Adventures in Aging

A  pernicious belief  in our culture is that getting old is a negative occurrence and that old people are inferior in various ways to the young.  In some more traditional cultures,  the aged are revered, believed to have achieved  wisdom in their long lives.  (I don’t believe that a person should be revered just because they have achieved advanced age.  In my opinion, they have to show that they actually have achieved some wisdom and experience that are valuable to the whole society in order to be admired.)  But many old people do not seem to have gained very much wisdom in their aging.  Many, out of a concern about safety, become more rigid and narrowed in their breadth and number of activities and interests.

Being old certainly has its downsides in terms of lowered physical and cognitive ability and medical ills; and the pain that results from serious medical issues.   I must admit that I am sad about negative changes in my health and cognitive abilities.  I feel frustrated when I can’t remember temporarily, for example, that that thing  in my sink that grinds up food stuffs is called a garbage disposer.  Or that the name of my best friend’s wife is Debby.  Or confuse Alzheimers with Asbergers syndrome   (And I do worry at times that my forgetting certain things means that I’m developing the former!)  The  worst part for me of getting old and facing the fact of my mortality is not being in control of it.  I can do things to try to ward off my death--eating right, exercising, doing things I enjoy and find meaningful, spending  time with friends and family. One of the activities that gives my life meaning is writing these blog articles. But, in the last analysis, I will die some day and fairly soon.  I can't keep that from happening.   And another very painful aspect of my aging is the loss of many friends who have died in the past several years:  2 fellow gestalt therapists, David Gorton and Bob Resnick whom I knew in Los Angeles for over 40 years; another psychologist, Tom Greening, an office mate and past editor of the J. of Humanistic Psychologist; Jackie McCandless, a psychiatrist whom I met at UCLA when she was a resident and I was a professor there, with whom I ran a therapy group and was the one who recommended I go into private practice; an ex-wife and rolfer; and, most recently, Steve Zahm, a very loving and beloved  Gestlt therapist and teacher who, along with his wife, Eva Gold, ran a Gestalt training institute in Portland for many years.   I have had to do quite a bit of grieving at the loss of these extraordinary people.

But there are some potential advantages in getting old, and ways to make it meaningful. I hope to empower those who read these articles to see that, despite their age and degree of enfeeblement, they are still able to do many things to enjoy their lives and to find meaning in them. I also hope to help those therapists who work with the elderly to be more effective with them.

One possibility in aging is that one can now devote themselves to growth and self- expansion, especially if they now have the time to read the books they may have wanted to read earlier in their lives but did not have the time or energy to do so. They can become involved in political causes if they are concerned about issues such as climate change or the political situation in our country. Or learn a foreign language; research has shown that this activity can stave off cognitive decline. If they have the energy and health for travel, they can visit areas of the world and friends and relatives they may not have had the time or freedom for earlier in their lives.

Clients Who Have Difficulties In Financial Self Regulation

One “error” I realize I’ve made with many clients in the past is assuming they know certain facts that seem obvious to me about how to support themselves.   I  have found out frequently, almost by accident, that many clients  don’t know how to handle their finances in a judicious way.  And, as David Krueger the editor of a book called The Last Taboo said years ago, discussing finances with others, including their therapist,  is a bigger taboo for many than sex, religion or politics.  It’s also the largest single issue in divorce.   Since my therapeutic philosophy usually involves my dealing with what my clients bring up rather than introducing topics, I have tended to avoid dealing with their financial issues.   And even when I saw them making financial mistakes, I had to be judicious in how I addressed this issue.  In addition, I  found that, even when we did not directly discuss it, some clients started being more successful in dealing with money after having been in treatment with me for an extended time. This was the result of them achieving more self support.  

Many clients make plenty of money so they don’t have to worry about it but are still not good at handling it.  Also, their chaotic way of dealing with it can be a poor lesson to their children, who may not have the same resources as adults.  I have often thought that one of the worst things that can happen to a child is being brought up in a family that is very rich. I have observed this personally in the family of a friend, and history is rife with examples of a child being brought up with unlimited resources, but is a failure, not only financially, but in other ways, as an adult. It doesn’t have to be that way, but it takes very wise wealthy parents to raise children who are well-functioning, reasonably hard working , successful adults. One example of a very rich man who was apparently able to accomplish this is Warren Buffett, whose kids knew from an early age that they were not going to inherit a large sum of money from their father. They are known to be financially successful.

Signs Clients Do Not Have Financial Self Support

In recent years I have become more openly curious with clients about their financial self-regulation when I suspect they have problems in this area.  Here are some signs of difficulties:  

1.  They are constantly behind in their account with me.  This can be indication they lack a systematic method for paying bills, an indication of chronic over-spending,  a sheer reluctance to shell out money or an unexpressed dissatisfaction with the therapy.     

2.  They describe frequent conflicts with a spouse, child or significant other about money. 

3.  They express resentment about not being able financially to live the lifestyle they feel entitled to or see friends living.  

4.   They express the wish to do something like remodel part of their house, then in a later session indicate they impulsively bought an expensive piece of jewelry or clothing.  

5.  They spend all their income each month, and then do not have the funds to pay for an unexpected expense such an illness that requires them to be out of work for awhile or an expensive auto repair.   Of course a huge percentage of the US population earns a minimum wage and can barely support themselves and their families.

6.  They have a gambling addiction.  

7.  They have great difficulty buying things for themselves, but no difficulty giving to others.  

My therapeutic approach when I see signs of issues dealing with money

When I see these any of these cues and we have a secure therapeutic alliance, I ask the client if they think they have difficulty dealing with money.  If they acquiesce, I ask if hey want to discuss it.  If they seem to feel shame, thinking this should be easy, I might let them know that this is an issue many people have and one I myself had in the past that I had to work through.   I also tell them that I have found many of my past clients having this problem.

I then ask the client certain questions, depending on the specific issue, starting with a general one concerning their feelings about money and what has been history their history about it.   I also might ask them to symbolize money in some way, to imagine it in front of them, so as to discover what they experience as they visualize it.

Here is how one client described money.

“I see it as as a pile of dollar bills and a bunch of change in front of me.  And I don’t like it!  It really looks yucky, disgusting.  I have always felt that way about money, starting as a child.  And I find myself getting rid of it as quickly as possible, just wanting to spend it all when I have it.”  

Another one described it in positive terms, but very far away from them and unreachable.  “I see it as a big pile of glittery gold.  I would like to grab some of it, but it is very far away, unattainable.”  

Still another saw it as a very desirable large pile of bills, and imagined wanting to pile it up and play with it.  They aw themselves throwing it up in the air, it coming down on top of them like confetti. I was reminded of the money hoarder, Silas Marner, in the book by George Eliot.  

Clients frequently spontaneously told me about their familial history with money.  But if they don’t and I feel it is important to explore, I might ask them what their experience with money was as a child.   

