Shades of Blue

May 3, 2009

“I thought, if I wore the plain dark blue one you would take it as a sign that I was depressed, or rather as a sign that I was giving in to my depression, instead of fighting it. But when I put on the bright one, I thought you would take it as a sign that I’d got over my depression, but I haven’t. It seemed to me whichever tie I wore would be a kind of lie.” Alexandra smiled, and I experienced that deceptive lift of the spirits that often comes in therapy when you give a neat answer, like a clever kid in school.” — from Therapy by David Lodge

I’m starting work at a new sick bay tomorrow and despite the attendant anxieties of having to get up an hour earlier in the mornings and adjusting to new staff and new clients, I’m looking forward to the challenge. Over the last few days I’ve been finishing up my files in preparation of handing over to the new community service psychologist. Quite a lot of work that finishing up turned out to be — and a good indication of how much I have procrastinated over the past year. After a particularly trying session for example, the last thing I felt like doing was writing up my process notes. What I tended to do instead was to leave the rough notes in the file for the day when I would come and tidy everything up. Unfortunately that day arrived on Thursday and as I surveyed the pile of unfinished files (18) and the amount of time remaining in the day (four hours) I knew that I would be working over the long weekend.

I’m almost there and it’s been a good experience mostly. I’ve enjoyed revisiting my (not so) old cases. The nature of this work is that there will be many clients who come for a session or two and then not return and it’s interesting to speculate about why that is. Incidentally, I saw roughly 75 patients over the past 12 months. (I couldn’t give you the average number of sessions per client but the longest period of therapy was probably about 25 sessions.)

As I’ve been tying up loose ends, I thought I’d share a couple of short cases studies here along the lines of “shades of blue”. The title reminds me of the movie named “Three Colours Blue” but I see from a quick Google check that that movie has a different focus.

But before we get to the snapshots of depressed clients, I wanted to make a quick comment on Laurence “Tubby” Passmore, the main protagonist and narrator of David Lodge’s Therapy, whose quote is above. My clients seem to live in an entirely different world to the likes of Laurence Passmore and the main differences have to do with class and race. Wearing a tie to therapy? Does anyone actually do that? Laurence’s therapist Alexandra, whom he describes as “a rather beautiful, long-lashed female giraffe drawn by Walt Disney”, tells him that he could have dispensed with a tie altogether and he has a answer for that which is not relevant here. But I couldn’t help wondering what it would be like to have patients such as this. An educated, articulate patient with not very demanding problems. Perhaps the real problems will emerge (I’m only on page 40).

My patients (on the whole) generally make for less entertaining reading but I often think that some of that heartfelt anguish could translate into powerful narratives. There’s the issue of confidentiality of course and my clients’ stories would also need a lot of work but there’s something therapeutic about the act of writing a story. For today though, I’ll just give two snapshots of two different shades of blue. If the details are scanty, you’ll have to forgive me for not referring back to the files.

Patient 1: The first-year university student

AJ* is a 19-year old male in his first year of a university degree who was referred by his mother for alcohol abuse and depression. She’s worried that he’s failing the year and that he’s drinking too much. He’s also very negative and uncooperative towards her and she’s worried that he’ll just get worse. His dad died about 7 years ago and she thinks that he misses him very much and that this is contributing to his depression.

AJ himself is one of those late adolescents who reluctantly comes along to the session because he realises he doesn’t have much of a choice. He says he’s not abusing alcohol (any more than his classmates) and that it’s true that he’s failing the year but there are problems around computer-access and assignments not handed in and things would be so much easier if his mom just bought him a car and why does he have to work part-time at the supermarket anyhow? He has some symptoms of mild depression but he doesn’t really meet the criteria and his drinking doesn’t really seem to be the issue here either. It turns out that AJ has recently started dating one of his classmates (his first girlfriend) whom he cares for very much and whom he has been dating for about three months. His mother sees the deteriorating grades together with the deteriorating attitude towards her and the increasing time spent with the girlfriend and feels resentful. Why should she, a working single parent, have to slave away for a son who is not pulling his weight? It’s a good question and in the relatively small amount of time I have with them I focus on this point. We hammer out a compromise: she’ll pay for another year’s university fees if he manages to pass (and take more responsiblity). If not, then he’ll have to pay for himself.

