On Humility, and the Limits of Formal Education, or More on Arrogance

I know everybody's watched it, but have any of you read the series A Song of Ice and Fire? I'm on Book Four, A Feast for Crows. When I'm not working, I think, I live more in Westeros than I do in America. It's that intriguing, enchanting, absorbing. And the other night, I came across this passage, in the Prologue: 

"The night before an acolyte says his vows, he must stand a vigil in the vault. No lantern is permitted him, no torch, no lamp, no taper . . . only a candle of obsidian. He must spend the night in darkness, unless he can light that candle. Some will try. The foolish and the stubborn, those who have made a study of these so-called higher mysteries. Often they cut their fingers, for the ridges on the candles are said to be as sharp as razors. Then, with bloody hands, they must wait upon the dawn, brooding on their failure. Wiser men simply go to sleep, or spend their night in prayer, but every year there are always a few who must try."  

". . . what's the use of a candle that casts no light?"

"It is a lesson," Armen said, "the last lesson we must learn before we don our
maestcr's chains. The glass candle is meant to represent truth and learning,
rare and beautiful and fragile things. It is made in the shape of a candle to
remind us that a maester must cast light wherever he serves, and it is sharp to
remind us that knowledge can be dangerous. Wise men may grow arrogant in their wisdom, but a maester must alwavs remain humble. The glass candle reminds us of that as well. Even after he has said his vow and donned his chain and gone forth to serve, a maester will think back on the darkness of his vigil and remember how nothing that he did could make the candle burn. . . for even with knowledge, some things are not possible."

That stopped me in my tracks. I read it again. And then once more. And I wished that (or something like it, since we have neither dragons nor dragon glass in 21st-century America) had been our last lesson, perhaps the night before our hooding ceremony, since we don't don chains like the maesters of Westeros.

How I wish they'd taught us how to simply sit with the dark. 

I have been a therapist for 33 years, and in that time I have seen many who have grown arrogant--in their knowledge, if not their wisdom. I have seen a few use their knowledge in dangerous ways. And I have seen not a few who think that because they have the terminal degree, they must know everything. I have known psychologists trained in the scientist/practitioner tradition who abandoned all pretense at critical thinking the evening of the day they defended their dissertations. I have known psychologists who thought they had nothing else to learn and shut their minds to new ideas and new data. And I've met very few who didn't hold themselves above the less-educated. The whole profession has come to think of itself as wholly superior to masters-level practitioners, and spends a lot of time dissing them and expending energy defending turf from them that might be put to better use elsewhere. But that is another rant for another day.

Worse, and there is another rant coming on this one in a future post, psychology has come to believe that they have the power to change people. Therapy has become and "intervention" to be "delivered" as if to a  retail consumer and its success is to be measured in "behavioral outcomes".

Our clients believe this, too, and will say to us, "What do we do about it?" or, "I am ready to be fixed, now." And when we can't, they ask us, "What is the use of a candle that casts no light?" So we are seduced into trying, only to bloody our fingers once more.

As the next passage in the Prologue to A Feast for Crows makes plain, the obsidian candle can give off light -- but that's not under our control.

 "I know what I saw. The light was queer and bright, much brighter than any
beeswax or tallow- candle. It cast strange shadows and the flame never
flickered, not even when a draft blew through the open door behind me."

Armen crossed his arms. "Obsidian does not burn."

"Dragonglass.'' Pate said. "The smallfolk call it dragonglass." Somehow that seemed important.

"They do," mused Alleras, the Sphinx, "and if there are dragons in the world
again . . ."

"Dragons and darker things,'' said Leo.

The dragonglass candle is in this sense a metaphor for healing, and gives another bit to the lesson Armen describes. Illness, unhappiness, neurosis--whatever you may wish to call it--is contained within us, and so is healing. There are things we may say or do, or not say or do in a session, things that grew out of our learning (not all of which is formal, by the way) that enter into a person in the same way that a maester's antidote enters the body to combat a poison, and we may contribute to a person's healing in that way. But in the same way that the antidote and the poison do battle inside the victim's body, with the body itself as one of the combatants, so, too, is psychological healing an inside job. We have very little power compared to what resides in you.

And powers far greater than either of us may determine whether that candle burns.