Common familial themes I have discovered over the years

1. Continual conflicts between the parents around money.   For example, one parent was frugal, the other a spendthrift.  And when the frugal parent saw unexpected items on the credit card or bank statement, they exploded and a fight with the other spouse ensued.  In some instances, the client reported that that one parent, usually the father, spent a lot of money buying adult toys such as boats and cars, but was very cheap at spending for the rest of the family.   In most cases these differences were never resolved.  The outcome for people with this history often has been much conflict about how to handle their money in adulthood.   

2.  A negative view of money itself and wanting to avoid the whole issue.  One client came from a family that was very left-wing, had learned the Marxist refrain that “money is the root of all evil.”  (The actual quote was from St. Peter and was “the love of money is the root of all evil.”)  

3.  Irregular and/or incomplete education around money.  This often included issues about receiving an allowance; many did not get a regular one and that increased as they got older.  Another issue I have found was the child did not get any help about how to manage their allowance, e.g., spending it as he or she saw fit, and whether to spend some immediately and to put some away for larger purchases in the future. Most got no information about investing some of it, especially when they received significant sums from relatives on holidays.   

4.  Secretiveness in the family about the familial resources. The result was they had no idea about how much money the family had, what it was spent on, why the child was told no when they asked for certain things, etc.  Some clients were made to think that the family was poor, only to learn years later that they were well-to-do.  They had a huge sense of betrayal.  

5.  Negative responses to the child when they asked for money for something they wanted to buy that was separate from their allowance.  Some clients reported they were immediately told no but then were later told yes, or were later bought the item by the parents. In either case, this behavior always had a very negative effects on their feeling okay about buying things for themselves and even about their being assertive in general.  

6.  A history of stealing money, e.g., from a parent’s wallet or purse.  And shop-lifting from stores.   This was often a way for the child to attempt to make up for a lack of affection and closeness in the family, i.e., substituting material things for love. In some, it was also an indirect expression of anger toward the parent.

I shall discuss in a future article how to work with clients who have difficulty in dealing with their finances.

Working With Clients Who Have Difficulties in Self Regulation: Introduction

A very important issue that I have only fairly recently begun to investigate is the difficulty in self regulation or perhaps better termed, Self Care or Self Support , many of my clients have had.    This difficulty occurred in various areas:  physical health,  emotional functioning, financial problems, work-related issues and others.   Of course people frequently have self-regulation problems across domains,  but one can be self-supportive in one area, but poorly self-supportive in others.  For example, one can be financially methodical and successful, but deficient in taking care of their physical  health.    

Many of my clients have not even seen  their relative inability to organize themselves in certain important areas as a therapeutic issue, so tended not to bring it up with me.  They took the viewpoint, “that’s just the way I am.”  Or they felt ashamed at not being able to do “simple” functions they thought should be easy.   The difficulties came to light when I began to comment, after they had been with me for awhile,  on certain observations I made about them.  For example, in numerous cases I remarked on a pattern of frequent lateness for their appearance at therapy sessions.  I of course thought to myself that their chronic lateness could be a sign of negative feelings about their therapy, which I felt needed exploration.  But it was frequently the case that the client reported being late to every appointment they had.  And when that came to light, it has almost always started a very fruitful exploration of difficulties in self-regulation which, although starting with time management , extended to other domains.  

In general when clients and I have addressed the self-organization problems fully, they have achieved the ability to give  themselves more self-support. This, by the way, often included the ability to ask others for support when needed, and their lives improved greatly.  

Here are some of the other clues I got from clients that motivated me to explore issues of self-support:   working overly long hours which meant neglecting time with family and friends; being poorly dressed even though they made enough money to buy decent clothes; having had a spotty work and educational history even though they obviously had superior  intellectual and creative  abilities; having  problems dealing with money, including little or no savings or investments for retirement; a chaotic relationship history; having nagging health problems, including being very overweight or extremely thin, dental problems, and difficulties in elimination or chronic insomnia.

Note that my exploring issues of self-support is a departure from my major therapeutic approach, which is to allow my clients to bring up what they want to deal with in any specific session.  But to me this questioning is akin to my asking a client about any obvious avoidance of significant topics.  And I don’t bring up the specific issue until I have established a solid relationship with the client and noticed certain significant patterns existing over time.  I bring up the relevant issue in the spirit of being curious, rather than accusatory.   I feel this is important lest the client feel defensive or ashamed.. I can say with much experience that adult difficulties in self regulation are almost always connected to some care-taker lack during childhood. But the client may not be ready to explore what they experienced during their childhoods, either due to suppression or repression of significant recurring events, or a need to protect their care-takers from blame. In any case, if they indicate they don’t want to discuss the issue, I drop it. I may bring it up in a later session, including inquiring why they don’t want to discuss it if they still take that tack.

I shall discuss a number of these important self-regulation domains in future postings.  

Humiliation, Mortification and Shame and Their Triggers to Intense Anger and Rage

As I said in my last blog, anger is a complicated topic and I shall write numerous articles on it.  In this one, I focus on the connections between intense anger, rage, and violence, on the one hand, and the very vulnerable feelings of shame,  humiliation and mortification on the other.  It is an especially important therapeutic issue to understand and find solutions to in view of the increased incidence of  violence in our country.  

Rage is an issue numerous clients of mine through the years have experienced, resulting in a loss of control and acting out in ways that hurt and frightened others and, in the long run, hurt themselves. Therapeutic working  on it in therapy can have a number of positive results:  

     1.  People who tend to become enraged then can realize their rage is triggered by certain events rather just proof they are bad and, when worked through, can result in a lessening of shame and violent behavior.  

     2.  They begin to support themselves and feel the vulnerable feelings of shame, frustration and helplessness instead of acting it out in rageful ways. 

     3.  They begin to be more accepting of more moderate, controlled angry feelings in themselves and others, and more able to express anger in appropriate ways,  depending on the situation  in which they find themselves.  This usually means they are better able to assert themselves since being justifiably angry gives one a sense of strength, focus and entitlement.  

 I will own that erupting in rage is an issue with which I myself have dealt in the past, but my acting out was usually not at people but inanimate objects.   For example, I remember with great regret exploding with rage and yelling furiously  many years ago after tripping  on some rocks near a campfire I had built for me and my children while on a camping trip in the mountains of California.  It took my teenage son to tell me how inappropriate my behavior was and how upsetting it was to all my kids.  So some of my understanding of the problem of rage is partly the result of experiencing and working through my own issues when rage was triggered as well as having had many clients who struggled with this issue.   

Some of these clients got into legal trouble  because of their rage reactions and were forced to attend anger management groups.  They experienced, however,  little change in decreasing the intensity and frequency of their rage episodes.  This is because these classes have tended to focus on behavior rather than the underlying causes of their rage, which very  adversely affected them and the targets of their rage, especially their partners, friends, siblings  and children.  One ex-client of mine, a brilliant college professor, lost university jobs because of his uncontrollable outbursts of rage, mostly  directed at the  heads of the departments in which he was teaching.   

