Therapeutic Texting

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My young client arrived in tears. Seems she'd not only had problems with a date this week, but also with the friend to whom she'd turned for support. A good deal of these problematic interactions had taken the form of text messages back and forth between the three of them. My client scrolled back to some earlier texts to quote both the date and the friend.

And then, and this is where it gets interesting, while we were talking about all this, she received a text and dashed off a response. I considered asking her not to do that during the session, but what the heck? Here was the very interpersonal issue we were discussing unfolding in the here and now! So I sat back and waited.

Pretty soon, the little phone buzzed with a response, I asked her about it, and so it began: We would talk a bit, she'd send a text or receive a response, and we'd process them. The whole thing was most interesting, and different from work I've done in the past. People have printed out e-mails before and brought them to therapy, and have even brought their laptops in to show me MySpace pages, but this is the first "live" internet interaction I've processed in session as it unfolded. I think it was productive.

Having the actual texts as they unfolded gave us accurate data from her interpersonal world as a basis for discussion of gender roles and expectations--this gave the work a here-and-now immediacy, vs. the there-and-then that is all too often the stuff of psychotherapy. In the course of the hour we were able to establish that she doesn't like confrontation. Smart, perceptive, and funny as hell, she responds with sarcasm when wounded. She is a feminist. She is highly empathic and tries to be supportive to the important people in her world, yet finds herself again and again in non-reciprocal, sexist relationships.

If I have a problem with how the session unfolded, it is that if one has needs that aren't getting met in one's relationships, then the phone is a tremendous distraction from the face-to-face opportunity to get those needs met, available right here, live and in real time, in the therapeutic relationship. So I guess I wouldn't want to do this every week. But today? Cool.

#7: Patience is a virtue

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Patients occasionally (okay, frequently) express impatience with their progress in therapy. Impatient with themselves, they become impatient with me for not fixing them faster. And they worry that perhaps I am impatient with them for not doing more, better, faster than they actually are. 

Wood's Rule #7: Patience is a virtue

Because cultivating this virtue helps you "cease contributing to your own suffering and confusion and perhaps to that of others", Jon Kabat-Zinn¹ describes patience as a "fundamental ethical attitude" (1994, p. 48).

"From the perspective of patience," Kabat-Zinn writes, "things happen because[emphasis added] other things happen" (p. 48). You get sober, whether sooner or later, because you got drunk. The teenager you've brought to me for therapy will develop maturity and judgment (eventually) precisely because he has been immature and impetuous. For that matter, we can only learn patience who began our journey with impatience.

And if that is true, then it is also true that

what will come next will be determined in large measure by how we are now. This is helpful to keep in mind when we get. . . frustrated, impatient, and angry in our lives (p. 50). 

What will being impatient and irritable right now this two seconds create in our next few minutes, days, weeks, or months? Years down the road, what quality of life will all this rushing around and crankiness have produced for us?

So I would remind my patients to, in Kabat-Zinn's words,

. . . [remember] that things unfold in their own time. The seasons cannot be hurried. Spring comes, the grass grows by itself. Being in a hurry usually doesn't help, and it can create a great deal of suffering--sometimes in us, sometimes in those who have to be around us (p. 48).

It's how I think of you when you are struggling, when you have hit a wall. I know that I cannot make a flower bloom, or control its form and color when it does. All I can do is make sure to plant it where it receives enough sunshine (but not too much); then I must water and fertilize it (but not too much). It grows on its own, in its own time and in its own way. And so will you, dear, so will you.

Kabat-Zinn closes this chapter, poetically titled "The Bloom of the Present Moment", with a quote from Lao-Tzu:

Do you have the patience to wait
till your mud settles and the water is clear?
Can you remain unmoving
till the right action arises by itself
                            -from the Tao-te-Ching 

If I allow myself to become impatient in session, then I act before my mud has settled. It is not likely that anything that I do will come out of right mindfulness or right understanding. To the contrary, it is highly likely that I will do something to make your journey harder, or longer. And that would be unethical.

 

1. Kabat-Zinn, Jon (1994). Wherever you go there you are: Mindfulness meditation in everyday life, pp. 47-51. Hyperion: New York.

The Carlat Psychiatry Blog: WebMD's Big Lie

The Carlat Psychiatry Blog: WebMD's Big Lie

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Just Who the Hell Do You Think You Are?

