Anger, Aggression & Diplomacy real and imagined

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

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

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

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

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

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

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

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

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

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

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

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

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

The savvy consumer's guide to picking a therapist

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

1.  It is reasonable to be concerned about price

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

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

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

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

3. Clear goals

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

4. You should feel heard

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

5.  Non-defensiveness

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

6. Professionalism

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

7. Strong

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

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

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

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

Scientists discover 'cool' particle, teens yawn.

Scientists have measured 'cool' and determined who has it so teens don't have to worry anymore; they can just ask the adult with the pocket-protector and clip-board.  In a neat piece of social science researchers looked at how kids made themselves popular at age 13 and followed them through to age 23.  Kids who did things to look older at age 13 in order to be more popular, such as engaging in delinquency, hanging out with good-looking peers and engaging in romantic relationships were less socially successful at 23.   (It seems to me there may be a tad of wish-fulfillment of grown-ups who were unpopular 13 year olds).  This is moderately interesting for people who work with kids and for parents of teens. 

The researchers conflated popularity and 'cool'.  Scientists like things that can be measured; popularity among thirteen year-olds is relatively easily measured while cool isn't.  The kids I thought were cool when I was thirteen weren't necessarily engaged in 'pseudo-mature' behaviour and weren't necessarily popular.  James Dean's character in Rebel Without a Cause which the authors adduce is a loner not a collector of pretty people.  Rather the kids who seemed cool to me did whatever they with seeming ease.  The Italian's call this sprezzatura.  Castiglinone in the Book of the Courtier has one of his characters say:

“What eye so blind as not to see in this the ungracefulness of affectation, — and in many men and women who are here present, the grace of that nonchalant ease (sprezzatura, for in the case of bodily movements many call it thus), showing by word or laugh or gesture that they have no care and are thinking more of everything else than of that, to make the onlooker think they can hardly go amiss?”

Pseudo-maturity doesn't play into this definition of cool.  Of course it can be exhausting to be attuned to how one appears to others at all times and probably detrimental to one's cool, as well, but that is a feature not a bug of adolescence I suppose.  Now that we have adopted pseudo-youth for adults as an unquestioned value it is probably a feature of middle age as well.   One of the features of Castiglione's work is the way in which people of different ages reflect on the blindness of others and in turn betray their own prejudices. 

“Thus it seems to me that old people are in like case with those who keep their eyes fixed upon the land as they leave port, and think their ship is standing still and the shore recedes, although it is the other way. For both the port and also time and its pleasures remain the same, and one after another we take flight in the ship of mortality upon that boisterous sea which absorbs and devours everything...”

— https://archive.org/stream/bookofcourtier00castuoft/bookofcourtier00castuoft_djvu.txt

What do we see with our insight?

I work part-time in the psychiatric inpatient unit of a hospital.  I was talking with a patient there who was sad and frustrated because he really wanted to go home.  He couldn’t leave because of a court-order for hospitalization.  According to the people who brought him in, he had said things that sounded delusional but it was hard to understand what he meant because he speaks poor English and French and so do the people who brought him in.  Even with the help of a translator it was hard to understand what he had said and what he was thinking.  Was he expressing anger and frustration or was he expressing delusions, including some thoughts of self-harm?  “Why can’t I go.  I am okay.  You see I am okay.  I talk normally.  I’m not sick,” he said.  I said, “We see two kinds of people in psychiatry who say they are not sick.  There are people who aren’t sick and there are people who are sick but can’t understand it because of what the sickness does to them.”  I was trying to explain the concept of insight.

