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Tough Customers: Is It Them or Us?
By Rich Simon As therapists, many of us practice in two different worlds. In the first, we see polite, well-behaved, articulate clients with solid values. They engage fully in therapy, talk cogently about their problems, listen attentively to our responses, make reasonably good-faith efforts to follow our suggestions, and sooner or later get better. No wonder we genuinely like these people! Does This Kid Need Medication? with Ron Taffel
Meds: Myths and Realities: NP0035 – Session 3
Do you feel like you could be a more effective therapist with your younger clients? Do you find it hard to determine when interventions--psychological and pharmacological--might be needed? Join Ron Taffel and learn to identify key diagnostic signs that indicate medications could be helpful when dealing with depression, anxiety, AD/HD, and affective disorders. After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.In Consultation
Peer Supervision Groups that Work
By Eleanor Counselman
Three steps that make a difference
Q: I’d like to organize a peer supervision group, but I’ve heard their failure rate is high. What do you recommend? A: Peer supervision groups provide a welcome respite from the isolation of private practice and an informal, nonevaluative setting after years of formal supervision, particularly for young therapists. They offer valuable guidance on difficult cases and tough ethical dilemmas to therapists at any level of experience. And they’re free! However, as you note, many of them fail. In my experience, careful attention to the initial contract and the ongoing group process can make a huge difference in helping them sustain their membership and thrive. Though they’re often called peer supervision groups, it would be more accurate to call them peer consultation groups. Members don’t have direct supervisory responsibility for one another’s cases: they simply offer suggestions, which members can accept or reject. They typically have four to six members who have approximately the same level of professional experience or share a specific area of interest. Members meet on a regular, usually biweekly, basis. Group consultation, with or without a leader, offers advantages over individual consultation. It includes the possibility of multiple perspectives on the same problem and the reduction of clinicians’ shame about confusions and mistakes as they share similar stories about their struggles with difficult cases. Another benefit is peer interaction, which develops one’s professional sense of self. The hall-of-mirrors effect—seeing yourself as others see you—which is so potent in therapy groups, is a major component of the supervision group experience. Nevertheless, despite the many benefits, it’s challenging to start and maintain a consultation group, particularly if it’s a leaderless one. They can fail to thrive or suffer from “task drift,” moving them away from discussing clinical material and into a form of therapy. It can be difficult to integrate new members and maintain clarity about the group’s own process. Presenting cases in supervision in any format poses obvious risks to one’s self-esteem, and group dynamics add additional risks: issues of power, competition, exposure, and shame can lead members to drop out. It’s especially challenging to manage group dynamics in leaderless groups, as it’s usually the leader’s role to remain aware of what’s happening within the group, and without a leader in charge, shame or fear of being judged may silence members. The most successful leaderless groups seem to be those in which the group members find a balance between a focus on cognitive and emotional issues—talking about cases and about the feelings that arise when seeing clients—while consciously managing the functions that a designated leader would serve. These include protecting the group contract, setting and maintaining appropriate norms, and handling gatekeeping matters, such as bringing in new members. A crucial component of maintaining an atmosphere of group safety is regular, dependable member attendance. Without this, a group will never feel like a place to take risks. Members need to be willing to bring up concerns about irregular attendance because, just as in a therapy group, member lateness and absences can indicate issues that need exploring. Chronic irregular attendance can be demoralizing and cause a group to fail. When it comes to group safety and cohesion, Woody Allen was right: 90 percent of supervision group success is about showing up. A significant issue in any supervision group is shame and the reluctance to expose oneself. To make supervision groups feel safer, therapist David Altfeld developed a model of group consultation in which all group members simply share their emotional reactions and associations to a situation being discussed, instead of one person presenting a specific case issue and everyone else giving advice as resident “experts.” This procedure levels the playing field by not allowing members to compete for the best case analysis. It leaves room for highlighting emotional issues, countertransference reactions, and parallel process. Making everyone vulnerable in this manner avoids opportunities for excessive criticism (or its counterpart, excessive niceness) and encourages emotional sharing. Another group consultation model, developed by Irish therapist Bobby Moore, focuses only on minimal case information, such as a patient’s age, length of time in therapy, and perhaps a little demographic information. Then the presenter talks about his or her thoughts, fantasies, feelings, and associations about the patient and the therapy. Group members then share their associations. Following that, the initial presenter is invited to share any further associations. Only at this point does the presenter give the facts of the case and the clinical dilemma. Finally, the group thinks together about what’s been discussed and what it indicates about the case. For those interested in the power of the collective unconscious, this is a fascinating process to experience. To succeed, a consultation group must feel safe and useful to its members. Here are a few simple principles to follow: Clarify the group structure. The group needs to agree on the frequency and length of meetings, which is best accomplished with a predictable schedule. The group needs to agree on its task and focus: is this group for any clinical issue or just for couples, or trauma, or group therapy? How much time will the group spend on “schmoozing,” and will there be one or more than one case presented each time? What will be the presentation format? While most groups use verbal presentation, some groups are now using videoclips—which makes the discussion much livelier. Agree on membership issues. How many members will the group have, and how will new members be integrated? Once a group has formed, I believe that