Ideally he should also make use of the available counselling to get himself back on track — but transport is an issue and he’s already struggling to make enough time for his studies. The mom is also not willing to come for therapy on her own, or together with him. Why should she? She’s not the one with the problem. True, I want to say, but perhaps there are unresolved issues around her husband’s death that she could explore? There are clearly issues around mother-son communication which could benefit from a neutral counsellor. I get a strong impression that the mother is feeling left out in this scenario. Her son is quite happy to use her money (and cooking and cleaning services) but he’s not her darling little boy anymore. And she’s rightly fed-up.

Patient 2: An SA story

Beauty* is a 36-year old single parent of three boys (18, 7 and 5 years). Her husband died about two years ago of AIDs and she herself is HIV-positive. She also has a poorly-paid job, financial difficulties and family problems. Her 18-year old son is involved in petty crime while her 7-year old is misbehaving at school and is not doing his homework. The doctor writes me a slightly bizarre referral in which he mentions that the patient has difficulty with aggression. He doesn’t pick up any mood symptoms (other than the aggression) but notes the overwhelming stressors. If ever the media wanted a poster-woman for an SA mother being overburdened with stress this woman would fit the bill. Where do we even start? The trauma of being HIV-positive and losing her husband? The behaviour problems of her two eldest boys? The disempowerment of not being able to provide properly for her family, not being able to drive, being stuck in a poorly-paid job? The consequences of being angry all the time?

I do what I can for her, which is to empathise with all her worries and offer regular therapy to help her to contain her emotions. Validation, problem-solving, a place for her to be understood. After a few sessions she doesn’t come back. Perhaps the shoulder to cry on is not enough. Perhaps the travelling time combined with time off work is just not worth the little tangible help that I can provide. In our last session I note her frustration with (Western) doctors who just don’t understand her and who weren’t able to help her. She says she’s going to see traditional healers instead.

Breaking up with your therapist is also hard to do

February 26, 2009

Breaking up, as Neil Sedaka sings it, is hard to do. Equally so with your therapist, as I discovered on Wednesday. I felt pretty angry afterwards, which is a good sign that the therapist was not supporting where I was coming from. At one point I told him, “Stuff you!” What I should have said was: “Shut the f… up, this is my session and you’re doing all the talking.” Now I’m bit embarrassed about the ‘Stuff you’ part but he was giving this whole speech without any regard for how it was coming across. I managed to put my side of the story (quite well I thought) but his blunt interpretations have also given me food for thought. Maybe he’s actually partly right, I realised today. Still, he’s a bully and an ass.

Now I hope the slightly flippant tone of this post doesn’t make you think that I’m taking this whole break-up thing lightly. Far from it. But I also think that we need to be able to laugh about the stuff that’s the most painful to us. After all, choosing your partner is probably the biggest decision of your life so there deserves to be a lot of agonising over it, right?

Coming back to the therapy break-up, I was interested to read other people’s experiences. In the NYT, Richard Friedman says:

With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place — depression, anxiety, relationship problems, you name it — the common goal of treatment is to feel and function better independent of your therapist.
To put it bluntly, good therapy is supposed to come to an end.

But when? And how is the patient to know? Is the criterion for termination “cure” or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?

The likeable Dr Rob over at shrinktalk adds the following:

… some clients are not connecting with their therapist or are not making progress that is to their satisfaction. No therapist can work perfectly with every client , and good therapists understand this. Again, honesty is the best policy here, and simply telling your therapist that you would like to work with someone else is completely acceptable. However, some clients struggle with this, and will often leave me voicemails with specious reasons so as not to deal with perceived confrontation:

I’m cured
My insurance won’t cover it
It’s too expensive
Your office is too far away
It’s too cold out

You are too young
You are too old
You are incompetent (commonly relayed as “you suck,” or “you’re an arrogant ass”)
I want to work with someone with blond hair
I need a Jewish therapist
Fuck off and die

Now I know he’s just joking about the “fuck off and die” part but it feels quite therapeutic just to read that and imagine someone saying it to their therapist via voicemail. Of course, as Rob also points out, very often clients leave therapy because the therapy is touching a nerve and it’s uncomfortable for them to go there.

