's body states and emotions. I needed to know more: Where does our ability to resonate with each other, with such stunning immediacy and accuracy, come from? What core processes drive the dancelike synchronizations of movement and mood that I kept encountering?
Throughout the 1990s, I became a voracious student of neuroscience--at first, as a way to learn about the physiology of trauma. In the course of those studies, I discovered the term "vicarious traumatization" and documentation that therapists could actually suffer symptoms similar to their traumatized clients. At once, I was both concerned and excited. I wondered if the physiological and emotional reactions that accounted for this might have any relationship to my earlier gait experiments with Nancy, the incident with Allison, and my body psychotherapy colleagues' enthusiasm for client mimicry. I'd need to dig further.
I nurtured my curiosity at the library, on the internet, and through the PsychInfo and Medline databases. From the vast literature of social psychology, I learned that facial expressions were contagious--when baby smiles, Mom usually does, too--and that such synchrony affects the nervous system and can convey emotions. I also learned that people commonly, if unconsciously, copy each other's posture and synchronize breathing patterns.
As exciting as that research was, I still felt something was missing. The writings of neurologist Antonio Damasio, attachment specialist Allan Schore, interpersonal neurobiologist Daniel Siegel, and others told me that scientists could locate the effects of empathy in the brain. But, astonishingly, until the mid-1990s, no one had looked for a source of empathy in the brain. And, as I was to find out, the later discovery of the source of brain-to-brain empathy happened by accident.
Monkey See, Monkey Do
In 1996, an Italian neuroscience research team led by Giacomo Rizzolatti and Vittorio Gallese was studying grasping behaviors in monkeys. They attached electrodes to the monkeys' brains to observe precisely which neurons fired when a monkey grabbed a raisin with its hand. The research was routine: monkey grasped, specific neurons fired.
Then, during a break, one of the researchers hungrily reached out for a raisin. His fellow researchers coincidentally noticed something extraordinary on the monitor: neurons in the monkey's brain fired-- the exact same neurons that had fired earlier when the monkey grasped a raisin itself!
The team was astonished: nothing like this had ever been seen before. Their serendipitous finding was the first clue to the existence of what scientists now call "mirror neurons," so called because they appear to actually reflect the activity of another's brain cells. The monkey's response wasn't just simple recognition, as in "I know what the researcher is doing." That kind of observation activates other areas of the brain. What happened between monkey and researcher required a brand new concept, an altogether new theory of behavioral interdependence. The monkey's neurons fired as if it had made the same movement itself. This was a genuine brain-to-brain connection. In an instant, the definition of interconnectedness, the notion of empathy, changed forever.
Subsequent neuroimaging research in humans suggests that we, too, may have a similar mirror-neuron system that allows us to deeply "get" the experience of others. When people watch other individuals drumming their fingers, kicking a ball, or biting into an apple, the sectors of their brains that turn on are the same sectors that activate when they perform these behaviors themselves. Meanwhile, in a paper published last year entitled "The Roots of Empathy," Gallese pushed the envelope further by hypothesizing that "sensations and emotions displayed by others can also be 'empathized,' and therefore implicitly understood, through a mirror matching mechanism" in the brain. Soon, he believes, scientists will discover a mirror-neuron network that establishes, beyond a doubt, that we're born to resonate with one another at the deepest emotional levels.
While neuroscientists continue the slow work of confirming these promising findings and theories, therapists can begin to apply them now to empathize more strategically and effectively with their clients. Because empathy is rooted in the body, the more mindful therapists are of their own somatic responses, the more skillfully they can choose to engage mirror neurons to gain valuable information about a client's emotional state. Equally important, a therapist can choose to slow down, or even halt, the brain's rush to empathize when it might overwhelm the client--or the therapist.
Let's begin with the body's gift for sleuthing. When you want to get a literal feel for what it's like to be in your client's skin, you can consciously mirror some aspect of his or her behavior or expression. I tried this when I worked with Fred, a new college graduate who'd come into therapy to address his anxiety about dealing with authority in his first "real job." Though he'd grown up with a tyrannical father who'd beaten him regularly as a child, Fred couldn't see or feel any relationship between his childhood trauma and his current fear of standing up to his boss.
One afternoon, Fred arrived for his session deeply depressed. He'd been thinking about suicide, he said, but had no idea why. I wasn't sure either. As I asked him to describe what "suicidal" felt like in his body, I tuned in by copying his flat facial expression and slumped posture. Almost immediately, I began to experience in my own body the sense of deadness he'd just described to me. It reminded me of the "freeze" response that's an instinctive reaction to inescapable threat.
All at once, a light bulb flashed in my mind. "Fred," I asked, "have you ever seen a mouse that's been caught by a cat?" He nodded yes. "What does the mouse do?" I prodded. "It plays dead," he replied, his face beginning to brighten with interest. We then discussed the protective function of freezing for all prey, both animals and people. Finally, I asked Fred if he'd ever reacted that way himself.
"Yeah," he said softly, "when my dad beat me." As his father hit him, he told me, his body would lose all power and "go dead." For the first time, he made a felt connection between his childhood horrors and his current emotional state. It seemed a light bulb was also flashing in Fred's mind. As he began to talk thoughtfully about his own "internal mouse," his body posture gradually became more upright and animated, and by the end of the session he reported that his thoughts of suicide had receded.
Could I have helped Fred make this breakthrough with talk alone? Perhaps, but it would likely have entailed several more sessions full of the usual conversational roundabouts, byways, and detours. Instead, by mirroring him, I could quickly feel and then understand Fred's deadness.
While purposefully synchronizing with your client can often provide added insight or even jump-start a stalled session, be aware that the data you pick up isn't "pure" information. Just as gaps can occur between speaker and listener in verbal communication, so can somatic communication be distorted by your own filters. If, for example, you mimic your client's head tilt and get a feeling of anxiety in your chest, your client may indeed be anxious. But it also could be that you habitually tilt your head when you're anxious, so that repeating this action triggers the emotion. So be sure to check out your bodily hunches with your clients, as I did with Fred.
The Risks of Resonance
Mirroring a client can be a bit of a tightrope act. You can easily lose your balance and crash to earth, especially if you fail to stay focused. I learned this lesson the hard way.
A few years ago, my client Ronald was angry with me because I was leaving town for a few weeks. He was so full of fury that, for the first hour of a double session, he wouldn't talk at all. He sat half-facing away from me, tense and seething. From time to time, his eyes would fill with tears. Repeatedly, I tried to make verbal contact with him, using such standard gambits as "You seem very angry" and "This looks very difficult for you." But I had the unmistakable feeling that my words projected about a foot from my mouth, and then thudded heavily to the floor.
Finally, I decided to hold my tongue and let Ronald work it out himself. With my mind emptied of fix-it schemes and nothing much else to do, I began to consciously copy my client's hypertense posture. I clenched my jaw, clasped my hands tightly in my lap, and scrunched my shoulders forward.
Two things happened. The first was that within a minute or so, Ronald's posture began to loosen up a little and he began to talk about his feelings of impending abandonment. (I've since learned that mimicking another's posture can nonverbally convey understanding.) As he aired his rage and hurt, I was able to acknowledge his feelings and let him know that I could understand and accept his anger. By the end of the session, he reported feeling somewhat calmer.
But not me. After Ronald closed the door behind him, I realized that I was very uncomfortable. Actually, that's an understatement: I was practically unhinged with fury. But why? Was I angry at Ronald? Had the session triggered something from my own life? I tossed around a half-dozen possibilities in my mind, but nothing seemed to fit. Only later, when I talked it over with a colleague, did I remember: I'd copied Ronald's infuriated posture! My mirror neurons had done their job too well. Once I made this crucial connection, the "infection" began to drain--I could almost feel the fury leaking out of me. I returned to myself again in a matter of seconds.
To some therapists, what happened between Ronald and me may look like a textbook case of projective identification--a case of Ronald's "putting" his uncomfortable feelings into me and thereby "inducing" my fury. I couldn't disagree more. I was a full participant in the process: only after I actively mirrored Ronald did I begin to feel angry. But while my mimicry was entirely conscious--if later forgotten--I believe that this kind of brain-to-brain communication occurs at an unconscious level between clients and therapists all the time. The next time you feel that you may be suffering from the impact of a projective identification, you may need to look no further than your own body to discover whether you've mimicked your client's posture, facial expression, or breathing pattern. Routinely adding such a simple step could eliminate the blaming of clients for feelings that are, in fact, rooted in our own, naturally responsive, neural circuitry.
There's liberation here, particularly for therapists who often find themselves on the edge of emotional overload. Active awareness of your own neurally-mediated role in absorbing clients' feelings can help you control the contagion. Once you become aware of your mimicry, any behavior that brings you back to the sensations and feelings of your own body, and out of synchronization with the client, will help you to apply the "empathy brakes." You might stretch, take a drink of water, get up to fetch a pen, or write some notes. These steps won't short-circuit empathy, but rather will allow you to return to yourself--to a place of clarity, presence, and helpful attunement to your client.
When a Client Feels Your Pain
Empathy, of course, is a two-way street. Our clients often unconsciously mimic our body patterns and take on our corresponding emotional states. Many therapists instinctively foster this process. When, for example, you slow your own breathing and your anxious client subsequently slows his, you're engaging his mirror neurons. No words need be exchanged for the client to gradually match your slower respiration and begin to calm down.
But if clinicians' serenity is contagious, so, too, is their agitation. One morning, upon returning to Copenhagen (my then home) after a long visit to the United States, I was suffering from a particularly nasty case of jet lag. Though exhausted and headachy, I jumped right into my usual work schedule. At the end of my afternoon session with Helle, I asked her, as usual, "How are you feeling?" Helle proceeded to describe my jet lag in precise detail. "I feel very tired, and there's a feeling of pressure in my forehead," she said, rubbing her eyebrows. "I also feel an odd heaviness in my chest. And I'm hungry, though I shouldn't be: I ate a good lunch just before I came."
I suggested to Helle that she stand up and walk around the room, hoping that the physical activity would move her out of my somatic sphere of influence and back into her own body. After pacing for a minute or two, she returned to her chair, noticeably more energetic. "My exhaustion and hunger have disappeared!" she reported. I then told her how I was feeling, that she'd described my sensations precisely.
Since consciousness is an important part of the process of controlling the neuronal dance, we spent a few minutes tracking how Helle had "caught" my state. In retracing her postures, she realized she'd rested her head on her hand as I'd tiredly done. That ordinary act of unconscious mimicry was enough to make her vulnerable to feeling my jet lag and the untimely hunger that accompanied it.
