Problems with Boundaries

Tuesday, May 31st, 2011

This blog post is going out to all fellow therapists!  The advice I gave earlier it appears I need to listen to as well.  Especially when one’s ability to provide life changing care is involved.  Unfortunately, when a therapist works with young people (these young people can be as old as 40!), they must work and communicate with the family as well.

The family MUST be involved in some kind of treatment themselves or else the dynamics that created the dysfunction in the young person in the beginning will most likely continue in some form.  The most frustrating aspect of this kind of work is when the parents will refuse to cooperate with the treatment, or even communicate with the clinician.  In these cases, one can conceive of the work in two ways:

1.  The work will always be sabotaged by the family, and therefore it’s best for the therapist get out of the case entirely.

2.  If this is the family the young person has, then perhaps one has to ally with the young person all the more.

In this way, one has to tolerate and accommodate for the “slings and arrows” that the family can muster as they will be determined to diminish and devalue the work both of you are doing!  Nonetheless, IF one can withstand situations like this, then one might be genuinely be engaged in a truly important work.

One is providing the young person with an alternative to the script that the family of origin might want the young person to internalize.  In this case, the therapist might have a moral imperative to stick with an individual, no matter how difficult it might be to tolerate the devaluation that occurs at the hands of those that made the young person sick.  It is times like these that one needs to listen to Stephen Sondheim’s “No one is Alone” on continuous loop!

I am confident that I’m not the only clinician to find himself (or herself) in such dilemmas.  But such is the price we pay for the privilege of beholding the miracle of healing that brave people bestow upon us like a gift of which we are unworthy.  Thus, if one is in this situation, perhaps it has a deeper meaning even for the clinician.  And thus, it becomes all the more important for us to listen to our own spirits to maintain the wisdom and energy necessary for this work.

What keeps people stuck

Monday, May 9th, 2011

A problem that many individuals in therapy and therapists often have to confront is the issue of why do people stay stuck in their symptoms. These symptoms can range from the mildly annoying to the truly life threatening and despite this, some patients stay wedded to their symptoms as if they were wedded by the Pope! What gives? Why do people stay attached to their symptoms? It is my belief that people (for the most part) do not want pain and suffering in their lives. Yet somehow their symptoms can plague them for months, sometimes for years. So what’s the underlying reason for all this?

It has been my experience as an analytic therapist that what keeps people attached to their symptoms is some kind of payoff – a gain that they get for having them. But what they are unaware of is a “secondary gain”; it’s hidden in the unconscious mind. People are often taken entirely by surprise when in therapy they realize why they have had to live with symptoms for as long as they had.

This is really important for the following reason: NO ONE is to be blamed for the secondary gain that other people can sometimes pick up on in the behavior of their loved ones. Even if this secondary gain is obvious to other people, it can remain a mystery to the person with the problem. And yes, it is a problem. Even if people seem to be enjoying some aspects of their symptoms, in reality their symptoms are keeping them from enjoying life and becoming their true selves. Thus, symptoms and even the secondary gain that sometimes attend to them are in reality not an expression of anyone’s genuine identity.

From this understanding, we can identify two important lessons:

  1. It does no one any good to nag someone about their symptoms – even if they seem to be enjoying life. Nagging, no matter how long or intensely practiced, has never gotten anyone to give up their symptoms. Not once.
  2. If you know someone afflicted by any kind of psychological or emotional symptoms, what they most truly need is the insight into why they have their symptoms and secondary gain. Thus, if they are in therapy, they need to persevere no matter how painful it might be.

For those who are trying to support those in therapy, try to hang on to the fact that their loved ones are making progress. Even if the process takes some time, remember that letting go of things that even had the appearance of working takes work and courage. In this way, therapy is truly a community action, and never occurs just with or by a single individual.

When in Limbo…

Tuesday, May 3rd, 2011

Many of my patients at SPARK are twenty-somethings who, for whatever reason, need therapy. Sometimes the most difficult aspect of treating someone of this age and generation is getting the pitch-perfect level of support and structure from their parents. The mistakes often get made in trying to provide too much of either.

A generational gap may lead to a state of limbo

Parents sometimes don’t understand that what they could do when they were 18 or 25 is NOT what their son or daughter can do. As a result, parents sometimes end up doing too much for their children, not letting them have the “stretching” experiences of having to work at something.

Sometimes, parents may throw up their hands in understandable frustration and say, “He’s on his own!” But their young adult child might not have the skills to be able to figure out the world on their own. This leaves parents in as much a state of limbo as their children, everyone floundering around trying to figure out what his/her appropriate role should be.

Being supportive means being there

The most difficult and most appropriate thing for the parents to do is to be in the limbo with them. What for one child could be very necessary help, might for another be enabling and infantilizing. So unfortunately there are no hard and fast rules for this limbo in which so many of this generation are living.

