Review: Saving Normal by Allen Frances

I recently heard the wonderful Ginger Campbell interview Allen Frances on the Brain Science podcast.  Almost before my headphones were off I had run out to buy Frances' book "Saving Normal, an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life."  Frances clearly and humanely outlines his case that "The cruelest paradox of psychiatric treatment is that those who need it often don't get it, while those who do get it often don't need it." 

I had some concern, even after the very thoughtful interview on BSP, that this would be a soft-headed screed against psychiatry.  I know a lot of people who have benefited from mental health treatment including psychiatric medication, and I think it is very wrong to frighten people away from psychiatry who really can use it.  I needn't have worried. Frances is a psychiatrist with a great love for the profession and confidence in the good it can do.  He is absolutely committed to the idea that psychiatry can be beneficial to seriously mentally ill people and at pains to illustrate that.

But he is also clear-sighted about the failings of psychiatry and medicine generally (he is very much talking about the US situation.  I will reflect a little on the Quebec context below).  The big failing Frances takes on is 'diagnostic inflation.'  He means the tendency to expand the criteria that are used to diagnose mental illness, either by loosening criteria for exiting illnesses or by 'discovering' new illnesses.  What prompted this call was the American Psychiatric Association's process to issue a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM.  Frances thinks the authors are too quick to expand definitions which will inevitably lead drug companies to step in and push for meds for people who could do without them.  Frances is in a good position to comment because he was in charge of the DSM-4.  He is very up front about his own failings in having lead that installment and apologizes for his mistakes.  It is extraordinarily refreshing to hear someone with such a level of authority offer a public apology. 

One of the diagnostic overreaches that he addresses is 'psychosis risk syndrome'.  We are close to being able to identify people who are at high risk of developing psychotic disorders like schizophrenia.  We know many of the risk factors including certain genetic markers, we think that delaying onset of schizophrenia means being less sick and we know that being very sick with schizophrenia is very hard.  Why not target teens who are at elevated risk and are exhibiting "prodrome" symptoms; self-isolation, quirky or aggressive behaviour in the hopes of forestalling or even preventing the onset?  Frances gives a very good answer to that.  First of all, target them with what?  The answer will probably be anti-psychotic medication.  We have no indication that taking anti-psychotics before developing psychosis will help stave off or mitigate the effects of schizophrenia and the side effects can be very serious, including obesity and diabetes and everything that comes with that.  And, he points out, we can identify teens who are at risk, but that would probably involve identifying a lot of kids who will never develop the disease and potentially subjecting them to this very serious intervention.  It begins to look a lot like the aggressive screening and treatment of prostate cancer, too many people, too invasive for limited benefit.  Frances doesn't mention the possibility that teens who are identified might benefit from interventions that have less potential downside like counseling about delaying use of street drugs including marijuana and psycho-education about reality testing.  Given the way Quebec is headed, it seems unlikely that we will see a targeted public health campaign that relies on disease prevention using labour-intensive methods like psychoeducation.  

Frances also alludes to something I have mentioned elsewhere in this blog; namely that not all conditions of the human soul are diseases in any recognizable sense and yet increasingly the DSM includes them.  The idea that mild to moderate depression, or attention deficit disorder, or anxiety is a neurochemical imbalance fits very nicely with a drug company's bottom line.  The emphasis of the last twenty years on neuroscience has tilted us towards a chemical fix for ailments of the mind.  Yet not one significant advance in diagnosis or treatment of mental illness has come out of all the important research on neuroscience so far.  Diagnosis remains entirely symptom-based.  The mechanisms for the function of treatments is poorly understood, if at all. 

“All of this may seem very much like “inside baseball” for people who don’t spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don’t need...”

All of this may seem very much like "inside baseball" for people who don't spend their days thinking about  mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don't need, medicines with serious side-effects that may not have been adequately tested on the populations for whom they are being prescribed.  He reports that the sale of anti-psychotic drugs at $18 billion (US) now delivers more cash to the pharmaceutical industry than anti-depressants.  Anyone who has any experience with them knows anti-psychotics are powerful medications with very serious potential side-effects.  They are helpful to people with psychosis.  But now they are being marketed for use with children and the elderly.  20% of people treated by primary care physicians for anxiety now receive an anti-psychotic as well, according to Frances.  The trend towards GPs prescribing psycho-active medication is troubling for Frances as well.  That GPs give out anti-depressants and anti-anxiety medications routinely should surprise no one, but I was amazed to learn that 50% of anti-psychotics are prescribed by GPs.  (I am not sure if that accounts for GPs taking over the prescription of anti-psychotics after an initial prescription by a psychiatrist.)  Frances goes through the familiar litany of the dangers and over-promises regarding SSRIs for treating the 'worried-well' market.  These are problems we see here in Quebec, though certainly not to the degree they are experienced in the US. 