Disturbed patient, disturbing therapy by St. Cloud psychologist | StarTribune.com

Somebody on Twitter alerted me to this story. Briefly, a therapist got over-involved with two of her clients and was disciplined for it. The problem, at least as it is framed by the local newspaper, is that she has poor boundaries and poorer reality testing: As they so cutely put it, she believed the client's delusions more than the client did.

The line between a memory and a delusion is a fine one, especially in Dissociative Identity Disorder (DID). DID occurs in people who have suffered especially severe and often bizarre, but quite real, abuses while at the same time there is an unreal quality to the disorder itself. Real memories, in other words, quite commonly exist side-by-side with unrealistic beliefs in DID.

Therapists are not, and cannot be, in the business of validating clients' memories. However, when a client questions her/his own memories, we can encourage reality-testing by the client. In doing so we must not forget that perpetrators of abuse quite naturally go to great lengths to hide what they are doing, so that validating a specific memory may simply not be possible. We also need to caution clients against attempts to validate that may be dangerous, such as directly confronting perpetrators.

Sometimes the only validation available is indirect: We are working on a dysfunctional behavior in therapy, a memory surfaces, and the behavior “spontaneously” clears up. Other examples of indirect validation that come to mind include addicted and sexually-acting-out siblings (possible co-victims) and an arrest of a relative for a related crime. None of these things proves the validity of a specific memory, but it does lend credence to the client’s family portrait.

It is a myth, by the way, that a person has to remember in order to heal. Or that survivors have to remember more: To quote the late Ann D. McAllister, Ph.D., "What [they] already remember is more than enough." Digging for additional memories runs the risk of (a) producing "memories" that aren't, and (b) completely unraveling the client's ability to function in the present.

Since disbelieving real abuse can be as harmful as becoming part of a delusional system, the therapist serves the client best by focusing on current functioning. The focus of treatment becomes teaching the client to manage flashbacks, switching between alters, emotions, appropriate boundaries, insomnia, self-harm, addictions, self-image, etc. And the key phrase here is “teaching the client to manage,” not managing it for the client. Treatment for DID is emotionally intense, and it’s not going to happen without a degree of dependency developing. But throughout the therapy, the therapist maintains the boundaries of the working relationship and encourages the client’s independence.

Please Hold While I Connect Your Call

We had a spirited discussion in supervision last week about what it is exactly that we as therapists do for our patients. Job #1, as I see it, is to make connections.

Our clients are invariably suffering from some form of alienation. Perhaps they are alienated from their feelings: They don't know what they feel. Or they don't know why they feel it. Perhaps they are alienated from their selves: They don't know who they are, or what they want. They don't know why they do the things they do. They see-saw back and forth between contradictory wants, thoughts, feelings, actions, and self-images. Or they might be alienated from others: They can't maintain a relationship.

So what we do is we help them re-connect to alienated, denied, repressed, suppressed, split-off, and projected parts of themselves.

If people are alienated from their feelings, we help them get back in touch with them. Some people are all in their heads, some have split off their feelings and either projected them onto someone else or created alter personalities to handle them. Still others drink and drug to numb their feelings. Some just deny that they have any, and hope that will make it so. Women in my practice are frequently (if not usually) especially alienated from their anger. We might help them make the connection between their abuse of alcohol and drugs and their wish to avoid feeling angry. Or their wish to reduce inhibitions to the point that they can let loose some anger. We help them re-own anger they have split off and projected, be it onto another person or into another personality. We help them look at patterns in their lives and what their anger might mean in response to people, places, and things. Maybe we help them learn to use their anger as valuable information, as signals.

Which brings us to power. Most of my clients are no more or less powerful than the next person. But women in particular tend to believe they are powerless: They have become alienated from their own strength, usually by the same social process that alienated them from their anger. Therapy, therefore, may involve getting women to exercise that particular muscle as well.

Other people are alienated from their reason and ruled by their feelings. These folk need to be re-connected to their rational sides. We can do that, too. Therapy is a whole lot more than getting in touch with your feelings.

Some folk have become alienated from their very selves: Their parents split off experiences that would otherwise be intolerable and projected them onto the patient. Or tried to live vicariously through the patient. Instead of mirroring for the child what the child is actually like, these parents' eyes are as inaccurate as funhouse mirrors: No child looking into them all day ever day is going to grow up with a realistic self-image. Therapists, if we are doing our jobs, help clients look at themselves with their own eyes (through ours) and begin to see themselves as they actually are. They learn what they really want, not what somebody else has been telling them all their lives what they should want. We reconnect them with their own opinions.

