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. 

But it's not fair

There is almost always a moment in couple's therapy (often lots of moments) where one or both partners says, "It's not fair."  I am not talking about "it's not fair" relating to housework or money or other life tasks.  I'm talking here about the cry of "its not fair" about the burdens of the relationship;  "It's not fair that I always have to put my feelings on hold to listen to her."  "It's not fair that I have to take responsibility for initiating every conversation about making changes." "It's not fair that I am the one always being blamed for not caring about us." 

Couples will often stare at each other over an abyss of fairness waiting for the other person to initiate kindness, intimacy, caring or even simple friendliness. 

It is easy to get into a fight over one of these statements that goes something like.  "That's not true.  I did ....... last Thursday." "Only when I told you to."  "But I never get to because you are always telling me to before I even have a chance to."  Or some other totally derailing fight that ends with them looking to me to adjudicate. Who is right?  Who is more aggrieved? 

The therapy is now in session...

The therapy is now in session...

I tell couples I am not Judge Judy.  I tell them I cannot say that if he responds kindly 55% of the time then she must say positive things about his appearance 64% of the time.  It is for them to decide what is enough.  It is for them to figure out what happens when their partner doesn't deliver. 

An obvious point but one worth bearing in mind: in couples therapy people don't generally say "It isn't fair, s/he is always putting my emotional needs first.  I never consider her feelings and s/he is always attuned to what I want."  This is a small hint that a search for impartial justice is not what drives most people when they say, "It's not fair..."

"Its not fair..." is often a way of saying a couple of things, a pair of contradictory messages and a meta-message.  The first message is "I have something I want or need."  The second message is "I shouldn't say that I want or need this thing."  The meta-message is "These two contradictory impulses make me feel out of control." 

People say it isn't fair when what they want is for the situation to be different.  "I want my spouse to be more loving, I want my partner to initiate compliments, I want my girlfriend to take my feelings seriously."  Why don't they just say that?  Why do they appeal to fairness?

Often what they want or need feels primitive, childish.  Harville Hendrix says that when people say things like "s/he always does this" they are experiencing time as a child experiences time; what is happening right now is what has always happened and always will happen.  "It's not fair" usually has an "I always" or "s/he always" flavour behind it.  The unmet, unarticulated desire feels primitive, childish. 

There are two things that usually work in tandem to keep such desires from being articulated.  One is, we are embarrassed.  We don't think it is okay for us to say that we want to be loved more or that we need more appreciation or to be criticized less.  It is childish, it is shameful, it is silly, name your poison.  The other reason we don't say what we want in those moments is because it doesn't feel safe.  If I say "I want more love," my partner may say "tough."  Our partner's power to withhold keeps us from saying "This is what I want or need." 

At that moment, we are bound between our two desires, unable to have the things we want and unable to get out of the situation.  We imagine that some outside power will do what we cannot do; deliver our desire and protect us from the dangers of having to take our desire seriously.  I think when people say "It isn't fair" they fantasize that I will say "You are absolutely right and s/he is absolutely wrong," then turn to their partner and compel him/her to want to freely and generously hand over the love/appreciation/caring.

Relationships are inherently unfair.  Another person has the power to deliver or withhold things we ardently desire.  On a whim.  Not because of our actions or our merits or our character but largely because of his/her own wants or needs or impulses.  In a relationship we confront our own insufficiency.  Hopefully we choose a partner whom we trust enough to be generous enough with the things we desire. 

Cheese factor five; the therapist's secret fear of being Elle magazine.

"How about a nice Wensleydale?"

"How about a nice Wensleydale?"

I broke down and did it.  Between appointments, I wrote index cards that said, "Your partner's favourite band," "What your partner was wearing when you first met," and "Your partner's secret ambition."  These come from a series of exercises developed by John Gottman called "Love Maps".  You hand the cards to the client and s/he says what s/he thinks is the right answer or asks his/her partner.  Gottman is one of the most prominent and serious researchers of couples ever.  There's a whole lot of theory and research behind "Love Maps" but the first time I handed these cards to my clients, I cringed a little (I hope I did a reasonable job of hiding it). 

