Monday, May 5, 2014

MUSINGS OF THE LONG DISTANCE THERAPIST

  

In a few months, I will turn 70.  It will be over 40 years that I have been in clinical practice.

That sentence is actually a pretty shocking one to compose.  It hardly seems possible.  Forty years is a very long time.  So many of my colleagues from the early days no longer practice psychotherapy.  They left the field for various reasons, some very early on.  Being a clinical social worker, or a family and marriage therapist doesn’t pay very well.  The working conditions are not always pleasant, clients are disappointed, they are angry, they lash out, they fire you without notice and sometimes even explanation.  You are sitting still much of the day absorbing the pain, the shame, the trauma, the fury of your clients.  If you work in an agency you can be subject to crushing piles of paperwork and a remarkable lack of respect.

And then there is the weight of responsibility, or felt responsibility, for the well-being of others.  There is always the prospect that you will fail.  There is the dire prospect that the client will harm themselves or others. 

But like the song says, “I’m still here.” 

Quite a surprise.  Starting out I thought I would never make it, that my high level of anxiety would kill me.  But as I client once scolded me, I am persistent, “like a dog with a bone” is the way she put it: not pretty, but apt.
  
I’ve never been much good at puzzles, either crossword puzzles, picture puzzles, or Sudoku.   You can always have the puzzle page of the New York Times out of my newspaper anytime you want. 

But the puzzle of a personality I find intensely engaging.  Without exception every new client is a new puzzle, an original.  Why this symptom and not that?  What happened? Why (seek treatment) now and not before. Why did he survive and she didn’t?  Why did this sibling make it through an abusive childhood and the other one, not so much?

And the key to the puzzle is not written in a book anywhere, there is no standard protocol, the way I work anyhow.  It’s always a new task to figure it out, how to treat this person.  What’s going to work?

Then there is my fascination with the story, the narrative of a life. I spent a lot of time as a child with the “orange biographies,” biographies of “great Americans.”  Our small town library had what seemed liked hundreds of them.  I took a stack out every two weeks.  I consumed everything thing from the story of Davy Crockett, frontiersman, to Florence Nightingale, Mary Todd Lincoln, Jane Addams, George Washington.  So was it the history that I loved so much, or the prospect of greatness?   Perhaps if I read enough of them, maybe I could join their ranks?   No, I think it was the story of lives, lived.  And I’m still here, with those stories.

It is a privileged perch, the perch of the therapist.  One gets to witness all the lives not lived: what it’s like being related to the mob, or to be the neglected child of great wealth.    I get a taste of growing up in Lake Woebegone, Garrison Keillor’s fictitious small Midwestern town, without having ever been to Minnesota.  I get to talk to the voices that populate the inner world of seriously traumatized individuals.

The “privileged perch” can be hazardous.  There is no doubt that if you work with trauma, as so many of us do, that your world view is darkened thereby.   The tales of ritualistic abuse and sadistic cruelty toward children are often hard for people to believe, even therapists.  A supervisee, new to the treatment of the long term effects of extreme trauma, once asked if I believed the tales of multiple rapes and torture that her patients and mine recalled.    I really cannot, of course, offer a definitive answer in any particular case. No one can. But we did live through a century when state sanctioned murder and torture and rape were applied on a mass scale, so why not? 

Here are a few things I have learned from being a therapist:

1.       Motivation counts more than the extent of pathology. People who desperately want to get better, generally do.

2.      Safety counts more than anything.  Anything one can do to help a client feel safe with you and in your office facilitates the healing.  Maybe it is the healing.

3.      Chemistry counts. Who you are is what counts:  “The person of the therapist is the converting catalyst, not his order or credo…not his exquisitely chosen words or denominational silences” (from A General Theory of Love, Lewis, T.,Amini, F., Lannon, R., p.187).

4.       Spirit often arises from the extremities of suffering.  It’s almost uncanny how those who have survived early and extreme trauma and make it into my office, arrive with rather robust spiritual lives.  Not conventionally religious, they are still believers in the transcendent and credit those experiences with their survival.  These patients have taught me a lot about resilienc, spirit and spirituality.
  
