Close Enough, Episode 2, "Very Carefully"

Episode 2 of my podcast about Closeness and Distance. Contributors to today’s show were Orit F, Mayan S, and Chana L, Menachem F and Elana F.

Dr Drinkling’s track “Late Nights” that you heard at the top of the show is our new theme music! Thank you so much Dr. Drinkling. Please go to his Band Camp page and support his beautiful, dreamy work. drdrinkling.bandcamp.com
 

Other music on the show was, "As a Porcupine Pines for its Pork" by Billy Jones and Ernest Hare and Jimmy Dorsey and his Orchestra, playing the absolutely beautiful “Praying the Blues.”  The Grand Duo Concertant opus 48 for clarinet and piano by Carl Maria von Weber was performed by William McColl, clarinet and Joseph Levine, piano which is shared under a creative commons share alike license.

Thanks to the Juno-nominated Gabriel Paquin-Buki for supplying clarinet squeaks and noises, and to Sivan Slapak key grip. Someday I will have you singing yiddish show-tunes on the podcast.

Thanks to my friend Norm for speaking so open heartedly about his experience of being a dad.

The letters from Johanna Schopenhauer to her son, the very grumpy German philosopher were read by Tally Abecassis whose wonderful podcast “First Day Back” you should download as soon as you are finished here. The translations were adapted from David E. Cartwright’s Schopenhauer: A Biography.

Caprice - Close Enough Ep. 1

This is the first episode of a podcast I am making about closeness and distance. I would love your feedback. 

Reality fights, shared mental states and couples

Some couples I see have what I call reality fights. Neither person is psychotic, neither has a brain injury but they can't agree about basic things relating to a fight they had last week. These aren't simply questions of perspective, they are disagreements about things that happened. And they are vexed about it. I want my partner to admit that events happened the way I say they did.

"You came downstairs, I was working at the kitchen table and you opened the fridge and you started complaining about the chicken."

"No, you weren't at the table. You were up in Keith's room." 

"Can I finish? And then you started swearing..."

"I never swore." 

"You did. You said, it was a 'fucking disgrace.'"

"I absolutely did not. And you weren't there so you don't know what I said, you only came down after I put the tupperware in the sink and then you started yelling about how I never clean up..."

Lather, rinse, repeat.

What is happening here?

In a recent previous post I wrote about research on how humans, from a very young age, seek shared mental states. According to the researchers we have a drive, evident even at 1 year old, to synchronize our minds with people around us.

We can't ever directly experience what happens in another person's head but we learn through a high-stakes, biologically driven life-long course of study to map others' inner states based on all sorts of outward signals, mostly without the use of language. What's more, these researchers contend that we don't just seek to know what others know, or to plan with others.

Importantly, joint attention is not just two people experiencing the same thing at the same time, but rather it is two people experiencing the same thing at the same time and knowing together that they are doing this (authors' emphasis)

We believe we know what is going on in the other person's head and we experience that not as a belief, but knowledge. 'Knowing together,' in the authors' evocative, mysterious phrase phrase, is a magic fairy dust that we sprinkle over our very detailed ideas, assumptions and guesses about other people's mental states is that we share them, that they are mutually held even when we haven't put them into words. This is particularly true with our romantic partners, we think we understand them before they even open their mouths, we assume that they know all information that we know and that they feel the way we feel, that they remember as we remember. We know together. 

The Dalai Lama once asked a group of neuroscientists, "Where is mind?" It is a question that has a lot to it. You could try to answer in many different ways, but one dimension to that question is "How much of our mind is shared or shareable? What elements of our 'inner' state is social?"

What is most significant to me about reality fights is not that the couple remembers the incident very differently but how disturbing these differences are to them, how focussed they become on the details of where each person was, and what words were said, if the chicken was in the tupperware or already on the late. The couple having a reality fight is manifesting dissatisfaction at lack of attunement in their mental states. Different memories of the incident aren't unusual, but they are significant to the people involved, painfully significant, because they show that the two people feel that their mental state was not aligned and may still not be aligned. I seek to force you to see things as I saw them because, if you agree that the chicken wasn't in the tupperware when you came down the stairs, then we will be back in a shared mental state. Even couples that don't like each other very much do this. The only thing harder than being married to someone you know very well and don't like very much is being married to someone you don't like very much and who you don't know very well. 

This is most remarkable where there has been an affair. The spouse who is betrayed is confronted in a profound way with the fact that what they thought was the couple's shared reality was partly illusory. While I thought we were a loving couple who were faithful to one another and sexual monogamous, you were sleeping with this other person. When I thought you were at work, you were in bed with them. The revelation that what I believed was a shared mental state was, in fact, not shared can be deeply destabilizing for people because the possibility of 'knowing together' seems not only to be gone, but to have become threatening. 