I can safely say that almost all of my clients’ rage reactions were triggered by experiences of humiliation and shame they experienced that were triggered by painful interactions with others or even inanimate objects.   The latter was true of me when I exploded after falling on the rocks by the campfire.  It was as if the rocks were sentient and had purposely caused my fall.  Of course I quickly realized my fall was caused by my own carelessness but, in the present moment, I was triggered into rage before I could access my rational mind and feel sad for myself.  As a result  I felt shame and helpless and almost instantaneously exploded.    

Shame tends to erase the individual’s sense of psychic worth.    It can also fragment the person’s cognitive functions so that enraged acting-out can occur before they realize they are triggered by shame. It can be in the moment, or it can be a chronic sense of worthlessness.  It is different from guilt, where the individual has an intrinsic sense of worth but has done something they feel is morally wrong.   With shame, on the other hand, one feels that one is wrong, in their very being.  The adaptive reaction to guilt is if possible, making amends.   The adaptive reaction to shame is withdrawal, a wish to disappear so as to protect oneself from shaming by others and to protect them from contamination by one’s badness.  The defensive reaction to shame is rage against that which one feels is the cause of one’s shame.  Fritz Perls made me aware of that many years ago.  Sometimes shame even  results in murderous behavior.   But in this article I am focusing on the situation where the individual has a general sense of (probably shaky) self worth but some event in the present triggers unfinished memories of past interactions where the person was continually shamed.   These events  almost always started in childhood, but can continue later in life as well.  

The outcome of childhood continual shame experiences is a propensity to feel shame when the current situation reminds them of the original experiences.  Such people are usually unaware of the similarity of the present stimuli to their past experiences, and the result is they tend to react with rage when they feel their basic self worth is under attack.  People labelled Borderline  Personality Disorder frequently fall into this category, and can be a huge problem for therapists who do not understand their exquisite vulnerability to inadvertent slights that threaten these persons’ sense of  worth.  

Sometimes the person treated this way as a child became enraged, even throwing temper tantrums.  Or they expressed their anger less intensely, but were forbidden from doing so.  In many cases they were  shamed for showing any anger.   I have often found this in the history of clients whose childhoods sounded pretty benign.  It was only through therapeutic exploration that subtle shaming had actually occurred.  These are some of the people whose shame is most resistant to working through.    In all of these people, however, the result is shame and resultant rage reactions to incidents that trigger shame.   They  usually have no idea that their expressions of rage are the inevitable outcome of the subtle or obvious abuse they suffered as children at the hands of parental figures, siblings or other children.  And they frequently feel ashamed that they react with rage in certain situations and paradoxically try to avoid  any angry feelings at all.  This is  because they fear they will become enraged if they allow themselves free experiencing and expression of anger.   .  

As an example of someone who erupted in rage when feeling shame was a young man in therapy with me many years ago in Los Angeles.  He had been sentenced to jail a number of times in his young life because of physically acting out his rage and was mandated to enter psychotherapy and ended up with me.  He was intelligent and handsome and showed some promise as an actor.  He was given medication by a psychiatrist who thought that his rageful outbursts were the result of a head injury but had not explored his history.  I learned that he had grown up in a neighborhood that was controlled and terrorized by gangs.  He was picked on by other kids because he was small and scrawny as a pre-teen, leading to feelings of shame, weakness and helplessness each time this occurred.  But he was eventually befriended by a gang of older boys and men and later became a member himself.  He also grew stronger and over a period of time was involved in a number of illegal gang activities.  He  also became involved in fights with other young men.  His beating someone to a pulp who had taunted him is what occasioned his being referred to me for psychotherapy.   

We worked for several months on his current issues and unearthing his history.  I tried to help him see that his rageful behavior was a result of the humiliating feelings he experienced when he felt insulted as a child and felt no support by his family.   He seemed to be making some progress in understanding his dynamics until an incident at the acting school resulted in his being incarcerated again.  He was attracted to a young woman in the class.  During a lunch break outside with her and other students, she was sitting on a brick wall smoking a cigarette.  He approached her and made some positive comment to her,  perhaps asking her out on a date.  Whereupon she blew cigarette smoke in his face and made a dismissive remark.  His reaction was to punch her in the face, breaking her jaw.  He was sent back to jail and I never saw him again.  In retrospect, he didn’t seem to see that his physically pageful reactions were a problem, only that he got caught and had to go to jail.  

A positive outcome of therapy was my work with a middle-aged man who was an executive in an entertainment company.  He had been an alcoholic but had managed with the help of AA to stay sober for many years.   He entered therapy to work on painful issues he was having at work and in his  relationship with his girl friend.  She was a very attractive, very popular, assertive,  professionally successful woman who lived in another state and would come to visit him for extended periods of time.  She had a habit of being late for almost all events that were scheduled  to start at a specific time, e.g., movies, dinners at friends’ houses, even plane flights.   As they were driving late toward these  events, he would become aware of being frustrated and angry at her for their lateness.  If he expressed any displeasure toward her, she would respond very dismissively, ridiculing him for being “petty.” At this, he would often become enraged, pound the steering wheel, yell at her and start driving very erratically and at high speed.   She usually then responded even more critically towards him.  Despite his frustration with her,  he stayed in the relationship with her because he felt fortunate  that such an accomplished, attractive woman was romantically involved with him.  

We worked together for about two years and managed to trace back his rage to the constant humiliating comments his father had made to him as he was growing up.  The comments were subtle, but they always had a belittling quality to them.  His father still treated  him this way even though he was a successful, well-functioning adult.  His mother had died several years before and his father lived in another state.  He always felt anxious when he was ready to go visit him, anticipating being humiliated by his father.  He had not gotten to the point where he could ignore his father’s passive-aggressive way of treating him and still needed his approval.    Because his father had shamed him for expressing any anger when he was growing up, he had learned to retroflect (turn against himself) his anger, telling himself that his anger was stupid, that his father was an old, well-meaning  man and that his negative comments shouldn’t bother him.  

 He felt obligated to visit his father on occasion and wanted the visits to be  cordial since his father was becoming old and he wanted to enjoy his visits instead of being anxious and fearful.    But he always felt uncomfortable beforehand about visiting him.  Before one visit,  I suggested he try to keep track of the interactions with his father, what he said to him, how his father responded and what he felt in his body at these times.  I said that if the old patterns still occurred that was still useful, that we could learn more about  his relationship with his father.   And by re-experiencing those events with me, we could make  progress in working through his relationship with his father and also learn more about his rage.  