Insight has two distinct meanings in psychological parlance; one is understanding something through non-logical means, the “un-huh” experience.  The other meaning, which I will use here, is the ability to reflect on one’s own mental processes.  This second meaning of insight includes the ability to understand when one’s mind is acting in ways that don’t seem normal.  Many people who experience delusions or hallucinations, depression, anxiety or mania understand that those experiences are strange mental states.  But insight can be affected by mental illness.  I saw a patient who was able to have reasonable conversations shortly after coming into hospital for some pretty strange and dangerous behaviour both for herself and for others.  She seemed a little unusual, her speech was a little disjointed, a little pressured but she didn’t seem mentally ill until the psychiatrist who was interviewing her asked about delusions and hallucinations she had expressed.  The patient, who was quite smart, was absolutely convinced that these things were real; she talked about them in the same relatively reasonable way that she talked about conditions and the routine in the hospital.  After a few weeks in hospital and a lot of psychiatric medication, when I asked her about the thing she had been hearing and thinking, she said they were almost gone.  I assumed that she would see her previous psychotic symptoms as strange, perhaps embarrassing, perhaps frightening, maybe amusing, or as a piece of herself she had to contend with.  Instead she expressed no surprise that she had experienced these things, no recognition that they were odd and no sense that they were connected with her mental illness.  The voices had stopped.  They had been real,  a feature of her life.  It was as if the grocery store down the street had gone out of business.  It was there, then it was closed, neither its presence nor its absence was remarkable or connected with her mental state.  

I asked a psychiatrist who had seen her about this.  He said that years of untreated psychosis had “burned out” the patient’s capacity for insight.  There is a “kindling hypothesis” in psychiatric illness.  The idea of ‘kindling’ in psychiatry comes from the study of epilepsy and other seizure disorders where it is demonstrated that more frequent and intense seizures cause lower thresholds for future seizures.  Seizures cause a change that leaves an organism more prone to future seizures, seizures create the kindling for future seizures.  Some psychiatric research think that affective disorders such as bipolar disorder may have work in a similar way, early and intense manic episodes may create ‘kindling’ for future manias.  I couldn’t find any compelling evidence that this is the case in psychotic illnesses or a clear explanation of what the mechanism might be.  

It is clear that certain kinds of brain trauma can cause severely impaired insight.  Anosognosia is the phenomenon of not recognizing that one has an illness and is usually applied to someone has suffered a brain injury.  A patient may be paralyzed on one side of the body and find reasons not to perform a particular task that requires both hands.  The patient is not deceiving; the brain’s capacity to recognize impairment is, itself, impaired.  

In psychiatry, insight into one’s illness may be more complicated than in neurology.  Going back to the first patient, cultural and linguistic factors can make it very hard to assess.  It is also subject to a lot psychological ‘noise.’  When I talked with this patient it became clear he dreaded the idea that people would think he had a psychiatric illness.  There are good reasons why people - whatever the state of their mental health - don’t want to be seen as crazy by others.  And recognizing one’s own mental illness is a mixed bag.  Schizophrenic patients with better insight are more likely to take their medication regularly but are also more likely to be depressed .  Paradoxically, denying that one is mentally ill looks pretty friggin’ adaptive if your idea of mental illness is a life sentence of misery and social ostracization.   

For me lack of insight was always deeply, primitively, frightening.  First of all, it evokes a trap played by the powerful; say you are unwell to prove you are well.  At the same time what was always most frightening about mental illness to me was the primal terror of my own insight failing me, the extinction of something that is at the heart of my ‘self’.  

I talked to a former patient this week, who had expressed very strange ideas when she was in hospital and who had little idea at the time that these ideas were strange.  She is back in her apartment working hard to keep herself well.  She still has paranoid thoughts sometimes but she recognizes that they probably aren’t accurate reflections of reality.  She is able to challenge them.  She tries not to let them govern what she does. She doesn't find it all that upsetting that some portion of her mind is so cruel.  It made me feel happy to hear about her improved insight and I think it bodes well for her.  

I find that after working with mentally ill people I am less fearful of losing my own insight.  I suspect that like any other mental process, especially those connected with creating a sense of self, insight is nine-tenths smoke and mirrors, an illusion played by our brain on our mind.  Insight is a kind of delusion itself, the folly that we can know our own minds.  

DWYL (Do what late stage capitalism tells you that you should love)

I recently heard Miya Tokumitsu being interviewed about Steve Jobs' famous “Do what you love” commencement address.  She has written eloquently about the late-capitalist wish fulfillment implied in this motto; that unlovable work should not only not happen to 'people like us' but shouldn't be seen or thought about at all. 