Psychiatrist and early attachment expert Daniel Stern calls the moments of true meeting in therapy a "shared feeling voyage." Though each voyage may last but a few seconds, we've all experienced its potent rush--the sudden throb of feeling not just for but with a client, a sensation of jolting connectedness that can be both exhilarating and fearsome in its intensity. What we've always imagined to be a resonance born of voice, smile, tears, or touch is encoded in us, it turns out, far more deeply and inexorably than we ever knew. It may be that our mirror neurons, those tiny and inescapable vessels of empathy, encapsulate one of the most exciting challenges of psychotherapy--that of attuning two brains, and two hearts, so that they warmly vibrate together without melting into one.
Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles and gives professional trainings worldwide. She's the author of The Body Remembers:The Psychophysiologyy of Trauma and Trauma Treatment and The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. Website: www.trauma.cc. E-mails to the author may be sent to: email@example.com.
Gallese, Vittorio. "The Roots of Empathy: The Shared Manifold Hypothesis and the Neural Basis of Intersubjectivity." Psychopathology 36 (2003): 171-80.Hatfield, Elaine, John T. Cacioppo, and Richard L. Rapson. Emotional Contagion: Studies in Emotion and Social Interaction. Cambridge, England: Cambridge University Press, 1994.
Rothschild, Babette, and M. L. Rand. Help for the Helper: The Mind and Body of Compassion Fatigue, Vicarious Trauma, and Burnout. New York: W. W. Norton, forthcoming.
by Mary Sykes Wylie
In 1999, a few months after child psychiatrist Daniel Siegel's book The Developing Mind: Toward a Neurobiology of Interpersonal Experience was published, Siegel received an e-mail, purporting to be from a representative of Pope John Paul II, asking him to come to the Vatican to talk to the Pope. Thinking the e-mail was a prank, Siegel ignored it--why would the Pope invite an expert on the neurobiology of childhood attachment over to the Vatican to schmooze? Nevertheless, one enigmatic detail of the message stuck in Siegel's mind as he deleted it: the Pope, according to the message, wanted very much to know why "the mother's gaze" was so critical to the growth and emotional well-being of a baby.
As it turned out, the e-mail was legitimate. An official letter soon followed from the Pontifical Council for the Family, formally inviting Siegel to be the main speaker at a Vatican conference for church leaders and Catholic social services providers and missionaries, to be followed by a private Papal audience for Siegel and his family. Siegel accepted the invitation with one caveat: he wanted the Pope to know ahead of time that the all-important loving gaze could come from either parent or from another attachment figure--it didn't have to originate with the mother.
Reading John Paul's biography before he left for Rome, Siegel discovered something he thought might explain the Pope's request. When John Paul was asked by the biographer if he remembered much about his mother, who had died when he was a young child, he said no at first. Then, a bit later, he backed up, saying he did recall one thing--"I remember my mother's gaze." Could the Pope want Siegel to explain what happened in the brain that made this ephemeral moment in the life of a young boy still resonate, like a lost dream, many decades later in the heart and mind of a frail, elderly man?
What drew the Pope to Siegel's work was apparently the search for some illumination about the small, everyday miracle of that gaze--what novelist George Eliot called "the meeting eyes of love"--that every child yearns for and must have, literally, to survive. Repeated tens of thousands of times in the child's life, these small moments of mutual rapport serve to transmit the best part of our humanity--our capacity for love--from one generation to the next.
For many therapists, what Siegel has done is to show just how, from the moment we're born, our most important relationships fire into being the neural circuits of the brain that allow us to understand and empathize with others and feel their feelings. But beyond that, he's gone on to link his interest in both science and the nuance of relationship with the almost unfathomable complexities of neuroscience to generate a field he calls "interpersonal neurobiology," which has brought the latest findings of brain science directly into the therapist's consulting room. As much as any figure in the mental health field, he's taken on, as both a professional challenge and a personal quest, the task of showing his clinician colleagues how the objective, physical matter of the brain--its lobes, modules, folds, lumps, tubes, and fibers--creates the possibilities for the subjective life of the mind, heart, soul, and spirit that is the glory of our species.
While still only 47 and not a formal brain researcher himself--certainly not the originator of the massive, accumulating body of theory regarding the processes of human attachment-- Siegel has displayed a unique ability as a synthesizer, weaving together strands of knowledge from a variety of fields. Through his highly influential book and hundreds of workshop presentations he's given around the globe in recent years, he's tried to bridge the previously disconnected worlds of neuroscience research and clinical practice. "Dan is the right person at the right time," says Pat Love, a noted couples therapist and workshop presenter who's devoted the past several years to integrating neuroscience into her own clinical work. "His work cuts across disciplinary lines to bring together neuroscience, developmental theory, evolutionary psychology, systems theory, psychiatry, medicine, and psychotherapy and point us toward the integrated thinking that will shape the future of our field."
Siegel is by no means the first clinician to have talked about the role of attachment and brain processes in clinical work. For more than 50 years, attachment theory has been a significant feature on the landscape of childhood development research. But until recently, how attachment research might inform knowledge about adult psychology was virtually ignored by psychotherapists. For example, Los Angeles psychologist Marion Solomon recalls traveling with a group of associates to England in the early 1980s to visit pioneering attachment researcher John Bowlby and enthusiastically bringing back tapes of his works. When she returned, however, she found that "no one was interested in considering the clinical implications of attachment theory. They just weren't buying the ideas." According to Solomon, however, "There's something about the way Dan has put this material together that makes the lights go on for people. He's propelled attachment theory and neuroscience beyond the tipping point within the therapy world."
Considered a tour de force by reviewers from the worlds of clinical and research psychology and psychiatry, The Developing Mind --a densely packed synthesis of childhood attachment research, cognitive science, the study of emotion, and complexity theory--has definitely established Siegel's credentials as a major expositor and interpretor of neuroscience esoterica to nonspecialists. But even the book's critical success doesn't, in itself, explain the excitement he's been able to generate within the field. After all, it's a daunting read that probably won't be chosen anytime soon for the Oprah book club.
Explaining Siegel's impact, students and colleagues again and again cite the distinctive personal electricity he conveys. "Dan is a born connector," says Marion Solomon, "whether it's one-to-one or with an audience of thousands." His friend Alan Schore, known for his groundbreaking research and theoretical work on childhood attachment, still remembers his first meeting with Siegel 10 years ago at a dinner party. "We just started talking, and before I knew it I was intellectually and emotionally in synch with him," recalls Schore. "The only other person with whom I'd ever clicked like that was my wife."
"Even if you're listening to him in a large audience, you have the sense that Dan is speaking directly to you," adds Schore. That seems to be part of the mesmerizing effect that Siegel's public lectures have. Take the 2003 Psychotherapy Networker Symposium at which Siegel delivered a 45-minute keynote loaded with high-end neurospeak, sprinkled with references to the orbitofrontal cortex, anterior cigulate, hippocampus, the intricacies of neural transmission, synaptic plasticity. and gene expression. Clearly, it wasn't the kind of thing calculated to electrify an early-morning crowd. But from the first moments of his talk, when the soft-spoken, boyish-looking Siegel, apparently dressed by L.L. Bean, ambled on stage without notes to address an audience of 3,000, he had the mostly neuroscientifically challenged crowd on the edge of their chairs with enthusiasm.
Hundreds of shoulders in the hall palpably relaxed as he drew a laugh admitting that, as a medical student, the task of trying to remember the multisyllabic names for different brain parts "made me nauseous." Like a class of born-again biology fans, the crowd happily imitated Siegel as he repeatedly referred to his "hand puppet" model of the brain--balled fist, with knuckles representing the prefrontal cortex and the middle of the palm standing in for the brain stem. "Dan can take complicated ideas and put them into everyday language," says Marion Solomon. "He just conveys a driving curiosity that's irresistible to audiences."
It isn't just Siegel's skill as a communicator that enables him to connect so well with an audience, but the message he brings about the nature of the brain. Most of us who had any exposure at all to the human (rather than, say, the frog) brain in our biology classes were taught about the "single-skull" version. Translating his thorny subject for nonspecialists, Siegel enthralls audiences with his vision of the brain as an exquisitely social organ. From birth, it's not the relentless unfolding of a genetic plan that determines the shape of our adult minds, Siegel explains, but what happens between different brains that largely shapes what happens inside our individual brains. He opens up unexplored vistas of a plastic, self-renewing brain, with capacities to rewire itself in response to changing circumstances that go well beyond assumptions about our innate, hardwired limitations prevalent in neuroscience circles until only a few years ago.
For those inspired by the synthesis Siegel offers, his contribution transcends a particular concept or a set of change techniques. "In recent years, the therapy field has been dominated by theoretical eclecticism and a lot of attention to techniques and practical interventions, as if you can believe anything you want theoretically," says Sue Johnson, an originator of Emotionally-Focused Couples Therapy, one of the most empirically supported marital therapy approaches. "What Dan Siegel has done is give us a bridge to science and a much clearer idea about the organizing brain structure of relationships," adds Pat Love. "For the first time, Siegel is offering a neuroscientific paradigm for understanding how all kinds of psychotherapy work. He's taking us beyond anecdotes and metaphors and vague theories and 'it-works-because-I-say-so' into a measurable science of human nature."
DSM 'n Drugs
But the ability to connect disparate disciplines didn't come easily. Soon after enrolling at Harvard Medical School in 1978, the young Siegel, still unsure of his own career path, found himself plunged into a professional culture focused on diseases and pathologies. It jarred him to listen to doctors and his fellow medical students refer to patients as isolated body parts--"I saw an incredible kidney today," or "There's a very interesting liver in room 415." He soon found himself regularly being dressed down for spending too much time listening to his patients' stories. "If you want to listen to people's stories, go to social work school--that's not what doctors do!" one irate supervisor told him.
Disillusioned, he dropped out of med school and spent a vagabond year considering various "careers," including professional dancing, carpentry, documentary filmmaking, and salmon fishing. It was a fellow fisherman who turned Siegel away from that particular career choice, pointing out that fishing was all about "getting up at 3 a.m, bending over the side of a freezing boat for hours, your back killing you, throwing fishhooks out and pulling them in until your hands are too crippled to do much else." This de facto career advisor told Siegel that he himself was quitting fishing and going back to graduate school in psychology, and that Siegel should go back to medical school. Soon after that, working on a film interview of a man writing a book about the left and right sides of the brain, Siegel had a mini career epiphany and decided he, too, was fascinated by the brain and the mind. But since it would have taken him too long to get the credits he needed for psychology graduate school, he decided to return to medical school at Harvard and focus on psychiatry.
Academic psychiatry during the '80s, it turned out, was exactly the wrong place for someone eager to develop a holistic, integrated view of the mind and brain. An increasingly reductionistic biological (i.e. psychopharmaceutical) psychiatry had just begun its relentless push for dominance. With the advent of DSM III and the torrent of new medications pouring out of the pharmaceutical pipeline, psychiatry grew ever more inclined to define emotional and mental problems as purely medical illnesses reflecting biochemical imbalances in the brain. Diagnosis became a game of parsing DSM categories and subcategories, and treatment a matter of prescribing meds to amp up or dampen down the synaptic exchange of neurotransmitters. The last thing that interested these scientist-psychiatrists was a vaporous, 19th-century concept like mind. "There was no understanding that subjective human experience--feelings--was an objective scientific reality," recalls Siegel. "Psychiatrists were supposed to be experts on the brain, and all they were interested in was knowing how neurons fire--they weren't interested in feelings."