In which Dr. Phil scolds a family, and I scold him

I came home early from work Friday, and caught a snippet of an ad for Monday's episode of Dr. Phil. I must say, the experience was a bit like coming home early and finding one's partner in bed with someone else. What I saw, however, was not Mr. Wood in flagrante delicto, but Dr. Phil verbally abusing a patient.

I caught Philip Calvin McGraw shtupping my beloved profession. And I have a few things to say about that. (You knew I would, didn't you?)

But first, the disclaimer: I do not watch the show. I do not believe that work around such personal, private issues should be done on national television. We are ethically bound to work exclusively in the patient's best interest, and this is in no one's interest that I can make out other than Philip Calvin's. I could not bear to watch another psychologist exploiting people's pain for money, or to get his narcissistic needs met. It would make me physically ill. And because I don't watch, I have no idea what is clinically indicated in this case.

Here's what I do know. You don't yell at patients. Never. Not for any reason. It's abusive, it's incompetent, and it's unethical.

Among the basic Principles that form the foundation for our Code of Ethics are the following:

Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally . . . .
Principle B: Fidelity and Responsibility
Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct. . . .
Principle E: Respect for People's Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. . . .

Back when I was a young grasshopper just starting out in the profession, some of the elders in the therapeutic community here liked to distinguish between two groups of therapists--huggers and hitters. Generally speaking, women were said to be huggers (literally and figuratively speaking) and the male therapists mostly tended to be hitters (not literally, ok?). I'm a hugger. McGraw obviously considers himself a hitter.

Even allowing for differences in therapeutic style, the man is going too far now. This is beyond Reality Therapy (anybody here besides me old enough to remember William Glasser?), beyond tough love. This is verbal abuse. "Who the hell do you think you are?" and calling a female client "Sister" in that tone of voice is inexcusably disrespectful. Telling her "It's time to grow up!" is not therapeutic, it's insulting: He might as well have told her that he thinks she's being childish. She's sitting there frozen, wide eyes fixed on him, tears rolling down her face. And speaking of hitters, if she'd ever been hit in her life I'd be willing to bet that at that moment she was physically afraid of him.

It's incompetent. Everything a patient does or does not do, and I do mean everything, is grist for the mill. All behavior has meaning, and the single best tool we therapists have in our armamentarium is the analysis of behavior. Part of what he was yelling at the patient for was not showing up for appointments and walking out of a session. After, and only after, he analyzed his own behavior for technical errors, McGraw could have gained a lot of mileage in the therapy by helping her analyze her own feelings, thoughts, and actions.

Any time we offer an observation, an interpretation, or some other intervention, we pause, observe the patient's response, and adjust our next move accordingly. The patient's response is the measure of whether we've got it right or wrong, so that if I were to say or do something that resulted in a patient getting up and leaving the room, I would have to automatically consider first that I screwed up somehow. This is so obvious I can't believe I have to say it.

So I look at myself first. Have I made the patient believe it's no longer safe in my office? Maybe I triggered overwhelming anger in her which she does not feel ready to handle yet. Regardless of the exact nature of what just happened, most likely the power differential between therapist and client prevents her from thrashing it out with me one on one. Whatever, she's not being bad. I have made an egregious therapeutic blunder of some sort, and she's taking care of herself the best way she can.

If I can get her back in the room, it will be my job to make this a safe space again to start the process of analyzing what happened, to apologize if necessary, and to help the patient learn from it something that is useful to her. Telling people to be different than they actually are is not therapy. Also, it doesn't work. You might as well yell at the weather for all the good that it will do you.

It's disrespectful, too. To be a good therapist, you have to believe that everyone has in themselves the potential to grow into their own best selves. Imposing what you think is a person's best behavior upon them not only ignores what they want for themselves, it discounts their own abilities to get it. McGraw is telling this woman by his behavior that he knows what's better for her than she does (she's stupid) and not only that, he's going to do it for her because he doesn't believe she can (she's weak). McGraw even talks on his website about "giving" people tools, as if they were his to give.

On the other hand, helping a client see that she can use words to deal with feelings instead of acting them out, that she has the power thereby to make changes in a relationship, helps her find within herself a capacity she has always had but has lost touch with. She will never again believe that when she runs into problems in a relationship that she has only Hobson's Choice between staying and taking abuse/neglect, or walking out. A good therapist can in this way turn potential therapeutic disaster into personal growth for the client.

