Do we marry the wrong people?

An article about "How We End Up Marrying the Wrong People" in the Philosopher's Mail is wonderfully thought provoking, full of great insights and very wrong.  I probably should agree with it since it recommends that people undergo lots of self-reflection and guided psychological processes before they get married.  In fact, the last line is a call for "psychological marriages."  Sounds like it would be good for business. 

The good.  

The article -- which, oddly, is unsigned -- has many fantastic observations about relationships.

We ‘project’ a range of perfections into the beloved on the basis of only a little evidence. In elaborating a whole personality from a few small – but hugely evocative – details, we are doing for the inner character of a person what our eyes naturally do with the sketch of a face.
We don’t see this as a picture of someone who has no nostrils, eight strands of hair and no eyelashes. Without even noticing that we are doing it, we fill in the missing parts. Our brains are primed to take tiny visual hints and construct entire figures from them – and we do the same when it comes to the character of our prospective spouse. We are – much more than we give ourselves credit for, and to our great cost – inveterate artists of elaboration.

This is a lovely way of showing us how much we project onto our partners.  I spend a lot of time with couples trying to get people to disentangle what they want or fear or expect from their partners, from what their partners are actually saying or doing or feeling. 

Prior to marriage, we’re rarely involved in dynamics that properly hold up a mirror to our disturbances. Whenever more casual relationships threaten to reveal the ‘difficult’ side of our natures, we tend to blame the partner – and call it a day. As for our friends, they predictably don’t care enough about us to have any motive to probe our real selves. They only want a nice evening out. Therefore, we end up blind to the awkward sides of our natures.

In my experience, both personal and professional this is true.  Couplehood can make us to examine our faults because there is a lot at stake.  But is knowing oneself a prerequisite for a good marriage?  Of course a publication called the Philosopher's Mail thinks so.  Me, not so much.  

The Mistake

What follows from this smart, though pessimistic, view of human nature and relationships -- that a battery of psychological testing prior to marriage will enhance self-knowledge and knowledge of the other person and thereby fix what ails marriages -- is a mistake.  A whopper of a mistake.  A mistake on the order of picking a life-partner with eight strands of hair and no nostrils. 

The mistake is that it both underestimates and overestimates what psychology is. 

I recently saw a couple who had been married for 25 years in which the man was completely resistant to all my psychological blandishments, he wasn't hostile or 'in denial' or 'defended'; he just was completely uninterested in his own motivations.  As he saw it, over the course of a long marriage, he had forgotten to treat his wife well and now he wanted a chance to do what she was asking for; more attention, more romance, more sex.  I wanted to know 'why' but after three sessions he had changed and she was happy.  The surgery was a disaster but the patient not only survived but felt much better.  The lesson: Who cares 'why' if a relationship works?  There are plenty of couples who are happy enough, for enough of the time that they don't need to spend a lot of time reflecting on it.  (This is one of the great discoveries of John Gottman's research).  It is easy to extrapolate from unhappy couples in a therapist's office to assume that all couples are unhappy.  The dubious statistic (Philosopher's Mail, thankfully does not) about 50% failed marriages can re-enforce this idea (for why the statistic needs to be taken with a grain of salt see here).  Even if we grant it for a moment that 50% of marriages will last sixty years, it is worth noting that the vast majority do so without without anybody ever stepping into a shrink's office.  As I have remarked before, marriages, like people, are resilient.  A realistically optimistic focus on individual and couple resiliency is honest and healthy. 

The most serious problems people encounter in couples are not magnifications of the same problems they encounter in friendships or the work place.  The reason for that is that a couple relationship isn't the same as other relationships.  I see a lot of young couples, couples who have recently moved in together after a year or two of dating.  They fight, they hurt.  They come in bewildered because what they are experiencing is so different from what happens in the rest of their lives and what happened for the first year of their relationship. 

From what I have seen, after a year or two in a relationship, if and when we feel safe with our partners people sometimes do something different than they do in other relationships such as friendships.  My metaphor for this is: we come to our partner timidly, expectantly, filled with hope and reach out to them and offer them a beautiful silver platter filled with our shit.  When we feel safe and loved and secure enough we bring out things that we haven't paid attention to or thought about or reflected on for years, things that we are ashamed of, afraid of, mistrustful of, don't have any idea how to handle.  It is a paradox that the tribute of love is our own least loved parts.  These are things that psychological testing won't discover.  And our partner's reaction to us offering up our damaged bits can't be easily predicted. 