Over 40 years of almost continuous practice: it is hard to really comprehend that amount of time. I do comprehend, though, what a blessing it is to have been part of a profession that has brought richness and meaning to so many days of my life.  I am grateful.





Saturday, June 22, 2013

New TED Talk blog posting on the Huffington Post.

Dear Readers,

The Huffington Post asked me to write a response to a wonderful Ted Talk, as part of the Ted Radio Hour.
Maybe some of you are familiar with this NPR program?
The talk is wonderful.  By Candy Chang, entitled "Before I Die."
And they were kind enough to select my blog (among others) to post alongside the video, this on their
TED page.  See it at   http://www.huffingtonpost.com/may-benatar-phd-lcsw/before-i-die_b_3468120.html
If you feel like commenting on the Huff Po page, it makes me look good.

Thanks!

Sunday, March 24, 2013

Rehearsing for Life and Death


REHEARSING FOR LIFE AND DEATH
A little boy of my acquaintance is worried about death and graveyards and ghosts.  I have been thinking of comforting ways to talk to him about this—something that might be accessible to a 6 year old.  In the midst of my musings I awoke to the fact that I am just as afraid as he, although ghosts and graveyards don’t really bother me so much.   It seems that the predations and losses of aging are my own version of his preoccupation.  The inevitable debility in the body, losing loved ones, mourning recent losses,  these are my ghosts.

I think after a year and a half of working at a cancer support and wellness center in the DC metro area, I am just coming to understand what drew me to this work.  I volunteer once a week to lead a mindfulness meditation group.  I have not been officially trained to do so.  This is in itself remarkable.  I am, however, a qualified, trained, and experienced therapist and a fairly long time practitioner of meditation myself, but my teaching experience is not particularly in this genre.  In the group we mix it up with other practices and I am always drawing on my skills and various tools acquired as a therapist, to deepen and broaden the experience for my very enthusiastic group of meditators.    Remarkably, the changes in those individuals who come consistently and even attempt to practice at home are discernible to themselves and to me.
The members of the group declaim rather loudly and proudly about the benefits and positive energy of the group—they testify to and regularly recruit new members.  But I am quite aware that my benefit is at least as great as theirs.  It is the high point in my week.  Really.

There is the pleasure in doing something that is popular, useful, and positive.  But beyond that, I think I benefit greatly from my relationship with members of the group and with the group as a whole
: their optimism, their strength, their ability to grow in the face of terrifying, often painful, and always life threatening conditions. 

Many are dealing with the long term effects of treatment, more than the threat to their lives.  Surgery, chemotherapy, and radiation leave a variety of “gifts” behind.  The hair grows back, but the neuropathy in hands and feet does not necessarily abate.  “Chemo brain” may recede, but memory may never be quite the same for some.  Unanticipated pain may linger for quite some time after radiation.  Anxiety may take up permanent residence, and thin places in the fabric of family may become deep fissures.

I get a front row seat on how individuals are dealing with these challenges to their bodily integrity and mortality.   Mostly what I see are courage, dignity, and grace under fire.  Of course it’s only an hour a week and a self selected group of individuals who are well enough to sit and listen to the sound of my voice directing them to more peaceful places inside of themselves.  And I don’t observe the moments of sheer terror and rage that walk beside them as well.  But these glimpses of resilience in the woman who dons a stylish chapeau to cover her sparse hair, or manages to look fetching in her outfit despite the loss of 25 pounds or so, enrich my spirit.  The man who teaches himself and practices piano to deal with his overwhelming anxiety and depression and the generous cordiality and even gratitude of those who face the final stages of their disease, inspire and soothe me.

This opportunity to bring comforting practices and to learn from my meditators represents for me a kind of rehearsal for what is inevitable in all of our lives.  Unless we die suddenly, we do need preparation for the last chapter and the loss of those close to us.  There are few models available, for most of death and dying are hidden.  We cannot model ourselves on the brave and the resilient if we don’t know them, if we don’t see them.    They are hidden in nursing homes, hospitals, or hidden away at home.  They are for the most part unidentified.   I have the unusual privilege of meeting, working with and learning from many.