Whose fault is all of this?  For Frances the answer is pretty clear.  Big Pharma and the big money it is willing to throw around to advertise direct to consumers (only in the US and -- apparently -- New Zealand as well), to co-opt the better judgement of doctors and researchers as well as to fight legal battles and pay fines when they get caught behaving badly (as with the off-label marketing of anti-psychotics for kids).  He gives policy recommendations for taming the excesses of big pharma.  Naturally, dear to my heart are all the plugs that he makes for psychotherapy as an alternative or adjunct to pharmacology. 

“There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs.”

— Saving Normal

Here in Quebec, we are retrenching from any kind of public outpatient psychotherapy, at great cost to our well-being, I believe.  It is nearly impossible in Montreal to get psychotherapy at a CLSC (public health and social service clinic).  This despite the fact that we know that psychotherapy can sometimes head off   episodes of serious mental illness later for certain people and keep them from needing much more expensive hospital care.  Follow-up care after a psychiatric hospitalization is spotty and seems unlikely to get better with more cuts coming. 

“The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. ”

While I am a believer in psychotherapy, if I have a quibble with Frances, it is over this.  My experience is that many psychiatrists and other psychotherapists have been and continue to be high-handed, overly jargonistic, faddish, opaque and sometimes deeply anti-scientific.  Frances himself mentions the terribly misguided satanic ritual abuse accusations of the 1990s and the role played by therapists who "developed and instant expertise on day care sex."  Many people mistrust us because they view psychotherapy as elitist mumbo-jumbo that changes tack every ten years.  All those primary care doctors who are prescribing medications rather than sending their patients to therapists don't trust talk therapy.  Why should patients?  Hell, I have met quite a few psychiatrists who don't have faith in psychotherapy.  The lack of a credible alternative is part of what is fueling the appetite for drugs.  If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. 

Mystics in Therapy

I read a wonderful reflection on mysticism the other day and started to think about what makes it hard to put some things into words. 

“Mysticism is a seemingly positive term that denotes a negative, as the word darkness, which seems a positive term, denotes only an absence — the absence of light... A nonmystic is someone who believes that when truth is explained to him in words, he should understand that truth. The mystic is some one who knows that real truth, meaningful truth, can never be fully expressed in words. ”

— Joseph Dan, The Heart and the Fountain, p 2-3

Sometimes I see clients in therapy who are mystics in the sense that Dan describes.  They may not identify as spiritually inclined but they mistrust language to adequately convey truth.  Dan goes on to says that for the mystic, "Only the trivial, or the false can be communicated and understood."  It is hard to administer a talking cure when a person views language as untruthful. 

Sometimes mysticism looks like a defense.  I will say something like: "Did that make you sad?"  The mystic replies "Not exactly sad."  I say, "So how would you describe the feeling?"  The mystic: "I can't describe it."  Talking about feelings is like dancing about architecture.  But in this scenario the mystic also can't dance about dance.  The mystic ineffability of inner experience can be a way not to experience feelings.  For many people, saying "I am sad" with intention is akin to God saying "Let there be light."  It is the baldest, most powerful truth of all, in that it creates the reality to which it refers.  (An odd variant on this theme: saying to another person, "I feel lonely" with intention can be a powerfully connecting thing).

Because being a mystic means having access to a truth which cannot be adequately conveyed, it holds a special status, for good or ill.  "I am sad," is a profoundly human statement, and it makes me like 99% of my fellow humans who have experienced sadness.  Saying "The word 'sad' is inadequate to describe what I am experiencing," means I stand alone.  Being an unremarkable human with unremarkable human feelings can feel good a.k.a. 'normalized,' or bad (as in 'unimportant').  To connect with another risks making my experience banal. 

