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. 

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.
— http://www.rebeccajorgensen.com/what-you-need-to-know-about-memory-and-insecurity-that-will-help-you-with-clients/

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.