decisions about adding more members should be a group decision. While it may be tempting to accept a request from someone who wants to join the group, a total of six members seems to be the maximum number for each member to have enough opportunities for presentations. Attend to the group process and dynamics. While groups should build in a “schmooze” or “check-in” time, there needs to be an agreed-upon limit to the socializing, so that the group doesn’t become a therapy group or a coffee klatch. Without a leader, the members themselves must monitor the group’s procedures and raise any important issues. Some groups do this ad hoc; others schedule a regular review meeting to evaluate how things are going. Leaderless peer supervision groups can help clinicians at any stage further clinical learning and combat professional isolation. They’re likeliest to succeed when the group members have a clear working agreement, maintain regular attendance, and create an environment in which both emotional and cognitive learning occurs. Eleanor Counselman, Ed.D., is a past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts.Case Study
Women Who Cheat
By Tammy Nelson
Understanding the message of the affair
Even though our ideas about sex and sexuality have greatly advanced over the last half-century, our culture still holds a double standard about infidelity. While no one is entirely surprised by the behavior of a Bill Clinton, an Elliot Spitzer, or a Tiger Woods—men will be men, after all—we still tend to pathologize women or shame them (or both) for having affairs. In my view, far from being evidence of pathology or marital bankruptcy, a woman’s affair can be a way of expressing a desire for an entirely different self, either separate from the marriage altogether or still in it. An affair can be what I call “a can opener” for women unable to articulate for themselves why they’re unhappy in their marriages, much less empower themselves to leave or begin an honest conversation with their husbands about what they feel is wrong. In my practice, I’ve heard many women say, “I didn’t even know what I wanted until the affair was over and I realized that I really wanted to end my marriage,” or “I had no idea that I used the affair as a way to wake up our relationship.” Many infidelity treatment approaches today are based on the idea that the unfaithful spouse is a perpetrator, someone who wronged the other person. While the pain caused by infidelity can’t and shouldn’t be denied, it generally isn’t understood well enough that many women cheat because they struggle with their self-identity in their lives and lack of empowerment in their marriages. To some extent, the affair makes up for a felt lack of an adult self. Sometimes, understanding an affair as an unconscious bid for self-empowerment, relief from bad sex, or a response to a lack of choices or personal freedom is an important first step toward a fuller, more mature selfhood. Searching for the Bartered Self Sarah came to therapy with her husband, Rob, for couples therapy after he caught her cheating. Married for 10 years, he felt hurt, angry, and hopeless about the marriage. He sat across from Sarah on the couch, with his head in his hands. “I have no idea how we’re going to get past this. Sarah says she wants to work this out, but I don’t know if we can put this marriage together again after what she’s done.” Rob had read emails between Sarah and her boyfriend that explained in detail how much they were enjoying virtual sex—watching each other masturbating over a webcam—which had both shocked and devastated him. He’d thought their sex life was good, but admitted that having kids had gotten in the way of their relationship. He thought they still loved each other, and Sarah agreed. They were both unclear why the affair had happened, but said they wanted to recover their marriage, if possible. At the end of their first joint session, Sarah asked whether she could see me individually. Rob consented, so I asked if they’d be OK with an open secrets policy: what’s said in the individual session stays in the session. They agreed that whatever Sarah said could be kept private, though she could share with Rob what she wished to from our individual sessions. In our first individual session, Sarah asked if therapy could be a place where she could talk honestly about the affair. This led to a discussion of the difference between privacy and secrecy, both in her marriage and in her sessions with me. Keeping secrets in her marriage had given Sarah a sense of space—a secret place where she could grow her sexuality, dream her dreams, and keep a part of her that no one else had control over. Our first conversation revolved around how the space she’d created could be shifted from secret to private, and how she could keep a differentiated, individuated boundary around herself in her relationship. This could give her a healthy degree of separation from her husband without having to lie or be deceptive to stake out her space. I then explained to Sarah that, in my view, infidelity recovery has three phases: crisis, insight, and vision. The crisis stage occurs right after disclosure or discovery, when couples are in acute distress and their lives are in chaos. At this point, the focus of therapy isn’t on whether or not they should stay together or if there’s a future for them, but on establishing safety, addressing painful feelings, and normalizing trauma symptoms. In phase two, the insight phase, we talk about what vulnerabilities might have led to the extramarital affair. Becoming observers of the affair, we begin to tell the story of what happened. Repeating endless details of the sexual indiscretion doesn’t help, but taking a deeper look at what the unfaithful partner longed for and couldn’t find in the marriage—and so looked for outside of it—as well as finding empathy for the other, who was in the dark, can elicit a shift in how both partners see the affair and what it meant in their relationship. Phase three is the vision phase, which includes seeking a deeper understanding of the meaning of the affair and moves forward the experience and resulting lessons into a new concept of marriage and, perhaps, a new future. In this phase, partners can decide to move on separately or stay together. This is where the erotic connection will be renewed (or created) and desire can be revived. In this phase, the meaning of monogamy changes from a moralistic, blanket prohibition on outside sex to a search for deeper intimacy inside the marriage. A vision of the relationship going forward includes negotiating a new commitment. Establishing Safety During early sessions in the crisis phase of treatment, Sarah’s view of the world was shifting, and she didn’t know what she wanted. She wavered about whether she wanted to stay with Rob, wondering whether she should move on and seek genuine emotional independence alone or stay and try to be both fully herself and fully married