Mysticism and depression are two degrees of separation apart.  Nihilism is the missing link.  The mystic denies the possibility of being able to bridge the gap between one's self and the universe beyond through language.  The nihilist denies the possibility of bridging the gap between self and other entirely.  Depression is the affective prison in which a person is convinced of the impossibility of connection with others, the world of sensation, God, even elements of the self. 

Some therapies have taken the mystical contention about language to heart.  Sue Johnson, the founder of Emotionally Focused Therapy views purely cognitive therapies as flawed because they don't address affective truth, a felt, experienced truth that is prior to and largely inaccessible through language or at least through cognitive language alone.  (I find it ironic that Sue Johnson has spent tremendous effort to empirically demonstrate EFT's claims that reasoning is insufficient for addressing matters of the heart.)

Rabbi Shais Taub talks about addiction as an expression of the urge to transcendence that is part of mysticism.  "Crippling self-consciousness is the root of addiction.  When they (the addict) take this poison it simulates the effect of spirituality in that there's this release from ego, rather than being self-transcendent release from ego... it is a self destructive release from ego.  ...(T)elling the addict... 'Don't you see you're destroying yourself?' is the most ridiculous thing you can say because if they could articulate what their soul they would say  'Yes, I am trying to destroy Self.'"  (You can listen to the whole episode of Tapestry here.  The interview with Rabbi Taub is at about 19 minutes).

I feel both the mystic's tendency to view some of the most important things as ineffable, the desire to connect outside of language and to transcend the crippling 'self'.  But I also feel a hard-headed commitment to the 'communicability' of many of our most complex and difficult truths. 

"It is not in heaven so that one could say, 'Who will go up to heaven for us, to get it for us and make us listen to it, to do it?' "Nor is it beyond the sea so that one could say, 'Who will cross the sea for us, to get it for us and make us listen to it, to do it?'"   For the thing is very close to you, in your mouth, and in your heart, to do it."

Tools for When Kids Lie

Some basics for dealing with kids and teens when they lie.  Parents often find this very difficult because they worry that a child or teen who lies will grow up to be a liar.  The fact is every kid lies at some point (as does every parent) and few people are chronic liars.  I hope these will help you if you feel like you are at the end of your rope.  One thing I didn't have space to point out in the printable: I mention various punishments or consequences in the printables.  These are examples and not recommendations per se.  It is important for you to set consequences you feel okay with (within the limits of not physically harming or humiliating a child or making a child afraid for his/her safety).  I may make a printable about consequences at some point so be sure to check back. 

This is the second in the Fridge Magnet Therapy printables series.  I love feedback so please let me know if/how these are helpful.  

You can click on the image which will take you to a pdf or on this link. Lying

Illustrations are by Alice Carsey (Pinocchio 1916)  and Charles Copeland (Pinocchio in Africa, 1911)

Fridge magnet therapy

5 things to do if your kid tests limits

I am starting a series of 8" x 10" posters that you can print with basic tips for parents and couples dealing with common issues I see in therapy.  You can download them, print and share them with attribution and a link. 

The first is "5 things to do when a kid tests limits." 

Thanks for the really cool old-timey clip art from the graphics fairy.

I'd love your feedback.

Couples old and new

I get requests for therapy from a lot of young couples.  This surprised me at the beginning.  When I was first learning about working with couples I read that couples often don't seek help until their patterns of negative interaction have been set for six years or more.  I expected to see a lot of couples in their late thirties or forties with kids.  Instead, many of the couples I see have been together for two to five years and are without children.  At first it was hard for me to get my head around the idea of people in their twenties seeking couple's therapy three years into a relationship.  The conflicts they bring to therapy are not the long-standing, cumulative resentments of a couple who have been together for fifteen or twenty years.  And without kids in the mix the collateral damage of choosing to end a relationship rather than work on changing difficult patterns is definitely less.  But when I speak with them, most of these young couples describe real challenges.  The value they place on their relationships is usually high.  And as one client told me, "We want to get this right, now, to set a strong foundation." 