For me, the answer was yes and no. Yes, we were touching a nerve and no, I wasn’t running away from it as much as getting frustrated that he wasn’t helping me to make progress in working with it. Just let me be, I wanted to say, let me do this therapy at my pace. And it also didn’t help that he was trying to pressure me into making a longer commitment to the therapy. Ambivalence is not a healthy state to be in, was the message I got, so you need to commit to the process. Now I agree that it’s not that helpful to be ambivalent but it’s also not helpful to ignore the ambivalence by rushing into a commitment. That way leads to resentment. What I think he should have done was to try and hold the ambivalence and try and be sensitive to the underlying anxiety rather than trying to bully me into doing things his way.

From a reader’s point of view I enjoyed some of the comments over at Yelp:

Take him/her out to dinner, get a couple of drinks going, and say, “It’s not you, it’s me.” Leave him/her with the check and SCRAM.

If it’s not working for you, be up front with him/her. Try to identify what it is that you are looking to work on and why that’s not happening. Maybe you’ve gone as far as you can go with this particular practicioner. You won’t know until you vocalize your concerns. … Sometimes it’s just time to move on.

As for the song, I like the Violent Femmes version.

The dance of therapy

October 16, 2008
Butterfly by Tommok at Flickr

Butterfly by Tommok at Flickr

I took the plunge and went for a session of therapy with a new therapist yesterday. The first session was a bit like a first date. I made sure I looked good and arrived on time, was pleasantly surprised that my “date” was well turned-out and that his room had a comfortable (red) couch and a laidback seriousness about it. I filled in a form, he asked me if I wanted a drink (water thanks) and then we were off. I’m always amazed at how much ground can be covered in 50 minutes.

Afterwards I thought it went well and had no hesitation in asking for a second date (even though it’s not exactly cheap). He had to check his diary and then agreed. He said something about discussing the terms of meeting. That makes it sound like negotiations, which I suppose is what the initial sessions are. There’s an assessment and then a negotiation of terms. A weighing-up on both sides and then an agreement to a controlled dance.

I was surprised at the stuff that came up. An old “crush” that I hadn’t intended to discuss at all. There was at least a year of my life where I thought about her almost every day (and possibly several times a day), each time with a mixture of pain and longing. Yesterday I was a lot more detached. She was definitely not serious relationship material, I said. But I added that it had taken me a good while to sort out all my own projections.

Coffe with an old friend beforehand also brought back happy memories of our time in Master’s class. The end result of all this stirring up of memories was that I slept fitfully.

Today I’m thinking about therapy as playing and dance.

“Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together.” (Winnicott, 1971).

“… sometimes the patient doesn’t like the frame but it may nevertheless be constructive and useful to maintain it— both for the analyst’s self-interest and for the patient’s ultimate benefit. … A patient once brought a boom box into my office, turned it on, and asked me, “Do you ever dance with your patients?” I replied without hesitation: “No. Never.”” – Gabbard (2007)

But Gabbard also acknowledges that the dance needs to happen metaphorically. At the end of his article he says:

“One of the great lessons of analytic work that applies to frame management is that one has to dance the patient’s dance steps for a little ways down the road. If one refuses to do so, the music may stop.”

My experience tells me this is not just metaphorical. It’s about getting into a similar emotional and physical place. The mirroring of body postures for example. Research in empathy has shown that when a therapist is “in tune” with a patient that there are similar physiological processes going on within the two of them.

I suppose the earlier point about the frame is that we need to be careful that our patients don’t take us for a ride or dance rings around us. But even if they do, is it always a bad thing? Perhaps it’s inevitable in terms of how their relationships happen. The trick then is to bring that awareness into the therapy and to modify the dance perhaps.

In the meantime, the verdict on whether the new therapist will be a good dance-partner is still out. One thing that bothers me is his seriousness. I want someone who can laugh (and play) in therapy. He asks good questions though (which is a form of playing). But does he have a sense of the absurdity of life? Of course life is serious, but that’s why we laugh.