to Rob. She wasn’t sure she could trust me to understand her and didn’t trust her husband, either, even though she herself had acted in a way that wasn’t trustworthy. Gradually, Sarah revealed that she’d felt that she had no space of her own in the marriage, literally or figuratively. Her husband had a home office, but she had no comparable space for herself. Her dependence on Rob was nearly total: he balanced the checkbook, paid the bills, earned the money, and told her when she could make ATM withdrawals. He even counted the cash in her wallet and decided how much she should spend at the hair salon. She’d never been encouraged or allowed to feel empowered and independent. As a result, she’d started rebelling against her husband like an adolescent against a too-strict father, sneaking out at night or during the day when he was at work and having clandestine sexual encounters. Sarah’s affair consisted primarily of quick liaisons in the back of her car. Her boyfriend met sexual needs not being fulfilled at home. Although the sex was quick, furtive, and secret, he gave her orgasms and oral sex and was willing to experiment in ways she found exciting. But while buoyed by the thrill and energy of this new relationship and her long-buried ability to feel pleasure—even wondering if she might be falling in love—she also felt guilty. Frightened by the growing intimacy with her lover when they were together, she began meeting him online, masturbating with him through a webcam. After Rob discovered the affair, he’d demanded Sarah’s email and voice mail passwords, which she gave him. Although this made her feel exposed, vulnerable, and humiliated, she thought her husband deserved the transparency—as the “innocent” party—and that she should be punished. All these thoughts conformed with many of society’s constructs about women who have affairs, but they reinforced her long-brewing resentment that her marriage wasn’t an equal partnership: she was the “bad child”; her husband, the aggrieved parent. At this point, I reframed the affair for Sarah in a way quite different from her own perspective (and that of many therapists). I asked whether it was possible that the infidelity was less a transgression than a move toward self-respect and self-empowerment. Could she have been seeking autonomy and individuation, as well as a more mature state of sexual development? Was she trying to find her voice, maintain a stronger sense of herself, create a personal boundary that no one could cross, and remain in her marriage? Yes, she’d betrayed her husband; this was beyond doubt, I added. And this method for finding herself was clearly not working if she wanted the marriage to survive. But perhaps she’d paradoxically tried to sabotage the marriage as a desperate attempt to develop more emotional maturity and become a more independent and grown-up wife. As we spoke, Sarah realized that, while her intentions in having the affair hadn’t been conscious, she did want to grow into a fuller woman and mature sexual adult. She admitted she thought she could bring that woman back into the marriage and into the relationship. This made one point crystal clear: she could no longer be satisfied with the marriage as it was. Gaining Awareness Having gotten a clearer portrait of Sarah’s marriage, we moved on to the insight phase of treatment. What did the affair mean about her? What did it mean about Rob? And what did it mean about their marriage? As we explored these questions, Sarah discovered quickly that the affair had far more to do with her marriage than with her husband, whom she said she loved and with whom she wanted to stay—but only if it could become a more equal partnership. When I asked what the affair told her about Rob, she said, “I felt that he wanted me to fill a certain kind of role; it wasn’t just about replaying my mother’s position. Rob liked being in charge, liked bossing me around and being a kind of father. I know why, too. He recently lost his job, and the only place he felt any power or control was at home. He was mad that they’d fired him and took it out on me. In a way, he’s always done that: when people reject him, he gets angry and controlling. But with us, the more he tried to control me, the more I wanted independence from him.” We worked in sessions to identify some key areas where she could feel more autonomy and still be in relationship with Rob. She started small, choosing their television shows, making decisions on where to go to dinner, instead of saying, “I don’t care where we go. Where do you want to go?” When Rob asked her to have sex, she told him she wasn’t ready yet, but would let him know when she was. Although Rob felt he had little or no control in these situations, he did begin to appreciate signs of the new, more adult Sarah, someone equal to him, with whom he could have a conversation and negotiate choices. He realized it was a relief that he didn’t have to do it all himself, and he actually felt less lonely in the marriage. When I asked Sarah what the affair meant about her marriage, she said, “In the affair, I felt stronger, more mature, sexier, calmer, more charming, and more alive.” We talked about whether she could integrate her sexier, more mature self into the marriage or whether the relationship was fundamentally flawed. To her, being in her marriage meant giving up a sense of personal power, while having an affair gave her a sense of independence, choice, and more control. She didn’t know how to have a grown-up relationship with her husband that encompassed safety and desire. Reenvisioning a Marriage Treatment in the third phase included helping Sarah get in touch with her fantasies and reconnect with pleasure—one of her greatest challenges in therapy. She felt guilty when she thought about her own pleasure, and had compartmentalized her needs into the affair, as something separate, wrong, and forbidden. Her fantasies and desires were something she felt shame about sharing with her husband. Bringing that sexual part of her into the marriage was the beginning of erotic recovery for her and for her marriage, but she still had to learn to connect with her desires and to communicate them to Rob. I asked her to write down some of her sexual fantasies and share what she thought the desire or longing underneath them was. For instance, if the fantasy was to have someone grab her hair and kiss her, was this spurred by a longing to be held, to be out of control, to know that she was wanted and desired, or all of the above? The goal was to normalize her sexual needs: her affair had been a breach of monogamy, not a sexual pathology. “If you could have anything you wanted, what would you ideally expect from your sex life with your husband?” Sarah answered shyly, “That he’d pursue me and we’d try new things in bed.” When I asked her if she knew what the longing underneath might be, she said, “My real longing underneath is to be totally special to him.” Sarah went on to