Siegel found the emerging infatuation with the DSM 'n Drugs combo deeply distasteful and a betrayal of what he considered the deeper mission of psychiatry. "I hated to see colleagues and trainees seeing patients for half an hour for a meds check, then sending them off until their next appointment three months later," he says. For him, the self-conscious scientism of the new psychiatry was a crabbed, distorted version of real scientific inquiry: "The only brain mechanisms we ever really talked about were neurotransmitter receptors."
One case from this frustrating period that underscored biological psychiatry's lack of imagination sticks in Siegel's mind. He was seeing a young woman in therapy who was suffering from unresolved grief and guilt at the loss of a parent. Eventually, she got better, and when she was ready to leave, Siegel asked her what had been most helpful about her treatment. She thought for a minute and then said, "When I'm with you, I feel felt. " Her remark about what is a perfectly commonplace experience in good therapy contrasted for Siegel with the indifference to relationship that he saw all around him. "She could see that my inner emotional state was affected by her inner emotional state, and that profoundly changed her experience of herself, which gave her hope that she could change." But the scientist in Siegel also wanted to know what exactly the objective brain mechanisms were that resulted in this profoundly healing interpersonal experience.
At the time, the psychiatry department at Harvard was a war zone of mutually antagonistic factions, each speaking its own language, sunk in its own pet paradigms (biological psychiatry, psychoanalytic psychiatry, descriptive psychiatry, social psychiatry) who, Siegel recalls, "all bad-mouthed each other." But whatever his feelings about the shortcomings of biological psychiatry, the field of psychotherapy offered little attraction for Siegel. Its most influential models didn't exhibit the barest interest in neurobiology or, in his opinion, even a decent regard for ordinary intellectual consistency. And despite his humanistic inclinations, he still wanted a disciplined, scientifically plausible explanation of the core phenomena therapists dealt with--human personality, emotion, memory, and identity. But none of the "explanations" offered by various psychiatric denominations, or the deceptively-neat DSM taxonomy, actually explained anything to him. Siegel regarded them as "ever more complicated definitions of observations--they all seemed about as substantial as plumes of smoke."
It seemed to Siegel that any explanation worth its salt must incorporate both the biological and the personal; it must somehow include the physical brain, the individual story of the particular human being, and the evolutionary story of the whole species. It had to reflect the tough-minded objectivity of science and the "soft" subjectivity of ordinary human experience. Neither "scientific" psychiatry, which reduced an individual to the ebb and flow of brain chemistry, nor a Tower of Babel of contending psychotherapies, which completely ignored the living brain, even came close to meeting these apparently impossible goals.
No Axe to Grind
During the late '80s, Siegel found something approaching the kind of theoretical connective tissue he was looking for when he discovered attachment theory. In the previous 40-odd years, attachment researchers following the pioneering work of John Bowlby and Mary Ainsworth had built up a formidable body of empirical research to show that a young child's sense of security, safety, and well-being depends largely upon the emotional quality of his relationship with his primary caregivers. And it was this secure base in early childhood, the theory continued, that enabled a child to grow into an emotionally stable adult and become a good parent to his or her own children.
For Siegel, attachment researchers, with their careful attention to measurement and moment-by-moment interaction, "seemed beautifully nonpartisan and unbiased, without any clinical or theoretical axe to grind." He also found in attachment theory something he'd missed in other explanatory models--a rigorously scientific field that focused on something more emotionally compelling than the synaptic vicissitudes of neurotransmitters. Here was a field that posed the most fundamental questions about the small miracle by which we actually become human beings: How does a coherent sense of self emerge from the turmoil of fluctuating sensations that is a baby's mind? How does early experience shape our personalities? How do we learn to love? Why do we tend to treat our children the way we were treated? Why does parenting matter?
In 1988, Siegel heard one of the pioneers of attachment theory, Mary Main, give a talk about her work on what she called "coherent narrative." Main and her colleagues had devised an instrument called the Adult Attachment Interview (AAI), in which parents were asked about their recollections of their own childhoods. What Main's research indicated was that the way these parents told their own stories--how they made sense of their past lives, or didn't--was the most powerful predictor (85 percent accuracy) of whether their own children would be securely attached to them. If adults could create a reflective, coherent, and emotionally-rich narrative about their own childhoods, they were likely to form a good, secure relationship with their children--no matter how "insecurely attached" they themselves had been as children or how inadequate or even abusive their own parents were. It wasn't what happened to them as children, but how they came to make sense of what happened to them that predicted their emotional integration as adults and what kind of parents they'd be.
The narrative material struck Siegel "like a lightning bolt," extending attachment research beyond the nonverbal attunement of "the mother's gaze" into the realm of memory and language. As much as we need the wordless love and the creaturely comfort of our parents and caregivers, we also need to acquire the ability--the mental and emotional wherewithal--to put our experience into words in order to fulfill our biological potential as human beings. For Siegel, the idea of narrative became the key to a bigger, more coherent, "story" than either psychiatry or psychology had so far been able to produce. "Anthropology shows us that every culture on earth tells stories. For the last 40,000 years we, as a species, have been trying to bring what's inside of us out--to make sense of what we see and put it out there for other people to hear," says Siegel. "Stories bring together the external, observable, objective world and our internal experience of our minds. The capacity and need to tell stories is not only part of our culture, but part of our evolutionary heritage, built into our genetic code and embedded in the circuits of our brains."
Furthermore, the findings on narrative were a real beacon of hope, empirically reinforcing the commonsense notion that people can change--their lives are not determined by their bad beginnings. In fact, according to the attachment researchers, a person can earn her emotional security and ability to create a coherent narrative about her past through personal growth and involvement in positive, healthy relationships with teachers, friends, lovers, mates, and, of course, therapists. "I loved the way attachment research showed that fate (having less-than-perfect parents) isn't necessarily destiny," says Siegel. "If you can make sense of your story, you can change it."
Of course, most therapists share Siegel's interest in the transformative power of narrative, but not his need to ground his beliefs in scientific principle. For him, however, it was as if he'd opened one of a set of nested Chinese boxes--discovering one powerful explanatory system in the connection between narrative and attachment theory--only to come across another, smaller, but even more intriguing box. What, he wondered, were the neurobiological mechanisms that made attachment so important? How does coherent narrative "happen" in the brain?
Of Coherence and Incoherence
The question of how we develop a coherent narrative was becoming clinically relevant for Siegel because he had a number of patients with PTSD, and one of the most striking symptoms of his traumatized patients was their inability to construct a coherent story about their past. If asked to talk about what happened to them as children, they became disorganized and incoherent, couldn't remember major events of their own life histories, and frequently became emotionally distraught just making the effort to recall the past. These patients remembered traumatic incidents while in one state of mind and then had no memory of the same incident when in another state of mind. They confused the past and the present and experienced highly charged, intrusive flashbacks that didn't seem like "normal" declarative memories. To Siegel, there was clearly some connection between their traumatic past--what was called their "disorganized attachment"--and something going on in their brains that prevented them from making sense of their own stories.
As a clinician, Siegel knew that PTSD was assumed to be related to dissociation, but what did that mean? How could clients both not remember enough to tell a coherent story and at the same time remember all too much, all too vividly? Psychiatrists still described these symptoms in the archaic and inadequate language of psychoanalysis--conscious versus unconscious or repressed memory--which was too schematic and narrowly sectarian to make sense of phenomena that, literally, burst the bounds of standard theories and models.
To find some more promising answers, Siegel began studying neuroscience in earnest. While exploring the complexities of memory, he learned from some of the leading authorities in the research world about the fascinating difference between implicit and explicit memory, and the newly discovered role of a horn-shaped region of the brain called the hippocampus. Implicit memory is a form of nonverbal, unconscious memory, present at birth, which lays down neural pathways encoding emotion (via the amygdala), behavioral patterns, and learned habits (like driving), perceptions, and probably bodily memory. We may experience very strong feelings or body sensations triggered by an implicit memory, for example, but have no subjective awareness of consciously recalling anything--we just feel something powerful. About a year after birth, the hippocampus comes online and begins to encode explicit memories, including consciously recalled facts--"Richard Wagner was married to Franz Liszt's daughter"--and the countless past experiences, feelings, and thoughts that make up our awareness of our autobiographical past.
Discovering the division between implicit and explicit memory and the role of the hippocampus in turning the former into the latter was, for Siegel, like finding a trail after hacking his way through a dense jungle. "The timing was wonderful, coming just when I was learning about attachment narratives and desperate to understand trauma," Siegel says. It dawned on him that the disruption of the hippocampus and the processing of explicit memory might have something to do with why both PTSD clients and "disorganized" parents in the attachment research couldn't relate a coherent story about the terrible past. What if trauma shut off the hippocampus, so that horrible sensations and experiences flooded the amygdala and were laid down as implicit memories, but were blocked from becoming explicit memories? That might explain the odd fact that people with PTSD experienced their memories in the here and now without having the sensation of remembering them. Today, this theory is old hat among trauma therapists and researchers (though still surprisingly unfamiliar to many other clinicians). Even so, however, when the discovery of what the hippocampus did was itself brand new, nobody seems to have made that connection.
Siegel first publicly floated his idea at a conference in 1992, attended by famous heavyweights from the trauma and neuroscience communities (including Eric Kandel, later winner of a Nobel prize for demonstrating how experience creates new neural connections in the brain). During one session, somebody in the audience asked, "How do you explain traumatic repression in terms of the brain?" Nobody had an answer. Siegel, still considered a junior colleague by many of the prominent figures in attendance, daringly raised his hand. "I was just this punk kid, but I threw out my idea--Is it possible that if the hippocampus is blocked during a trauma, you could be vulnerable to flashbacks and dissociation because, while you'd have the implicit memory of the event, you'd have no explicit, declarative memory of it?' Then I sat down."
At the break, an intrigued mob surrounded Siegel and asked him to amplify on this extremely interesting and radical idea of his. "It was the first experience I ever had of going to the brain to find out how people's mental processes work and coming up with an answer that might pave a way to better treatment," Siegel remembers.
Brain and Mind
Siegel was soon feverishly exploring anything else he could find out about how the brain worked and what light neurobiological research might shed on the problems of his patients. From 1991 to 1995, while the head of training in child psychiatry at UCLA, he led a study group, a multidisciplinary dream-team loaded with experts--anthropologists, evolutionary biologists, linguists, geneticists, psychiatrists, and heavily weighted with neuro-types, including neurobiologists, neurologists, and neurosurgeons. "I was realizing that the brain held the secrets to the mind," he says now.