There are probably a couple of reasons why I see more young couples than I expected, more than perhaps I would have seen if I was practicing twenty years ago.  One, I work on a sliding scale, so  young couples with less disposable income who are looking come my way.  Two, stigma around couple's therapy may have decreased.  The third factor, I think, is generational.  Unlike previous generations, people in their twenties and early thirties have been living with the sense that lifelong couple-hood is unlikely to succeed.  They have grown up with the idea that as many committed long-term relationships fail as succeed (the much bandied 50% divorce rate number for the US has never been that meaningful.  The odds of a particular relationship staying together for life are probably higher.  A 2005 article in the NYT article gives a good run down of the difficulties with the 50% number).  They have seen long-time married couples at close range that were full of anger and hurt, either their parents or friends of their parents.  It is my sense that many of the young couples I see, feel that they are doing something very nearly counter-cultural and difficult by trying to stay together and stay loving for the long haul.  Viewing staying together in a loving relationship as hard may make some couples more likely to seek help earlier that they otherwise might. 

Is 'crazy' an illness?

I have been working in an inpatient psychiatric ward in a hospital for almost a year.  It has been sad and joyful and sometimes boring or infuriating and full of discovery and very occasionally frightening.  Before February, the last time I had been in an inpatient psychiatric facility was twenty years ago when I was a social work student at Columbia and I went on a visit to Ward's Island in New York.  In between, I viewed inpatient psychiatry as the place where people who were 'truly mentally ill' were treated.  By contrast, the people I worked with, people who were not in hospital beds, didn't seem ill in the same way that someone who is diabetic or has cancer is ill.  Of course, I would speak of mental illness when I talked about moderate depression or anxiety or Asperger's syndrome.  There are good reasons for this.  I have always believed that a person's biology is intertwined with how his or her mind works.  The things for which people seek the help of a therapist or a social worker are impacted by their brain chemistry, their genes, in short the organism in which the mind arises.  And almost everyone finds having a mental illness -- a biological condition -- less shameful and frightening than being labeled crazy. 

But I was never fully convinced that these conditions were illnesses like physical illnesses, either.  I am not a doctor and perhaps my layperson's lingering idea of illness -- a microbe from without setting to work to destroy tissues -- is part of the reason I have resisted the description of these conditions as mental illness (most types of cancers and diabetes do not meet this definition of illness).  Still, I imagined that behind the doors of a psychiatric ward there were examples of mental illness that clearly demonstrated a causal connection, while yet poorly understood, between disorders of the mind and the physical organism. 

I feel like my ideas about mental illness have been made more confused not more clear by working with people whose minds are so disordered they need to be in hospital.  I sat in the hospital hallway with a man who positively knew that someone was breaking into his brother's home hundreds of miles away.  When I asked him how he knew, he could not give any answer except that he knew.  The fact that his idea made no sense to others or to himself did not diminish its intensity.  But it saddened him deeply; he understood -- at least in part -- that this thought was nonsensical, yet it was absolutely real for him.  It seemed to me, at that moment, that something biological was clearly going on, as if this man had suffered a brain injury and it was only a matter of time before medical science could discover where exactly it was located and how he might be helped.  I imagine that almost everyone who has worked with people with schizophrenia must have had this experience and yet the causes of schizophrenia remain unknown after a century of research, and treatment is focused on symptom management.  This man has lived much of his adult life absolutely bubbling with paranoid ideas and the accompanying sadness and frustration of not understanding where these ideas come from. 

There are people who come into hospital deformed by love.  There are the suicide attempts and the severe depressive episodes brought about by failed or elusive love.  Occasionally people with no previous history of mental illness come to emergency manic and delusional because love has gone wrong.  On the one hand this is the most easy form of disturbance to extrapolate from for most people; everyone has experienced heartbreak or rejection and can imagine him or herself driven to extremes by love.  But it is precisely this universality that makes those who end up in psychiatry unusual.  After all, what makes one person see his love everywhere, believe she is sending him messages through strangers, chase her barefoot all over the city and fight with police and security guards, when nine hundred and ninety-nine other rejected suitors cry, listen to sad music and then move on?  Is that the difference between health and illness?  Or is it something else? 

In the hospital psychiatry ward you can find people who just about everyone would agree are ill.  Even though no one can explain exactly the mechanism, it seems that their biology is making their minds work very differently from the minds of most people and often in ways that feel awful to them and put them in danger.  But mental illness of this unmistakable type is a I-know-it-when-I-see-it kind of phenomenon because for every clear-cut case there are people who are odd or sad or exuberant who fall in a grey zone. 