Couples can and should talk about their expectations: money, career, housework, children, sex.  People need to be honest with themselves about what is important in a partner but also need to know that will change over time. 

I don't believe in compatibility so much as I believe in kindness, flexibility and positivity.  Those qualities will see couples over a lot of hard stuff including a lot of incompatibility.  

 

Therapy: who decides?

Nobody knows why therapy helps.  We have theories but no solid understanding of the mechanisms involved and we probably won't for a long time. Therapy isn't alone in this. Nobody knows, for example, why SSRIs, a commonly prescribed class of anti-depressant works either.

André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."

André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."

We do know that for certain categories of psychological problems -- some couple and family distress, mild to moderate depression or anxiety, certain personality disorders, and some psychotic disorders -- psychotherapy helps a significant portion of people and has minimal down sides (there are possible negative consequences to therapy some of which I discussed here).

These two points -- that therapy works and that we don't know why it works -- are important to emphasize because government and private insurance are increasingly involved in the practice of psychotherapy.  An example; this week the Order of Psychologists of Quebec announced that it is proceeding against two people for practicing psychotherapy without a license.  Here, in Quebec, since 2012 you must have a license from the Order to offer psychotherapy, which is defined as follows...

A psychological treatment for a mental disorder, behavioural disturbance or other problem resulting in psychological suffering or distress, and has as its purpose to foster significant changes in the client’s cognitive, emotional or behavioural functioning, interpersonal relations, personality or health. Such treatment goes beyond help aimed at dealing with everyday difficulties and beyond a support or counselling role.

Clearly, the provincial government is taking psychotherapy more seriously.  Also it is clear that it is hard for lawyers to write a good definition of a process that we don't understand very well.  How far in can the government wade?  So far it has been restrictive legislation.  André Picard of the Globe and Mail, who writes as well as anybody in Canada about psychiatry, mental health and mental illness, has written a very good piece aimed at beginning (again) a discussion around the funding of psychotherapy through public health insurance.  Currently, no provincial government funds non-MD-provided psychotherapy in the same way that it funds medical procedures.  Here in Quebec, non-MDs -- psychologists, social workers, creative arts therapists sexologists etc. -- who work as psychotherapists in the public sector get paid a salary through their institution, they don't charge per procedure.  They are also increasingly rare.  The vast majority of out-patient psychotherapy is provided by private practitioners for whom clients pay out-of-pocket and either get reimbursed by their private insurance or not.  This means that people who might greatly benefit from psychotherapy but can't afford it are unable to access it.  The more seriously mentally ill a person is the more likely it is that he or she is poor, and the less likely it is that he or she has private insurance so this way of delivering non-emergency mental health care is seriously off. 

I like the idea of people being able to access psychotherapy regardless of income.  But I have some serious reservations about the idea of public health care funding for psychotherapy.

  1. Psychotherapy is one thing that can help with mental illness.  There are lots of other non-medical treatments that can help the mentally ill: stable, supportive housing is a big one; case management is another.  If we want to spend billions helping the mentally ill do better in the hopes that we will benefit as a society, we need to take these two as seriously as psychotherapy and medication. 
  2. It can be a bonanza for some and create rich, entrenched interests that distort psychotherapy.  Research into psychotherapy can make for very dispiriting reading. It often looks like this; I have developed Wexler's Wonder Therapy (TM).  I test WWT (TM) on people with depression by giving them 8 sessions.  I exclude from my study anybody who has a drinking problem, couples problems, a history of childhood trauma, depression that has been treatment resistant or anyone with a cat because these other factors would confuse the research.  I begin with 15 people who meet these criteria.  Six drop out.  Of the remaining nine, six experience greater relief than they would if they were on a waiting list.  Wexler's Wonder Therapy (TM) is 67% effective!  It works on non-drinking, non-childhood trauma, non-treatment resistant, non-cat owning depressed people in only 8 sessions so it is incredibly cost effective.  It becomes the treatment standard for psychotherapy for depression.  I will train clinicians in WWT (TM) for a mere 1200$.  With that money I prove that WWT (TM) is also effective for anxiety and couples difficulties.  And so on.  This is not to say that psychotherapy isn't effective.  It is.  But for many conditions there does not seem to be much daylight between different therapies.  And people are a lot more complex in clinical settings than in research trials, which means that claims to deliver highly-effective, short-term psychotherapies are often over-hyped.
  3. Psychotherapy isn't medicine. These difficulties come of trying to shoehorn psychotherapy, and psychological care generally, into a medical model.  Psychotherapy is connected to medicine because of its origins and because there is real overlap, but it isn't the same thing and trying to use our health-care system to pay for it means putting a square peg in a round hole.
  4. It seems very unlikely to happen.  Quebec is in the midst of cutting hundreds of millions of dollars from its health care system and psychiatric outpatient care is being hit hard.  Proposals to take on additional expenses seem likely to be DOA here and elsewhere. 