Do we feel together or alone?

To what degree are our feelings products of our social environment and interaction and to what degree are they uniquely inner states? 

Sometimes when I am talking with a couple, I ask "How did you feel when that happened?" The person's response is "Disrespected."  Disrespected is the most obvious example to me of words that both describe an emotion but also put it in the context of an interaction, something that happened to me, rather than purely an inner state. Think of frightened, disgusted, enraged, excited. They all have this quality of being both a feeling and a piece of an interaction. 

Sometimes I think that this is a way of avoiding facing the reality of one's own inner experiences as well as the reality of another's behaviour.  Saying "I felt disrespected" assumes another's motivations. It can also be a way of smooshing together a feeling, an interaction and an assertion about a standard of behaviour. We often do this when we have a hard time taking our own feelings seriously. Replace "I felt disrespected" with "I don't like how he treated me." Now the person who doesn't like how she was treated has to take seriously that her bad feeling may have importance not because it was disrespectful but because it felt bad to her. In case you haven't noticed, there is an important gender piece here; women are often the ones who talk to me about feeling disrespected. I suspect that saying disrespected rather than "I don't like it" has to do with women being told that their feelings don't matter. The message seems to be that it is okay to object to being disrespected, but it is not okay to object when you feel bad. I would say that for some people, it is important to relearn the lesson that feelings are important. It is important information that you don't like something regardless of whether it is disrespectful. 

A similar recent phenomenon has been clients telling me they feel 'gaslight-ed'. While actually gaslighting is unusual, a lot of people, women in particular, feel that their partners don't take their experience seriously enough. But it is hard for these people to feel confident in the worth of their own subjective experience. It is not coincidental that gaslighting comes from a movie in which a man makes a woman appear insane; 'crazy' is one label that is often thrown at women who assert the value of their own subjectivity. 

None of this means that our feelings don't have a social dimension to them. There is interesting research that shows that very young children have a drive to seek shared mental states with others. Attachment theory is one well-studied manifestation of the social dimension of human emotions. 

All of this has implications for how couples succeed or fail; should people grow stronger boundaries between themselves, containing emotions, taking responsibility for their own feelings and managing them, or should we seek shared emotional states, emotional and psychological connectedness, interdependence? 

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.

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.  

Dinosaur Shame: Emotion and Self

Prof. Heather Macintosh spoke last week at McGill on Childhood Trauma and Emotional Regulation in Psychotherapy.  She was talking about shame and jokingly differentiated between "felt shame" and "dinosaur shame," primordial shame at a level largely inaccessible to language or cognition.  She talked about the difference between feeling shame and shame as an identity. 

Shameosaurus (a.k.a. "Afrovenator abakensis dinosaur" by Mariana Ruiz Villarreal LadyofHats - Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Afrovenator_abakensis_dinosaur.png#/medi /File:Afrovenator_abakensis_dinosaur.png)

I am curious about how emotion, intense emotion, our own, or another's can overtake our sense of self.  Virginia Goldner, who I have mentioned before, talks about how anger, for violent spouses, can often feel dissociative.  Emotion can displace a sense of self for a while; the person becomes lost to him/herself through emotion. This reminds me of the line in the final scene of the (exploitative, yucky, though gripping) film "Seven," where the killer, John Doe, played by Kevin Spacey, urges the hero to "become Vengeance, become Wrath."  The conceit of the film was the Catholic doctrine of the seven deadly sins being incarnated in different people, but that line, and the experience it encapsulates of a self- and world-eclipsing embodiment of wrath reminds me more of Robert Oppenheimer quoting the Bhagavad Gita "Now I am become Death, destroyer of worlds" when reflecting on the detonation of the atomic bomb.  

Oppenheimer had studied the Bhagavad Gita and knew that the context was Krishna's injunction to Arjuna to destroy men in a cataclysmic battle, both friends and enemies with selflessness, for the sake of the Divine who had per-ordained their deaths.  It is a wonderful encapsulation of the sense of the self vanishing in the face of forces that feel transcendent and wildly violent.  As far as we know, no dinosaur ever experienced shame, either as an emotion or as an identity.  I love the way "dinosaur shame" evokes how primordial shame and other intense emotions can be, prior to and remote from language, as well as the feeling of destructiveness they come with.  But given that shame is a human legacy, -- "man hands on misery to man" -- perhaps a more accurate description would be from the other end of the time line; "atomic shame". 

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.