None of the disorders treated by psychiatry today have a blood test or pathology lab test for diagnosis.  They are all diagnosed by symptoms and reading symptoms remains quite subjective. 

How we think about disorders of the mind has a real impact.  One of the most powerful impacts is the use of drugs to treat mental disorders to the exclusion of talk therapy.  Thankfully we have left behind the era of  psychoanalysis to treat schizophrenics (as well as  cruel theories about how schizophrenia was caused by bad mothering).  But now we have moved to a situation where -- in Quebec, anyway -- talk therapy is almost never viewed as a way to treat mental illness despite its proven effectiveness for many -- though not all -- disorders.  People discharged from hospital for surgery can get physio and occupational therapy to help with recovery as part of the services covered under their provincial health insurance.  Psychotherapy is almost impossible to get in the public system either in hospital or out.  I think that this is partly a function of not viewing talk therapy as a way to address a medical illness.  How can an illness be treated by talking?  As much as disorders of the mind may not look like illnesses, talk therapy doesn't look like medicine.  Not to patients and not to doctors and certainly not to ministers of health.

Here is a story that illustrates the constraints of operating solely with a illness/health model of the mind.  A man in his late forties was brought into hospital for running around in traffic.  He was a chronic schizophrenic.  How did we know?  Because that was his diagnosis for many years.  It was also possible that he had a mild intellectual handicap.  Doctors over the years had examined him and observed symptoms that pointed to these conclusions.  The psychiatrist I was working with spent a long time talking to him and his family.  What we learned was that the man had experienced a terrible set of traumas when he was young and had used a lot of street drugs.  He was very reticent but eventually he talked about the toll that the pain he had experienced had taken and his guilt over what he had done to others.  For years he had been a patient of various psychiatrists who saw a painfully inarticulate, inwardly focused man who had gone spectacularly off the rails at eighteen and came to the conclusion that he was schizophrenic.  But with time it became clear that he was a confused, deeply hurt person (absolutely no intellectual handicap) with very little if any of the psychotic features that are integral to schizophrenia.  The voices that he had reported hearing telling him he was bad were much closer to the 'voice' I hear in my head telling me that I better get my work done than the voice a psychotic person hears which causes him or her to look for someone speaking.  He had never,  in the course of twenty plus years of psychiatric treatment, been given enough space to talk.  When we asked him why he was running around in traffic pulling on car doors, he said "I guess I wanted to get away." 

This is not just a story about misdiagnosis, "House goes to the psychiatric floor."  It is a story about using the tools of medicine to examine something adjacent to -- but not the same as -- medicine.  Not every affliction of the human heart calls for a cardiologist. 

“The physician, who through his studies has learned so much that is hidden from the laity, can realize in his thought the causes and alterations of the brain disorders in patients suffering from apoplexy or dementia, a representation which must be right up to a certain point, for by it he is enabled to understand the nature of each symptom. But before the details of hysterical symptoms, all his knowledge, his anatomical-physiological and pathological education, desert him. He cannot understand hysteria. He is in the same position before it as the layman. And that is not agreeable to anyone who is in the habit of setting such a high valuation upon his knowledge. Hystericals, accordingly, tend to lose his sympathy; he considers them persons who overstep the laws of his science, as the orthodox regard heretics; he ascribes to them all possible evils, blames them for exaggeration and intentional deceit, “simulation,” and he punishes them by withdrawing his interest.”

— Freud, five lectures on psychoanalysis

Anger, Aggression & Diplomacy real and imagined

At the beginning of this week's This American Life there's a piece in which the writer David Hill,  who has dabbled in playing the strategy game Diplomacy, takes Dennis Ross, Bill Clinton's old Middle East envoy, to the world championship of the game. 

It is based on Hill's article in Grantland.  A couple of things were percolating in my head when I heard this.  The most prominent was that Dennis Ross seems like a jerk.  As much of a jerk as the people who get angry and overturn the board and yell at the Diplomacy tournaments.  Maybe more.  Not because he is evilly-intentioned or malicious.  Quite the opposite. 