He focused, for example, on the clinical implications of the fact that the right and left hemispheres work in dramatically different ways. By then it was commonly understood that the left brain is associated with logic, cause-effect reasoning, verbal processing, and linear thinking, while the right is associated with nonlinear, holistic (big-picture) thinking, intense emotion, body sense, social awareness, and nonverbal communication. What Siegel became interested in was that a coherent narrative about the past requires both hemispheres to be fully online: the right holds the images, themes, and sense of personal self existing across time, while the left holds the drive to make logical meaning and put words to these wordless feeling states and perceptions. Right away, this seemed to explain the difficulties many people had in creating coherent narrative: if the two sides of the brain weren't working together, the story would either be chaotic and confused--overwhelming feeling, overwhelmed thought--or superficially logical but lacking the emotional oomph of a good, coherent autobiographical story
He decided to try out the theory that integrating brain function could be beneficial therapeutically with clients who had an impoverished sense of their own past and couldn't really feel or express emotion: "I'd worked out a hypothesis that this type of patient might respond to therapy that explicitly stimulated the development of the right hemisphere." And it worked. A lot of the patients, who usually intellectualized their way through talk therapy, responded very well to guided imagery, sensate-body focusing, and practice in using and picking up on nonverbal cues.
Simply telling patients what might be going on in their brains, he discovered, could also be both deeply comforting and therapeutic. He explained to patients with PTSD the difference between implicit and explicit memory and the function of the hippocampus, and they felt less crazy. "You're telling me I'm not nuts," said one greatly relieved patient, who thought she was going insane because of the flashbacks and intrusive images that hounded her. As she put it, "It's just that the bad things that happened to me got fragmented in my mind and were never put together into my regular memory by my hippowhatsis."
Soon, he was spiking his therapy with brief, neurobiological vignettes that helped clients understand why they were so prone to sudden rages, or had such rotten love lives, or felt so anxious all the time. Siegel became adept at explaining the role of the unbridled amygdala, the self-calming talents of the neocortex, the heroically integrative properties of the orbitofrontal cortex, the amazing system of mirror neurons that allows us to pick up and feel the feelings and intentions of others--the remarkable capacity for "mindsight." He even started keeping a chalkboard in his office to draw rough sketches of the brain and its parts, which helped ground discussions of subjective mental experience in the world of physical reality. "Unlike most psychological concepts, the brain is a three-dimensional object that you can hold in your hand," he says. "It's also a visual entity, and we're very visual creatures--a lot of our cortical real estate is devoted to vision. So when I sketch the brain on the board, people can really 'see' it."
His patients loved it. Far from making them feel that their lives were completely determined by physiological processes beyond their control, they felt empowered. They discovered that their negative feelings weren't them, but originated from one part of their brains, which could be controlled by another part, actually altered by what they think . "Connections in the brain shape the way you think, but the flip side is true, too," says Siegel. "The way you think can change your brain. Neural firing changes neural connections--if you pay attention." We often have the idea that we have no power to control our own attention. Not so. "You can harness the power of your mind," says Siegel. "You can sit in your prefrontal cortex, where self-regulation is mediated, and simply notice, just notice, the mental processes emanating from different neural circuits of the brain--without locking onto them."
By now, the concept of mindfulness--detached attention to one's own feelings and thoughts--has acquired the fuzzy quality of overfamiliarity among therapists, becoming something of a New Age platitude. But Siegel gives it a fresh dimension by grounding it in the realities of neurobiology. His interest is in how mindfulness works in the brain and how it can, literally, change brain function. "Mindfulness promotes the integrative function of the prefrontal cortex," Siegel says. "It allows brain circuits to fire that have perhaps never fired before, giving people a sensation of inner awareness that they may never have had before." In short, it brings about neural changes that Siegel alternately calls "integration," "coherence," or "self-regulation."
At first glance, "self-regulation" is a mildly soporific term reminiscent of the psych lab, but from Siegel's perspective it defines the basic goal of all psychotherapy. "When you think about it, you can understand almost every mental health problem--anxiety, depression, eating disorders, personality disorders, thinking disorders--as an issue of self-regulation," Siegel remarks. Self-regulation, in the Siegel lexicon, is the balanced and integrated "flow of energy and information" through the major systems of the brain--brain stem, limbic circuits, neocortex, autonomic nervous system--and between one brain and another. When we're in this secure, stable state of mind-brain-body equilibrium, we can face life's vicissitudes with some measure of emotional calm, flexibility, self-awareness, and reason. Our relationships are good, and we're "mindful" almost as a matter of course.
But, according to Siegel, "self-regulation" is really something of a misnomer. What should by now be blindingly obvious is that our capacity for self-regulation depends so much upon our interactions with other people that it might well be called "other-regulated self- regulation." We're not born knowing how to regulate ourselves--in fact, we're alarmingly, chaotically, un -self-regulated creatures at birth, more so than most other newborn animals on earth. Loving parents, if we're lucky, begin the long process of teaching us how to organize and regulate our inner selves--encoding their care and attention in the pliable neural fibers that integrate various regions throughout our brains. No matter how good we had it in the beginning, however, we'll need reinforcement of these early lessons throughout life, and much remedial work if we were shortchanged early on.
For Siegel, therapists are the remedial attachment experts and rescuers of the chronically un-self-regulated, and it is their job to, in effect, help rewire the frayed neural connections, reintegrate (or sometimes integrate for the first time) different areas and functions of the brain--implicit and explicit memory, right and left hemisphere, neocortex with limbic system and brain stem. From Siegel's viewpoint of interpersonal neurobiology, here's how a therapist influences a distraught patient reliving a past traumatic event that hasn't yet been consolidated and turned into an ordinary memory.
Imagine you're such a patient sitting in your therapist's office. She sees that you're not in good shape--pale, shaky, agitated--and knows that your sympathetic nervous system is clearly running in overdrive. She listens to you try to explain what happened and realizes right away that your story isn't coherent--your left brain is struggling to make sense of this past event, but your words are being swamped by waves of intense right-hemisphere emotion. You stutter, forget things, swallow nervously, feel nauseated, and have to keep starting your story all over again. Something about what you're trying to say is still locked in your amygdala, in your implicit memory--still hasn't been processed by your hippocampus so it can become simply part of your explicit memory, and then incorporated into your consciously remembered autobiographical story. How can she help this neural integration happen?
Listening closely to you, your therapist lets you know that she's really there with you, she feels some of what you're feeling. She picks up your fear, confusion, despair, but without being overcome by them as you are. As a result, you "feel felt" through nonverbal signals and mirror neurons and you "see yourself" in her, allowing you to realize that you're authentically in her mind, and this changes your experience of the moment. You take a deep breath and feel a little safer, more grounded, calmer, almost as if her strong, steady mind is embracing your fragmented, chaotic one.
Knowing the brain is an associational organ, your therapist tries to elicit what it was about the recent triggering experiences that might have reminded you of something from the past. She sees how the past event affects you in the present and she joins you in this mental time travel, carefully probing your past and your present life. This helps bring the two into a more stable, integrated relationship with each other--allowing you to put a past event in the past, so you can viscerally distinguish the present moment from it and move forward into the future without fear that it will continue to haunt you. By doing this, she helps you increase neural integration between differentiated areas of the brain--the consolidation of memory via the hippocampus into the neocortex, and the synthesis of left-brain logic and right-brain emotion, so that the past event becomes no more and no less than an aspect of your conscious autobiographical story.
And so it goes. With her as your guide, you go back and forth with her between mind and brain, using your capacity for conscious thought and reflection on the buzzing activity within that neural hive beneath your skull. And as you do so, your immediate experience--your sense of yourself and your story--gradually changes. You begin seeing the past event in the context of other events, other times, relationships past and present, and you can weave it into an ongoing narrative of your life. As the implicit memories from years back are turned into part of a more coherent and inclusive autobiographical story, you feel relieved, somehow lighter. You also feel deep gratitude and affection for your therapist, as you would for someone with whom you've been through a life-or-death struggle and emerged victorious. In a sense, nothing has changed-- the past is still what it was--but everything has changed, because, in concert, your mind and this other sensitive, deeply attuned, intelligent mind have changed your brain. The gradual improvement in your capacity for "self-regulation" hasn't been a solo performance, but a duet sung in counterpoint.
For all his curiosity about the brain and its workings, Siegel professes himself largely indifferent to the subject of therapeutic technique. He doesn't seem to care particularly what methods therapists use, and consistently avoids telling them what they should do in treatment. "You can shape and harness synaptic connections in the brain by giving patients medications or doing therapy," he says. "You can also do it just by teaching them to meditate and get in touch with their bodies, go jogging, play music. Or you might use the fact that the self is defined by interpersonal communication to form reparative attachments with them." He doesn't even try very hard to sell the idea that all good therapists must know about neurobiology. "If you're doing great work, I suppose you probably don't need to know about the brain," he says. In fact, he readily admits that, at this stage, many of the tenets of interpersonal neurobiology remain hypotheses, not scientific fact. Nobody really knows what exactly is going on in the brain during therapy--how a clinical encounter or two or seventy actually affect synapse formation. But he's convinced--and has convinced many thousands of others--that learning about the brain and the power of relationship to create and change neural circuits is the most important challenge the therapy field will face in the years to come.
Forty years ago, family systems theory transformed psychotherapy by forcing clinicians to see beyond the single psyche to the interlocking circles of relationships that also make up the reality of the "individual" self. It might be said that Siegel's system brings into every therapy encounter an even bigger system, which includes the entire psychological, biological, and genetic history of the human species. This awareness of the fact that every human being contains multitudes and carries within him- or herself a lineage extending back to the origins of life on this planet may not immediately change what a therapist does, but it almost certainly will change the way she understands her work and its impact on her patients. And as Pat Love says, describing the way neuroscience has transformed her own work, "Information is intervention."
At this point, what Siegel offers therapists in his synthesis of evolutionary biology, neuroscience, and developmental psychology has more to do with a way of seeing than practical clinical advice. To explain the effect of this way of looking at ourselves and others, he likes to describe a walk he recently took on a deserted Oregon beach late one night, with his flashlight turned off. It took his eyes a while to to pick out of the darkness the vague outlines of rocks, the billions of stars, the serpentine border of the sea and sand. Unlike the familiar reality that we see by the light of day, the world revealed to us by this kind of night vision, he notes, can be disorienting, even surreal, possibly menacing, but often magical. We feel our capacities for perception sharpened and transformed as we become more attuned and attentive to the smallest, most subtle, variations of shape and shadow. In some way, by seeing less, we see more.