“In ignoring most work and reclassifying the rest as love, DWYL may be the most elegant anti-worker ideology around. Why should workers assemble and assert their class interests if there’s no such thing as work?”

A further critique of "Do What You Love":  As a therapist I work with people in their late twenties who feel that they are somehow psychologically unwell because they have not discovered their life's great passion. They have been told by the culture that they should be fully satisfied and thoroughly successful in their social, romantic and work life, drivers of change at every moment.  They believe that life can be an unending climb to success and that if they are 'right' all that climbing will feel GREAT!  To be anything less than full of love for life (including work) at every moment is a mark of some fundamental wrongness in them. They are discouraged and bewildered by their lack of passion though they have experienced relatively little of life. They live in terror of being soulless drones in marriage and in work and carry the secret shame of not feeling suitably passionate to escape this fate.  (Or not passionate about the right things; the internet is built to be terrifically engaging but our culture doesn't view hours spent intensely focused on porn or playing World of Warcraft as DWYL). 

The fact is that a person's twenties are early to discover lifelong passion.  I vastly prefer Ms. Frizzle's advice to Steve Jobs'.  (There may need to be a future blog post about the psychological phenomenon of frizzophilia; sexual desire for Ms. Frizzle.)

I tell clients to focus on trying things out, making mistakes, and picking themselves up when it doesn't work out in love and in work.  Perhaps they will stumble upon something that grabs them.

But passion is not guaranteed.

Some people are, by temperament, not very passionate.  This is another thing that the DWYL approach elides.  It seems to me that love is portrayed in the DWYL approach as a near-rapturous state, fully energized, intensely focused that does not mellow with time.  This betrays a misunderstanding about love and about the variety of human temperament.  A passionate temperament is a mixed blessing; passion can lead people to wonderful accomplishments but can also lead them to reckless self-regard and cruelty.  Those who are less passionate can often be steadier companions and kinder partners.  Shame about being imperfectly passionate and fear of being locked into a life without total fulfillment keeps these twenty somethings from moving in any direction. 

In a happily directionless part of my twenties, I read George Eliot's Middlemarch, which ends with this very un-Jobs-like valedictory for its heroine...

“The effect of her being on those around her was incalculably diffusive; for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been is half owing to the number who lived faithfully a hidden life and rest in unvisited tombs.”

Thoroughly contrary to the spirit of the age. Precisely what we need. 

The Illusion of Explanatory Depth. Can you explain how your plumbing works?

My supervisor and mentor Sylvia always says that "clients come in with an idea about what the story is and our job is to confuse them."  I have seen this borne out.  Clients have a very firm idea about what the problem is and how they got there but no idea how they can solve it.  The therapist drills down and down and down, "slicing it thin" as Sue Johnson says.  "I don't think I understood that.  How does your mom being too lenient keep you from getting a job?"  "Sorry.  You said that when she gets angry, you shut down.  What does 'shut down' mean?"  "I missed that.  You were talking about how in 1985 you had a miscarriage and that was connected with not wanting to eat.  How does that work?" 

How does that work? 

I recently read about "The illusion of explanatory depth."  The illusion of explanatory depth is what research psychologists Frank Keil and Leon Rosenblitt call the human tendency to be confident that we understand something -- usually how a familiar but complicated piece of machinery works -- until we are asked to explain it.  Suddenly we recognize that a toilet or a sewing machine is way less familiar than we thought. The illusion falls apart and we become more humble.  We start to know that we do not know.  

I was amazed that nobody seems to have written about this in the context of psychotherapy.  It used to feel to me like this kind of questioning that psychotherapists were doing about a person's experience was disrespectful.  Aren't we supposed to see the client as the expert in his/her/their own story?  But there is a difference between being intimately familiar with something and being an expert in it.  Asking people to tell a coherent story about themselves and their difficulties can be painful but that doesn't make it disrespectful. 

One of the things that can happen in a family in difficulty -- particularly where there is a lot of secret-keeping -- is that the explanatory depth is very thin.  These families often have very limited, incoherent stories of themselves yet they are often very convinced that there narrative makes sense.  If a therapist asks clarifying questions it can feel very scary because the family may intuit that the illusion of explanatory depth is about to fall away.  Like all illusions, the IOED serves a very important function, it gives us a sense of coherence and comprehensibility in the face of things that feel chaotic and scary.  But more coherent narratives are therapeutic. 