I want to ensure that people who need non-emergency psychological care can get it regardless of income and at the same time maintain a practice of psychotherapy that is flexible and not overly bureaucratized.  Here is a suggestion: borrow from the Americans, specifically Obamacare.  Rather than expand Medicare to include non-hospital psychological treatment, require private insurance companies (which are making billions of dollars a year) to offer all Canadians 25$/year mental health insurance plans.  No cherry-picking, no pre-existing condition exclusions.  All plans must cover the cost of non-hospital services like psychotherapy, case management and emergency supportive housing.  Require all Canadians to have a mental health insurance plan.  Plans that do a good job of keeping policy holders out of hospital for a year get a portion of the cost of saved hospital psychiatric care.  Incentivize non-hospital based psychological care and let groups of clinicians experiment with what gives the best results.  This is  probably more likely to happen than provincial governments finding a few 100-million$ a year in spare change at the back of the couch and might preserve some creativity and flexibility in psychotherapy as well as ensuring non-psychotherapeutic treatments are on the table when necessary.  

Dinosaur Shame: Emotion and Self

Prof. Heather Macintosh spoke last week at McGill on Childhood Trauma and Emotional Regulation in Psychotherapy.  She was talking about shame and jokingly differentiated between "felt shame" and "dinosaur shame," primordial shame at a level largely inaccessible to language or cognition.  She talked about the difference between feeling shame and shame as an identity. 

Shameosaurus (a.k.a. "Afrovenator abakensis dinosaur" by Mariana Ruiz Villarreal LadyofHats - Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Afrovenator_abakensis_dinosaur.png#/medi /File:Afrovenator_abakensis_dinosaur.png)

Shameosaurus (a.k.a. "Afrovenator abakensis dinosaur" by Mariana Ruiz Villarreal LadyofHats - Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Afrovenator_abakensis_dinosaur.png#/medi /File:Afrovenator_abakensis_dinosaur.png)

I am curious about how emotion, intense emotion, our own, or another's can overtake our sense of self.  Virginia Goldner, who I have mentioned before, talks about how anger, for violent spouses, can often feel dissociative.  Emotion can displace a sense of self for a while; the person becomes lost to him/herself through emotion. This reminds me of the line in the final scene of the (exploitative, yucky, though gripping) film "Seven," where the killer, John Doe, played by Kevin Spacey, urges the hero to "become Vengeance, become Wrath."  The conceit of the film was the Catholic doctrine of the seven deadly sins being incarnated in different people, but that line, and the experience it encapsulates of a self- and world-eclipsing embodiment of wrath reminds me more of Robert Oppenheimer quoting the Bhagavad Gita "Now I am become Death, destroyer of worlds" when reflecting on the detonation of the atomic bomb.  

Oppenheimer had studied the Bhagavad Gita and knew that the context was Krishna's injunction to Arjuna to destroy men in a cataclysmic battle, both friends and enemies with selflessness, for the sake of the Divine who had per-ordained their deaths.  It is a wonderful encapsulation of the sense of the self vanishing in the face of forces that feel transcendent and wildly violent.  As far as we know, no dinosaur ever experienced shame, either as an emotion or as an identity.  I love the way "dinosaur shame" evokes how primordial shame and other intense emotions can be, prior to and remote from language, as well as the feeling of destructiveness they come with.  But given that shame is a human legacy, -- "man hands on misery to man" -- perhaps a more accurate description would be from the other end of the time line; "atomic shame". 