I learned to teach graduate students, something I was also terrified of, by “channeling” one of my most admired teachers and then pretending I was him.  I faked it until I made it. 

Sounds like a plan.

 

 

 

 

 
 
 
 
 
 
 
 
 

 

 

 

Sunday, January 27, 2013

ME AND NEWTOWN




It was probably 1965 when I did my co op job at  Fairfield Hills State Hospital in Newtown, Connecticut.  This was a huge state hospital campus housing thousands of inpatients from all over the state in need of (mostly) long term custodial psychiatric care.  Although this was decades ago, many of my memories of this time are fresh and crisp.  It was one of a few experiences that shaped my interest in becoming a mental health professional.

The setting, a large institution in rural Newtown, Ct.,  was woefully isolated for two young women in their early 20 's dispatched by Antioch college to fulfill their co-op job requirement. We hung out with some other co-op students from Boston and two male psychologists doing their internship at the hospital.   Gimlets at weeks end with the psychologists were all that was available for “partying.”

There was basically no town in Newtown, as I remember it.   We had to catch a ride into NYC if we expected much fun. 

My memories of the facility where we worked, me as an occupational therapy assistant, my friend J. as an art therapist, are quite positivE, however.  The woman under whom I worked was a consummate professional.  She was highly skilled at creating a program for people who were severely mentally ill and compassionate in her attunement to each individual.  I learned a lot from her.   When I wasn’t working directly with patients, she sent me down to read case records.

On one of those occasions I accidentally discovered that one of the in-patients with whom we worked had come to the hospital  voluntarily, for a short period, had somehow gotten lost in the system and was now a long term resident.  Tommy was not psychotic,  he had come to the hospital for the treatment of depression. Over time he had come to look like he belonged there and did not have anyone to advocate for him. He was heavily medicated, and a physical impairment made him look much sicker than he was.

When I shared this with Madelyn, my boss, she got busy, had him re-evaluated and in short order, "sprung" from the hospital.   Tommy was the poster boy, you might say, for “institutionalization.”  The system had swallowed him whole. It was only a lucky accident that freed him.

Madelyn was not alone among the staff of competent and compassionate employees.  This was a good facility.  Some people got stuck, but most were there because they needed the shelter and the supervision.  Many had nowhere to go.  Larry was an example.  He was in the end stages of Huntington's disease,  a neurodegenerative genetic disorder (the disease that Woody Gutherie succumbed to)  with no cure.     The end stage was often characterized by psychosis.

Larry was a very sweet, bright guy.   He had been a working jazz musician in his prime.  Now he had a hard time walking, controlling the jerky movements characteristic of Huntington’s disease.  And he had psychotic episodes.  He needed the  care that the hospital offered and had few or no other options.  Madelyn was very fond of him and took good care of him.

Patients like Tommy inspired the civil rights activists who felt that the mentally ill were unjustly stripped of their legal rights and were often incarcerated against their will.  They became “institutionalized” and were unable to care for themselves out of the hospital only because they had been socialized to the hospital setting.   In Tommy’s case all of this was true.

But they forgot about Larry, and so many other patients who derived protection from the system, not exploitation and abuse. Sadly, Larry needed the care and protection that the hospital provided.

How strange it is for me to meld my memories of Newtown with current events, in which how to care for the mentally ill is heartbreaking front page news.  My  memory is also vivid for the sweeping policy changes and paradigm shifting of the late 60’s and 70’s that emptied the state hospitals, filled the streets with the homeless mentally ill, and made it next to impossible to care for the seriously mentally ill in any viable custodial arrangements. 

In the name of freedom,  we forsook the mentally ill decades and decades ago.  Instead of re-thinking the system, we jettisoned it, de-funded it, and provided nothing to take its place. 

I join my voice to all the others calling for a humane reconsideration of our responsibilities to the seriously mentally ill.