John Byng-Hall citing the work of Mary Main among others wrote about attachment and coherent narratives in families.

“This would suggest that making sense of the events that traumatized the attachments is important. But the most effective way of creating a coherent story line is to help the family to manage their current attachments in a way that takes into account all its members’ attachment needs. This will require them to tune into each other’s pain. The children might then also be able to tell a coherent story to their children.”

One of the interesting elements of the IOED is that if we know that someone knows how something works, we take on that knowledge as if we knew it, too.  "Well somebody understands how a toilet works," our brains say, "So I must, too."  In a psycho-therapeutic context this can manifest as jargon not connected to real feeling or much detail; "I'm codependent."  "He's got a borderline personality disorder."  "It's because of early trauma."  "He's from Mars and I'm from Venus."   This is why a not-knowing approach by the therapist can be so important, even when it is frustrating for the client.  Families need to go from being familiar with their own family functioning and stories to being experts in them.  That doesn't mean they need to replace one prepackaged expert story with another, as easy as it is for our human brains to do that. 

When all goes well, the client or clients are able to construct a more coherent and flexible understanding of themselves, understandings that can better tolerate challenge and reorganization. 

Friendship, kids and mental health.

A researcher from Ste. Justine here in Montreal, Mara Brendgen did a really interesting piece of research about friendship as correlated with depression in children.  You can read the article (if you have academic access) or a nice summary of it at BPS Research Digest by Christian Jarrett.   By studying kids who have an identical twin with depression and kids with a fraternal twin with depression Brengdan and her colleagues were able to identify kids who were genetically pre-disposed to depression but not depressed themselves.  Then she looked at those kids and looked at the quality and quantity of their friendships.

“Genetic vulnerability to depression in girls was less likely to manifest if they had at least one close friend. Stated differently, the apparent protective effect of having at least one close friend was magnified in girls who were genetically vulnerable to the condition. This means that for girls there was an interplay between genetic risk and the protective effect of friendship. ”

— http://bps-research-digest.blogspot.co.uk/2013/05/stand-by-me-close-friendships.html

There was a beautiful piece on This American Life last week about a girl who had something like Asperger's.  Her stereotypical conversation and poor social reciprocity get in the way of friendships.  But she still wants friendships.  Eventually she becomes angry and aggressive because she is so lonely.  Her moms take her to all sorts of specialists (a humbling note for those who work with kids with learning and/or developmental disorders) and none of it really helps until... she makes a friend, a friend who is interested in the same things as her.   (It starts at about 41:00 minutes)

A question I have about Brengden's research (or Jarrett's summary, not sure which) is cause and effect.  While kids who are genetically pre-disposed towards depression may have fewer friends or friendships they value less, is that a cause or an effect or are they related through some other factor such as personality type or attachment style? 

There is a correlation between people with schizophrenia and social isolation which has lead to the recommendation (here, for example) that people at high risk of schizophrenia make a conscious effort not to self-isolate.  But we all know that correlation doesn't mean causation or else we would all demand more importation of Mexican lemons until highway deaths were eliminated (link to this and other bizarre correlations). 

Nurturing a kid's positive friendships and encouraging him/her to view friendships as worthy of investing some time and energy in seems to me like a good idea whether or not they are at elevated risk of mental illness.  Of course, for a kid who is less good at friendship or less interested in it placing a lot of emphasis on making friends can backfire by making him/her feel more incapable.  Socially awkward kids often view friendship as an ability akin to drawing or music that relies on a high degree of innate talent (it is interesting that many kids who feel bad about their ability to make friends do so around the age of nine or ten when they also start to notice that other kids are way better than them at some things without having to try hard).  It may be true that some combination of genes and very early wiring can make a person better at social situations than others, but I tell kids that friendship is more like riding a bike than playing music; it is something you can learn at just about any age, something you can always get better at by persevering and something you will never be able to learn do by watching others.  You need to try it, fall down and try again. 

4 ways therapy can do harm and why that is good news.