Dennis Ross is sometimes referred to as the architect of the Oslo Peace accord.  For those who don't remember, the Oslo accord in 1993 brought together then Israeli prime-minister Yitshak Rabin and PLO chairman Yasser Arafat to agree on movement towards a two-state solution to the long-standing fight between Israeli Jews and Palestinian Arabs.  There are people who spend a lifetime studying the ins and outs of these things and they can't agree what went wrong, but one thing is clear in the summer of 2014 as a war rages in Gaza and the south of Israel; the Oslo peace process did not lead to anything that anyone could call a solution.  Meanwhile Dennis Ross is a prof at Georgetown in the school of foreign service and a Distinguished Fellow at a fancy institute and Diplomacy coach for hire. 

I am not going to go on about Gaza and Israel.  My interest here is in the dangers of bringing in expert-consultants and why some people chronically behave badly in interpersonal situations and what they have to do with each other.

Dennis Ross could have told David Hill, "If you want to win, don't take me to the game.  You will be painting a huge bulls-eye on your back.  And since I am busy at Georgetown I won't be able to stay and clean up the mess you will make for yourself."  Instead Ross comes in, gives advice based on his gut and his experience, then leaves Hill in an awful situation, possibly a worse situation than if he had just said "No."  Experts generally give bad advice. There are a lot of reasons for this.

1. Experience itself is at best an indifferent teacher.  People need clear, unambiguous, immediate feedback in order to learn.  In complex areas like adult human interactions its very hard to build in such feedback.  When Ross claimed there was a resemblance in the body-language between a Diplomacy player and a Soviet diplomat he dealt with I groaned.  I imagined hearing a cop say "Evidence?! I don't need evidence.  I've seen lots of guilty people and I can tell when someone is guilty."  Which leads to number 2...

2. People who believe they are great at reading people are usually no better than average and sometimes worse.   

3. Experts don't have to live with the consequences of their advice.  But their clients do.  In therapy, I very  rarely give advice.  I look at what I see and hear and offer it back to my clients.  I ask what it means for them.  I try to give them different perspectives on their situation, but I m extremely reluctantly to give advice or make predictions, first because I will likely as not get it wrong and, second because they have to live with the consequences, not me. 

I once worked at a social service agency.  The bosses brought in a consultant who started the session by saying something like, "I usually consult for business.  I don't know anything about mental health and social services but I am sure the principles of managing an organization I will teach you are the same."  I felt like I'd been slapped.  To me, it is rude to come into a room full of people who have over a hundred years of collective experience in their work and say, "Please do not confuse me with information about what you do."  If a consultant or expert is talking more than s/he is listening s/he isn't worth paying attention to. 

The second thing that caught my attention in this piece had to do with angry aggression.  There is a lot of discussion in the piece about whether a person's anger is real or strategic.  Angry aggression like swearing, yelling, threatening and ultimately violence is profoundly paradoxical in that it is a way of gaining control by 'losing control'  Virginia Goldner has written wonderfully (here for example) from a feminist, psycho-therapeutic perspective about how abusive men's anger is both a willed act of control and an out of control act.  Someone else's aggression often provokes such strong reactions in us, even when we know that there is no threat of violence, because it can makes us feel dominated, like control is being wrested from us. 

Because it is so frightening, people who aren't comfortable with strong, aggressive expressions of anger, often treat badly-behaved, angry people like they are weather systems, irrational forces of nature, vaguely predictable, but absolutely uncontrollable.  This can be a great way for the angry person to get others to defer or comply.  Most angry people have absorbed this; the out-of-control expression of real anger gets them what they want.  Angry aggression can be highly adaptive, at least until it becomes a disaster. 

Which brings us back to Diplomacy and one of the questions posed in the piece: How can less aggressive people deal with aggression?  One of the things that the piece explores is the context of angry aggression.  In the game what is strategic, would be unacceptable in real-life.  Except those boundaries are kept deliberately vague.  People are unsure whether aggression is notional or real.   The possibility that anger is real and may become out-of-control is what gives it its power.  If there were a card in Diplomacy that you could present to another player that said "I storm off, angrily," it would have no impact.  For anger to get people to change their behaviour, it has to be real enough. 

One of the most pernicious things Ross does is not to account for what the real-enough aggression of other players will do to Hill.  Most people can learn to become more detached from another person's angry aggression, to feel less out-of-control in the face of it.  Angry aggressive people can learn they won't regain dominance through an intimidating 'loss of control.'   But that takes time and establishing safety, things Ross (and IMHO many other fly-in consultants) view as outside their job description. 