Friday, January 4, 2013

What Good Can It (Psychotherapy) do?


What good can it ( psychotherapy) do?

The  question above is one that I encounter frequently in one form or another from friends, potential clients, close relatives.  It takes various forms:

  1. What can they tell me that I haven’t already thought of myself?
  2. Life will take its course no matter who I talk to.  My partner will die and I will be alone.
  3. I’m going to die anyhow.
  4. Talking won’t bring her/him back.
  5. I’ll still have cancer/multiple sclerosis/end stage heart disease.
  6. There really is no way out of my marital/familial/work dilemma.
  7. My depression is a result of a chemical imbalance.

I’m frequently not quick enough on my feet to respond thoughtfully, so I’d like to take a moment to do so now.

Therapy, at least the kind that I know about, is not chiefly about finding solutions, i.e., problem solving.  Intelligent people are generally quite aware of a range of solutions to their problems.   They just can’t act on them.  They are frozen.

They  think that no potential solutions are really applicable to their situation or relevant or available to them.  Or they feel, and perhaps this is the  most frequent, that in their particular case there are no real solutions.   Its almost reflexive for the listener, the relative, the loved one, the good friend, the clergy person, even some therapists to offer some thoughts as to possible solutions.  Inevitably they fail.  Its not about that.

Within most adult folks there is an inner wisdom that would offer great assist in resolving the impasses of our life. Therapy is about accessing our inner, innate wisdom, not replacing it with someone else’s.  I can think of many instances where I felt that there were no solutions.  I was trapped.  In retrospect I knew the solutions and just found them totally unpalatable.  I could not end that destructive friendship, it was just too important to me.  I could not resolve a domestic or an economic problem, I just wasn’t strong enough.

So what are the elements of psychotherapy that  enable that inner compass.

  1. the magic of relationship.  When researchers have tried to isolate the “active” ingredient in successful psychotherapies, across many theoretical approaches (CBT, psychoanalysis, mind/body  approaches)  they frequently come up with the same answer:  “it’s the relationship, stupid,” the connection between therapist and patient is the key remedial. 

Neuroscientists have a more exact way of stating this, it’s about “limbic (a key brain structure) resonance.”   Simply stated,  therapy is not so much about the rational, linear, thinking mind.  It’s more like music.  In the best situation the therapist hears the particular melodic essence of the individual, playing softly in the background and is able to tune in and hum along, maybe even in harmony.  Just this tuning in is deeply healing.  How many people in your life have actually heard your “melodic essence”?  Do you think even you have heard it?


2.  A therapist listens differently than other people. I heard a story once of a psychotherapist describe his occupation, at a cocktail party, as one of  listening  “I listen for a living.”

A therapist’s training and experience sharpen and educate their musical ear.  It has been called “listening with the third ear, (Theodore Reik)” among other things.   When things go well, a good therapist hears what others do not, even the speaker.

A therapist may hear anger where others only hear hopelessness, fear where others hear anger, shame where others hear belligerence.   Truly thrilling for both the patient and the therapist is the moment when a door opens and the narrator gets a slightly different perspective, a different way of hearing their own feelings/problems.   “Maybe its not my inadequacy, maybe I am feeling truly alone in this intimate relationship.”  “Perhaps my adversary doesn’t hate me, perhaps they are deeply ashamed of their failures in life and feel humiliated.”  And most powerfully, “maybe there is meaning embedded in my confusion and in my unremitting pain.”   Meaning can set one free.

Certainly there is much more to be said on this subject.  But I will pause here and invite readers, both those who have experienced therapy and those contemplating dipping a toe in, to share their thoughts.

Happy New Year to all!!




Thursday, August 23, 2012

MENTAL HEALTH NOTES: Personal Transformation and Wrestling with the Dark Side


After writing my last post (www.huffingtonpost.com/may-benatar-phd-lcsw/neuroplasticity_b_1729070.html)  and reviewing the comments I received, it occurred to me that I hadn’t told Stuart Smiley’s entire story.  Stuart’s  dark side is an important part of his story, indeed an important part of all of our stories.  I did mention that he was a mess.