Why science won't improve mental illness treatment

Science made tremendous strides in treating mental illness in the years between 1800 and the 1930.  As Edward Shorter points out in his "A History of Psychiatry" perhaps the greatest challenge of 19th century psychiatry was neuro-syphilis.  Nobody treats neuro-syphilis today with talk therapy or anti-psychotic medications because we know what causes it.  In the developed world syphilis is treated with anti-biotics before it ever destroys a person's nerves and brain.  But the days of simple cures for debilitating mental illnesses are over for the foreseeable future, though, for obvious reasons, people wish it weren't so.  

Marvin Ross wrote a piece about evidence-based medicine versus alternative medicine in mental health care titled "The Only Thing That Will Improve Mental Illness Treatment is Science."  Like Mr. Ross, I am opposed to using public money for treatments that not only lack a base of evidence showing their efficacy but have been shown to have no benefit.  But I am also opposed to huge investment in research when known, effective treatments go begging hat in hand.  There are plenty of things that we know help people who are mentally ill to live healthier, safer, happier lives.  These are treatments that have been demonstrated to be effective in study after study; stable supported housing, case management, regular follow-up, early intervention for psychosis, psycho-education and, in some cases, talk therapy.  As a society we don't do them.  In fact, in most places in North America government is pulling away from offering these services at taxpayer expense. 

If there is a limited pie of government money to be spent on the mentally ill, why do we persist in spending it to look for a magic bullet that will cure schizophrenia or autism or Alzheimer's when for the same money we could treat these diseases mitigating a lot of the worst effects of the illness?  In the last forty years with all the billions of dollars in tax breaks and subsidies that has been spent on brain research there has been no significant clinical advance on the treatment of these diseases -- despite hundreds of breathless reports that a cure is just over the horizon.  If you want to look for magical, non-evidence-based practices, spending public dollars on neuroscience in the hopes of an imminent cure for serious mental illness is akin to using Reiki to treat a broken leg. 

I think there are several reasons we persist in this way of doing things. One relates directly to the rise of alternative medicine.  Both Reiki and neuroscience journalism about fantastic breakthroughs in neurotransmitters appeal to a similar human impulse; the desire for a comprehensive and elegant solution to complex problems.  But the low-hanging fruit of scientific discovery has been plucked already.  Science has become so arcane that Clarke's rule that 'any sufficiently advanced technology is indistinguishable from magic' is true of most science today for most people.  We may believe that we understand how our cellphones work but I am guessing that most non-scientists would have a hard time being able to say clearly where the limits of science (eg. the dubious theory that imbalances of neurotransmitters cause mental illness) leave off and where the limits of magic (homeopathy's dubious claims that microscopic amounts of certain natural occurring substances can treat imbalances in your body's chemistry) take up.  Add to this the hiddenness of science which is increasingly conducted behind paywalls and the result is that most people have as strong a sense as ever that "scientific" means whatever a person in a white lab coat says and the only choice is whether to swallow it whole or reject it. 

The other factor that is stopping us from treating mental illness as it should be treated is the fact that people don't get fabulously wealthy by giving home follow-up and nursing and psychotherapy and regular injections to the mentally ill.  If reimbursed properly, a lot of people might live good lives working in these areas.  Nurses and social workers, clinical psychologists and psychiatrists put more of the money they make back into the economy than executives and board members of pharmaceutical and medical tech companies.  I am not convinced that we need to choose between good research in neuroscience and effective high quality treatment of the mentally ill.  But spending on treating mental illness in the ways that we know work well is a much better investment as a society than chasing the unicorn of a single molecule to cure schizophrenia and incidentally make a few people fabulously rich.

Science can't fix our culture's obsession with quick fixes or our bent ideas about money and mental health.  It is our collective responsibility to demand that public dollars be used where they will most benefit the mentally ill.  That isn't Reiki but it also isn't putting college students into MRIs and asking them to read Jane Austen and saying you're looking for a cure to autism. 