For Siegel, night vision is a metaphor for the world of subtle processes that interpersonal neurobiology opens up for our investigation. It awakens us to the everyday marvels of the human brain--our ability to transcend the quotidian boundaries of space and time, to "see" through the barrier of the physical body into the invisible precincts of another's mind, conceive of imaginary worlds that never did and never could exist anywhere else except in the imagination--in short, to shatter the laws of ordinary reality. Interpersonal neurobiology not only gives us some idea of how these impossibilities really do happen in the physical world, it makes us more aware of them inside ourselves and in our relationships with others, taking us into unsuspected realms of consciousness. "We can see ourselves connected to other human beings, belonging to the whole planet, and even a part of the entire universe in a way that extends our own dimensions far beyond our merely mortal selves," says Siegel. "In this state, we become part of something that has existed long before we were born and will continue long after we die."
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker. E-mails to the author may be sent to firstname.lastname@example.org.
by Mary Sykes Wylie
Psychiatrist Daniel Amen is a trim, elfin figure with a puckish smile and the staccato delivery of a stand-up comic. The winner of a Distinguished Fellow Award from the American Psychiatric Association, a clinical professor of psychiatry and human behavior at the University of California, Irvine School of Medicine, the author of 20 books and as many peer-reviewed papers, and a hugely popular public lecturer and workshop leader, he sounds, somewhat paradoxically given his own sum, a bit like a wiseacre underdog impudently challenging a reactionary establishment. He cheerfully rails against the self-satisfied stuffed shirts from the worlds of academic psychiatry who, in defiance of reason and good sense, don't accept his view that a brain-imaging method called SPECT is an invaluable tool for understanding and treating psychiatric disorders.
"I just don't get it. Why are we the only medical specialists who never look at the organ we treat?" he asks, his voice rising in exasperation before a jam-packed audience of 500 therapists drawn to a full-day workshop on his work. "Why is it controversial to get more information on people who suffer? The images are really easy to understand. What's the problem with having more data?"
And then the "piece de resistance". We're always being told that the brain is so terrifyingly, irreducibly complex that nobody except Nobel-caliber neuroscientists could ever begin to understand how it works. But Amen says, in effect, that it really isn't that hard for anybody--with a little training--to get a good sense of what all those brain modules are actually up to. "The images are really easy to understand--you don't need to make it any harder than it is," he says, as if explaining a new recipe to an insecure cooking student. "All SPECT does is measure three things--areas of the brain that work well, areas that are underactive, and areas that work too hard. Then you just gear the treatments to rebalance these areas."
So why not just take a look? What's the harm? His case is helped by the elegant, crisply articulated, brain images he shows that, in concert with his simple explanations, seem to luminously reveal what's actually going on upstairs.
Amen flashes two computer-reconstructed, three-dimensional, exquisitely tinted color scans, each of a different brain. One, a "healthy" brain, is a smooth ovoid shape, with some softly modulated rises and depressions; if it were a landscape, it would be a gently rolling pastoral scene. The other brain looks an awful mess. With its deep fissures, crevices, and "holes"--areas of severely low activity--it looks as if uneven chunks of it have been eaten away by a voracious rodent. This latter brain, Amen dramatically announces, is the brain of Kip Kinkel, the 15-year-old boy from Oregon who, in 1998, shot to death his mother and father and then drove to his high school, where he shot 24 more people, killing two.
Kinkel, Amen explains, had been seeing a psychotherapist and taking both Ritalin and Prozac, which only made him worse--more volatile and unreachable. His demoralized parents had taken him off his meds, after which he went on his murderous spree. "If a scan had been done on him before the killings, it would have shown an extraordinarily abnormal brain," says Amen. On the SPECT scan, he tells the audience, Kinkel's prefrontal lobe--associated with impulse control, judgment, and planning--exhibits extremely low activity. At the same time, his temporal lobe, controlling such functions as temper and mood stability, also showed abnormal patterns of blood flow, which can make a person more prone to aggression, emotional volatility, and violent suicidal and homicidal thoughts.
"If his therapists had actually seen his brain, they could have put him on mood stabilizers, and the odds are they'd have diminished his violent thinking dramatically." Amen pauses to let this sink in. "But because the current 'state of the art' in psychiatry is not to look at the brain, his doctors were simply throwing darts in the dark. Today you can try to kill yourself or kill other people, and nobody will look at your brain. But if your brain's not right, you won't be right."
Amen has a vast fund of salvation stories about people misdiagnosed and mismedicated, often for years, whose real problems are only finally revealed through the combination of intense clinical detective work--the kind any good therapist would do--and the nuclear magic of a SPECT camera, which, literally, casts light into the hidden recesses of the brain. "Giving a diagnosis of 'major depression' or 'ADD,' is like giving a diagnosis of 'chest pain,' or 'belly pain,'" says Amen with some asperity. "These are symptoms with many, many possible causes. And one treatment will not fit every person with similar symptoms. We need to start looking at the brain, to begin seeing the underlying physiology of what's going on. Scans aren't the answer, but they're certainly part of the answer. A psychiatric profession that doesn't look at the brain is archaic, dated, and stupid."
Amen now has the audience in the palm of his hand, laughing at his jokes, moved by his stories of troubled little kids whose lives were either saved or ruined, depending upon whether their underlying brain problems were discovered and treated. He seems to be as much on a personal crusade as a professional quest. But, periodically, a note of unabashed salesmanship and self-promotion intrudes--the repeated references to his "cool" books and their worldwide distribution; his bestseller, Change Your Brain, Change Your Life ; his column for Men's Health ; his media appearances on The Today Show, The Leeza Show, CNN ; his recent gig at the National Security Agency. For some in the audience, it's enough to induce emotional whiplash: are we hearing from a fearless pioneer dedicated to transforming the mental health field or a salesman whose most important product is himself?
To be sure, Amen has acquired a small, but growing, crowd of supporters and colleagues in psychiatry, psychology, and nuclear medicine--he says more than 1,000 professionals refer to him--who consider him a trailblazer and believe SPECT scans will revolutionize the practice of psychotherapy. "I think he's a real pioneer, making an enormous contribution to the field of psychiatry and helping to change the paradigm of how people think about the brain and psychiatric symptoms," says Joseph Wu, professor of psychiatry and clinical director of the brain imaging center at the University of California, Irvine. "Daniel Amen introduced me to a whole new universe of subcortical brain structures that we in nuclear medicine had only looked at casually before. He helped me realize that SPECT can be very useful for evaluating complex, difficult cases in which comorbidities are present," notes Dan Pavel, professor of radiology and nuclear medicine at the University of Illinois. "I came away from Amen's clinic convinced there is a place for SPECT in clinical psychiatry," writes AD/HD expert Edward M. Hallowell, coauthor with John J. Ratey of the bestselling Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder. "It is obviously helpful to be able to look at the brain before you try to treat it. Perhaps SPECT will prove to be the most practical way for psychiatrists to do that."
But utter the name Daniel Amen to some of the leading members of the psychiatry and neuroscience research community and the reaction ranges from dismissal to derision and denunciation. "He's made a mountain of money doing scans [a two-scan evaluation at one of Amen's clinics costs $3,250, which also includes, a history, physician evaluation, and follow-up visit], but never, to my knowledge, published any data, or provided one shred of evidence that an independent investigator would be able to reproduce," says George Bush, psychiatry professor at Harvard Medical School and psychiatric neuroimaging researcher at the Martinos Center for Biomedical Imaging. "Amen is extremely successful, has many franchises and is a wickedly good salesman, but what he's doing isn't supported by scientific evidence. Where's his data? What does he know that all the other practitioners and researchers don't know?" asks Helen Mayberg, psychiatry and neurology professor and brain-imaging researcher at Emory University. In fact, so exercised is much of psychiatric officialdom by Amen's approach that, last January, the American Psychiatric Association's nine-member Council on Children, Adolescents and Their Families felt moved to issue an independent position paper opposing the use of SPECT in the clinical practice of child and adolescent psychiatry.
It seems strange that a person so disarming and apparently eager to please, who's clearly distressed by the uproar he's caused and seems like the last person who'd mount a Rambo challenge against entrenched power, would arouse such hostility. Or that his cause--the incorporation into psychotherapeutic and psychiatric practice of SPECT scans, a technology that's been around for decades--should be so contentious. So what is it about Daniel Amen and his mission to get therapists to use brain imaging, and SPECT in particular, as an aid to diagnosis and treatment that makes him such a lightning rod?
The Man Behind the Cause
Daniel Amen's personal and professional biography is a palimpsest of the odd and extraordinary, which may help explain why he's never found a home in the clubby atmosphere of the psychiatric and research establishments. His entrepreneurial success seems to particularly gall them--it adds insult to injury that he's not only doing something totally beyond the scientific pale, but making pots of money at it.
His talent for business seems almost foreordained by his background. His parents, the children of poor Lebanese immigrants, went to the West Coast during the 1940s. There, Amen pere began clerking in a relative's grocery store and then, embodying both the American dream and the ancient Phoenician talent for trade, worked his way up to become chairman of the board of Unified Grocers (a position he still holds), one of the largest wholesale grocery businesses in the country. Amen's family was large (five sisters, one brother), loving, but strict and Roman Catholic, headed by a tough, authoritarian paterfamilias. "I grew up with an extraordinarily successful father, who always expected the most from us," says Amen. "Our family honored work, and our lives were centered around work--I worked from the time I was 10. And nobody ever thought it was a bad thing to be successful."
Amen joined the Army at 18, partly because he had a low draft number, but also because his father told him not to. It was 1972, and the Vietnam War was in full swing, but Amen believed the recruiter who told him he'd be assigned as a vet's assistant. (He'd always loved animals and, as a teen, considered becoming a vet.) "I thought that the odds were good that nobody would be shooting at a vet's assistant." Instead, he ended up as a combat medic in Germany, where he got himself retrained as an X-ray technician, mainly so he could work in a nice, warm dispensary, rather than a chilly tent. But he became fascinated by X-ray technology and found that he loved studying the ghostly images of people's insides. "I looked at kidneys, lungs, skulls, thigh bones," he says now with remembered relish. "That's where the imaging story really begins."
Because of his religious background, Amen had seriously considered becoming a priest, but, as he says sardonically, "I couldn't stand the idea of being called 'Father Amen.'" He declined the priesthood, but certainly not religion. In Germany, he found himself drawn to the wholehearted, emotional expressiveness of Pentecostalism--shouting, praying in tongues, healing ceremonies, and all--so different from the restrained solemnity of the Roman Catholic mass. He was sufficiently moved by his new religious tack that, when he returned home, he got off the plane dressed in a "Jesus loves you" T-shirt and carrying a Bible, much to the consternation of his blindsided mother. By this time, 1975, he knew he wanted to go to a small school, and a religious one, so he finished his college education at Vanguard University, a small Christian college. Then, in 1978, he became a member of the first class of a newly opened medical school (since closed) at Oral Roberts University.