I’m going to switch characters here.  The story of  Jacob’s struggle with an angel in (Genesis 32:24-30), provides a more sober and profound metaphor for the following exploration.  Personal transformation is not just about affirming the positive, it’s about investigating the negative as well; its about struggle.   The task of psychotherapy,  at its most profound and meaningful level is all about transformation, inhabiting more fully who we are.  And that is Jacob’s story as well.

In Genesis (32:24-30), the first book of the Bible, the first book of the Jewish Torah, Jacob leaves home to meet his nemesis and twin brother Esau.  Esau  wants to kill him.  Esau is angry with Jacob for having stolen his birthright, his father’s blessing, many year’s before.

While on this journey to meet Esau, Jacob has the famous encounter with a mysterious entity.   It is an encounter marked by struggle and suffering.  They wrestle throughout the night.  They wrestle  to a draw and  Jacob is released by the angel who insists Jacob take a new name: Israel.

Interpreters of the Bible story have various ways of interpreting this narrative.  Who is the angel?    Is it G-d?  Is it Jacob’s own fear of the coming encounter with Esau?  Or is it Jacob's own dark side.   And it appears he had a very prominent dark side.  He manipulated his father and stole from his brother for one thing.   The latter explanation, the most psychological one, of course, appeals to me.  This interpretation has Jacob struggling with his own flawed character.   In the process he is both wounded and reborn.  He gets a new name,  he becomes more of who he really is.  And this is the nature of transformation.

What a wonderful paradigm for the best outcomes of psychotherapy.  And I emphasize best, over common.  While the power of positive thinking is an important and real possibility for us all in recasting our fates—the need to embrace the shadow,  those elements of our personality, our souls of which we are least proud, is a  necessary element of transformation.

Trudy wanted to retire and to begin working seriously at her bucket list:  to travel to Nepal,  to write more poems,  to read and garden to her heart’s delight.  She knew it was time.  She felt really burnt by her 40 years of work as an emergency room physician.  Nothing called to her any more about her profession.  The adrenaline generated by the high intensity work had in the end depleted her.  It was definitely time to move on.

Strangely she found that she couldn’t.  She was dogged by guilt, haunted by bad dreams.  And that was when she could fall asleep.  Insomnia and an exacerbation of her long dormant ulcer had her prescribing medications for herself.  Finally, feeling it was a last resort, she went into therapy.

It took about 6 months of pretty intensive work with her therapist to uncover the source of the guilt.

Trudy came from a high achieving, well to do, but essentially emotionally disconnected family.  The three children  had had to fend for themselves as their parents pursued their
own interests, their travel, and their careers.   Despite this the two oldest children adapted well.  They performed well in school, had many friends, and took care of each other. 
  
The youngest did less well.  He struggled in school,  seemed to be the odd man out socially, frequently got into trouble with the authorities, and was finally expelled from school.  As the oldest child, Trudy knew what was expected of her to help:  she needed to take care of  her little brother.  But she didn’t want to.  For one thing she didn’t know what to do about him,  although 5 years older, she was a kid herself.   For another she was successful both socially and academically and had no real interest in parenting. 
She had made half hearted tries but she resented anything she was asked to do for him.  And plenty was asked.  The parents were preoccupied and clueless themselves as to how to help their son.

The baby brother never did pull himself out of his troubles.  As an adolescent he got into harder and harder drugs and very tragically died of an overdose at age 20.

What Trudy discovered in psychotherapy was that she had never forgiven herself for abandoning her brother.  And she really had to acknowledge that it was an abandonment.  True, she was a child herself and did not have the knowledge or skills to help her brother,  but on a deeper level she just didn’t want to.  She didn’t much like him or sympathize with him—he was always a trouble maker and a drain on the very slim emotional  resources of the family.  The stain on her soul was not what she did or didn’t do,  it was what she felt.  

What she had to wrestle with was her own nature, or what she thought was her nature.  She had not wanted to help her brother and he had died of neglect.