When he returned from one trip, he related to me the subtle put-downs his father was continually directing at him during the visit.  And he felt the humiliation and sense of worthlessness that got triggered in him each time this happened.  He began to slowly realize that the way his father treated him mirrored how his girl friend treated him, especially when he expressed annoyance toward her.  Through working through the feelings of humiliation, shame and helplessness with both his father and his girlfriend, he came to understand why he felt the way he did and to communicate without exploding to both these people the anger he felt toward them when they belittled him.  He learned more about his father’s past history and was no longer triggered when the latter made his belittling comments.  He also told him calmly what he felt when his father made those comments and, although his father at first belittled him for feeling that way, he told him that he didn’t like the comments and wanted him to stop making them.   His relationship with him improved and he was better able to enjoy his trips to see him.  His girlfriend did not change her behavior toward him,  he realized the relationship was no longer worthwhile and he soon ended it.  By the time he had terminated, he was no longer subject to rage reactions and had formed a relationship with a woman with whom he felt very compatible.  

In the next posting I shall discuss in detail one of the ways I work with clients who tend to become enraged when they experience shame.

The Complex, Difficult Issue of Anger: #1

One of the most difficult problems most of my clients over the years have had is dealing with their angry feelings in an effective way.  The topic is complicated and I shall be devoting several blogs on it, including how to deal with it in therapy.  The difficulties fall into these non mutually-exclusive categories:

1.  They equate anger with blame, e.g., when they begin to realize in therapy ways in which they were failed by their parents, beginning to feel angry toward them, but then experiencing guilt about that.    

2.  They have a moral judgement about it, seeing it as a bad, even evil emotion. This attitude is often fostered by certain religious entities, communicating that anger is the opposite of love.

3.  They hold themselves up to the standards of certain historical, even spiritual figures who are mistakenly seen as non-angry. One of these figures is Gandhi, who actually felt much anger toward the British, but used his anger is a nonviolently resistant way to overthrow their rule.

4.  They don’t discriminate between different levels of anger, e.g., equating all anger as destructive rage.  

5.  They don’t discriminate between physical and verbal ways of expressing anger.

6.  They are unable to express mild levels of anger, squelch it, and then explode with rage when squelching no longer works.

7.  They turn their anger against themselves instead of expressing it toward those they are really angry at.  

8.  They displace their anger from the person they are primarily angry at to someone who is a safer target.  

  The Etiology of Anger and Learning Its Uses in Everyday Life  

Anger is actually one of the eight precursors to emotion that trained psychologists can reliably code when observing the behavior of newborn infants.  It would be a mistake to call the yelling, intense facial expressions  and thrashing around infants display as anger because infants don’t have the cognitive development and verbal ability to encode intense frustrating bodily sensations as anger.  That ability comes later in life when they have parents who, themselves, are comfortable with this emotion and know how to help their children deal with it.  This type of parent can help their children label their felt experience as anger and teach them how to use it appropriately.   Unfortunately, the majority of the clients I’ve had through the years have not had this type of parenting.   Then anger becomes one of the most conflictual and taboo emotions  they experience, the result of not having learned how to identity the feeling and how to use it in various contexts throughout their lives.  Bob Stolorow and his late wife. Daphne, wrote about what parents need to do in dealing with all of their emotions, including anger.   I referenced this article in my blog:  Emotion And The Self: Inclusion Of The Concepts Of Robert Stolorow And Colleagues.  I shall recap the main points here as they relate to anger.  

1.  Responding to the child as being the same, worthwhile person whatever they are expressing.   In other words, the child is cared for, accepted and valued when they are showing and expressing anger. 

2.  The parent is able to tolerate the child’s intense expressions of anger without becoming frightened and overwhelmed by it.  

3.  They are able to understand, interpret and accept the child’s anger and respond empathically to their individualized and constantly changing anger states.  In so doing,  they are enabling the child to internalize this understanding and acceptance of anger, eventually providing it for themselves. 

4.. Desomatizing  and cognitively articulating the child’s expressing of anger.   This is the process of transforming affects into emotions that can be verbally expressed.   The parent can see by the child’s intense bodily expression that they are angry and able to say something as simple as “You look like you are feeling very angry right now.”   This eventually helps the child to label their own bodily sensations as “Oh, I’m feeling angry.”

And I would add a fifth job the parent must do: helping the child learn how to express their angry feelings in appropriate ways depending on what the parent can accept and the context in which the child finds themself.  For example, telling the parent in an angry voice, “I am very mad at you.”  The parent may not accept the child saying “I hate you” or “I wish you were not my mother.” And letting the child know that expressing it to the parent or practically anyone else physically by hitting or throwing something is not acceptable.  

And  helping the child to understand the difference between feeling angry and expressing anger.  The parent needs to let the child know that it’s okay to feel angry in certain situations, but that they need to find some other way of dealing with it rather than showing it openly. For example, Grandma may be a very sensitive, easily hurt person who responds very negatively to anger.  A teacher in school might not accept the child’s anger and retaliate in some way.   A classmate may become very physically aggressive if the child were to express anger to him or her.  I had to learn early in my career that showing anger toward certain clients resulted in them quitting therapy! I had to learn why I was feeling that way and finding a way to deal with it that helped the client and was satisfying to me.

I will discuss some specific examples of client difficulties in dealing with anger in a future post and how therapists should deal with the difficulties.

The Medical Model Implied by Referring to Psychotherapy Clients as "Patients"

I cringe when I hear therapist colleagues referring to the people in therapy with them as “patients.” My online dictionary defines patients as “persons receiving or registered to receive medical treatment: “ My online Thesaurus uses synonyms as these: “A sick person, case, sufferer, victim; invalid, convalescent, outpatient, day patient, inpatient, hospital patient; the sick, the infirm.” The term “patient” is thus clearly in the realm of the medical model, where the practitioner is a physician who treats patients by using their medical knowledge for treatment of physical illnesses. The patient is usually ignorant about the details of the physician’s treatments. In many cases, there is even little cooperation needed by their patients beyond following their directions during their course of treatment, including taking the medications they prescribe. Perhaps my humanistic colleagues have the same dialogic, egalitarian stance toward their clients that I do, but I also wonder if their thinking of them as patients may be an indication of an unconscious bias to see them as sick people who need to be fixed.

The term patient to refer to people in psychotherapy started, of course, with Freud, an MD. Most of the analysts he trained were also physicians, but he actually did not want psychoanalysis controlled by the medical profession, and even openly supported a non-MD, Theodor Reik, in receiving analytic training and practicing psychoanalysis. It was only in the United States that the most prestigious training institutes would not even admit non-MDs for training unless they promised only to do research. But the medical model actually tended to fit most psychoanalytic treatment because the analyst was clearly the "doctor," the holder of the truth about the patient. In Freudian analysis the practitioners were not supposed to reveal anything about themselves to the patient and the relationship between analyst and patient was clearly a hierarchical one. The patient was supposed to be passive, to say whatever was on their mind, and the analyst interpreted the meaning of the patient's verbalizations. It is only in the last 20 or so years that some psychoanalytical theories have begun to see the therapy relationship as more egalitarian and relational.