My cringe went a little like this: "I went to graduate school for three years and then did post-graduate training for years afterwards.  Now I am doing an exercise that feels like it has been clipped from Elle magazine."

Love Maps has a high 'cheese factor.'  That kept me from using it for a long time even though it is an evidence-based practice for helping couples do better. 

What is it about cheese?  I rely on being able to offer people something they can't get from a popular magazine or an online quiz for my living and my sense of professional attainment.  Not only that, coming to someone who they believe knows a thing or two, helps people feel safe, which is a prerequisite of a lot of the work of therapy.  I worry that the pungent odor of cheese can destroy that confidence that my clients and I rely on. 

Its not just me.  My training has been aimed at instilling a sense that therapists have complex, scientific knowledge that allows us to serve as serious professionals with something to offer that goes beyond the self-help section of a book store.  I think that is true.  But I also remember what Sylvain and Elise told me (names are made up).  They came every week to therapy and used it really well.  But at one point they said to me, "You're nice and all and you're probably good at what you do but for us the metro ride over is the most therapeutic part of the whole thing. We never have a half an hour where we are just sitting and talking about what's going on with us." 

Family doctors are highly trained professionals who spend a big portion of their time telling people stuff that their moms could have told them; "Have some soup and rest."  "Stop picking at it."  Sometimes you need a professional to tell you (because you won't listen to your mom).  In plenty of cases the mechanics of having a loving relationship aren't rocket-science; be kinder to one another, develop affection, show caring, stop bad habits that drive one another away, pay attention to your own and your partner's feelings etc.  What is hard is making the commitment to do it; taking the weekly metro ride over to my office may be some or even most of the therapy. 

So now I don't cringe (much) when I take out the Love Map cards.  Some couples roll their eyes and laugh at how cheesy it is and I laugh with them, but usually they smile at each other they laugh at one another's foibles or shared memories.  When they do the Love Maps exercise, couples understand one another a little more.  They have a little more feeling of affection after they do it.  And despite doing something they could have done online or from a magazine, many of them find it worthwhile to come back. 

Not doing things because they feel cheesy is actually a pretty big issue for some clients as well as for their therapist.  Some people hate the idea that doing basic, pedestrian things is going to help them.  (I wrote little about this here).  As the therapist, I sometimes have to model that we can push past our impulse to eye-roll just like we can push past other things that keep us from doing what helps. 

I would love to know your experiences of cheese in therapy.  The person who sends in the best example will get ... hmmm. a lovely stilton? or perhaps a nice wensleydale? whaddya say Gromit?

Couples therapy & Mental Illness

Jess says, "I want him to be more understanding of my mental illness."  I ask, "What do you want him to understand?"  Jess: "How to talk to me when I am upset so that I will calm down."  I ask Steve, "What does Jess look like when she is upset?"  Steve hesitates.  He doesn't know how much it is okay for him to say.  "She can't stop moving.  She walks all over the house for hours.  She's talking, talking, talking." Jess says: "I know I talk a lot but I just want him to tell me its going to be okay.  I know I get intense when I am upset but I don't think its that bad.  Steve: "She talks super fast for hours at a time, till three in the morning.  And I have tried touching her, she doesn't want to be touched. Everything I say is wrong. She's super irritable.  She screams at me, sometime she throws things.  Hits me."  I say: "That doesn't sound like you were upset.  That sounds manic.  Or maybe a mixed depressed-manic.  I don't think a anybody -- the best trained psychiatrist or nurse -- could talk to you in a way that would calm you down when that's going on.  I understand that you want him to soothe you, to make it better in those moments but I don't think he can." (This couple is a composite of many couples I have seen).   

People with mental illnesses can have problems in their relationships just like other people.  (For my thoughts on the fluid and ever-expanding definition of mental illness, see here and here).  But serious mental illness impacts on couples work in a few ways that can tell us some interesting things about all of us. 

The first time I worked with a couple immediately after one of them was discharged from psychiatry, I spoke to the treating psychiatrist about trying to help the couple re-establish some sense of intimacy.  He said something very wise. "Sometimes people who have psychotic disorders can't stand too much intimacy."  Intimacy is the bread-and-butter of couples therapists, whatever our orientation.  Help people feel a little safer, a little better heard and they will feel closer and more connected to their partners.  For people who have had the integrity of their sense of self fall apart, being connected with another person can be an existential threat.  It may be a human drive to connect with others, but it can also be something that threatens our psychological wholeness, not a small consideration if you believe your psychological wholeness is fragile. 