work on a vision of a more intimate and adult sexuality. This included asking Rob to behave in ways that made her feel special and trying to make him feel special as well. By this point, she was committed to creating a mutual vision of a new monogamy with her husband, and I suggested they return for couples therapy and focus together on their erotic recovery. Several months later, Rob and Sarah are still working on an agreement for a new, monogamous marriage together. Sarah is committed to sharing her real thoughts and feelings with Rob. In this way, her adult self and her adult needs become a priority that can be talked about and negotiated in the relationship. She feels they’re now given as much importance as Rob’s needs. Rob’s commitment to Sarah is that he tries harder to share his feelings and work on creating a more emotionally intimate relationship. They both try to be conscious of the distant and disconnected roles learned in their childhoods, and focus instead on the emotional intimacy they really want from the relationship. Their new monogamy includes a focus on their erotic recovery. The affair created an erotic injury to their relationship, and Rob and Sarah continue to work on this as a goal of healing. They’ve made a commitment to sharing their fantasies and talking about what’s working in their love life. When they feel distant or dissatisfied, they want to learn to talk about it and turn toward each other instead of shutting down or turning to someone else outside the marriage. Sarah now understands that her journey to self-empowerment and freedom can happen at the same time that she’s a wife and partner. Her adult choices include staying in a mature, monogamous relationship, while creating space for working on her own self-identity. Her worth in the relationship continues to be a focus of our couples therapy. Her cheating makes sense to her now in the context of her life issues, but she has a new empathy for Rob and how it affected him. As therapists, it’s important to discern what our goal is for the women we treat in infidelity therapy. Are we helping them end an affair or end their marriage? Is it our job to remind them of their vows or simply to help them heal? By viewing women’s infidelity as a possible search for a new way of being, we can help them reenvision a fully committed relationship with greater empowerment and equality. CASE COMMENTARY By David Treadway While I admire the sensitive work Tammy Nelson did in rejuvenating Sarah and Rob’s marriage, both emotionally and erotically, I believe that zooming in too quickly to examine the root causes of an infidelity without addressing the emotional impact of the betrayal on both parties usually leads to incomplete healing. Although I say to couples that each partner is 50 percent responsible for what’s not working in a marriage, I always add that choosing to have a secret affair is 100 percent the responsibility of the unfaithful spouse. Most of the time, couples need a way of healing the fundamental breach of trust before being able to fully repair the relationship. In working with couples following a secret affair, I use a four-step model based on the treatment approach of clinical psychologist Janis Abrahms Spring: Step 1: The betrayed partners have as much time as needed to share their hurt, anger, and sense of devastation while unfaithful partners listen as nondefensively as possible without explaining or rationalizing their behavior. The therapist helps the partner who had the outside relationship to be compassionate and caring about the impact of the affair. Needless to say, this may take more than a single session. Step 2: The unfaithful partners are then taught to write a letter in which they take full responsibility for having done harm, indicating what they’ll do to ensure it won’t happen again and what concrete steps they’ll take to make amends. In addition to agreeing never again to see the other party in the affair, other ways to make amends might include giving up drinking for a year or getting rid of the boat where the affair took place. Step 3: The letter of amends is read in session, and the concrete actions that constitute an attempt at atonement are agreed upon by both partners. Step 4: Only at this point is the challenge of learning how to forgive discussed, and only if betrayed partners are ready to begin to work on it. If so, they’re coached on how to write a forgiveness letter that involves accepting the attempts at atonement and expressing a willingness to let go of a sense of injury. This all takes place with the understanding that forgiveness can’t be legislated; it has to grow over time. It’s my experience that patiently and thoroughly working through this difficult process without shaming and blaming is what allows a couple to move on to achieving a level of intimacy and trust that they typically never had before. I remember a man named Paul who’d gone on to transform his relationship with his wife after her affair and referred to their new sense of connection as his “second marriage.” In one of our last sessions, he put his arm around his wife, smiled at me conspiratorially, and said, “You know what I like best? Here I have this extraordinary woman and a brand new ‘second marriage,’ and the lawyers didn’t get a dime!” AUTHOR'S RESPONSE I agree with David Treadway’s observation that working with couples after an infidelity takes lots of finesse and that, of course, the feelings of the person who’s been deceived and betrayed need to taken into account and addressed. Like Treadway, I think Janis Spring’s “secrets policy” can be invaluable, offering helpful clinical guidelines for individual work when necessary. Since this case study was told from Sarah’s point of view, it doesn’t delve into Rob’s feelings, nor do we get to see much of the couples work. Instead, the focus is on the special issues of identity and empowerment for women who have affairs. If I’d told the fuller story of the therapy with this couple, I’d have devoted more attention to the third phase of treatment—the attempt to help them develop a new vision of their marriage, which I call the “new monogamy.” However, the most important message I hope readers take away from this case is that even after the wrenching pain of an affair, therapists still have an opportunity to help troubled couples create a new relationship with better communication, fuller intimacy, and realistic hope for a better future together. Tammy Nelson, Ph.D., M.S., a board-certified sexologist, licensed professional counselor, certified sex therapist, and Imago therapist, is the founder and executive director of the Center for Healing. She’s the author of The New Monogamy; Getting the Sex You Want; and What’s Eating You? David Treadway, Ph.D., is director of the Treadway Training Institute. He’s the author of Home Before Dark: First Year with Cancer and Intimacy, Change, and Other Therapeutic Mysteries: Stories of Clinicians and Clients.