Carl Rogers was, as far as I know, the first theorist to object to the use of the term patient, preferring the word client to refer to people with whom he was working. He called it Client-Centered Therapy. Later on, it was changed to Person-Centered therapy so, perhaps, he even objected to the word client.

The hierarchical relationship implied by the doctor-patient phrase patient does not, in my opinion, fit with therapies, such as Gestalt Therapy and Person Centered Therapy, which emphasize dialogue, a partnership between therapist and client. I of course see myself as having more knowledge than my clients about human development and problems of living, but I never am, on purpose, in the hierarchical type of role implied by the term patient. The client and I are a team, my attempting to understand them and communicating that understanding to them. I at times will take a more directive role with someone whom I feel is avoiding self-awareness by, e.g., talking constantly and not giving me the opportunity to provide input. Or I might take a more directive role with very young clients when I feel they need some information that they did not get from other people, such as the parents, in their lives. The psychiatric profession of course tends to see all of the people who have emotional problems in their lives as sick and most are not even trained to do psychotherapy. My opinion is that only people with psychoses, such as those who have bipolar or schizophrenic disorders , can be termed “sick.”

At the same time, I learned many years ago from Heinz Kohut, the founder of psychoanalytic Self Psychology, that some clients need to idealize me, see me as a fount of wisdom and power. They are at a developmental level where they need to idealize someone in somewhat the global way a child needs to idealize a caretaker in order to feel safe, protected and loved. For example, I have had some people in therapy with me for years who still insisted on calling me “Dr Tobin” rather than “Stephan” but that is often an expression of respect rather than idealization. I learned from sobering experience with some clients that it was a mistake to attempt to communicate to them that I was just a fellow traveler rather than some near-perfect being. It was actually threatening to them to see me as less than very wise and powerful. Some would even interpret a mistake I made with them as purposeful, sometimes to an astonishing degree! But I did not “get off” on them looking up to me in that way. I assume that, at some point, they may see me as an imperfect but caring human being who is concerned about their best interests and using my skill in working with them. .

Dealing With One's Own Unconscious Racism

Becoming Aware of My Own Unconscious Racism

In my opinion, the subtle unconscious racism of educated liberal people like myself must be recognized and dealt with as one of the remedies to deal with this systemic issue in our country. The problem has many causes, of course: the poor educations most black, Hispanic and Native American people receive, the relatively poor health care they get, the lower wages they receive in comparison to what white people get with the same educational and experience levels, the awful criminal justice system, etc. And we know about the overt racism by many Americans, particularly in the South. We cannot do very much about this. But one area I and other psychologists can focus on is the subtle, unconscious racism in well-meaning people like us who think we are not racist. Our unconscious racism is an important part of the problem because we can then easily avoid dealing with it in a substantive way. We can say “I am not racist. I don’t discriminate against other races.” We actually do, but are just not aware of it because it’s unconscious One cause is a lack of personal exposure to what minority people go through. I myself don't come into contact with that many minorities in Oregon in comparison to LA, and it has been shown that personal, continual contact with minorities results in a decrease of racism. This happens, for example, in the integrated armed forces. I did come in contact with many hispanic people living in one of the canyons in the LA area. Hispanic undocumented day workers congregated at the local post office, hoping to get some odd jobs in the community. My wife and I hired many of them through the years, and I was always interested in why and how they came to the US. I found them to be honest, hard working people who were only interested in supporting themselves and, if possible, to make enough to send some money home. So I learned to have a generally positive attitude toward them.

Unfortunately, I did not learn the same lessons about black people. I was taught as a teenager many years ago by my father that black people were equal to whites. As a result of that teaching and my education, I took an overtly egalitarian view of black people. Yet probably partially because of the way black people were portrayed on TV, movies and in newspapers through the years, I had an unconscious bias against black people that I discovered, shockingly, during a visit to San Francisco about 35 years ago. I went to visit for a weekend with my two oldest children, who were renting a house in an area about three blocks from a predominantly black neighborhood. I took a couple of puffs from a joint soon with my kids after I arrived and then walked to buy some food from a Mexican restaurant for our dinner. Because I was a bit high I was much more aware of my senses and emotions. I saw some black people walking toward me and suddenly realized I was feeling very frightened! Note these were ordinary people, not raucous black youths. And as I passed them, I realized they looked frightened of me! This was the start of realizing that, despite my overt beliefs about equality, I was subtly prejudiced against black people. I don’t think I would have even realized this were I not stoned on pot.

My Continued Awakening

Through the years I have had contact with a few black people in my profession. I had a few black psychologists in training groups and in workshops I ran. But these people tended not to talk about their personal experiences of racism and I, not being very aware of it, did not indicate I was interested in hearing about it. I have also never had a close black friend. In subsequent years, I knew cognitively about what black people go through by reading about them in books and seeing movies depicting their travails. But it's been only in the past few years that I found out about the thousands of black people who were lynched, how they were redlined against when they tried to buy houses, how they were prevented from getting good jobs, the poor educations they received, etc. I learned from a couple of recent movies and a couple of books about the real horrors of slavery. And I welcomed what I learned. I was so upset, however, about the horrible, murderous treatment slaves received in reading a couple of autobiographies by Frederick Douglass that I had to put them aside.

Some Reasons Black People Elicit Conscous and Unconscious Racism

One reason why black people are seen as lesser throughout the white world is because they obviously look different. Asians, Middle-easterners, and Native Americans are also different because of their facial structures, but the dark skin color of blacks is, I think, a very important determiner of whites seeing them as different and strange. And the prejudice can be the result of a vicious circle that some blacks have a part in. Some black people, for example, do act in a way to be annoying to some whites. For example, several years ago I went to a local small coffee shop to get a cup of coffee. The owner also sold snacks such as cans of soda, candy, etc. While I was waiting for my coffee to be made, four black teenaged boys came in, talking loudly and aggressively. One picked up a can of soda and demanded the owner give it to him for much less than the retail cost. I'm sure the same behavior could have occurred by a white kid in certain neighborhood, but this is an upper middle class neighborhood in a white city with a very low percentage of black residents. I, of course, had some idea why these kids behaved that way: the discrimination they've faced, their justified hatred of white people, particularly because of their probable treatment by the white students from the school they attended, their feeling they would rather be aggressive toward than aggressed against, and many other causes. But I was put off by their behavior and my first thought was, “Oh, it’s like those typical rowdy black kids to behave that way.” But then I felt guilty about the way I immediately put them into the category of the gang members that achieved so much notoriety in LA for many years while I lived there. But while I was able to realize what I had thought and considered why they behaved that way, most people probably don’t go through that process. After all, most people tend not to consider the underlying causes of the behavior they observe, just react to the behavior itself. This is also true of most of my married clients who have complained about their partners' behavior through the years. Much of what they said did sound outrageous to me. But I have often discovered, in one way or another, their outrageous actions toward their partners that triggered that behavior from them. When one sees a news account of a person committing a crime, whether it's by a white or a black, we condemn the criminal and hardly ever get information about what triggered that behavior. And when it's a black person committing the crime, it's all too easy for us, unconsciously, to conflate that into our negative unconscious category of “angry black people.” And black people, like those teenagers in the coffee shop, sometimes contribute to these stereotypes. I’m not speaking judgmentally, just causally.

