Great Resource for Anxiety for People of Any Age

So here’s my theory about Lawrence J Cohen’s great book “The Opposite of Worry: The Playful Parenting Approach to Childhood Anxiety and Fears.” He wrote a book for anxious parents and then decided he would have more luck getting them to read it if he said it was for helping their kids be less anxious.

I love the title and for that alone is worth it; the absence of anxiety isn’t the opposite of anxiety. Feeling playful, full of creativity, joyful as when we are goofing around with someone we love that is the opposite of anxiety. Cohen really emphasizes parents and kids feeling connected rather than simply focusing on behaviour, something I really appreciate.

The book is full of great, practical approaches to anxiety that anyone can use. Hug yourself when feeling anxious, wrap both arms over the opposite shoulder, alternate pats or squeezes on the opposite shoulder. It feels warm and embracing, it requires a little cognitive and kinaesthetic work, so it takes us out of our anxiety, it is easy to remember for a person who is feeling freaked out.

It also contains a lot of wisdom addressed to anxious parents (a.k.a. the part of ourselves that might think other people’s anxiety is a problem but our own is absolutely reasonable and the only thing keeping us together.)

If you know you are safe, but you still feel anxious, then you may welcome a chance to lower your anxiety. If you believe you are in danger, however, then it would be foolish to relax. You need to be prepared to act at a moment’s notice. That’s why some highly anxious children angrily reject suggestions to relax. Abe [a] boy who was ... afraid of thunderstorms, once said to his mother, ‘three deep breaths are not going to stop us from being hit by lightning’

Finally, Cohen takes a very humble and humane attitude towards his clients, friends, family and himself in this book; he is definitely not the all-knowing therapist who understands clients much better than they can understand themselves. He learns from kids and parents alike about how to manage anxiety.

Do we marry the wrong people?

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

The good.  

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

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

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

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

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

The Mistake

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

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

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

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

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

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

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


Therapy: who decides?

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

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

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

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

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

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

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

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

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

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

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

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. 



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. 

Important Parenting advice! Ignore Parenting advice!

When did "parenting" become a word?  When a publisher realized that there were millions to be made from telling anxious, well-off parentingers about all the things that can go wrong with kids.  (And a guy named Stan, in marketing, suggested they move away from the term "child rearing").  Nobody ever sold a book called "If You Can Afford the 30$ to Buy This Book Then Your Kid Is Doing Better Than 99% of the Humans Who Ever Lived."  21st century Canadians live in an age and place where most of us can provide our children with nutritious food, shelter, education, clothing and medical care that most of our ancestors (and many people around the world today) would have been delighted to be able to give to their kids.  That and love will go a long way.  We live in an age and circumstance of tremendous blessing.  So why do we consume parenting advice books and lectures by the SUV-load?

I work with a lot of families in difficult situations and I have seen some pretty bad parenting (by today's standards).  I can tell you that very little of what I have seen happens because people didn't read a book on parenting.  Occasionally, I will meet parents who honestly did not know better.  I tell them to stop and, usually, they do.  Twice in my career I have told parents not to threaten to hit their kids with a belt.  These parents felt overwhelmed by out-of-control kids and thought that threatening such a beating was better than actually following through.  I told them that, for a kid, the fear of such a beating can be almost as devastating as the beating itself.  They thought about it and saw that what I was telling them was probably true.  We brainstormed some better ways to deal with their kid's behaviours and they never resorted to that kind of threat again.   

I see parents who want to stop doing things they know or suspect are bad for their kids but they can't because they have mental health issues or are struggling with the ghosts of their own past or trouble in their present.  Just about everybody knows that parents should keep their marital acrimony away from their kids.  There are dozens of books that will tell you that.  But I have seen a lot of parents who tell me that in their particular circumstance, because their soon-to-be-ex wife/husband is such a poisonous viper, it is absolutely critical for the kids to know everything.  Or they make every effort to hold back only to find themselves pouring out all their hatred to a kid who is caught in the middle.  A book may help re-inforce a message in such a circumstance but I think that person needs supportive friends, a caring community and probably counselling.  

The people who buy books on parenting are often the worried well; parents who lack confidence in their own ability to parent.  That is where I have the biggest issue with the parent-advice-industrial complex.  By turning something that humans have done pretty successfully for our whole history into a gerundified 'parenting' with classes and manuals and DVDs, it makes parents feel less confident in their own judgement rather than more confident.  Ron Taffel wrote a wonderful piece in Psychotherapy Networker a few years back called "The Decline and Fall of Parental Authority... and what therapists can do about it."  He wrote about some of the forces undermining parental confidence and what that does to people's lives.

[A] chronic sense of being held hostage by kids and the culture at large helps explain why parents so often show up in our offices looking and sounding like spineless wimps. With so little time to bond with their children, parents are afraid to take even one step that could drive them farther away, undermine their already shaky school performance, and ruin their chances for social success when little else seems to matter. Not surprisingly, a multibillion-dollar public and private enterprise monetizes these insecurities by selling a raft of social modules and remediation services—including tutors and homework helpers for the well-heeled and supplemental educational materials designed to jack up reading and math scores. The issue isn’t just parental abdication, but what I call the “merchandising of childhood,” based on a deep-rooted fear of failure.