The nexus between capitalism and religion appears to have shaped Amen's life. In Healing the Hardware of the Soul, his book about the connection between a healthy brain and the capacity for morality, conscience, and faith, Amen writes that he felt "led by God to pursue this [SPECT] work." These days, he uses his training and skills as a kind of reverse mission to churches, in an effort to persuade Christians and Jews that much "sinful" behavior may be due to brain problems, rather than evil motives. Some of his critics haven't looked kindly on this sense of religious mission. "He's a true believer, and evangelical medicine is scary," says Mayberg.
After medical school, Amen took a residency in psychiatry at Walter Reed Army Medical Center. In 1987, the Army sent him to Fort Irwin, California, as the chief psychiatrist--the only psychiatrist in the middle of the desert for thousands of soldiers and their families--a population rife with drug abuse, depression, anxiety, domestic violence, psychosomatic ailments, and stress. This new gig would have been a daunting job for any psychiatrist, let alone a young, newly minted, and relatively untried one.
Serendipitously, in the old World War II building that housed his office, he found an antiquated biofeedback machine (an instrument that measures physiological responses, via electrodes or sensors attached to various parts of the body) left by his predecessor. He found that, even as a novice, he could use the machine to train people to warm their own hands by using their imaginations--thinking about burying their hands in hot sand, for example. He could also use it to help them reduce their anxiety or relieve their migraine headaches, while gaining a sense of self-control and personal mastery. Enthusiastic about his new toy, Amen convinced his dubious commander to pay $30,000 for an up-to-date model and send him for 10 days' training in biofeedback.
The biofeedback training program in San Francisco was, Amen remembers, a revelation: "The best, most exciting, training I'd ever had. I was just stunned by what I learned." It was the first major introduction he'd yet had to the powerful interaction of brain, body, and mind, and he was hooked. He discovered that people could learn how to control their own autonomic nervous system--relax their muscles, calm their breathing, reduce their sweat-gland activity, lower their blood pressure and heart rate--to relieve both physical tension and mental anxiety. Moreover, through neurofeedback (a form of biofeedback in which electrodes are attached to the scalp), they could learn to change their own brain-wave patterns, and thus their mental states. "I was so excited to have this cool new technology that I went back to Fort Erwin and started using it on everybody."
Amen was particularly anxious to try out this new brain-mind technique on kids with AD/HD. "Standard psychotherapy, as I'd been trained to do with AD/HD kids, made me crazy--they just never got any better," he recalls. Medications helped, but not nearly often enough, and there was no way to predict whether or not they would work. So Amen began using neurofeedback with his AD/HD patients to encourage more normal brain waves and reduce their symptoms. While not exactly the fast-track cure he'd have liked (it could take from one to two years to produce significant improvement), neurofeedback did work encouragingly well, with the side benefit of helping many kids avoid or lessen medications. In 1989, when he opened his private practice in northern California, he equipped it with his own biofeedback equipment.
Amen's clinic was an immediate success, no doubt partly because of the workaholic habits, business acumen, and marketing skills he says he inherited from his father; but also because he was the only child psychiatrist for 300,000 people in the county. During this period, he worked six- and seven-day weeks, building up his practice, directing the dual-diagnosis unit of a local hospital, lecturing in the local community, and writing a news column (he'd already published two self-help books on getting ahead in school and in work).
In March 1991, Amen attended a lecture on SPECT imaging at the hospital where he worked. If learning about neurofeedback had been a revelation to him, seeing SPECT scans was an epiphany. SPECT is the acronym for single photon emission computerized tomography, a nuclear-medicine imaging technique that measures an organ's blood flow or activity level--its function . An MRI, by contrast, looks at brain structure or anatomy, just as an ordinary X-ray does (but provides far more detailed images). A patient being SPECT-scanned is injected with a "radiopharmaceutical" and then lies on a table for about 15 minutes while a multiheaded camera rotates around his or her head picking up gamma rays (which are like pulses of light) from the radioactive material taken up by the brain cells. The data obtained by the camera are processed by a supercomputer to produce a series of two-dimensional cross sections of the brain. Different activity levels--relative blood flow--show up as shades of different colors or gray tones, depending on the color scale of the software program chosen by the imager.
These cross sections are then reconstructed into three-dimensional images. Notwithstanding Amen's suggestion that brain scans "aren't that hard to read," it's definitely not a simple process, requiring real skill and judgment to do well. To a lay viewer, the cross sections that first come out of the computer look like a meaningless kaleidoscope of colors and patterns. It takes an expert in reading, understanding, and manipulating the scans to tweak them into an accurate but elegant form--the dramatic, 3-D pictures of the kind Amen shows his audiences.
The Society for Nuclear Imaging officially recognizes only four common indicators for the clinical use of SPECT: to detect and evaluate strokes, brain trauma, and suspected dementia (a recent article says that brain scans like SPECT can predict Alzheimer's disease nine years before people have symptoms), or to locate focal points of epileptic-seizure activity. But SPECT has been used in a huge and highly eclectic number of research studies on almost every conceivable psychiatric and neurological condition, as well as some nonpsychiatric studies, like measuring the impact of meditation and prayer on blood flow to different brain areas.
The lecturer at Amen's hospital, a local nuclear physician named Jack Paldi, showed brain images of patients with depression, dementia, schizophrenia, and head trauma, comparing them with normal brains. Using these amazing images, Paldi tried to demonstrate that one could actually see the differences between brains that worked well and those that didn't, see how medications changed the way brains functioned and where those changes occurred. In this rush of graphically astonishing images, Amen thought he could begin, finally, to understand why some of his patients just couldn't seem to benefit from therapy or get their lives in order, no matter how hard they tried. It wasn't psychological resistance or personality type or deep-seated unconscious motives that kept them from getting better: it was simply that the software of their brains wasn't up to speed!
"I was absolutely blown away," remembers Amen, who took up Paldi's offer to do no-cost SPECTs on interested physicians and, six months later, got one himself. Shortly after the lecture, however, he ordered 10 scans on particularly difficult patients, which, according to Amen, resulted in "literally miraculous changes" in five of them. One patient was a 12-year-old boy with a nasty temper, a history of aggression, and school failure, who'd been hospitalized three times, prescribed assorted drugs (including Ritalin, which made him hallucinate), and treated with two years of psychoanalytic therapy. The scan showed low temporal-lobe function (associated, as in Kip Kinkel's case, with anger, violence, and mood swings), as well as frontal-lobe problems (which kept him from being able to concentrate in school). Amen placed him on mood stabilizers and a different stimulant, and voila! Within three weeks, he became milder tempered, began making friends, and, says Amen, "turned into the sweetest boy you'd ever want to meet." His school performance improved dramatically as well.
Another woman had been diagnosed with Alzheimer's after she'd nearly burned down her own home and lost her driver's license. Amen scanned her and found no signs of the characteristic abnormalities associated with dementia. But he did see that her deep limbic structures were "on fire" (a favorite bit of Amen-speak to describe brain areas of severe overactivity). This suggested depression, which can sometimes mimic Alzheimer's symptoms of memory loss, apathy, indifference, and disorientation. Amen prescribed Wellbutrin--an antidepressant and stimulant--and voila` again! Within weeks, she'd regained her memory, and her mood was much better. Within six months, she got her driver's license back.
"How many experiences does a psychiatrist have like these in a whole career?" Amen asks. "I had five of them in the space of a few weeks."
By Amen's lights, SPECT was not diagnosing new conditions. The scans didn't remotely correlate with DSM diagnostic categories, but they often revealed the inaccuracy of previous diagnoses and suggested functional anomalies that shed light on otherwise unexplained symptoms. Nor were his treatments miraculous, radical, or novel; they apparently just hit the target better than earlier interventions. In short order, he was a true believer in the modality. "I thought, 'How can I do psychiatry in good conscience without using scans when I don't really understand what is going on? How can I just continue to rely on guesswork when I have this tool at my disposal?'"
Between 1991 and 1995, he became something of a SPECTomaniac, reading everything he could find, attending meetings about SPECT, and ordering SPECT scans on hundreds of patients at the local hospital. He was asked to talk about SPECT at hospitals and at the University of Colorado medical school. He wrote a research paper comparing SPECT brain images of ADD children to those of normal children. He became an enthusiastic promoter of SPECT.
But there were signs of smoke from an impending firestorm almost from the beginning. In 1992, at a meeting of the American Psychiatric Association (APA), where he attended an all-day course on the use of SPECT in child psychiatry, he went to a lecture by National Institute of Mental Health child-psychiatry researcher Alan Zametkin. This would-be colleague used PET scans (a form of nuclear imaging with higher-quality resolution than SPECT, though more difficult and expensive to use) in a groundbreaking study of what ADD brains look like. Zametkin, says Amen, was one of his heroes, so he went up to him after the talk in the spirit of a fan approaching a star. "I told him that, partially based on his work, I was using SPECT in my own practice," remembers Amen.
But if he'd expected an avuncular smile of approval, he was mistaken. Zametkin angrily barked at Amen that these techniques were strictly for research and in no way intended for clinical use. In no uncertain terms, he told Amen, in effect, to cease and desist what he was doing.
"But why do you do these studies if you don't intend this technology to be used clinically?" Amen asked, baffled.
"I do them just to learn more; it's interesting basic science," Zametkin replied loftily.
This is an attitude foreign to Amen. "I really have no interest in science for science's sake," he admits. "I'm a clinician through and through--it's my reason for living. I get my juice from my practice, from relationships with patients, not from research."
Back home in California, the natives were also getting restless. A local pediatric neurologist, after calling three or four researchers around the country and hearing that SPECT wasn't ready for clinical prime-time, complained to hospital officials about Amen's heterodox behavior. "The neurologist told me that my reasons for ordering scans weren't empirically proven, and that I should quit doing them. He said, 'The brain is for neurologists, not psychiatrists,'" Amen recalls, even now incredulous. "I told him he was nuts." At a meeting of the hospital authorities, Amen was given permission to continue getting SPECT scans for his patients, but he was now required to have the medical director sign off on his requests.
In 1993, he was asked to help teach a brain-imaging course at the APA annual meeting, but when the program came out, a Dallas SPECT researcher wrote the APA program chairman demanding to know why such a controversial figure was included. The program committee chair sat in on the presentation and supported Amen's work, but many others were openly hostile to him, making a point of telling him he was a fraud and a mountebank and ought to be drummed out of the medical profession. It had gotten to be too much, so he decided to retreat from the public field, help his patients in the relative privacy of his clinical practice, and let other people do the research and fight the battles.
It's hard to imagine as restless and driven a figure as Amen ever really settling for a quiet, low-profile practice in suburban California, so he'd probably have taken up the gauntlet again sooner or later. But a crisis involving his 9-year-old nephew, Andrew, launched him back into the fray.