The savvy consumer's guide to picking a therapist

Friends sometimes ask how to pick a good therapist.  Since I can't just say say "Me!" I have had to give this some thought.  So here's what I say...

1.  It is reasonable to be concerned about price

Therapists want to make money doing what they like to do and -- within reason -- therapists can set their prices based on the market.  Therapists who are highly sought after can charge up to 135$/hour.   Some professionals (me included) offer a sliding scale based on your income, others don't.  Here in Quebec, there can be a difference in price of around 65$ per session depending on who you see.  That can add up over ten or twelve or more sessions.  Figure out what you can afford to pay and then look around and see if you can match that.

2.  Membership in a relevant professional order (Boring but important)

There are a lot of different kinds of professionals who can offer therapy in Quebec.  The biggest difference for a member of the public is that medical doctors, including psychiatrists, can prescribe medications and nobody else can.  Aside from that there isn't a hard and fast rule about whether a social worker or a psychologist or a drama therapist is going to work better with a particular kind of person or problem.  Whatever his or her professional training, a therapist should be a member of his or her professional order, the Order of Social Workers and Family and Couple Therapists, the Order of Psychologists, the College of Physicians, the Order of Occupational Therapist etc.  There are three reasons; one, a professional body has looked at this person's professional qualifications and said "S/he is able to do the work."  The second reason is that the person is bound by a code of behaviour which you can read.  If you aren't sure whether the person has the right to ask for payment in a particular way, for example, you can check (For example, I cannot take barter according to my professional order.  Sorry, cabbage growers).  Finally, if you have some dispute with the person or if you think his or her behaviour is unprofessional, you have an organization that serves the public interest that you can go to. 

Here in Quebec we have a new licensing regime which requires everyone practicing psychotherapy to become a licensed psychotherapist with the Order of Psychologists whether or not he or she is a psychologist.  So whether someone is a drama therapist or a nurse or a couple and family therapist she or he will eventually need to be licensed for psychotherapy by the order of psychologists.  Among other things, this means that the fabulous art and drama therapists of Quebec -- who haven't had a professional order until now -- now have a place to hang their hats.

3. Clear goals

A therapist should work with you on setting realizable goals for therapy.  If a therapist doesn't ask what you want to achieve and can't say what you are working towards and it is something that you want then you should look for someone else. 

4. You should feel heard

This will come and go.  Sometimes I do a better job listening than other times.  But if my clients don't feel heard and understood most of the time then I am not doing my job. 

5.  Non-defensiveness

You should feel like you can talk to your therapist (politely) about the therapy including what isn't working.  Recently a client told me that she was really mad about something I had said in a previous session.  I was glad because if she had just continued being angry without raising it we wouldn't have gotten very far.  I spent a lot of time asking her about what had bothered her so much and when I understood better why it was so hurtful for her, I apologized and we talked about how I could avoid doing something similar again.   Most therapists are happy to have this feedback.  If you don't feel like you can, then you need to consider whether you can really get what you need out of therapy with this person. 

6. Professionalism

A therapist should be professional about how s/he conducts business; timely, efficient, knowledgeable, organized, respectful of you. 

7. Strong

You should feel that your therapist is strong enough, emotionally, to be able to hear things that are painful for you without falling apart.  You should not have to worry about taking care of your therapist.  Some people have a very hard time with this.  Because they are used to caring for others, it can be hard for them to let go and be cared for.  But if you don't feel that your therapist can handle your hurt, you need to talk about that with him or her and if you can't resolve it then s/he may not be right for you.

8.  Recommendations are helpful, but only to a point. 

At this point in my shpiel people usually ask for names.  I can give names of therapists I like and admire but fit is important.  Ultimately it doesn't matter that much what I think.  What matters is, do you feel good about this person.  If you try therapy with someone that I recommended or your best friend said was amaaaaazing and after two or three sessions it isn't working, take that seriously.  Talk about that in therapy.  You may find that turns out to be really helpful.  It gives the therapist the chance to adjust.  But If that doesn't work, try someone else.  It doesn't mean therapy isn't right for you and what you want to deal with.  It doesn't mean the therapist is no good.  It may just mean that the fit between you and the therapist wasn't right. 

Good luck and please leave comment about what has helped you find a good therapist or how you would suggest a friend make a choice.