The Zeigarnik effect: Uncompleted Tasks and Passover Memory

"There is a story of a certain pious man who forgot a sheaf of grain in his field [thereby allowing him to fulfill the commandment of leaving the forgotten sheaf in the field for the poor Deuteronomy 24:19]. He said to his son, 'Go and make an offering...'  His son said, 'Father, what makes you so happy about doing this commandment more than any other commandment?'  The pious man answered, 'The All Present One gave us all the other commandments in the Law to do on purpose, but this one [which involves forgetting] cannot be done on purpose.'"  Tosefta Peah 3:8

I was re-reading John Gottman's The Science of Trust today in between various tasks of preparation for Passover, the holiday of interrupted memory. 

In 1922, a petite 21 year-old newlywed Jewish woman named Bluma Zeigarnik sat in a cafe in Vienna and watched as professional waiters listened carefully to huge orders from large gatherings without writing anything down. Then she watched as the waiters flawlessly filled their orders. Always the astute observer, Zeigarnik later interviewed these waiters. As they moved rapidly from table to kitchen to table, she found they remembered everything the customers asked for. However, when she interviewed the waiters after they had filled the orders, they had forgotten everything... This later was coined the ‘Ziegarnik effect’. It is defined as follows. We have better recall for events that we have not completely processed. Zeigarnik found that on average, there is 90% better recall for ‘unfinished events’ than for events we have somehow completed.
Paul Klee's Angelus Novus.  Walter Benjamin said of this painting "His eyes are staring, his mouth is open, his wings are spread. This is how one pictures the angel of history. His face is turned toward the past. Where we perceive a chain of events, he sees one single catastrophe which keeps piling wreckage upon wreckage and hurls it in front of his feet. The angel would like to stay, awaken the dead, and make whole what has been smashed. But a storm is blowing from Paradise; it has got caught in his wings with such violence that the angel can no longer close them. The storm irresistibly propels him into the future to which his back is turned, while the pile of debris before him grows skyward. This storm is what we call progress."

Paul Klee's Angelus Novus.  Walter Benjamin said of this painting "His eyes are staring, his mouth is open, his wings are spread. This is how one pictures the angel of history. His face is turned toward the past. Where we perceive a chain of events, he sees one single catastrophe which keeps piling wreckage upon wreckage and hurls it in front of his feet. The angel would like to stay, awaken the dead, and make whole what has been smashed. But a storm is blowing from Paradise; it has got caught in his wings with such violence that the angel can no longer close them. The storm irresistibly propels him into the future to which his back is turned, while the pile of debris before him grows skyward. This storm is what we call progress."

Zheyna Bluma Gerstein was born in 1901 in Lithuania, in the town of Prenai.  In one sense, that sentence tells you everything need to know of Bluma Zeigarnik nee Gerstein.  To be born in that place, at that time, with the name Gerstein, was to be on a collision course with one of humankind's most ambitious projects in the obliteration of memory.  Her work's title "Remembering Completed and Uncompleted Tasks" could be an understated, Proustian premonitory description of Europe and its Jews over the next 50 years.  Bluma Zeigarnik was writing a fortune cookie oracle to herself.

She marred Albert Zeigarnik when she was eighteen.  They moved to Berlin and she studied psychology with Kurt Lewin.  "Remembering Completed and Uncompleted Tasks" was published in 1927 and she received a doctorate from the University of Berlin.  Albert became a communist in the face of mounting Fascism.  In 1931, the couple moved to Soviet Moscow.  No more Viennese waiters with flawless memories.  There she could not claim the title of Doctor since a PhD was considered bourgeois and ideologically suspect.  She studied post-traumatic dementia and published little.  She worked with two greats of Russian psychology, Lev Vygotsky and Aleksander Luria, both of whom eventually ran afoul of Soviet repression of unorthodox scholarship, Lysenkoism and anti-Semitism.  Luria is famous among non-specialists for his case study, "the Mind of a Mnemonist," the story of S., also a Jew, a synesthete with a very nearly boundless memory who performed great feats of memorization in public, quickly looking at huge tables of numbers which he reproduced flawlessly.  S. eventually encountered the difficulty of being unable to forget the tables of numbers.  He was afraid that he would confuse the tables because he could see them all before his eyes long after they had been erased.  He resorted to various devices, technologies for forgetting.