One area which presented a dilemma to me in the past occurred when I was teaching an online course for psychologists with master’s degrees who were working toward PsyD degrees. In some classes there was a black student who had relatively poor writing skills and psychological knowledge compared to most of the white students. I understood that at least some of the students had been hampered by not having had the level of education of most of the white students. But I didn’t want to pass them just because I felt sympathetic to them. I felt responsible to help turning out doctorate level people who would be credits to the profession. I wanted to help these black students get up to speed, but did not have the time or energy to make up for their years of poor education. At least one woman became very defensive, even hostile, accusing me of being racist when I pointed out that she needed to improve her performance. But I did what I could with her and the other students.

The most enlightening experiences I've had on a personal level about what black people go through on a continual basis is working with some black clients in the past few years. I have heard first hand about the continual, negative attitudes, usually very subtle, that they encounter almost every day. Some of them have, because of past experience, entered social situations expecting mistreatment and, by their covert chips on their shoulders,, may have actually triggered the negative reactions of the whites in the environments. But this often made them feel in conflict and unsure about how much they had “caused” and how much they were innocent of causing. In any case, it’s a complicated issue to parse out. Black people have been suffering for 400 years of first, slavery, and then another 150 years of oppression. People who say that slavery and Jim Crow ended a long time ago, are not aware of the continued psychological effects that get handed down from generation to generation to black people today. But the white person who doesn’t get the personal stories of black people does not become aware of what they experience and thus can’t really understand them. And not realizing the insidious unconscious effects of years of seeing non-whites portrayed in negative, stereotypic ways in movies and TV shows, they have no way of correcting these stereotypic attitudes.

My Recommendations for People in Dealing With Racism

So, what do I recommend well-meaning white people like my fellow therapists do? First, become aware of your own unconscious racism. There is a test Harvard University has created to tap into unconscious racism. There are also tests in this series about other isms: sexism, homophobia, attitudes about people who are overweight, etc. The website is: https://implicit.harvard.edu/implicit/takeatest.html Second, try to notice the emotions you experience , both positive and negative, when you visualize different black people in various situations: varying skin colors; nose and lip sizes; negroid, frizzy hair vs. straight hair; word pronunciation; grammar, etc. Third try to get an actual, personal experience with black persons in some way, either with black colleagues, clients, or in an encounter group with mixed races. Fourth, don't make the mistake, if you are a therapist, and do work with a black client, to be too eager to elicit information about their experiences with racism. They may be willing to do so only after long experience and feeling safe with you. After all, they probably have had years of negative experiences with whites and, just as you probably are unconsciously racist, they are too , against white people. Finally, this issue, amongst all of the other huge problems we have on our planet, can feel overwhelming and can lead to a sense of helplessness and hopelessness. This can easily apply to the very knotty, long-standing issue of racism against black people, Native Americans and Hispanics. It can feel psychologically more comfortable to just take the position that you can do very little, so why bother. That attitude can certainly lead to much less internal upsetness and conflict. But think about actions you can take that you are reasonably comfortable doing. Doing nothing is precisely what I and most other people have done through the years. Avoiding the problem will just make things worse and worse, and we will all suffer in the long run.

As always, I welcome comments to this posting.

Helping Clients Enjoy Their Positive Experiences

Most humans want to experience pleasure and avoid pain. And yet I find that many of my clients have trouble allowing themselves to savor positive experiences when they do have them. A common experience is with a client who is doing well and comes in saying, “Things are going well and so I don’t feel have anything to talk about today.” What they are usually implying is that they don’t have anything painful or upsetting to work on. And they often see me as an authority figure, like a parent or teacher who will expect them to work on some problem they have. If I find out they’ve been feeling better lately, I might say something like, “That’s great. How is it for you to be feeling that way and telling me that now? “ Frequently, they express a sense of anxiety or confusion, even guilt, about being with me in this state. After all, they are coming to me to work on difficult issue in their lives. So, if things are going well, they might feel they don’t even have the right to take up my time or they might even think they should now stop therapy..

(This issue about not being able to stay with positive feelings is a very important issue now, during the Covid-19 pandemic because the opportunities for the many pleasures people are used to are now non-existent. But the inability to stay with pleasurable feelings I have found to be true for many clients even before the pandemic hit}

What I usually say at this point is something like, “Maybe what we need to do is to help you enjoy feeling pleasure or joy or happiness. Would you like to do that?” We then go on to explore how they stop themselves from savoring positive experiences. These are often very fruitful and enlightening sessions. Clients are often surprised to realize that what they’ve been coming to therapy for—to experience more positiveness in their lives—they are preventing themselves from realizing! I have found there are many reasons for this.

Causes of People Not Being Able to Savor Positive Experiences

1. They simply weren’t supported in childhood to enjoy themselves because they were told they had to earn a feeling of well-being. Just having that feeling without doing something was not okay. This connects to the following point.

2. They were supposed to be continually active, producing, whatever that meant in their families. The implicit or even explicit message was “You can’t play until you {do your chores} {finish your homework} or something similar. The problem often was they never did finish doing what they were supposed to do. For example, one ex-client’s parents put so much pressure on her to get top grades so she could go to an ivy-league college that she was usually not allowed to play with other kids.. At the age of 10 she was frequently up until 1:00 AM doing homework or writing papers. Children at that age are açtually supposed to get about 10 hours sleep rather than the 6 hours she was getting. And as an adult, she had great difficulty just kicking back and enjoying being in the present even though she had already achieved a great deal, professionally.

3. They never saw the caretakers in their lives savoring their own experiences. For example, just looking at a sunset, reminiscing about the past, watching a movie or sports event on TV and obviously experiencing pleasure. That pattern could even apply to vacations, where there was often much family strife and/or the emphasis on visiting as many tourist sites as possible, not savoring the sites they did visit. It was like marking off a checklist of items on an itinerary.

4. The parents were harried, having to work very hard at what they were doing, without any pleasure in it, or were just unhappy, dissatisfied people. So a child looking like they were enjoying themselves could feel guilt, either from the parent actually expressing resentment that they had to work so hard, while the child was enjoying themselves. Or they showed, in subtle way, that they were jealous of the child’s pleasure. Frequently children in that situation feel they have to take care of the parent by making them happy. Of course, they really can’t do that, but children tend not to have that perspective. And trying mightily to do that, without succeeding, can lead to a sense of shame and failure. And a feeling they don’t deserve to enjoy themselves. I have found clients like that becoming involved with adults, e.g., a spouse, who is unhappy , but feeling they have to make that person happy. It can, of course, work out badly for both persons because the unhappy person is not then motivated to take responsibility for their own happiness; and the one attempting to achieve that never can accompllsh it. One person can’t make another person happy, although they can enhance it.