And we reconnect them with their voices. Perhaps a child has been told all his life that what he has to say isn't important, or is incorrect, or must not be spoken of at all. This child, as an adult, is alienated from her own voice. We help her re-learn to speak her piece, often by simply listening objectively, without judging her or injecting our own points of view.

As a psychodynamic therapist, of course, I thrive on making connections between peoples' pasts and their presents. Why do they do what they do? Where did they learn that? What impulse/fantasy/wish/fear are they acting out? Where are its roots in the distant past? How does what goes on in the therapy session connect with how they conduct (or fail to conduct) themselves in their "outside" relationships?

The list of possible connections is endless. What is alienated and needs to be brought back into self-awareness varies with each client. Our job is to help them ask the right questions, observe themselves, analyze the data. We listen. We observe. We make connections.

So that's what therapists do. We are the telephone operators of the psyche.

Busted!

A psychiatrist who practices at Peachford has been indicted for sexual exploitation of a patient. Psychologists' ethics specifically forbid sexual relationships with patients, as does Georgia law, and as do most professionals' ethical codes--for good reason. The doctor-patient relationship, whether the doctor is a doctor of medicine or a doctor of psychology, is not an equal relationship and gives the doctor the power to engage the patient in activities that are not in the latter's best interests.

Adult patients who are exploited are usually female, and there has been some argument that such an ethical/legal prohibition is therefore sexist. It has even been said that, male or female, such prohibitions might deny adults their constitutional right to freedom of association. But studies of this issue have consistently found that it is not usually a case of two consenting adults falling in love (or lust) but rather one in which the therapist has serial affairs with patients, acting out her or his own issues in the treatment, much to the detriment of the patients. So I'm gonna go out on a limb here and predict that now that his mug has been on the 6:00 news, there will be more patients coming forward to report that they, too, have been taken advantage of in this fashion.

Often, it is not until someone else files a complaint that a patient realizes that s/he has an unethical therapist. In the first place, some such patients have been abused before (e.g., incest survivors) and have very poor boundaries to begin with. Their idea of what is abnormal is way, way out there, based on their growing-up experiences, and a little kiss or a date with a therapist doesn't even come close to tripping their radar. To them, this is business as usual. Therapists who are sexual predators in this way are no different from child sexual abusers in that they have a well-honed instinct for who is exploitable. Is this client emotionally needy? Does this client lack a good support system? This re-traumatization is an especially awful betrayal of what to my mind is a sacred trust placed in us.

Seduction by a therapist then proceeds in much the same way as an adult/child exploitation: Early inappropriate behaviors are highly deniable and serve as a test of what the therapist can get away with. Test behaviors also serve to 'groom' the victim, as the therapist (like any sexual predator) gradually increases hir demands. The victim is sucked in one small step at a time, and by the point that s/he feels things are badly out of whack here, s/he (a) is too far from the exits to be able to extricate hirself, and (b) has come to feel complicit in what is going on so is too embarrassed and ashamed to tell anyone. Plus, these therapists, like all sexual predators, instill the importance of secrecy in the victim's mind long before reportable, criminal behaviors occur.

In some cases, the therapists told the patient that this was part of their treatment. For example, the therapist may tell the patient that s/he needs the experience of feeling attractive, lovable. Or that sexual inhibitions can be worked out in therapy by having sex. An unsophisticated patient really has no way of knowing any better: S/he trusts the doctor and complies. This is so not a love relationship, people. It is an abuse of power, pure and simple.

This particular psychiatrist has also been charged with inappropriate prescription practices. Reading between the lines, I'm guessing that the drug was part of the exploitation. This can happen in one of two ways: First, the drug impairs the patient's judgment. Second, the patient may become dependent upon the drug, and by extension, the psychiatrist. This is especially an effective trap if no reputable psychiatrist would prescribe the particular drug, or so high a dose of it--the client has become addicted to it and can only get it from her perpetrator. If she reports him she loses her source. See what I mean about power?

Psychologists' ethics do allow for relationships between therapists and former patients under certain conditions and after a certain period of time has elapsed. This, too, is controversial. These rarely (if ever) turn out well because the power imbalance from the original relationship persists. The roots of these relationships are in transference-countertransference manifestations that were never properly worked through in the therapy, but which, instead, are now being enacted outside the therapy. By definition, then, the therapist wasn't doing hir job in the therapy, and the patient by definition got short-changed.