[H]e began to throw away and then to burn the papers on which was written the material he needed to forget...
However the “magic of burning” did not help and one time, throwing the paper with the written numbers into a burning oven, he saw that on the remaining burned paper the traces still remained and he was in despair: it means that even fire cannot erase the traces of that which was supposed to be destroyed!
The problem of forgetting, which did not allow any naïve methods of burning papers, became one of the most tormenting problems with S.
— Ivan Samokish's translation http://fusionwriter.com/wp-content/uploads/2014/10/A-Small-Book-About-A-Big-Memory.pdf

In 1940, Albert Zeigarnik was arrested and sent to a prison camp for ten years.  Bluma's time in Berlin and cafes in Vienna, her important work on memory which was now being celebrated and elaborated outside of Soviet Europe, all this was a liability.  Central European psychology of the 20's with its bourgeois (not to mention, Jewish) flavour could not have been more at odds with Stalinist-Marxist materialism.  She did not speak of it.  She had two small children.  To recall her past was to risk making her children orphans.  When Albert was arrested, family papers were seized, the relics of her past disappeared. 

She was sent away from Moscow to the Urals.   Her grandson, A.V Zeigarnik, wrote a long and loving biographical sketch of his grandmother.  In his telling, her life story in the post-war period becomes a series of ellipses and repressions of memory. 


"After World War II, Bluma began to prepare a dissertation based on the medical studies she had begun in that period. But just as the dissertation was nearing completion, it disappeared. To put it bluntly, while visiting Bluma at her home, one of her coworkers at the psychiatric institute had stolen it. Bluma then promptly destroyed all the drafts. She was afraid that it might be published, and she would then be accused of plagiarism. Today, such a turn of events may seem implausible, even absurd, but fear is sometimes more compelling than clear thinking.

Other aspects of her research were simply not publishable. For example, among the experimental methods used in attempts at restoring a patient’s motor activity, the following was actually tested: A stand-in, dressed in a military uniform, announces to the sick person that he is a commissar. The commissar gives orders to the patient, the fulfillment of which could lead to the restoration (possibly partial) of lost motor functions. Today, no documentary evidence about such experiments has been preserved; nor is there any data about their reproducibility. But one thing is completely clear: In those years, one could find oneself in prison for conducting such experiments, whereas now it is no longer possible to repeat them, at least not in Russia, since there are no longer patients with such a reverent attitude toward commissars or other political figures.

In 1943, when Bluma returned to Moscow with her sons, she found her apartment had been robbed. While they had been living in Kisegach, the authorities had housed in their Moscow apartment an unknown and unpleasant person. For some reason, this person considered everything his own property, with the result that he had used the home library and much of the furniture as firewood for the stove. It is possible that part of the family archive vanished during this time. During this resident’s struggle for warmth, he tossed into the fire, in addition to the writings of scholars who were unfamiliar to him, all the publications of Marx and Engels to be found in the home. (Does there not seem to be something mystical in this unabashed materialism?) The writings by Lenin, however, remained. Bluma had to endure numerous humiliations, but, after the intervention of a military prosecutor, the apartment was returned, and she was then finally able to resume her normal daily life."

In a final triumph of materialist erasure, Bluma's one reflection that has been translated into English about the Berlin period is hidden behind Wiley's paywall.  In 1984 she wrote a memorial for her old teacher Kurt Lewin on the occasion of his death.  For 32$ you can read and print the reminiscences of a pioneer of the study of the human mind, fugitive from fascism and prisoner of Stalin about her old beloved teacher and mentor on the occasion of his death.  She died four years later, to all appearances a loyal daughter of Soviet communism. 

I imagine a ghost, the memory of an unfinished task persisting even after the body that contained it has gone;  a waiter at a Viennese cafe, unable to forget, because she left before he could deliver her order, her odd meal, which he seeks to deliver year after year and which she can never receive; four cups of wine, three pieces of flat bread, like the poor people eat, a roasted egg, some bitter herbs, a shank bone, a bowl of salty water. 

 

 

Am I crazy?