If she's truly responding to something internal--especially likely in a trauma survivor--then my job is still to get her back in the room any way I can and help her analyze it. This probably happens elsewhere in her life and by understanding herself better she can get some control over her reactions and learn some better tools for handling them. She will only do that if she feels safe with me to explore her internal reality. That won't happen if I'm busy yelling at her.

Yelling, getting angry at a patient, is not about the patient's therapy any more. It is about using the power inherent in your professional role (and perhaps also in gender, racial, class, and other differences) to gain control of another person's behavior. It's now about the therapist and the therapist's needs, not the patient's ultimate welfare. What we have in McGraw's clip is an older male authority figure yelling at a younger, female client. This is a flagrant abuse of power, and as in any abusive relationship, it is about controlling the victim's behavior.

McGraw also yells at her that when he asks her a question, she'd better 'tell the damn truth'. This reveals a total lack of understanding of the patient's experience of psychotherapy and of the process of therapy. It's the kind of incompetence you might expect from a first-year graduate student in the first weeks of his therapy practicum. Clients don't tell the truth. Any lawyer can tell you that, without the first bit of training in clinical psychology. In the first place, clients don't always know the truth. That's what they're here for, dumbass Doc, to learn the truth about themselves.

In the second place, they are afraid to tell the truth. They are afraid that we will think they are crazy, or evil, or stupid. They are afraid we might yell at them for it. They are afraid that they might scare us, disgust us, anger us, and then we might refuse to work with them any more. Which of course is exactly what happened here: McGraw acts out the patient's worst fears instead of working through them.

You see, Philip Calvin, whatever we think or act or feel (or don't) is also grist for the mill, except we don't just blurt it out in the session. We analyze it privately or in supervision--which I think Philip Calvin could really use--and then and only then decide if we want to use it in the hour and how we might best do so. If a client makes us angry, for example, or renders us impotent (as seems to be the issue in this case) by not showing up or not getting better or whatever, first we need to check and see if this is our issue. Did my mother make me feel like that? My Dad? My boss?

If so, I need to let that one pass on through me and get myself back to the reality that is the client in front of me. If it's not primarily an issue from my past, then my next best bet is that the client makes a lot of people feel this way. Will I help her understand her impact on other people if I scream at her? No. Will I help her change her behavior by telling her to cut it out, or else? No. If it were that simple, she'd have done it already. But if, on the other hand, I can help her look at what just happened in the session and the feelings and intentions behind her behavior, then she has a chance of learning something that will help her in the future to behave in a way that works better for her.

Instead, McGraw takes the no-shows and the lying and the walking out of sessions personally, as if it were about him and not the client. Which of course by now it is, due to his ham-fisted attempts to exert control. If the only way she can retain some of her power and dignity is to not show up or to leave when he's being an asshole overbearing, that's what she's going to do. He's so contaminated the therapeutic field that by now it's going to be nearly impossible to sort out what's hers to work on and what's his. If I were his employer, I would assign the family to another therapist at this juncture, because it's not the family's job to help him sort out his stuff. They're here to get help for themselves, and they aren't getting it. 

Don't get me wrong: There are times you have to fire a patient. If you are working in the patient's best interest, though, you don't yell, "You do that again, Sister, and we're through!" and "Don't try me!" The sacking is a therapeutic process, handled properly. McGraw, again, is trying to control another person's behavior with threats--in this case, as if he were a parent threatening to withdraw the father's love if the child doesn't do what he wants. He's attempting to get his needs met in the therapy, and if he does fire them in the coming weeks, it's going to do damage.

While we are on the Daddy thing, by the way, you may have noticed that I have been speaking about this case from the standpoint of individual psychotherapy. The reason for that is that I don't practice couples or family therapy--I don't have enough training or experience in it. I'm guessing McGraw might not either, because one thing I do know is that the therapist's job in family therapy is most emphatically not to step in and be the Daddy. If I'm right, he's practicing outside the boundaries of his competence (Standard 2.01, Boundaries of Competence) and that's not only unethical, it's dangerous. Do the wrong thing in family therapy and you have the power to not only permanently disrupt vital relationships in people's lives, but even to get someone killed.

Specifically, that Standard states in part:

(a) Psychologists provide services. . . only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

Philip Calvin wrote his dissertation on rheumatoid arthritis. Make of that what you will.