Amen's sister called him in tears one day early in 1995, telling him that her son--his nephew and godchild--had attacked a little girl on the baseball field for no reason. Over the preceding year, this friendly, active, outgoing little boy had become surly, angry, mean, and depressed, and had begun drawing pictures of himself shooting other children or hanging from a tree. Amen told his sister to bring the boy in the next day and, after a lengthy interview, personally took him to the hospital to be scanned. "When I looked at the image, I saw he had no left temporal lobe at all!" recalls Amen. This was, again, a part of the brain associated with violence, aggression, and suicidal and homicidal feelings. Andrew was almost immediately given an MRI scan, which showed a cyst about the size of a golf ball where his temporal lobe should have been.
But Amen couldn't find anybody willing to remove the cyst. Three pediatric neurologists--one at Harvard--told him that Andrew's behavior was probably not related to the cyst and that they wouldn't remove it until there were "real symptoms." Amen was beside himself. "Hearing this made me nearly psychotic, I was so angry." He remembers shouting, "What do you mean, 'real symptoms?' You don't think suicidal and homicidal thoughts and behaviors in a 9-year-old are real symptoms?" Real symptoms, the Harvard neurologist coolly informed him, meant seizures and speech problems. Period.
Finally, he located a pediatric neurosurgeon at UCLA who said he'd operated on three other children with the same problem--a temporal lobe cyst resulting in aggression. This doctor performed the operation on Andrew. When the boy finally woke up after the surgery, he smiled at his mother--the first smile from him she'd seen in more than a year. Shortly afterward, he became, once again, the youngster he'd been before his problems began.
This event changed Amen's life, he says. "From that moment on, I felt I could no longer be shy, or allow myself to be hurt by criticism, or fearful that people wouldn't like what I was doing. I just thought of all the kids who are in residential treatment facilities or end up in prison because they've done terrible things, and nobody ever even knows whether or not it's because they have something terribly wrong with their brains."
Now a newly energized Amen charged full-steam ahead. He completed the 1,000-hour training and supervision program to obtain the license in handling radioactive material that's necessary to do scans, bought SPECT equipment, and became, as far as he knows, the only psychiatrist in the world who had then incorporated brain imaging in his own practice. He once again took up the SPECT gospel and began spreading the word, and once again was met with virulent attacks.
In 1996, after Amen gave the State of the Art Lecture in Medicine at the Society of Development Pediatrics, a San Francisco pediatrician stood up and excoriated him for using brain imaging to justify giving drugs to children for AD/HD--in effect, accusing him of shilling for Big Pharma. Shortly after the meeting, he was anonymously reported to the California Medical Board for practicing outside the generally accepted standards of care. The state medical board began an investigation, which took a full year--of lawyers, interviews, questions, reviews of his articles, office visitations. "The worst year of my life," Amen calls it. Finally, after his work was sent to the departments of neurology and nuclear medicine at UCLA, he was exonerated and became an expert reviewer of psychiatry for the California Medical Board.
Amen and His Critics
Today, about eight years later, Amen has no doubt succeeded as a medical entrepreneur. He has two clinics in California, one in Washington State, and one in Reston, Virginia. By any measure, he's a huge success. Besides founding his clinics and cranking out books (another is on the way), he's produced a "Clinician's Toolbox" of brain-related materials for therapists, a brain-scan atlas, and assorted CDs and videos. He's given more than 100 presentations in the United States and abroad, written or been the subject of numerous articles in the popular press, appeared on scores of radio and television shows, testified at numerous trials, and developed a 12-week high school course on the brain to be piloted in 30 schools this fall. There are perhaps 15, mostly for-profit, psychiatrist-run clinics around the country that now use SPECT--a fair number of the proprietors trained by Amen himself. In addition, an indeterminate number of psychiatrists around the country quietly, but regularly, refer their own patients for brain scans.
Nevertheless, most of the research community and the psychiatric establishment remain deeply unimpressed. Indeed, there isn't anything about Amen or what he does that his critics do like. Following the back-and-forth between them and him is like watching a bunch of increasingly infuriated boxers all trying to knock down an inflatable punching doll--the harder they hit, the faster he bounces back. They argue that Amen isn't competent to use scans because he's not board certified in nuclear medicine, didn't train in radiology (his several hundred hours of imaging training don't count), and doesn't follow science-based methods of differential diagnosis (using appropriate tests to differentiate systematically between distinct diseases with similar symptoms). He counters that he has the proper licenses to do his studies, teaches SPECT at a major medical school, has written or cowritten chapters about SPECT in three professional textbooks, has produced nearly two dozen peer-reviewed papers, instructs nuclear-medicine doctors who come from far away to spend weeks at his clinic, has chaired workshops on SPECT at the APA annual meeting, and, finally, just a year ago, received a Distinguished Fellow Award from the APA. "I have more experience with SPECT than anybody else in the world, and there are mountains of scientific literature backing up my clinical work--1,500 such studies are on my website alone."
They argue that he sits on a proprietary stash of 27,000 scans, like a miser sitting on a pile of gold bullion, and won't give researchers access to his data because he's afraid an independent look will undermine his claims. He contends that researchers are perfectly welcome at his clinic, to talk to his doctors, see how they interpret scans, and look at his database. But one leading researcher he invited out to see his scans hasn't followed through, and no one else has ever asked to see them.
They say, to quote Harvard's George Bush, that "he's unethically subjecting people, including children, to potentially dangerous ionizing medication in a diagnostic test of no proven benefit." He cites Michael Devous, a leading nuclear-medicine expert, who writes that "there are no data that have ever demonstrated any harm to humans by radiation exposure at diagnostic imaging levels." The average radiation exposure for one SPECT scan, Amen points out, is similar to that of an abdominal X-ray, which is routinely ordered for common childhood medical conditions, including constipation.
They say, repeatedly and maddeningly in Amen's view, that he claims to diagnose psychiatric illnesses from the scans. He just as repeatedly insists that he never uses SPECT to "diagnose" anything, but looks at the scan within the context of the person's life and after a full psychiatric evaluation to get more information that might shed light on puzzling, difficult, or anomalous symptoms. "I've never said the image is 'the answer.' We use it when we don't know what's going on, when we think it might supply a piece of the puzzle--it's like radar that helps us better target the problem. The alternative to doing scans is blindly putting kids on meds or multiple meds without looking at their brains either before or afterward."
Finally, and most damagingly, they say that what Amen is doing is totally unsupported by the facts--that he hasn't remotely demonstrated the scientific validity or reliability of using scans as he does. They argue that it isn't yet possible to identify subtle distinctions in single subjects that reliably correlate with specific symptoms. "When a radiologist looks at a chest X-ray, he recognizes pneumonia, or an enlarged heart or liquid at the base of the lungs that correlate with disease because he's compared these abnormal scans to thousands of normals and other abnormals," says neuroscientist Bush. "Maybe in 50 years, when someone comes in looking as if he or she has a certain syndrome, we'll be able to refer them to a radiologist who'd be able to interpret that individual scan. But we're not yet, as a field, in a position to distinguish one brain scan from another. Right now, you can look at any individual scan and what you'll find is color blobs across a screen. What separates science from nonscience is the ability to pick out quantitative, statistically reliable, patterns [in those blobs] based on large numbers of scans--set certain criteria for a disorder, show it in 50 cases compared with 50 normals, for example. Amen isn't doing that. Essentially, all he's doing is 'blobology.'"
To this, Amen responds that factoring in the individual variability in each brain, rather than drawing general, statistical inferences from a large base of cases, is a strength of his method, not a weakness. Researchers look for signature features in a scan that will reliably correlate with specific DSM categories, which do not reflect the complexity and heterogeneity of psychiatric disorders as they're experienced by real people, Amen argues. " DSM diagnoses are artificially derived from symptom clusters," he says. "But they don't explain why people are having these symptoms--why one person's depression or anxiety or AD/HD may be entirely different from the same formal diagnosis in somebody else. Only by looking at each person's individual scan can you get some insight into the underlying physiological pattern in the brain, so we can target treatment specifically to what that person needs."
In addition, he says, researchers study "pure" cases--people with one supposed diagnosis without the confounding variables of comorbid conditions (i.e., drug addiction along with their depression, AD/HD symptoms along with their anxiety). This approach simply doesn't reflect the complexity, variability, and individuality of real people and real patients.
Finally, researchers compare people with a DSM diagnosis to presumed "normals," but Amen doubts that there's such an entity as a "normal" brain. Recruiting people for a database of normals, his office screened 1,500 people and found only 72, who met the criteria for "normal"--no signs of head injury, no history of substance abuse, no psychiatric illness, and no first-degree relative with a psychiatric illness. "'Normal' is a myth," he says flatly.
Whatever the specifics of his critics' objections to Amen's work, it's hard not to suspect that underlying the intensity of their response is their objection to Amen himself--his persona, his style, his modus operandi. Most scientists lead comparatively monastic, inconspicuous lives (though not necessarily impecunious--many act as paid consultants to pharmaceutical and medical-device companies). Even those few who achieve eminence do so largely within the circumscribed universe of their peers. How many people can name a recent Nobel laureate in any scientific field? They have their own worldview, and what they consider Amen's heavy-handed promotion of high-tech gimmickry is as far from it as earth is from Pluto.
"The nature of science is agnosticism," says Helen Mayberg in a passionate defense of the way researchers do things. "Our job is to ask questions, measure data, continue doing the research until we find out what's real, what isn't. I've devoted my entire professional life to using imagery to understand depression, and the more progress I make, the more complicated it gets. As a clinical neurologist, I see patients die all the time. I don't have to have anybody tell me how much people suffer. But no matter how much, as a doctor, I want some idea for a promising new treatment to be true, as a scientist, I have to remain an agnostic. We all know the system isn't as good as it should be, but it's the best we've got. We get accused of living in ivory towers, but we do what researchers do--we can't leapfrog over the process."
For researchers like Mayberg, Amen is anathema--a leap-frogger to the nth degree. His disregard for professional politesse can make even his friends and defenders cringe. Jerry Rodos, a psychiatrist in the Chicago area, who regularly refers difficult patients for scans, remembers taking a younger colleague to hear him lecture. "We walked into the conference room, my friend took one look at the Amen concession--tapes and books and CDs, advertisements for his clinics, posters, etc.--and was completely turned off before he even sat down. I think Dan has done a lot of neat work, and what he is saying is very valuable, but he's not a traditionalist and hasn't spent a lot of effort trying to get refereed journals to review his material. If you have something important to say, you submit it to peer-reviewed journals, rather than just run off and start four clinics and write popular books about it. Dan Amen is a big promoter of Dan Amen, and that offends many of his colleagues."
Partly in response to critiques like this, even from allies, Amen has hired a statistician-researcher and is preparing several studies, including one on predicting treatment response in AD/HD patients based on their different scan subtypes. But Amen doesn't believe his opponents will come to like him anytime soon, no matter what kind of studies he publishes. "A friend of mine told me I was like somebody under an old Romanian curse--doomed to know something that's true, but nobody believes him," he says gloomily.