5. The parent(s) were unable to support the child experiencing pleasure. For example, let’s say the child comes home with a drawing they did in class and is proud of it. The child needs positive mirroring for what they created but, if the parents, for whatever reason, can’t express pleasure in the creation, the child receives some very powerful, negative messages: “My creation isn’t any good.” “I’m not supposed to enjoy what I create,” “What I do and enjoy elicits unhappiness in my parents, so I am not entitled to my enjoyment.” These are, of course, vague, subconscious feelings, which makes them much more powerful and harder to deal with. Even if the child is able to enjoy themself because the process of, for example, drawing, in a solitary way, there’s something missing in not having that supported by caretakers. In adulthood, It’s like not having an internal good parent giving permission to the person to enjoy themself.

6. If the person has enough incentive to experience pleasure, the above dynamics often result in the child doing so in indirect, sneaky ways. And then enjoying themselves always has a driven, subtly fearful quality in adulthood. There is an unconscious sense the more powerful parent is going to come in at any moment and express displeasure at the way in which the person is attempting to enjoy themselves. I have found this is often a partial explanation for people who overeat or are addicted to substances or gambling. I also think it may partially be the cause of the driven attempts in many of our billionaires to acquire as much more money as possible even though they can’t possibly spend it all.

Of course many people during this time of the Covid-19 pandemic are either having to worry about surviving because they have lost their livelihoods, having to work very hard at a dangerous job, or are in the subgroup of people who, because of ill health or age, are worried about contracting the virus. So enjoying their lives may be a luxury they realistically can’t afford.

Now that I have spelled out the syndrome, I will in a future posting, discuss how I work with people who have trouble savoring their positive experiences.

Why I Love Being a Psychotherapist

I am sometimes asked why I am still a practicing psychologist at an age after most therapists have already retired.. The short answer is that I love my work and feel blessed that I chose this profession. I write this blog article with the hope it will inspire other psychologists and therapists to continue to grow and get as much joy out of doing this work as I do. Here are some of the reasons I am still practicing. Note that these points apply mostly to work with long-term clients. I like working with many short-term clients too, but that will wait until another blog posting.

F irst, I see the work of a psychologist as endlessly growthful. Every year brings more development in newer forms of therapy and added development in many older ones, at least in their methods. I love learning new ways of understanding and dealing with certain issues clients bring to our sessions.

Second, I see each client as a new, unique adventure. There has never existed anyone like him or her in my office, I have often, through the years, quickly thought at times that I have figured out what is wrong with a specific client, but am delighted to find out I was wrong and having to change my views. This requires a degree of non-defensiveness and humility. I am known for the former, not so much for the latter when communicating with other therapists!

Third, I love focusing on the quality of contact with most of my clients and helping them to learn how they may be avoiding contact with me. Practically all of my clients through the years learned they can't trust most other people, particularly authority figures that remind them, albeit unconsciously, of past caregivers. Hence they won't trust me at certain levels until we have met for awhile and I have helped them traverse their negative organizing principles through me about other people, particularly those in authority. And I use the term "levels" because different negative organizing principles arise at different points in the therapy.

This issue of trust is, of course, a continuum, from very fearful and mistrustful at one end, to very trusting and willing to be vulnerable at the other end. Of course, as Bob Stolorow has pointed out, while negative expectations and fears arise at certain points in the therapy, positive yearnings for resources they didn't get but have needed and still need, also arise in the therapeutic relationship.. These are usually of a childlike nature, the result often being shame, and their yearnings must be dealt with delicately and tactfully.

Fourth, I am delighted to learn from my clients, for they are all different from me in varying way. For example, I have had a number of African-American clients, both male and female, through the years. I have, of course, learned from TV, books, movies what it is like to live in our country as a black person. But having first-hand contact and learning about the subtle assaults on their dignity most black people experience every day has deepened my knowledge. And being a white person, able to empathize with them, has been enormously moving to me. Similarly, I have learned from Asian and Iranian clients about how important family is and how different their views of independence and individualism are from Westernized American culture. I at first viewed certain Iranians when I was practicing in LA as “enmeshed,” but then realized I was pathologizing what is a normal cultural norm for them. In order to help them, I needed to decenter from this viewpoint and see their problems from their perspective.

Fifth, I view each client's symptoms the way a detective in a mystery novel searches for the meaning of each clue, seeing it as the inevitable organizing principles or, in Gestalt Therapy terms, creative adjustments that person had to learn to make in her or his life, usually in childhood.. Viewing their symptoms in this way, rather as “defenses,” is much more helpful to them in working through them.

Sixth, I see myself as a participant in the interactions between my clients and me, truly believing that the therapy relationship, whether with an individual, a couple or a group, is what Gestalt therapists have termed a relational field. I am not a blank screen or an objective authority figure in the relationship with a specific client. Instead, who I am is partly a function of all my past experience that has shaped my own organizing principles and my dynamic view of that client as it changes during the session. . And who my client is with me is a function of their past life experiences that have shaped their organizing principles and who they perceive me to be in that session as it unfolds. But this also means that I need to sense what role a specific client needs to see me in. Some need to idealize me, others need to see me as a trusted equal, others need to see me as an audience while they tell me how wonderful they are. I try to have the kind of self that Heinz Kohut describes a good therapist needing: supple, resilient able to change, and strong.

Finally: This may sound a bit arrogant, but I think I am making a contribution to my community and my country by the work that I do with individual clients, couples and supervisees. I donate money to various causes in which I believe, but I no longer go on marches, rallies or demonstrations. I see, however, many of my clients becoming more successful, creative, more socially active and kinder to their loved ones and people in their communities. I delight in the cooperative role I have played with them in their growth.

As always, I look forward to comments about these views, positive or negative.

The New 'ism' in describing world leaders: the case of Donald Trump

Although psychologists are ethically not supposed to make mental health diagnoses in absentia, a provision of the APA states that issues adversely affecting the general public supersede the issue of diagnosis. In this light, I submit the following.