It took another 18 months at least for Trudy to come to terms with all of this.  Actually it probably will take many years beyond these months.  Trudy had to seriously consider that she had become an ER doctor because it was an arena in which she could save people. And that she did.  And now she couldn’t leave it, because to do so would expose the wound: her own self-loathing.

The struggle (in this case her work in therapy) left its mark on Trudy—the wound that had been  there but invisible became visible.  For a short time she needed anti-depressant medication,  later something to help her with her anxiety.  But in the end, she knew her own name.   She became more of who she was.   And eventually she retired.

Wednesday, August 1, 2012

Mental Health Notes: Stuart Smalley and Neuroplasticity


Stuart Smalley was a  character on Saturday Night Live played by Al Franken,  now a distinguished member of congress, then a distinguished comedian. In the  90’s he was a regular on Saturday Night Live.   Blonde and dimpled, somewhat effeminate, Stuart was an earnest simpleton, distinctly un-cool in his cardigan he was “a member of several 12 step programs, not a licensed therapist.”   Actually he was a mess.

One of his funnier bits was staring into a mirror and speaking aloud affirmations, to be repeated daily? “I am good enough, I am smart enough,  and doggone it  people like me.”  There was also: “I am an attractive person, I deserve my share of happiness, I deserve good things.”

The hilarious implication was of course how silly and self indulgent it was to think flattering yourself in front of a mirror really meant anything.

But you know what, it turns out that Stuart Smalley was on to something.

What we now know about neural functioning indicates pretty strongly that what we think can and does change our brain.   In the last twenty years there has been an explosion of new understanding in brain science.  There is more sophisticated, detail mapping of the brain and its functions and very importantly we have learned that the brain is malleable, not fixed as we once thought.  This is why a meditation practice, learning a language, and taking up a musical instrument can demonstrably change brain structure, even quite late in life.

What changes the brain, and/or the mind, changes the body, the immune system, blood pressure, cardiac function, stroke recovery and so much more.    Sophisticated methods of brain scanning have given us access to how all of this works.

The slogan is : what fires together, wires together.  As neurons fire (which is what happens with thought),  they connect to each other.  The more they fire, the stronger the wire.   If you practice weight lifting, or swimming, or piano, or French, you gain more facility, you get better and better—the neural connections grow stronger and stronger.  So if you think good thoughts, that might have an effect also, right?

I have just read the book Freedom from Pain: Discover Your Body’s Power to Overcome Physical Pain, by Peter Levine, Ph.D. and Maggie Phillips, Ph.D.  This book is chock full of exercises and regular practices, that can help people in acute or chronic pain, manage their pain.  Many of the exercises are based on Somatic Experiencing (SE), many on energy medicine.  Somatic Experiencing developed by Peter Levine, is a body awareness approach to treating trauma  http://www.traumahealing.com/ 
Pain is a form of trauma.

See previous posts on this site on the subject of SE: http://www.postsfromtheunconscious.blogspot.com/2012/06/ptsd-kills.html
http://www.postsfromtheunconscious.blogspot.com/2012/04/orange-biographies-healing-narrative.html

Pain management is a very challenging area of healthcare with pain conditions nearly epidemic.  Medication can be helpful, but sometimes falls far short of bringing comfort, and almost always has side effects that can be distressing.  So practices that depend only on our ability to focus attention have enormous potential benefit.   And no side effects.

I was somewhat amused to see that Stuart Smiley’s methodology was one of the practices recommended by Levine and Phillips.  Here is the scientific justification:

Neuroplasticity research has turned this theory (genetic determination)on its head and gives us an entirely new way to look at the impact of our thoughts and beliefs.We know that thoughts literally change brain chemistry.  Research indicates that the chemical composition of the body can change in relation to a specific thought within twenty seconds (Levine and Phillips )p. 112.
…Research indicates that the chemical composition of the body can change in relation to a specific thought within twenty seconds p. 11.

Neuroscience has caught up to Saturday Night Live!

Try it.  And if you need inspiration, consider where Stuart Smiley is today:  The United States Senate.