The Client's Experience
Meanwhile, anathema or not, Amen's clinics do 400 to 500 scans a month, and, according to follow-up questionnaires given one month and six months after treatment, 85 percent of this patients think they received "significant benefit" from the process. According to therapy researcher Jay Lebow, however, this isn't unusually high--about 90 percent of psychotherapy users report being satisfied with their treatment, which can simply mean they liked the therapist and felt understood and cared for.
At least some of Amen's patients, however, clearly feel that the experience transformed them, even saved their lives. Whole families get scanned, and then refer their friends and acquaintances and fellow church-members. Some of Amen's most convinced champions are evangelical Christians, who believe that Amen is doing God's work and want to help him do it. Linda and Gaylen Bronson, a California couple who are committed Christians, were so delighted with Amen's treatment of their family that they started the Recovery Assistants Foundation, a tax-exempt, charitable organization that helps people who couldn't otherwise afford it to get and pay for SPECT scans, therapy, and medications.
To get some idea of how the Amen phenomena can build on itself, consider the Woodmansees--Jack, a retired general and businessman, and his wife Patty--who live in a suburb of Dallas. The Woodmansees heard about Amen a decade ago from a friend who felt the SPECT scan and his treatment had dramatically improved her life. Because the Woodmansees had a grandson diagnosed with AD/HD, who was doing very poorly on Ritalin, they sent for an Amen video about AD/HD. Watching it as a family, their adult son (the father of the AD/HD child) came to the conclusion that he probably had AD/HD, too. The senior Woodmansees made appointments for the son and grandson to get scanned, and then decided to take their granddaughter, who had behavioral problems. Eventually, three different branches of the family trooped out to California to be scanned.
Soon they were all talking about the temporal lobes, cingulate gyrus, prefrontal cortex and noting the interesting family resemblances in their brain-perfusion patterns. They also became advocates for Amen, sending along friends, neighbors, and members of their congregation, and even financing scans for people who couldn't afford them. They brought Amen to Dallas to give lectures, and have been trying to convince him to open a clinic there.
Two years ago, Richard and Sarah Mitchell took their 10-year-old daughter, Terry, in for a scan. Always a difficult child, Terry was now throwing herself on the floor in explosive temper tantrums, harassing her siblings, causing classroom disruptions, and failing in school. Diagnosed with AD/HD and oppositional defiant disorder, she'd been prescribed a stimulant, which she vociferously fought taking, and which only made her worse. After the scan, Amen prescribed an antidepressant, a mood stabilizer, and a handful of supplements. He also recommended several therapists. But not one of the three therapists worked out, and the drugs didn't help much, either.
So Amen shifted course. He took Terry off meds, cranked up the supplements, including large doses of over-the-counter omega-3 fatty acids, GABA, and other amino acids (believed to reduce anxiety), recommended a high-protein diet, and helped her parents learn some techniques for handling their daughter better. Now, about two years later, Terry still tends to be bossy and overbearing, has a hard time picking up on social cues, and is emotionally immature. But she's much better than she was--her grades are now high Bs, she likes school, and her mood has generally improved. "She isn't raging anywhere near as much," her mother reports, and she clearly feels more at peace with herself.
Terry's case points to a paradoxical and perhaps misunderstood aspect of Amen's approach. However radical the use of SPECT may seem, his treatment is unconventional only in that it's far more heterogeneous and informed by alternative-healing methods than the Johnny-one-note pharmaceutical orientation of most psychiatrists. While not shy about prescribing medications, often in twos and threes, he also recommends nutritional and herbal supplements, cognitive therapy, EMDR, biofeedback, parenting-skills training, diet, exercise, meditation, and abstinence from alcohol.
How does treatment with Amen compare with what another psychiatrist might recommend? Might not Terry, for example, have done just as well if she'd found a reasonably creative and open-minded therapist willing to try a variety of different approaches and hang in with the family for as long as it took? Of course. Did the SPECT scan speed up the process? Possibly. Does Terry's family believe that scans are magical keys to the kingdom of the inner brain and that Amen is the sorcerer who, essentially, saved their child? Completely. "Without Dr. Amen, she'd probably be in some military school now," says Terry's mother. "I feel blessed to have met him." Among the Amenophiles, this attitude isn't unusual.
For all that people say about what most mattered to them about their experience at one of Amen's clinics, it would be a mistake to underestimate the weight of the old saw that a picture is worth a thousand words. People believe they're seeing an actual picture of something empirically real, fundamentally true, and undeniably revealing about themselves. This apparently incontrovertible glimpse of reality can be unwelcome, even shocking, but it has to be taken seriously. Before the scan, Terry Mitchell had furiously refused to take medications, and felt her parents were disciplining her unfairly. When her scan was shown to her and explained, she looked at it quietly and somberly for a long time, and said, "I guess I really do need medications." It's easy to believe Amen when he talks about the power of these scans to convince even adolescents that the drugs they ingest really are hurting their brains--there's the evidence.
Critics might argue that this troubled child has been conscripted into a possibly false sense of her personal pathology by a misused and misleading test. But, paradoxically, scans that show something amiss can be oddly reassuring. "Do you know what people's biggest worry is about seeing their scan?" Amen asks. "That the scan will show nothing ; that it'll look normal, which means that they're suffering because they're weak or bad." After her scan, Terry felt relieved, her mother said, because the scan explained why she was having so much trouble and removed her sense of self-blame for not acting like a "normal" girl.
Brain and Soul
This peculiar, but almost universal, sleight of thought--"it's not me, it's my brain "--helps explain Amen's appeal and, for that matter, the appeal of all "biological psychiatry." Whether or not we're religious, spiritual seekers, or hard-nosed materialists, we feel intuitively that our real selves, our souls, if you will, aren't the same as the soft "hardware" of the brain. And unlike many drive-thru drug dispensers, as psychiatrists have too often become, Amen actually seems to care about the soul, perhaps even in some way believes he's doing his part to save souls, or at least free them from the malign influence of a sick brain. And clearly, Amen and his staff do everything they can to make the people who come to them feel like real people with basically whole souls, whatever is wrong with their neurophysiology.
Recently, Ted, a nonprofit administrator who'd seen Amen at the Networker Symposium, decided to get his own brain scanned in Amen's clinic in Reston, Virginia, which is directed by psychiatrist Charles Parker. Now in his mid-fifties, Ted says he's been depressed since his late thirties. He describes his emotional state not as sadness so much as apathy, lack of energy, zest, and motivation. "Nothing's wrong in my life. In fact, I think I have a great life. I just don't enjoy it very much," he says. He also has a hard time concentrating and, while he used to read a lot, now just zones out in front of the TV. He was in therapy many years ago, though not since becoming depressed, and has tried a number of medications--Prozac, Wellbutrin, Cymbalta, Paxil--and acupuncture, all to no avail.
Ted loved his whole experience at the Amen clinic. The staff seemed entirely made up of young, attractive, extraordinarily pleasant women with big smiles who, Ted was intrigued to see, all wore very high heels. "It was a little like the Stepford Wives, only they seemed genuinely nice." He filled out a 15-page questionnaire, went through a lengthy interview with the "historian," and then underwent a concentration scan. Two days later, he went in for his resting scan, and a day or two after that, Dr. Parker reviewed the scans with him.
Ted found Dr. Parker to be the nicest person of an amazingly nice staff, scoring about 110 on a 100-point friendliness scale. "The psychiatrist I go to for my meds checks is a nice enough guy, I guess, but he's like an iceberg compared to Dr. Parker, whom I liked much better. He really seemed to want to spend as much time with me as I needed."
As for the scans and what emerged from them, things get a little murky. The report was long, complicated, and somewhat confusing to Ted, who said that, as he listened, "after five minutes or so, I kind of glazed over." The scans showed less than normal perfusion in areas of the prefrontal cortex, temporal lobes, and parietal lobes; increased, or excessive, perfusion in the basal ganglia and limbic system; and "scalloping," or dehydration, on the outer surface. Altogether, all of this signifies . . . well, a lot of possibilities--including, but not limited to, short attention span, low motivation, memory problems, abnormal perception, impulsivity, disorganization, distractibility, anxiety, irritability, depression, and mood cycles.
In this somewhat jumbled mass of findings, what fascinated Ted the most was the pronounced indentation in his left prefrontal cortex, consistent, said Parker, with past brain injury. Amen contends that many psychiatric conditions may result from undiagnosed, and even apparently mild, brain trauma without unconsciousness, and he makes it a practice to ask his patients at least five times if they've ever experienced head injuries. Ted was also interested to learn that several of the patterns picked up on in the scan are often seen in people with AD/HD.
The upshot of all this was that, according to Parker and Amen (who read the scan), Ted had been taking the wrong medication--Cymbalta only exaggerates symptoms of AD/HD and concentration difficulties. He was to begin taking Effexor right away, and Adderall a few weeks down the line. Besides this, he should begin exercising and take various supplements. Ted was given a list of books and referrals to holistically trained MDs specializing in nutrition and brain-injury recovery, neurofeedback experts, and brain-health websites. He was also told to make a follow-up appointment. For a technique that's supposed to provide the focus for well-targeted, specific clinical interventions, Ted's SPECT scan seems to have resulted in something of a hodgepodge of generic recommendations.
But Ted came away from his adventure feeling elated--less like somebody who's had a high-tech medical procedure with no very clear prognosis, and more like somebody who'd won the lottery and been given a new lease on life. "I thoroughly loved the whole thing. I'm very glad I did it. It was uplifting and made me feel so hopeful." And the scans? "They're interesting to look at--very pretty. It's neat to have somebody show you what your brain looks like. And then to be shown this big indentation that's not supposed to be there; well, it's concrete evidence that something really did happen to you. I do think I understand my own brain a little bit better."
Whatever the outcome for Ted's case, or for Amen's crusade overall, it seems inevitable that his work, or some variant of it, represents a glimpse into the future. With the development of revolutionary new technologies permitting a direct look inside the brain, people will be increasingly dissatisfied with the clinical guesswork and serial medication trials that constitute so much of psychiatry today.
Nor will psychotherapists, the workhorses of the mental health industry, be content to wait until the last peer-reviewed, double-blinded study demonstrating SPECT's empirical validity and reliability has been published before making use of these technologies in their own practices. They've never been willing to delay using what seemed useful to their patients until they've gotten the okay from the higher orders of scientific inquiry. EMDR and many forms of body-oriented trauma therapies, as well as a host of other therapeutic methods, are still considered fringe by research psychologists, but that isn't stopping therapists from using them. Whether one considers Amen a devil or a new messiah, his use of SPECT visionary or voodoo, it seems likely that time is on his side.
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker. Contact: email@example.com.