| Sleepless in America |
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Making it Through the Night in a Wired WorldBy Mary Sykes Wylie It's 3:00 a.m. Your eyes suddenly snap wide open and stare unblinking into the darkness. You try to remember the dream you were having, but it's gone, and anyway you're now as tightly tuned as a bowstring to the mysterious night noises of your house—pings, drips, rustles, hums, creaks—that send little electrical jolts zinging unpleasantly through your nervous system. You determine not to move, because that would be to admit you really are irrevocably awake. So you lie very, very still and clamp your eyes tightly shut again, though they fight back, quivering in the effort to reopen. You're aware of a dull, inner pain in your lower left side, or up near your heart, or deep in your belly, or behind your right eye. How long have you had this pain? What does it mean? Cancer? Stroke? Heart attack? Just lie quietly, relax your muscles, breathe slowly from the diaphragm, watch your breath, you think to yourself. But your body doesn't want to lie still—a cascading series of itches, prickles, cramps, and aches build up to an unbearable restlessness. So: roll over to the left, curl up into a fetal position, roll over to the right, stick one foot out from under the covers, roll back to center, straighten legs, bend legs, flex feet, stretch, yawn, scratch stomach, scratch upper back, rub eyes, drum fingers on covers, throw off covers, pull up covers, pound pillow, massage temples, crane head around to look at clock (3:13), try the breathing thing again. By now, your hyperactive brain is in full gear, a gazillion neural networks churning out a kaleidoscopic vision of every awful moment of fear, loss, frustration, fury, humiliation, and failure you've ever had, going back to college, to 7th grade, to kindergarten. (Now is also a good time to relive the really grisly part of that horror movie you watched years ago, still lodged permanently somewhere between your amygdala and prefrontal cortex)
If you're lying next to someone, you listen resentfully to that person's deep, regular, innocent, animal breaths, hating him or her for not joining you in your night of sorrows. If you're by yourself, you might sigh, sit up, turn on the light, arrange the pillows behind you, and begin reading the book that you almost fell asleep over just a few short hours ago. But you can't concentrate very well—you feel exhausted and wired at the same time, preternaturally alert and jumpy, but with a deep, penetrating tiredness. After reading the same paragraph 12 times, you get out of bed, go into the bathroom, turn on a light, pee, and take a look in the mirror at your haggard face. It's now 3:42, and you begin wandering aimlessly around your house like the undead, looking out different windows at the quiet nighttime neighborhood. You know with great, hallucinatory certainty that everybody in your community, your town, your state, everybody within four to six time zones, uncounted millions of people are all peacefully asleep—all except you. You, however, are wide, wildly awake, and absolutely, utterly alone. Fostering Wakefulness Insomnia. Almost everybody has it at one time or another. Some poor souls live (or barely live) with it. It's hard to know exactly how widespread it is—prevalence rates are all over the map. As many as 30 percent of the population, or as few as 9 percent (depending on the source of the statistic, or how insomnia is defined, or what impact it has), suffer from some form of it at least some of the time. Critics maintain the higher estimates are overblown, partly by insomniacs themselves, whose suffering leads them to overestimate the time they spend lying awake (10 minutes of lying wide-eyed in bed feels like an hour) and by the pharmaceutical industry (that all-purpose villain) in order to sell billions of dollars in sleeping potions.
Chronic insomnia is linked to a multitude of physical and psychological ills: increased risk of cancer, hypertension, heart disease, obesity, diabetes, infertility, miscarriage, depression, anxiety, irritability, dementia, impaired cognitive and reasoning skills, lowered immune-system function, heightened awareness of pain, and who knows what else? Probably bunions, dandruff, and pinkeye. But while insomnia apparently contributes to, results from, or is comorbid with the ailments on this laundry list, why we get insomnia, which parts of the brain are most implicated, and how it actually hurts us, even what it is exactly, all remain largely a mystery, as does sleep itself. Thus researchers summed up a lengthy 2005 National Institutes of Health report on insomnia with deadpan succinctness: "Little is known about the mechanisms, causes, clinical course, co-morbidities, and consequences of chronic insomnia." What's undisputed, however, is that sleep is as necessary to physical and mental health as air and water, and that, without it, we suffer—often severely. So, those annoying world-beaters, who brag about needing only four hours of sleep a night (the better to forge multimillion-dollar start-ups and do their Nobel Prize–winning research) are perhaps not being entirely candid. According to sleep expert Thomas Roth of the Henry Ford Sleep Disorders Center in Detroit, "The percentage of the population who need less than five hours of sleep per night, rounded to a whole number, is zero." Yet if a vast conspiracy were afoot to create an entire civilization of insomniacs, it would operate pretty much the way our society does now. Over the past century or so—roughly coresponding with the invention and worldwide adoption of electricity—the average time allotted to sleep in the industrialized world has shrunk by as many as four or five hours. The average North American now sleeps about six and a half hours a night—even fewer for ambitious careerists on an upward trajectory—down from eight hours a generation ago and ten hours in the early 20th century. In fact, thanks to technology, particularly the Internet, there's nothing you can do during the day that you can't do at night. The glory of 24/7 is that, using our computers or TVs or cell phones, we can continue working, buying, selling, playing, communicating, gambling, managing our portfolios, following the latest news in Karachi, or London, or Santiago, or Shanghai without stopping for a time-waster like sleep.