My former supervisor and teacher, Sylvia, used to tell me, "If you are stuck with a client, you need to put that on the table.  If you and the client can't get unstuck, stop the therapy."  I have been thinking about what great advice that is and how hard it can be to follow.  Clients will often say to me, "More therapy can't hurt, right?"  I even hear that from medical professionals and sometimes mental health professionals.  Generally, people know that insulin can hurt, and they don't take it just 'cause.  People don't undertake minor surgery for no reason.  Aspirin if taken improperly can put a person in grave danger.  If a therapy is capable of affecting someone's well-being for good, then it can also do harm if administered when it isn't indicated or in ways that aren't indicated.  Stated another way; If it can't do any harm then it is not worth doing.  I am not talking about an abusive or incompetent therapist or an unproven therapy.  I am talking about how psychotherapy can hurt when administered properly for the wrong situation or in the wrong dosage.

1. Psychotherapy directed towards a fundamentally well person in a bad situation can make the person feel responsible for his or her situation and aggravate worry.

This one happens with kids a lot.  The parents come into a therapist's office and say, "My kid is anxious/sad/angry all the time.  We don't want to discuss our fighting/grief/parenting.  Work with the kid."  The therapist can treat the kid using behavioral techniques for tackling whatever his/her symptoms might be.  I have heard therapists say, "At least I can offer the kid tools for dealing with X that may alleviate one difficulty in a difficult life."  I don't agree with this.  I think treating that kid in isolation gives the parents license to continue their behaviour and can put the spotlight on the child whose symptom is really the family's.  This may exacerbate feelings of responsibility for the family's difficulties.

2. Therapy that doesn't change the music.

This one happens with couples often.  Couples will come into therapy and insist on having the same arguments that they have at home.  I often say to them, "It's okay to fight in therapy, but I want you to at least have a different fight than you have at home."  Therapy is about making change in patterns and if you are doing the same thing in therapy that you are doing at home, you aren't changing a pattern, you are rehearsing it and you may be reinforcing it.   Some couples can't stop this, which is painful for therapists and the clients, but rather than have a bad experience of therapy and a lot of extra practice doing what hurts, it is better to stop therapy.  The couple may be able to come back when they are in a different place or work with a different therapist who can get them pointed in a different direction. 

3. Psychotherapy in place of something else that would give more well-being.

People are busy.  Therapies can be expensive.  People may prioritize psychotherapy over other things, either other therapies or other activities that could improve their well-being.  People are often choosing between therapy and a gym membership or a babysitter or a speech therapist or a soccer practice.  Those can sometimes be false choices but I actually think that more often than not, they are real.  I am all in favour of people prioritizing their mental health and their close relationships but the best expression of wellness is living a full life, not being in therapy.  Sometimes people believe, mistakenly, that because they are in therapy, they are taking care of their well-being when, in fact, they are using therapy as a smoke screen.  A good question for clients and therapists is "If the client wasn't here, where would s/he/they be?  What does missing X mean?"

4. Ending too early.

The pioneer of systemic, family therapy, Salvador Minuchin pointed out that sometimes people try something new to make a change but stop early when they see no benefit.  Some changes yield benefit in a one-to-one ratio -- a straight ascending line -- but sometimes change comes more as an exponential curve or even a "hockey stick" curve in which a person sees little benefit at first but experiences big pay-offs when s/he persists.  The down-side of ending early is that it can feel disheartening to work at something and see no result.  Depressed people often cognitively distort failures so that is all they see and they see those failures magnified.  If a depressed person tries cognitive behavioural techniques in therapy, for example, and doesn't experience change fast enough s/he can view it as yet another failure and feel worse.  Going back to the surgery analogy, if we abandon surgery in the middle the results will be not only a return to pre-surgery function but worse functioning. 

Avoiding these pitfalls is part of providing good therapy just as providing good medical care involves more than just prescribing medication, but knowing when and where to prescribe and when not to.  All this isn't meant to scare people off therapy, but rather to point out that therapy has real effects.  If a therapy isn't working, feels like it is hurting more than it is helping or feels stuck, take the time to look at that, client and therapist together.