Embracing anxiety

May 10, 2008

“Since anxiety is a natural, even a sacred part of life, we need to learn how to become anxious about the right things in the right way, one that leads to personal and spiritual growth. Unfortunately, many current therapies are directed towards merely reducing stress and anxiety. But if, as the existentialists observe, anxiety is life being aware of its own aliveness, then the only way to reduce our anxiety is to become less alive, to numb ourselves to life. In fact, our problem as individuals and as a society may not be that we are too anxious, but that we are not anxious enough, and we are not anxious about the right things.” — Robert Gurzon, Finding serenity in the age of anxiety

For the past while I’ve been thinking quite a bit about anxiety. Anxiety at starting a new job, making new friends and generally making small and big changes such as moving house etc. Getting to the anxiety that underlies a secondary emotion such as anger was quite a revelation for since it took much of the sting out of my anger. And what Gurzon writes about anxiety being the key to personal change has certainly been true for me. Becoming aware of my own anxiety, and the ways in which I react to it, has helped me to respond to it in a more healthy way, and to also understand others better.

Gurzon, a Massachusetts-based psychotherapist and author, says that the way we react to anxiety determines our personalities and our characters. Do we try and control it, desperately avoid it, numb it with excessive alcohol and reckless living, internalise it? I think I tried a combination of all of the above. Attending an all boys private school I got the message that boys don’t show fear (and don’t cry, although they could perhaps get a bit misty-eyed at a brilliant try in rugby). Part of the teasing at any boys school runs along the lines of: Don’t be a whuss, a girl, a moffie. Be a man. So I drifted through my school career, blindly unaware that I was even anxious. By the time I got to university I went through the usual drinking phase and then became mildly depressed. Counselling helped, I studied psychology and, after Honours, I went into teaching to get some life experience.

As a young teacher, anxiety is a daily occurrence but I learned to tough it out, partly through preparing thoroughly enough to try and be in control of the situation. But it was only when I actually studied Masters several years later that I really understood the significance of the anxiety that I was experiencing. This isn’t just something you grow out of as you become more experienced — this is a fundamental and important part of life.

One of the things I have noticed in my short time as a psychologist is that people who suffer from anxiety just want it to go away. But repressing it has the adverse effect of making it come back, often stronger and in a different guise. Anxiety can take the form of recurring worries, disturbing dreams, panic attacks, stomach complaints, sweating, dizziness and palpitations (to name just a few symptoms). But what happens, if as Gurzon suggests, you acknowledge the anxiety and try to understand its riddle? If you embark on a conversation with your anxious thoughts? Hopefully you learn to dance with anxiety, to interact with it in a way that leads to greater awareness and a more meaningful personal life.

The personality-forming side of anxiety is also an interesting one. Gurzon says that our reaction to anxiety determines our personalities. I often wonder if I would have progressed more quickly in therapy if my therapist had spelled this out for me, and given me the benefit of her psychological knowledge regarding personality traits. I think in my mid-to-late twenties when I was in real therapy for the first time I would have appreciated knowing about some of the different personality traits and disorders (e.g. Borderline, Narcissistic, Avoidant, Histrionic, Anti-social, Dependent). Since everyone has a personality, everyone has traits which can be understood in terms of psychological diagnoses. For someone who’s intelligent and who already has a good grasp of psychology I think it can be empowering to be given tools (labels, knowledge, patterns) with which to re-examine their own personal development.

Of course the counter-argument to this is that imposing a label on someone who could be vulnerable and distressed is likely to push them away. Bion says that therapists should sit on their wisdom rather than offering their interpretations too readily. And I know from my own experience that often the most helpful thing a therapist can do is to listen, to understand and just to sit with what the client brings and then reflect that back to them. Allowing people to come up with their own solutions and insights can be more meaningful and rewarding than being given the answer. But, since knowlegde is power, learning about maladaptive reactions to stress and anxiety can actually help people to learn more effective coping strategies. This education function is one of the aims of Dialectical Behaviour Therapy (DBT), which is a treatment of choice for Borderline Personality Disorder.