Like just about everyone, the mentally ill want their partner to complete or heal the parts of themselves that are broken.  Jess, in the composite above, wants her partner to keep her from being sick.  A lot of people with mental illness who I have seen, want this from their partner, whether they articulate it or not.  They long for their partner to save them from this serious and frightening condition.  Cognitively they may know that it isn't realistic but they want it so strongly that it can be very hard for the relationship.  Sometimes it can turn to blaming the not-mentally-ill partner for things way outside his/her control.  This is tricky: stresses in relationships, hurts and frustrations, neglect and emotional abandonment, not to mention outright abuse can be very psychologically destructive.  For someone with a mental illness, a cruel partner can make things worse.  But I am clear with both partners that a loving supportive partner can't heal a mental illness, and a garden-variety jerk can't cause it.  Mentally ill people need to take responsibility for getting appropriate care (for how difficult this has become see here).  

I once saw a woman in psychiatry who was recovering from an episode of psychosis that had been induced by a side-effect of a medication.  She was afraid about how she would remember the episode.  She was worried that she would be humiliated, frightened and ashamed by how she had acted.  I told her that in my experience many people don't remember episodes of psychosis very well.  Like a bad dream, psychotic episodes are vivid and intense at the time and often evanescent afterwards (in particular if they are ego-dystonic, that is if they experienced it as troubling and contrary to their usually sense of self).  I have seen this with mania as well.  People are often amazed and doubtful about the descriptions of their friends and relatives about how they acted after the fact.  I think this is a tremendous mercy that our minds show us in regards to these unusual mental states, that they can be forgotten or minimized.  It can be very adaptive.  However, it can be very painful and destructive for a relationship.  A client says, "We can't talk about what he is doing when he is acting really crazy because there's no talking at that moment, and we can't talk afterwards because he doesn't think it was that big a deal and its mean to rub his nose in it." 

There's a really neat blog post by Rebecca Jorgenson summarizing a study about attachment style, memory and conflict. 

The results were clear. Clients with Avoidant Attachment Styles, those who when feeling threatened manage distress through emotional distance and acting independently from their partners, and who withdraw under threat, were far more likely to remember the distressing conversations in a way that matched their autonomous reactivity. The avoidant partner remembered being far more clear and assertive than they actually were.

People who manage distress through emotional distance from a partner are more likely to cognitively distort their memory of their arguments. 

We all have a fragility of the sense of self.  We all seek to protect ourselves from the hurt a loved one can cause.  We all look back at arguments and paint ourselves as a little calmer and a little more patient than we were because recognizing that we were irrational is so painful.  These are human ways of being in a couple that can be magnified when mental-illness is part of the picture.  People with mental illnesses deserve couples therapy that takes them seriously as people, and part of that is taking seriously the impact their illness has on them and their partners. 

Should Quebec pay for your therapy?

"After slaying the giants, perhaps we should have a go at barriers to accessible psychotherapy, Sancho?" 

"After slaying the giants, perhaps we should have a go at barriers to accessible psychotherapy, Sancho?" 

Spring 2014 was a different time.  Back before we had a Liberal government that looked like it was going to rule Quebec for the next 10 years, a push was on to publicly fund psychotherapy.  The Quebec order of Psychologists was pushing for it.  An organization called the Coalition for Access to Psychotherapy was pushing for it.  Then two doctors got elected and decided to dismantle the health care system.  The idea of the government paying for anything in the health or social service sector that can't be contracted to the rapacious SNC-Lavalin or some equally befouled Quebec engineering firm seems Quixotic. 

As readers of the blog know, I used to work in settings where I got to provide psychotherapy for people who really needed it and often could not afford it.  Dr. Barrette laid me off (there were some intermediaries involved, too).  Now, I provide psychotherapy privately to people who benefit from it and who can afford to pay for it out of pocket or through private insurance.  I work on a sliding scale but my overhead, much of which is government mandated licensing fees, means I can't see the clients I used to and still make some money at the end of the day.  I feel useful, but I doubt I have kept anyone out of the hospital doing this.  Even for a person with serious mental illness who everyone agrees would benefit from psychotherapy, it is nearly impossible to get it in the public system anymore. 