These are the same interpersonal relationship dynamics that probably brought the patient to therapy in the first place: If they caused the patient problems then in hir relationships, they will cause problems in this one. Similarly, the therapist's lack of self-understanding, poor boundaries, and behavioral disinhibitions exhibited during treatment spell disaster for any outside relationships as well, including especially one with a former patient. Two such relationships of which I am aware became physically abusive; in one, the patient wound up killing hir former therapist in self-defense--and went to prison for it. In a third case, the pair got married, the therapist made the former patient hir office manager, and then proceeded to be unfaithful--with patients!

There are cases in which the patient initiates sexual contact. This is no defense of the therapist: Freud long ago recognized that when the patient falls in "love" with the therapist that it is not the therapist the patient loves--and that the therapist would be a fool (not to mention an under-analyzed narcissist) to think so. The patient/victim in some of these types of cases has been previously victimized, and presents with all sorts of sequelae of previous abuse that makes hir more likely to sexualize the therapy relationship than a patient without an abuse history. When such a patient introduces sex into the mix, it is clearly a therapeutic issue and should be analyzed, not acted out. And it is the therapist's responsibility to make sure that this happens. As one of my clients is fond of pointing out, "That is what you are getting paid the big bucks for."

The ethical and legal prohibition against sexual relationships with patients is a sound one. No good can ever come of it, no matter the participants' rationalizations to the contrary. If your therapist has said or done anything even slightly sexual before, during, or after one of your sessions, run like hell in the opposite direction. And please consider filing a report with hir licensing board and/or the Ethics Committee of hir state and national professional associations. The affirmation that your therapist was in the wrong will do you a world of good.

The basics

I am reading Jane Hall on Deepening the Treatment. It's a book for beginners (she teaches technique at an analytic institute). I didn't realize it was for beginners when I bought it, otherwise I would not have.

Liv Ullman wrote in her memoirs that the book you need comes into your hands when you need it. I picked this one up the other day because every time I walked past my bookshelf it called out to me.

So far, and I'm a couple of chapters in, I haven't read anything I didn't already know. But I'm hanging on every word, nevertheless, partly because Hall says what she says so well, but mainly because she is reminding me why I became a therapist in the first place.

Managed care and training as a psychologist exert a powerful pull. Hall reminds us all of our roots.

All I need to know I learned by watching tv (not)

My mail carrier once told me that he'd figured out there were only three things you needed to know to be a therapist, and he got this from watching tv.

1. Mm-hmm.
2. Tell me more.
3. How do you feel about that?

I only wish it were that simple.

Audubon Doe

The first time I ever saw her was on the cover of Audubon.

The photograph had been made into a wrap-around cover, but because the magazine was on a waiting-room coffee table back-side up, all I saw at first was the the left half--the half with the spider web sparkling in the sun and all the pink wildflowers and prairie grasses back-lit in the misty early morning. It was absolutely beautiful, so perfect that I thought it was the whole photo: Imagine my amazement when I turned the mag over to find the the other half with that doe looking back at me!

I stole it (sorry, Joen).

I kept that magazine for years, thinking that I'd eventually figure out a way to mat and frame the cover without ruining it. And then one day, some time after Google, it dawned on me that the photographer credited inside might sell prints of his work... duh. Which is how I discovered Carl Sams's website. This particular photo had actually become quite famous as "The Audubon Doe." I ordered a print for myself and eagerly awaited its arrival.

What I got instead was a polite e-mail from Mr. Sams saying that he was sorry, but the photo was out of print. Oh, boo.

But some things are meant to be, I guess, because in a week or so instead of a refund to my credit card, lo and behold I got the print in the mail. There's a wonderful framer down the street from my office who did a perfect job on it and now "The Audubon Doe" hangs on the wall in my office, right across from the Little-Old-Lady-Bad-Back Chair from which I work.

She is so serene. So unto herself. Her huge ears, pricked forward, are backlit pink in the morning sun. Her eyes are large and round and soft and shiny and dark. Her big, black, moist nose dominates her velvet face; long, sensitive whiskers adorn her muzzle. She is all perception, all sensation, her attention totally fixed upon the human before her. She is, in short, the perfect therapist: Silent, attuned, waiting, receptive, ready.

She reminds me to just, simply, be.