Roz Chast's Big Egg Lady.  To see more of Chasts's eggs click on the image

Roz Chast's Big Egg Lady.  To see more of Chasts's eggs click on the image

"Do you think that you might be crazy?"  It is one of those impolite questions that I get to ask that makes being a therapist fun and rewarding.  When people come in to see me they are sometimes half-convinced that they are crazy.  Sometimes people confuse the intervention with the malady.  Smart people can have the unexamined belief that "If I take the pill, if I see the therapist that means that I am crazy."  Recently, I've started asking more.  A lot of people who come to see me are.  Worried, that is.  I guess whether they are crazy or not depends on what you mean. 

People who have a personal or family history of mental illness are often very worried about being crazy, sometimes terrified.  They may have a very particular idea of what mental illness looks like and be terrified that that's what's in store for them.  Other people come in with a fear that is augmented -- with lots of good intentions and some greed -- by attempts to broaden people's picture of who can experience mental illness.  On the one hand, attempts to destigmatize people with mental illness are laudable.  On the other hand, hyper-sensitizing people to mental illness, encouraging them to view themselves and everyone around them as psychological orchids who need specialized interventions simply to survive in the world, is IMHO, plainly nonsensical, inimical to good mental health and partly motivated by the desire to sell us stuff (medicines or other therapies) that we don't really need

I recently saw a woman who is a new immigrant to Canada.  She is having difficulty learning French and is a new mother.  She felt stressed, scared, overwhelmed, sad and very lonely.  She had been prescribed anti-depressants and an anti-psychotic for sleep (the practice of GPs prescribing anti-psychotics off label without the simplest discussion of sleep hygiene is troubling to me).  On top of everything that was going on in her life she was terrified that she was crazy.  The persistency and intensity of the feelings, a family history of mental illness, her sense that she should be able to get over them and probably the fact that she had been prescribed medication all fed into her sense that she was going crazy.  This is not to say that the anti-depressant was not appropriate.  But it had a powerful meaning for her.  When I asked if she was worried she was going crazy, she began to sob.  She is scared to pick up her French classes again or try to find a job because she views herself as too anxious to take on anything new.  She is becoming more isolated.  I asked her if seeing me was going to make her think she was crazy because I did not think she was and I did not want to do anything that would give her that idea.  If coming to see me would make her think she was crazy I would refuse to see her.  Why?  Because viewing herself as crazy was making her crazy(-er). 

People have all sorts of ideas about what being crazy might look like and what it would mean.  I saw a young woman the other day who wanted to know if she had Borderline Personality Disorder.  First, I told her that I am not a doctor and I can't make a diagnosis.  Then I asked her what it would mean if she did have it.  She felt like then doctors would have some direction about how to treat her so that all the stuff that wasn't working in her life would get better.  "And what if you are sad and lonely because important people in your life have been hurtful towards you for a long time?  What would that mean?"  "Then I'm just a screw up."  Crazy might be better than the alternative; the frightening responsibilities of sanity. 

It probably isn't very wise of me to admit this but I use the term crazy in my own head sometimes when I think about clients.  Usually what I think is, "What a crazy thing to do."  It means something like 'inexplicable and self-defeating'.  In other words "Human."  One thing I don't mean is "mentally ill."  Mental illness to me means something is going on in the person's mind that is far beyond the usual degree of human irrational, self-destructive behaviour.  I think what my clients worry about -- or sometimes even long for -- is being far beyond the human pale, unable to return, irreparably psychologically destroyed. 

Resilient is the opposite of crazy in that sense.  Child birth is messy, it is occasionally very dangerous.  But our survival as a species up until the 20th century is incontrovertible proof that it can usually be done outside of a hospital.  Similarly, the fact that humans are around at all is proof that we are well-equipped psychologically to deal with hard stuff, to suffer, to hurt,  and be hurt even to go crazy and to recover. 

I am glad to live in an age of medicine.  I believe in therapy.  Part of resiliency is having people around who can help you.  But therapists also need to remember to 'first, do no harm'.  And if the cure is worse than the malady then it's no cure.  

Resistance is where the work begins

Ginger Campbell host of the Brain Science podcast, after a great interview with Norman Doidge about neuro-plasticity, said that doctors often don't prescribe behavioral therapies because they have the experience of patients not following through (1:05:00). "Many patients would rather take pills than follow treatment regimens that require them to do most of the work themselves."  I will write about Doidge at some point soon, but I thought a lot about Ginger's statement about homework and follow through. 