But I digress. The way to handle this is to point out the reality of the situation to the client, to wit, therapy cannot happen if you [fill in the blank]. We need to find a way to help you stop [whatever it is that's undermining your treatment]. How can we best do that? Or is it possible that your behavior is your way of saying that you are not ready to be in therapy yet? Or perhaps just not in therapy with me? In this way, you are helping the client see that she is making a choice--to engage herself at the next higher level in her therapy or to stop treatment for now. It's her choice, to make with integrity. McGraw's approach is punishing her for being herself, for doing the best she can with what she's got. The method suggested here challenges her to to make a conscious decision, and that's growth for her no matter which way she goes with it.

According to Wikipedia, McGraw is no longer licensed, and presumably he's not a member of the American Psychological Association (APA) either. If correct, he does not subscribe to and is not bound by the Code. Also according to Wikipedia, he claims his show is entertainment, not the practice of psychology. Assuming a judge would accept that distinction, he's therefore not practicing psychology without a license, which otherwise would subject him to possible legal sanctions. His website is a bit fuzzier on this latter point, listing as it does his academic credentials and talking about helping people, so somehow I seriously doubt that either his victims--dang! I did it again!--patients, I meant to say, or his audience fully understand these fine distinctions.

It makes me sick to see something like this on television. It is exactly the reason that people do not come to therapy, or if they come they can't fully engage--they are afraid that the therapist is going to judge them. Our job is not to judge. It is to act as guide to the client's inner life. One three-minute tirade like McGraw's, and 6.7 million people will be frightened off forever.

I'm telling you, it just makes me sick.

Welcome to Rape Culture, Joe

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Valdosta State University's remarkably inept recent posting of Rape Prevention Tips for Women triggered a number of blog posts on Rape Culture in which the bottom line was as follows: There is only one cause of rape, and that is the presence of a rapist. Tips for preventing rape, therefore, should be targeted at rapists. (Anna posted a great one in the Comments section, here.)

Personal Failure at Forever In Hell was one of the bloggers responding to the VSU gaffe. In response she got, perhaps inevitably, the usual mansplaining troll who took her to task for her "tone", among other things. He criticized her for being angry and anti-male. Fannie, of Fannie's Room took him on, and her post is so right on that I feel compelled to reproduce a goodly chunk of it, verbatim, here. (The last time I asked someone to attempt such a flip-flop, I got totally flamed. I hope she does not, because seriously, this is really good.) I would ask every man who does not believe that we live in a Rape Culture to try this one on for size:

"A good flip-flop comparison would be to imagine a world in which women routinely kicked men in the balls really hard for no reason at all, so much so that men wore protective cups on their genitals at all times and, if they didn't, they knew full well what they were asking for. One wonders, how would men react if the ball-kicking led to the formation of Ball-Kicking Prevention Tips that advised men to never walk alone at night, to avoid dangerous neighborhoods (especially where groups of women congregated), and blamed men for Getting Their Balls Kicked if they chose to move in the world like how people got to move?

It's not so much that the tips are not useful. Some of them are. But wouldn't the men rightly be angry about living in a culture that seemed to focus more on all the ways men could limit their lives to avoid getting kicked in the nuts, as opposed to how we could make women feel less entitled to attack men in the first place?

. . . .

Welcome to Rape Culture, Joe."

Right on, Fannie! There's really not much I can add to that.

Always Be Aware of Your Surroundings

Do you monitor the internetz for potential rapists? Perhaps you should.

I myself have one of those automatic Google thingies set up to scan for variations on my name and report links to me in a weekly e-mail ('course that's not why I do it, but never mind). Perhaps that's how this rape victim discovered a Craigslist ad in her name asking for a partner to act out a rape fantasy. Or not.

In any event, by the time she found out about it and got Craigslist to take it down, a real-life rapist had already seen it and was happily on his way to her house to fulfill some of his deepest fantasies.

Turns out she was set up by her ex-boyfriend.

So if we are responsible, as so many rape-prevention experts advise, for maintaining a constant awareness of our environment, now I guess we are to not only acquire eyes in the backs of our heads (this would be especially tricky if, whether for religious reasons or simply because it is raining cats and dogs, you cover your head when you are out in public), figure out how to see around corners and through parked cars and tree trunks, but also be aware of every transaction on the internet around the entire world in every language all the time! Because you will have nobody to blame but yourself if you get raped because you were unaware of your surroundings.*

My goodness. When will I ever find the time to wash my hair?

*Nobody in the original article--not the reporter, Ben Neary (AP), or anyone interviewed, implied any such thing--but wait for it. It's only a matter of time. I'll bet you a guest post that someone, somewhere, will at least say that once the victim found the ad she should have taken extra precautions. Any takers?