Taffel sees economic difficulties as the driving factor in parental lack of confidence.  I would go one step further;  I think we live in a fear culture.  We are encouraged to be fearful rather than generous and open towards people and the world around us and we are especially encouraged to transmit those signals to kids.  Engagement in community organizations has plummeted in North America over the last 50 years.  People don't join clubs, religious institutions civic organizations.  In Robert Putnam's famous phrase, today people are "Bowling Alone."  And people are 'parenting' alone as well.  Living in a more mobile, deracinated society that is fearful and highly individualistic means people don't have great social networks for parenting.  There are fewer norms for parenting and the norms that exist are harder to learn than they once were.

That makes for a lack of what social scientists call self-efficacy among parents; basically the feeling that you know what to do and are able to do it.  That is a problem because self-efficacy in parents correlates highly with good outcomes for kids.  (Obviously, if you are convinced that the way to deal with a kid is by threatening to hit him/her with a belt or to dis your ex to the kids, that's not good.  But it is better to parent with confidence than to parent without confidence, even poorly, and parents who feel confident in their parenting are less likely to parent badly.)  Researchers don't know exactly why that is the case, whether confidence comes from success, or if it comes from shared norms and those things generate success in parenting or maybe that kids perceive confidence in their parents and feel a sense of safety because of that.  Or a combination of those things.  But it is clear that feeling that you can manage being a parent without getting post-doctoral training in child development and arts and crafts is good for families.  

This doesn't mean that parenting books can't be helpful for everyday kinds of problems with kids.  I have mentioned "How to Talk so Kids will Listen, How to Listen so Kids Will Talk" before which I think is great.  But I actively discourage parents from trying to anticipate and preparing a fully developed response to every potential disaster of childhood and adolescence.  Now if you'll excuse me I have to go work on the next chapter of my parenting book.  The working title is "1001 Things That Will Definitely Go Wrong With Your Kid That Only This Book Can Fix."        

Too much social awareness and too little; Autism and Borderline

I work with a lot of kids with Autism Spectrum Disorders (ASD) in the context of family therapy.  One client of mine will sometimes say something pretty innocuous and then suddenly get worried.  He looks at me anxiously, trying to read my expression.  He asks me “Are you mad? Did I do something wrong?”  He feels like the world is filled with unexpected land-mines. Social situations seem to follow weird rules that everyone but him knows intuitively.  People often get angry at him for mysterious reasons, so I might as well.  This is pretty common for people with ASDs.  They have a tougher time with something called “mentalizing,” which means understanding that other people have different mental states -- knowledge, thoughts and feelings -- than themselves. (I wrote in a previous piece about Theory of Mind, which is very similar to mentalizing. There is a great video demonstrating what this looks like in kids.)  People with ASDs can find it really hard to figure out what those other mental states might be, based on cues that most of us read without thinking about it much like tone of voice, facial expression or posture. 

Some neuroscientists think that the neurology of people with ASDs is different from other people, that they may have fewer 'mirror neurons,' neurons that are thought to help with connecting to another's experiences on a totally unconscious, physiological basis.  Prominent among these is VS Ramachandran, who, in addition to being one of the foremost neuroscientists today, and an interesting philosophical mind, has maybe the coolest accent of anyone I have ever heard speak.

Mirror neurons are pretty spectacular according to Ramachandran, but others dissent.  One of the biggest doses of cold rain on the mirror neuron parade is the fact that we lack clear evidence that they exist in humans.   

Whatever the reason, people with ASDs do really poorly on a relatively new test for reading social cues called the Movie for the Assessment of Social Cognition or MASC. MASC is a really neat psychology test that lacks the flash of fMRIs but actually quantifies people's understanding of social situations very well.  The subject is shown a video of a social situation and asked a series of true or false questions about the mental states of the people in the video.  What is really interesting to me is what researchers have found out about people with Borderline Personality Disorder (BPD) when they take the MASC test.  

Among other things, BPD is characterized by very conflictual interpersonal relationships.  This great animation outlines some of the things that go on for people with BPD and the criteria for diagnosis.  

People with BPD do very poorly on the MASC test but for almost exactly the opposite reason than people with ASDs. While people with ASDs tend to mentalize poorly -- that is to consider and evaluate correctly the inner experiences of the people in the video -- people with BPD tend to “hypermentalize.”  They are very tuned in to the mental states of others, perhaps too tuned in.  Some research indicates that people with BPD may actually be better at correctly “reading” other people's emotional states based on limited information than non-BPD people.  But like many people with ASD, people with BPD can find the social environment confusing and overwhelming, not because they have too little information to understand what is happening, but too much.  I suspect they are also lopsided because their hypermentalizing often tends towards the negative; that is they read negative cues very clearly but positive cues get less focus.  

Think about how many quick, frustrated glances or disapproving sighs a person might encounter in the social landscape in a typical afternoon.  People who don't have BPD may register them almost unconsciously, as subtle social cues to "hurry up", "hold on a minute" or "give me some space".  Those things help most of us adjust our social behaviour.  But people with BPD experience each negative micro-expression like an angry, screaming tirade leaving them as bewildered as the young boy with ASD asking, “what did I do wrong?”