Recently, I have been finding that the most interesting moments in therapy come when I ask a client to try something that he/she/they won't or don't do and we unpack that resistance.  I have said before that on a handful of occasions, I have given people really good advice in therapy.  But much more common are people who know more or less what they need to do to make changes in their lives but resist it for reasons they cannot fully understand

I recently told a client who was feeling ambivalent about his marriage -- he couldn't commit to it and couldn't leave --  that he should try being fully invested in his relationship for 3 months.  At the end he could still leave or stay or continue being undecided, but in order to see what the relationship might be, he should try actually working at making it good for a limited amount of time.  He physically writhed at the idea.  He almost began to twitch.  What makes committing to the relationship, even provisionally, so hard? 

I told a couple that they should spend ten minutes a day talking about something tough in the day and supporting one another.  When I asked them about the exercise he said, "It feels weird because we see each other all day, she knows everything about my day."  They began to see how her being available to him for almost all his emotional needs throughout the day was not so great for their relationship. 

I told a client to meditate so that he could be a little more present to his partner.  "Sitting still for ten minutes is my idea of hell," he said.  She began to cry because she wants him to be able to be still for her.  It turns out that he has missed some crucial hurt feelings of hers because sitting still with emotions is so painful for him. 

People have reasons for not changing.  Sometimes it is a cost benefit analysis: "This requires a lot of work and I don't have enough confidence that it will make a difference."  I think a lack of confidence that medical science actually knows what is good for us is an important and neglected part of that cost benefit analysis.  It is hard to take your doctor's prescription seriously if you don't think s/he understands what is going on with you and what you want.  That doesn't come in 15 minutes.  Sometimes the road to such confidence comes from taking the time to unpack what else makes change hard.  

It is ironic that most doctors probably know that just prescribing behavioral change is unlikely to get people on board, yet they still do it.  Another opportunity to ask the question, "What makes it hard to do this?" And perhaps the beginning of real change. 

Does your insurance company flout Quebec's psychotherapy law?

When I get a referral for my private practice I ask people if they have private insurance. If they do, I tell them to check with their insurance to see if they will be covered.  As often as not, they won't be covered for my services as a Social Worker - Psychotherapist.  Despite years of graduate and post-graduate training, despite the Quebec government's law 21 which requires all professionals practicing psychotherapy to meet the same rigorous standards -- not to mention additional fees -- in order to be licensed by the order of psychologists.  The law does not require private insurance companies to respect the title of psychotherapist. It is frustrating as a business person and clinician to hear regularly, "I would like to see you, but my insurance won't cover me."

Let's leave aside for now the question of why psychotherapy is not covered by our public health insurance (I have written some about this here).  Insurance companies aren't required to recognize the title psychotherapist even though mental health professionals are.  This means additional costs for me, higher fees for consumers and a distortion of the market because clients with private insurance tend to go to psychologists, who often charge more than other psychotherapists. 

The insurance industry could fix this.  They know the law.  They choose not to respect it.  (It is impossible to tell which companies and which policies do cover psychotherapists and which don't because insurance companies keep the various policies they offer secret).  The Quebec government could correct this.  Private insurance is provincially regulated.  The government could require insurers to respect the title of psychotherapist and reimburse clients equally whether they see a 'social worker - psychotherapist', 'a creative arts - psychotherapist' or a 'psychologist - psychotherapist'.  They haven't.  It is, after all, easier to pass legislation that affects hundreds of small, independent clinicians than to pass a law that would affect a few big and very wealthy companies. 

If you care about this issue, I would urge you to contact your MNA. (as of writing this, Kathleen Weil hasn't returned my emails or my call.  UPDATE: April 17, 2015. Got a form email a few weeks back and on April 8, after tweeting a lot about this, I got a call from a staffer who said 'we take it very seriously' though he didn't really seem to have any idea what I was talking about.  He also said Ms. Weil's office would be in touch in a week.  Hmmm.).  If you hold a private insurance plan, contact the company and ask them if you are covered for psychotherapy by a psychotherapist.  I would love to know.  Tell your insurer and your employer that you want your insurance to respect Quebec's law 21 regarding the title of psychotherapy.