You CAN Prevent Your Own Rape, You Know

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I heard it from an expert.

I've been at an otherwise pretty good two-day workshop that was supposed to be on the neurobiology of trauma, but turned out to be a whole lot about treatment. The seminar leader is a genuine nice guy, a brilliant researcher and clinician who has devoted his career to helping people recover from trauma.

In some ways, I think, that makes what happened today even worse.

He was telling us about a case of a martial artist who was raped, and suggested that women like her get raped because they are unaware of their surroundings and/or are frightened into immobility due to past trauma. He clearly could not think of any possibility other than something about the victim. And I gotta give it to him, maybe she was spaced out--trauma survivors often are. Maybe she did freeze--trauma survivors often do. But still. Why be trying to puzzle out what it is about the victim that gets her raped? That makes me want to set my own head on fire.

Maybe it was a "blitz attack", which of course by definition would mean she wouldn't have known she was even being attacked until she was already down. Or maybe her rapist had a weapon: I have to ask--do men really believe that a martial artist can kick a gun out of an attacker's hand like good ol' Chuck Norris on the teevee? And then there's the rapist who comes in through the bathroom window in the middle of the night and has you under his control before you even wake up. Now how you gonna karate-kick his ass outta bed with your legs all tangled up in the kivvers? And then there was the woman I knew whose attacker told her if she cooperated, he wouldn't harm the children sleeping in the next room: All the martial arts training in the world won't trump that one.

And seriously, even assuming a normal (i.e., non-traumatized) level of awareness, how far can tracking your surroundings possibly take you? You can only watch your back-trail so closely before you get a crick in your neck--or worse, stumble into traffic. A guy who's determined to sneak up on you will. Or jump out from behind something: Can you see through tree trunks, around corners of buildings? I can't. And how aware can we be when we are sleeping in our own beds? 

The expert thinks it is empowering to teach a woman to kick the shit out of a model in pads and a helmet. He noted her proud stance after the class and said something to the effect of, 'Now she's in control of her own destiny.' The sheer illogic of this is stunning when a lifetime of training in martial arts didn't protect her. (I've seen this from a women's self-defense expert, too, who repeatedly tweets that it is up to you to be appropriately assertive--in control--so you don't get raped.)

Let us note that one in every six women in the U.S. will be assaulted in her lifetime. Maybe it's just me, but I think that's frequent enough to suggest that we are not, in fact, in control of our own destinies--at least not when it comes to rape. Indeed, that kind of thinking sounds to me like a form of privilege: The not-raped can believe they did/do something to earn/deserve that status ("I kicked the shit out of him!" or "I'm always aware of my surroundings." Always? Really?). That kind of thinking allows the not-raped to feel safe and secure in the fantasy that "it will never happen to me" and to look down on victim/survivors as people who screwed up somehow.

But I digress. I'm sure beating up on that guy in class was fun for her. And maybe all women should know some self-defense. But shouldn't anybody think that's going to necessarily prevent a rape (see above). Heck, it might get her hurt worse or even get her killed, because some rapists escalate when you fight back, either because it angers them or because they are excited by it.

These are all reasons why it is both cruel and ignorant to blame women for not paying sufficient attention to what every potential rapist within arm's reach might or might not be doing, or for not fighting off a dude who outweighs her, has a longer reach, has got the drop on her, or who is carrying a weapon--or all of the above. I'm sure the presenter didn't mean to blame anybody, but that is, precisely, victim-blaming.

My stance has always been (and I learned this at Grady's Rape Crisis Clinic back in the '70s, by the way--I don't get original credit for it) that whatever the woman does and survives is the correct thing. I wasn't there. You weren't there. The expert wasn't there. She was. She read the situation and handled it instinctively--and survived. That right there gets her a grade of A+.

The scary part, again, is this guy is a recognized expert who amply demonstrated a high level of sensitivity at other times during a career spanning decades. If he can have a mental lacunae like this. . . well, I just despair sometimes.

And of course he's not the only professional to do this, nor is it always a man. A recent report of a "female" getting raped in a park caused a female psychologist to nearly throw herself onto Twitter to warn "girls" not to go to parks alone or after hours. I clicked on the link and found that the original news article had never specified the victim's age, the time of day, or whether she was alone. Never mind that none of these things is in the least bit relevant anyway, because rape, dear readers, is caused by rapists.