Insomnia is exactly what the movers and shakers of our society want for us. The buzz-term used by advertisers and corporate honchos for the monetary windfall of our 24/7 lifestyle is the "attention economy," and there's a perceived need to increase it, which means finding ever-growing numbers of people (consumers) awake and aware of the proliferating Internet-mediated information sources (the "product") popping up on their screens, and ultimately buying something, somewhere, from someone. "The winners will be those who succeed in maximizing the number of Ôeyeballs' they can consistently control," writes Columbia art historian and social critic Jonathan Crary in the essay "On the Edge of Sleep." According to Crary's dystopian view of the 21st century, in a nonstop globalized economy where night never falls, sleep is a passive, useless occupation taking up precious time that might better be spent producing, circulating, buying, and selling. This is the kind of world that demands an endless supply of insomniacs for its economic lifeblood. But never doubt capitalism's fiendish ability to take advantage of a market opportunity, whatever its origin. Even as massive entrepreneurial energies are expended on keeping people awake and entertained, countervailing commercial efforts are put forth to lull them to sleep. Besides the blockbuster sales of sleeping pills with soothing names like Ambien, Lunesta, and Sonata, the well-heeled spend more than $20 billion a year on an astonishing array of sleep paraphernalia, including herbal supplements, aromatherapy massage, reflexology, calming soaps and lotions, massage pillows and buckwheat-seed body wraps, Hungarian goose-down duvets, white-noise machines, and specialty mattresses that can cost from $5,000 up to $60,000 (yes, you read right—the $60-grand number is Swedish, filled partly with hand-selected horsehair, and takes 160 hours to make). The Need for Sleep Still, it's doubtful that any of these expenditures make much difference in sleep quality to the truly dedicated insomniac—he or she will just have spent more money on greater luxury in which to thrash around all night. Yet even the most desperate of us will fall asleep eventually because our bodies will make us. You can refrain voluntarily from eating until you literally starve yourself to death, but you can't willfully keep awake beyond a certain point on your own any more than you can command your blood to stop flowing. Even the few competitive "athletes" of voluntary sleeplessness who force themselves to stay technically "awake" for more than a couple of days (the Guinness record holder is an Englishwoman, Maureen Weston, who apparently went without sleep for 14 days and 13 hours in 1977), involuntarily fall into "microsleeps" of a few seconds to a few minutes without being aware of it.
But it was only in our own "enlightened" era, once the invention of electricity made bright, 24-hour lighting and sound amplification technically available, that sleep deprivation as a form of state-sponsored "no-touch torture" came into its own as an art and science. The Gestapo used it in Nazi Germany, the Japanese used it on POWs during World War II, the Chinese on prisoners during the Cold War and on dissidents to this day, the Israelis on Palestinian militants (and Palestinian factions on each other), the British on IRA members, the Pinochet dictatorship on subversivos, the police and army in Iran, Saudi Arabia, and Tunisia on their own alleged enemies—it's probably the rare country that hasn't used it at one time or another. The Soviet secret police called sleep deprivation a "conveyor belt," because prisoners were kept awake day and night by revolving shifts of interrogators who had at them until they signed the requisite "confessions." (One Russian dissident of the 1960s said interrogators bragged that after many hours of this treatment, they'd gotten his 14-year-old son to "confess" to writing the novel Eugene Onegin—actually written, of course, by Alexander Pushkin, an insomniac himself, and published in 1837). Considering the horrible array of tortures widely used in hellholes around the world, people often find it hard to believe that simply keeping people awake really qualifies as torture, or even "enhanced interrogation," as our Interrogator-in-Chief calls it. But according to prisoners or detainees subjected to "sleep management," the antiseptic term used by Lt. Gen. Ricardo Sanchez, the former U.S. military commander in Iraq, the modern forms of tormentum vigiliae are indeed as tormenting as many far more draconian torture methods. "After two nights without sleep, the hallucinations start, and after three nights, people are having dreams while fairly awake, which is a form of psychosis," says John Schlapobersky, psychotherapist to the Medical Foundation for Victims of Torture, who was subjected to sleep deprivation in apartheid South Africa. "By the week's end, people lose their orientation in place and time—the people you're speaking to become people from your past; a window might become a view of the sea seen in your younger days. To deprive someone of sleep is to tamper with their equilibrium and their sanity." In his book White Nights: The Story of a Prisoner in Russia, about being a POW in a Siberian labor camp during World War II, former Israeli prime minister Menachem Begin wrote that prisoners "subjected to extreme tortures had not cracked, but lost the will to resist with sleep deprivation. In the head of the interrogated prisoner, a haze begins to form. His spirit is wearied to death, his legs are unsteady, and he has one sole desire: to sleep, to sleep just a little, not to get up, to lie, to rest, to forget. . . . Anyone who has experienced this desire knows that not even hunger or thirst are comparable with it. I came across prisoners who signed what they were ordered to sign, only to get what the interrogator promised them. . . . uninterrupted sleep!"
Nonetheless, unforced insomnia that ends only in death, though very rare, does happen. Consider a disease called fatal familial insomnia (FFI). As described in The Family That Couldn't Sleep by D. T. Max, fatal familial insomnia is a genetic disease, first identified in the 1980s, in which prions—the same kind of mysterious, viruslike rogue protein responsible for mad cow disease and Creutzfeldt-Jakob Disease in humans—caused a rare, always lethal, condition characterized by relentless insomnia. Upon autopsy, the brain seems mostly normal, except that the prions have essentially scoured out the thalamus—a nodule still not well understood, which helps control the body's autonomic nervous system and natural sleep–wake cycles. The affected person experiences increasingly dire symptoms: worsening insomnia, profuse sweating, stiff neck, pinprick-sized pupils, sudden menopause in women, impotence in men, listlessness, tremors, uncontrollable crying, thrashing limbs, elevated blood pressure and pulse, loss of balance, dizziness, and emaciation, ultimately culminating in a state of chronic, agitated, hallucinatory stupor, alternating with ever-shorter periods of lucidity. No narcotic or anesthetic agent has any effect, and the end—generally around 15 months or so after symptoms first appear—is usually awful. Max describes one dying man "howling in the night, his arms and legs wrapped around themselves." Almost nobody gets fatal familial insomnia, and yet, don't these symptoms strike a terrifying chord in the heart of anyone who's ever spent more than a few nights staring hollow-eyed into the darkness? The exhausted longing for sleep combined with the paradoxical inability to force yourself to "fall" asleep is maddening in that the harder you try, the greater your physiological stress, and the more awake you feel. The sense of existing in a surreal state, all nerves quivering as if expecting at any second that ominous knock on the door by the KGB or the Gestapo (or Homeland Security?), breeds anxiety and dread, an enveloping foreboding that something nearby is wrong and strange and dangerous. With our poor night vision and relative helplessness before predators that growl and stalk the darkness, we have always felt, from our deepest hominid past, most vulnerable to harm after sunset: the "hour of the wolf" has more than metaphorical meaning. Night and death, sleep and death, have a long history of association. In The Iliad, Hades, the "Kingdom of the Dark," is also the kingdom of death, and it's during the night that the dead visit the living in the form of dreams. To be up and about in this land of the dead seems to be breaking a taboo, to be entering a forbidden borderland between waking and sleeping, living and dying, and risking unpleasant and unsought encounters with ghosts and specters, goblins and ghouls. And encounter them we often do, even if they originate in our own minds, haunting presences from our own lives. As an anonymous Japanese poet once put it, "the night offers toads and black dogs and corpses of the drowned."