Minister Barrette (centre) tours the new Super Hospital with SNC Lavalin's Robert Card (right).  $172 million could buy a lot of psychotherapy.  Gazette photo. 

Minister Barrette (centre) tours the new Super Hospital with SNC Lavalin's Robert Card (right).  $172 million could buy a lot of psychotherapy.  Gazette photo. 

By contrast, for the cost of one night's stay in a psychiatric hospital bed, I could offer one year's psychotherapy once a week at the low end of my sliding scale to someone recovering from a severe depression.  I could give a year's family therapy to a family supporting someone with schizoaffective disorder.  I could offer a twice a week dialectical behavioral therapy group for people with borderline personality disorder.  

Nevertheless, I have serious reservations about government funding psychotherapy.  Government will insist on putting psychotherapy through a meat-grinder; make it highly routinized, outcome driven (as opposed to outcome-minded) metric-oriented etc.  In other words they will use all the bureaucratic tools that have protected us from corruption in the construction industry.  And like with the construction industry, where government money goes, corruption will surely follow.  If psychotherapy becomes publicly funded, I predict within two years you will have psycho-therapeutic equivalents of SNC-Lavalin springing up, offering to fix major depression in four sessions using a manualized, patented therapy that has been extensively tested (on seven people who were feeling a little blue) and can be administered via the internet by qualified practitioners in the developing world.  Doctors will be the gatekeepers for publicly-funded therapy meaning a huge uptick in psychiatric diagnoses.  Think psychiatry and big pharma in the US

Speaking of the US, maybe it would be worthwhile looking at Obamacare.  If we want Quebecers to be able to get psychotherapy regardless of their income, maybe we should be looking at some of the deepest pockets in Canada. 

Sun Life Mutual, Manulife and Desjardins make billions of dollars in profits each year and sell plenty of insurance in Quebec. They could be doing more to ensure that access to psychotherapy is equitable (and I am sure they will embrace the chance to show civic-mindedness and gratitude for the billions). 

First, they should be required to offer packages that are in line with Quebec law.  Manulife among others has plans that only reimburse you for psychotherapy delivered by a psychologist (check with you insurer about the details of your plan).  That despite the fact that by Quebec law, psychotherapy can be delivered by a variety of professionals.  Quebec insists social workers, creative arts therapists, OTs, nurses etc. meet specific criteria and pay for a psychotherapy permit overseen by the order of psychologists.  But the government doesn't require insurance companies to use the title.  If all psychotherapists meet the same standards, and are delivering the same service, that service should be reimbursed equally by insurance companies.  Require insurance companies doing business in Quebec to respect Quebec's own regulatory regime, offer equal coverage for any psychotherapist, regardless of training.  That would increase access for insured people and reduce the costs of private psychotherapy. 

Second, insure the uninsured.  25% of Canadians do not have supplemental health insurance (that statistic is from 2004 and I am guessing the number is considerably higher today).  The mentally ill are less likely to have private insurance than most people because they are less likely to work.  The onset of many mental illnesses is in early adulthood.  Young adults are less likely to have private insurance than older adults.  Quebec could require insurers to offer low-cost individual health plans that include mental health services (and no prior-condition clauses) that the unemployed, underemployed or independent workers would be required to buy. 

Now that would be a public-private partnership that might actually serve the public interest. 

Making Humans

When I worked in inpatient psych the stories people would tell me were always a mix of sadness and joy, brokenness and resilience, the ways family can heal and hurt, sometimes simultaneously, back and forth across generations.  Drugs, what we call -- for lack of a better term -- mental illness and plain old human hurt wound together so tight the divisions between them become indistinguishable, the things that bring people into hospital are always part of a story of a family, trying, failing and succeeding in various ways to hold a human soul.  The CBC radio documentary "Tragedy Builds a New Family" from the Sunday Edition took me back to that. 