My wife and I were watching Fareed Zakaria on January 12, as we usually do on Sunday, and he enumerated the numerous times in the past couple of years where Trump has said and done something that, seemingly inexplicitly he had done the opposite soon after. But this behavior is only inexplicable if you consider it from a position of what's rational, wise, understandable in normal adult terms. In what has been considered through the years in the best interest of the US and the rest of the world. Much of Trump's behavior can be understood as stemming from a deep sense of inadequacy, from severe parental lacks during childhood, which had led to a never-ending search for validation, love and adulation. That's appropriate for a five-year-old, not for an adult. For example, he obviously feels inadequate when compared to Barack Obama. That' why he claimed he had more people attending his inauguration than Obama did. And why he's been so intent on undoing the Affordable Care Act, which is considered Obama's major achievement. In naming different movements like socialism, capitalism, etc., we need to have a new designation: narcissism. Dictators, who are described usually as power-mad, or money-mad are, at their cores, motivated by primitive narcissism.

We are , or course, all narcissistic to some extent. But adults who have gotten the requisite strokes to their self esteem while growing up, don't need it in such a primitive way as people who haven't gotten it during childhood. Or they at least felt loved and appreciated for who they were, not solely for their achievements. Trump obviously didn't get that. And he clearly wants to be a dictator. We psychologists know that therapists through the years have been very unsuccessful in treating primitive narcissists in psychotherapy because they didn't understand them and did things like confronting them. For example, "you didn't get the love and appreciation you needed from your parents, so try to get it from me." That was bound to make this type of patient depressed and/or enraged because it triggered shame rather than curiosity about themselves. It wasn't until Heinz Kohut came along, that we began to understand these patients and work with them more effectively. But psychotherapy doesn't work when the narcissistic behavior serves a primitive narcissist, one with a personality disorder. Then therapy is impossible. Those people don't even seek treatment. It's only when the narcissist is hurting and wants help, that we have any chance of aiding them.

I don't see us "helping" Trump, because what he most wants is glorification,, not addressing his grandiosity. But we do need to understand him and world leaders like him, and know how to deal with them. Which is, when possible, to remove them from office Therefore I support the demands of the World Mental Health Coalition, headed by Dr. Bandy Lee, that Trump be required to undergo a mental health examination. He will, of course refuse, and do it violently, but, at the least, this information needs to get out into the public. We, as a planet and as a country, can't afford to have such a damaged, personality-disordered person as head of state.

Have Psychiatrists Forgotten About Psychotherapy as an Effective Treatment?

I have had contact in the past several years with anxious, depressed, traumatized  people who, despite not getting any help from the drugs they were prescribed by their family physicians and psychiatrists, were not told that they might get help from a psychotherapist.  This, to me, with respect to non-psychiatrist physicians is understandable, albeit sad; with respect to many psychiatrists, is inexcusable,    

Psychotherapy has been in existence for over 100 years now.  Granted, the orthodox Freudian analytic method has proven to be not very effective for most patients, but we know a lot more now about methods that are effective.  And we also know that a person’s upbringing and attachment history has much to do with the lives they lead as adults. This information is known, I think, by many in the general population. But many psychiatrists don’t seem to know that. Or at least not believing it.

Most psychiatrists used to practice psychotherapy, but  for a variety of reasons, stopped even getting that training for it  One reason was because psychologists and masters level practitioners began to do psychotherapy and charged a lot less than psychiatrists,. Therefore the latter did not have a financial incentive to continue to practice psychotherapy.    Secondly, the inefficiency of Freudian analysis as a treatment for most people and lacks as a personality theory, turned many of them off of psychotherapy.   The result is many of them today just prescribe meds and do med management.   If specific meds are not working, the remedy is trying different ones.  Many times four at a time.

A few years ago I read an article in the New York Times by a psychiatrist who regretted no long practicing psychotherapy because his wealthy lifestyle depended on his seeing patients for 15 minutes at a time,. This was just to check on how they were faring on their meds.  And if a patient needed to talk to him for longer than 15 minutes, it played havoc with his schedule. I thought that he might have better started practicing psychotherapy again with more professional satisfaction, if being somewhat less wealthy.

Here are two examples from my practice of this troubling issue.  

A man has a daughter who was in one of the twin towers during the 9/11 attack and who barely escaped with her life. They are very close and he heard in great detail from her abut what she went through. The result was that he was traumatized himself and the PTSD symptoms lasted for years. He tried to get help from a variety of physicians , but all they did was prescribe a variety of psychotropic med. They didn’t help and he was still very anxious.  When he went back to New York, which he had to do on occasion for business, he felt frightened and anxious, had trouble sleeping and could hardly wait to come back home.  He was referred to me by a friend and I did two sessions of EMDR treatment. He accessed his intense fear, we did the EMDR processing and he was cured of his PTSD.   He was soon after able to go back to New York City, actually had an enjoyable time there, and was able to go to Ground Zero with little anxiety. He later o talked with his daughter. She had tended to avoid him because of his obsession with 9/11. But she was now able to share with him her leftover trauma from her ordeal, probably because he was now calm enough to listen to her. She began to realize, from his telling, that she probably still had anxiety about her ordeal and considered getting some treatment on her own.  

(Note that I am not writing about this as an endorsement of EMDR as a panacea for PTSD. Many people with more complicated attachment histories would take much longer for relief and probably would need f other types of therapy, perhaps with EMDR as an adjunct, to become free of their PTSD.)

Another example.

Years ago, while still practicing in LA, I was referred a young man for mandatory treatment by the courts because of a history of violent behavior. Even though only in his early 20;’s, he had been in jail a number of times. He was also seeing a psychiatrist, who had prescribed a variety of drugs which were unhelpful. I called the psychiatrist to find out what he knew of his history, which included having been raised by a violently abusive father in an area that was controlled by gangs. He also had been bullied by gang members as a child, probably because he was somewhat better off financially than them, was obviously intelligent and very handsome. The older members of another gang kind of adopted him and protected him from the bullying of the rival gang. He became a member of this gang as a teenager and was involved in a number of violent illegal activities through the years. But having some acting ability and wanting a better life style, he had gone to an acting school. He was doing well there until he punched a girl in the face, breaking her jaw, after she had contemptuously blew cigarette smoke in his face when he had approached her during a break in the class. It was clear to me that her treatment of him had resulted in his feeling humiliated and enraged at her. When I talked to the psychiatrist, he knew nothing of his history except that he had been knocked unconscious once in a gang fight. He thought his violent behavior was solely due to that injury!

I have seen other people in psychotherapy with similar stories of not getting help from drugs prescribed them by psychiatrists and other health care professionals.  And these professionals had not even questioned them about their childhoods and other important life events. 

I am not saying that drugs are not helpful for some people.  The science behind them has been shown to be faulty and the placebo effect can account for some of the benefit people get  But I have had numerous clients through the years swear by them.  And psychotherapy doesn’t work for everyone.  Also, no therapist is effective with every patient.  But when drugs don’t seem to be working, it behooves these medical people to refer their patients to someone who can potentially help them, and that is a well-trained psychotherapist.    When a new clientt of mine is getting medication from an internist or other physician and I get a release of information from them, I always contact them to talk about the client. In this way we can collaborate in the client’s treatment and, of equal importance, I can help to inform the physician about the benefits of effective psychotherapy.