The Literary View Writers, past and present, have been no strangers to insomnia. An incomplete, ad hoc list of confessed insomniacs includes Charles Dickens, the Bront' sisters, Franz Kafka, Marcel Proust, Lewis Carroll, Ernest Hemingway, Mark Twain, Gertrude Stein, and Philip Larkin. Other possible sufferers were Sappho, Dante, Shakespeare, Cervantes, and Dostoevsky—all of whom wrote about insomnia as if they knew it all too personally. As you'd expect, insomnia is often paired with guilt, fear, and despair. In the Divine Comedy, adulterous lovers in the second circle of hell are kept perpetually awake by a "hellish hurricane, which never rests, drives on the spirits with its violence: wheeling and pounding, it harasses them. . . . Now here, now there, now down, now up, it drives them. There is no hope that ever comforts them, no hope for rest and none for lesser pain." (Lying awake at 4:00 a.m. listening to the winter wind howling and rattling the windows provides a reasonable facsimile.) Probably Shakespeare was the master of characterizing insomnia as the wages of sin and guilt. Think of Macbeth's cry to himself after he's murdered Duncan: "Methought I heard a voice cry 'Sleep no more! Macbeth hath murdered sleep'—the innocent sleep. Sleep that knits up the raveled sleave of care." Or Iago, about Othello, whom he deceives into becoming jealous of the innocent Desdemona and murdering her: "Not poppy nor mandragora, Nor all the drowsy syrups of the world, Shall ever medicine thee to that sweet sleep Which thou own'dst yesterday." Or Queen Margaret, who curses serial killer Richard III: "No sleep close up that deadly eye of thine, Unless it be while some tormenting dream Affrights thee with a hell of ugly devils." But in more modern times, a tradition has emerged linking insomnia, like madness and melancholy, not so much with guilt as with Faustian powers of creativity and imagination, and perhaps even the promise of immortality, not granted to dull slugabeds catching their nightly eight and a half hours. "There is a nocturnal personality, a nocturnal spirit, distinct from that of daylight and available only in solitude: hence the secret pride of the insomniac who, for all his anguish, for all his very real discomfort, knows himself set apart from others," writes Joyce Carol Oates in her preface to Nightwalks: A Bedside Companion. "Unable to sleep, one suddenly grasps the profound meaning of being awake: a revelation that shades subtly into horror, or into instruction," continues Oates, who's herself both an insomniac and a master of literary horror fiction.
In some literary works, the insomniac sets him- or herself proudly above the natural laws mandating sleep, but pays for this arrogance in a horror of madness, damnation, or death. At the end of Isak Dinesen's short story Night Walk, a guilt-ridden insomniac encounters an ugly redheaded man, who sits at a table and counts a pile of silver coins over and over. Repeating "with extreme arrogance" and "deep scorn, "I never sleep. Only dolts and drudges sleep,'" the coin-counter reveals himself to be none other than Judas Iscariot, who hasn't slept since the night he betrayed Jesus. Now, he's doomed to spend eternity alone with his demonic pride, his 30 pieces of silver, and his insomnia. Vladimir Nabokov once called sleep the "most moronic fraternity in the world, . . . [a] nightly betrayal of reason, humanity, genius." He really did have it in for Hypnos, the ancient Greek god of sleep. In his memoir, Speak, Memory, he writes, "People in trains, who lay their newspaper aside, fold their silly arms, and immediately, with an offensive familiarity of demeanor, start snoring, amaze me as much as the uninhabited chap who cozily defecates in the presence of a chatty tubber [bather]. . . . I simply cannot get used to the nightly betrayal of reason, humanity, genius. No matter how great my weariness, the wrench of parting with consciousness is unspeakably repulsive." Nonetheless, in Nabokov's novel The Defense, a chess master is so obsessed with his "chess life" in which "everything obeyed his will and bowed to his schemes" that he doesn't go to sleep at all, but devotes himself night and day to perfecting every conceivable chess strategy. In the end, he's horribly punished for his monomaniacal determination to win at all costs by an insomnia that drives him mad and kills him. Exhausted and reeling during a heated match, he falls into a delirious phantasmagoria of "twilight murk, thick, cotton-wool air," in which strange voices, lights, chess figures, ghosts, and shadows, snatches of landscape and architecture appear and disappear before "a wave of oppressive blackness wash[es] over him," whereupon he collapses and dies. In "Sleep," a surrealist story (surrealism, fantasy, magic realism, all lend themselves to insomnia, and vice versa) by Haruki Murakami, a woman, suddenly liberated from the need to sleep at all, finds herself becoming a tireless, perfectly functioning humanoid machine—entirely free of ordinary biological constraints, more energized, intelligent, self-confident, her consciousness expanding, expanding until . . . until her life explodes, literally, in terror and death. "I had imagined death as an extension of sleep. . . . Eternal rest. A total blackout," she thinks, on the way to her demise. "But now I wondered if I had been wrong. Perhaps death was a state entirely unlike sleep, something that belonged to a different category altogether—like the deep, endless wakeful darkness I was seeing now."