Burkhard Bilger's piece about kids riding bulls, "The Ride of their Lives" in Oklahoma and Texas in this week's New Yorker provides a fantastic illustration of how kids can grow and thrive in all sorts of lives and how our ideas about what childhood 'should' be are circumscribed by our tribe.

I thought about a playground near my house in Brooklyn, in Park Slope. A couple of years ago, it was beautifully renovated by the city, with a rock-lined stream meandering through it and an old-fashioned pump that children could crank to set the water flowing. The stream was the delight of the neighborhood for a while, thronged with kids splashing through the shallows and floating sticks down the current. Yet some parents were appalled. The rocks were a menace, they declared. The edges were too sharp, the surfaces too slippery. A child could fall and crack her skull. “I actually kept tapping them to check if they were really rocks,” one commenter wrote on the Park Slope Parents Web site. “It seemed odd to me to have big rocks in a playground.” Within two weeks, a stonemason had been brought in to grind the edges down. The protests continued. One mother called a personal-injury lawyer about forcing the city to remove the rocks. Another suggested that something be done to “soften” them. “I am actually dreading the summer because of those rocks,” still another complained.

The parents at the camp flipped this attitude on its head. They valued courage over caution, grit over sensitivity. They revelled in the raw physicality of boys. The mothers sat in the bleachers taking videos and hollering advice—“Wyatt, just ride the way Daddy taught you!” The fathers straddled the chute, leaning over their sons to cinch the rope and shove the calf into position: “Are you ready?” “Yes, sir!” “You’ve got to take the fight to him.” “Yes, sir!” “You’ve got to want it.” When the gate blew open, they leaped up on the rail and watched their sons with clenched fists and narrowed eyes. They weren’t stage parents, for the most part. They just took following your bliss to its logical extreme. “I’d let my kid do whatever he has a passion for,” one mother told me, “even if he wanted to be a piano player.”
— New Yorker

"Even if he wanted to become a piano player" instantly become a piece of shorthand at my house. 

Finally, I have been thinking about that stupid bromide "It takes a village to raise a child," because of the reaction that has been prompted by two similar law-suits filed by people who have left hasidic communities, one just outside of Montreal (Mike Finnerty conducted a really thoughtful interview with Yohanan Lowen, the man formerly of the Tosh community; you can get there if you follow the link to audio).    I don't write about it much, but I have spent a lot of time working with ultra-Orthodox Jews in various settings.  One thing that the reaction to these two stories illustrates to me is how confused we (by that I mean everyone who isn't an ultra-orthodox Jew or part of some other tight-knit, small traditional community) are about 'community.'  We value 'community' in the abstract, we love to say "it takes a village to raise a child" but we have little experience of the travails of living in a village.  Someone I know who grew up in Grenada told me that if he did something wrong at school he would get spanked by the teacher and then when he walked home, the neighbour-ladies on his street would see him come by, crying, and each in turn would call him by name up to their front porch and each one would give him yet another spanking because they knew why he was crying "You didn't listen to the teacher?"  To me this is a perfect illustration of the mixed-blessings of growing up in a village.  Tight-knit communities are tight-knit because people feel responsible for one another and entitled to enforce compliance to community standards, in particular when it comes to kids.  They coerce people to act right.  They are conservative; they do not value change and are wary of outside ideas and different people.  Some communities are more like this, some less but you can't have maximum individualism and still eat the cake of a shared set of values and communal responsibility.  There is a reason people are leaving villages all over the world; we live in an age where personal expression and individualism are more important than adhering to norms set by the past and our neighbours. 

Three angles on how those around us grow us up into who we are. 

Whining in Toddlers

Whining can truly make you want to pull your hair out.  Here is another in the Fridge Magnet Therapy series of printables all about how to deal with toddler whining, a suggestion from reader and friend of the site Ms. T.  I hope it proves helpful.  Your feedback is always appreciated.

Click on the image to download the pdf

Click on the image to download the pdf

Illustrations are from project Gutenberg's "A History of Champagne, with notes on the other sparkling wines of France" 1882 by Henry Vizetelly (chevalier of the order of Franz-Josef, no less.  No note about whether chevalier Vizetelly illustrated the work himself or not.)  I included an additional one (right) that didn't make it into the printable.  Is he wondering if a drink might help him be patient with the whining at home?