In our own culture, there's an eerie echo of this insatiable striving to rise above our stupid, beastlike, physiological need for sleep and become unflagging, bionic powerhouses. For some years now, a drug called Provigil has been marketed as an alternative to amphetamines for keeping people awake and alert without the screaming meemies that are often a side effect of Dexadrine and other forms of speed. Provigil was originally intended to treat people with narcolepsy, but 90 percent of all prescriptions now are written "off label" ($575 million worth in 2005) for travelers who want to avoid jet lag, night-shift workers and long-distance truckers, military personnel, people in high-stress jobs (those 15-hour-a-day junior lawyers bucking to make partner), and students pulling all-nighters (or just partying all night). "There is a multibillion-dollar demand from civilians who wish to sleep only when they want to sleep," Jonathan Moreno wrote in the November 2006 issue of Scientific American. Provigil is only one of several such wake-up drugs in the research pipeline. The Pentagon's Defense Advanced Projects Research Agency (DARPA), which pioneered Internet technology in the '60s, is investing at least $100 million for research into even better wake-up-and-stay-up contrivances, including more powerful, side-effect-free drugs, focused magnetic waves, and light stimulus. "The more we understand about the body's 24-hour, clock the more we'll be able to override it," says Russell Foster, a circadian biologist at Imperial College London quoted by Graham Lawton in the February 18, 2006, issue of New Scientist. "In 10 to 20 years we'll be able to pharmacologically turn sleep off." To anyone not enchanted with this forecast of perpetual, goggle-eyed wakefulness, who still values sleep and rues insomnia (which is most people, barring self-defined masters of the universe and Dr. Strangelove types), for anyone who still has some retrograde attachment to the idea of natural body rhythms, this kind of scientifically generated defeat of so integral a part of human biology as sleep is inherently abhorrent. But, it turns out, we've long been insulting our natural wake-sleep cycle—for well over a century anyway—simply by expecting ourselves to fall asleep precisely at 10:00 or 11:00 p.m., sleep solidly the entire night, and wake promptly at 6:00 or 7:00 a.m. There's now accumulating scientific and historical evidence that human beings, like many of our mammalian cousins, weren't meant to follow what we consider a "normal" wake-sleep pattern of two strictly segregated blocks of time—16 uninterrupted hours awake, 8 uninterrupted hours asleep. In studies conducted at the National Institute of Mental Health during the '90s, psychiatrist Thomas Wehr and colleagues found that when research subjects were deprived of artificial light and restricted to a dark room for 14 hours a day (closely approximating the natural light-dark conditions of winter) for several weeks, their entire sleep pattern shifted dramatically. They didn't sleep solidly for 8 or 10 or 14 hours, but first lay quietly in bed for two hours, then slept in two sessions of about four to five hours each, separated by one to three hours of calm, reflective, wakefulness. Instead of having the stress hormone cortisol streaming through their bodies—like insomniacs have when they can't sleep—these subjects exhibited heightened levels of prolactin, the pituitary hormone that stimulates lactation in mothers and permits chickens to brood contentedly on their eggs, during their periods of nighttime wakefulness. Their brain-wave measurements at these times resembled a state of meditation.
Some researchers, including Ekirch, are apparently drawing the conclusion from this material that midnight or early-morning insomnia is possibly more "natural" than the pattern of eight hours straight sleep that we've come to expect, but often fail to achieve. Perhaps, the implication is, we ought to accept the reality of those hours awake and cultivate a better attitude toward the inevitable—we should accept and make friends with those wakeful hours in the middle of the night. According to sleep researchers, lying quietly and peacefully awake can be as restful and restorative as sleep. And it's undoubtedly true that expending much anxiety on insomnia just makes the problem worse. But those gentle, midnight ramblings and tranquil musings of the bimodalists clearly have nothing in common with what we experience as insomnia, in all its tense, anxiety-haunted misery. Anyway, we don't have the time for playing around with first and second sleeps and late-night contemplation and conversation—we've only got what we've got, which is usually a pitifully few hours after work, after dinner, after the kids are settled, after we've answered our e-mail, after we've made some calls, after we've paid some bills, after we've done some laundry, to get whatever sleep we can steal from what's left of the night. In obvious ways, we've long since abandoned the ancient habits and rhythms of our primordial ancestors, not only in our patterns of waking and sleeping, but of working and playing, mating and child-rearing, thinking and believing. We aren't likely ever to return to those old patterns—barring a worldwide catastrophe that sends those of us who survive back into paleolithic times. And we might not want to: the staggering scientific and social progress of the modern era probably owes a good deal to all those extra, artificially lit hours of wakefulness devoted to thought, study, research, invention, and production.
Mary Sykes Wylie, Ph.D., is senior editor of the Psychotherapy Networker. Letters to the Editor about this article may be e-mailed to letters@psychnetworker.org. The following Networker U Courses related to this subject or author are available on this site: Audio Home Study Online Course |
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