The smart parenting question is: “Can my child do this (whatever this is) by themselves?” This might be a difficult question to answer. But a realistic assessment of what young people can and cannot do is essential to giving them the structure and support they need in order to get to the next step. Oftentimes, young people will act out, avoid, or complain about tasks that they simply do not understand or are beyond their skill sets. They engage in these behaviors because they find this internal experience of humiliation (which is what it is) intolerable and have to vent this uncomfortable affect somehow. One hopes that these acting out behaviors are not inherently self destructive.

If parents think that their children (of any age) are engaging in behaviors that are inherently self destructive, getting a professional consultation is advised. And might save a life. Remember, problems – if left alone long enough – don’t get better or go away. They only get worse. The problem is not finding oneself in limbo with one’s child; it’s not knowing how to navigate out of there!

Parenting the “Other”

Saturday, April 9th, 2011

Perhaps one of the greatest challenges that parents face is the parenting of a child (of whatever age) who is radically different than you.  This difference could be as basic as something as gender, or it could be deeper.  Maybe, it’s values: they place worth in places that you might not or, worse, that you disdain.  And maybe the difference is psychological, making the rift an emotional one as well.

Change! Be like me.

The reason why this becomes a problem is that in your efforts to parent, the subtext of your interactions could be something like, “Change, be like me, don’t be yourself.”  Sometimes this is called for (i.e. a drug abuse that could be life threatening).  But all too often, the attempts to parent are experienced by the child as a form of devaluation; the parent comes off as not caring about or, worse, diminishing the child’s opinion or views.

Sometimes, this can become so intense for a young person that the introject of “Don’t be yourself” becomes translated into self-destructive behaviors:  chemical abuse, addictions, self-injury, even suicide attempts and completion.

Choose to love, and try not to be frustrated

The answer to this cycle is insultingly simple:  Love your child.  By this I don’t mean just provide things like food, which is rather expected.  (If you’re not doing that, just call DCFS now.)  But loving things that are different than us or that we don’t always understand, even if we are talking about one of your own children, is not easy.  Indeed, it is perhaps one of the the most difficult things you will ever do.

But despair not!  There are concrete steps that one can take to improve one’s relationship with one’s child:

1.  Identify the way in which your child is different than you that is disturbing

2.  Examine your own heart and mind as to why this trait is so disturbing/difficult to make some kind of connection

3.  Learn where you learned your distaste for this trait and what’s at stake for you; perhaps it could be some sense of your own identity

4.  Examine the trait that is so difficult and force yourself to see what possible purpose it serves your child

5.  Attempt to see the benefit it provides your child and see if from this perspective you might be able to value it in some slightly different way.  Often times, it is through our children that we learn how to be more open to the world.

It takes time and patience

Now this process is NOT easy.  I can safely say it will be one of the most difficult things you do in your lifetime.   It might require the help of someone trained in psychotherapy and analysis.  It might even prompt a new, challenging journey for yourself.  But the price you pay for not taking this journey is to continue to engage your child in unproductive ways.  That gets NO ONE what they want.

Perhaps your child is your own walking, breathing invitation to your own journey to human growth.  And if your child ultimately invites you to a life that is more full and abundant, what better gift could he/she give you?  It might not be comfortable at first, but perhaps the life of real attachments is not supposed to be.

Parents: What’s wrong with my kid???

Sunday, April 3rd, 2011

It’s happened more than once that a young person will be brought to my office, sometimes unwillingly, by parents who are confused and very frequently very scared by the behavior of their son/daughter.  This behavior usually falls into one of two categories:  familiar inappropriate behavior and unfamiliar inappropriate behavior.  With all this behavior living on a spectrum, it can get dicey trying to figure out what exactly is offending the family subculture.  In some families, marijuana use is just part of what people do–I know of parents that will get high with their kids.  In other families, a single joint is cause for a trip to rehab.  In all these cases, what is very important is the parental perception of their children.  Often times it is the young person not meeting the traditional marks of adulthood that becomes the root of family concern.  Things like:  not graduating from high school on time, trouble with college, not graduating from college on time, difficulty finding a job, not being able to live on one’s own, not being to obtain healthcare, or lacking a sense of direction in life can become cause for a trip to the therapist’s office.

For parents and children perhaps some comfort, albeit cold, can be found in the fact that none of you are alone.  Studies are showing across the board that much more than many believe, young people are taking longer to hit the developmental milestones than their parents did.  In short, 30 is the new 21.  The decade of the twenties becomes a searching period; when young people are taking the time at hand to explore their world or themselves.  That is in many way a best case scenario.  Better to ask the hard questions now, rather than asking them at mid-life when one has more obligations and less freedom to make changes.  If on the other hand, this time is spent getting high all day and playing x-box live, then a trip to the therapist’s couch might be in order.  But even this young person is not beyond hope!  I for one would say that even if a young person appears “stuck”, they might be searching for something:  some kind of attachment or work that might give their lives the meaning they are trying to achieve on their “quests.”  In this sense, there is hope for all of us!

His decision, your outcome: dealing with father alienation

Thursday, March 31st, 2011

Today, I would like to talk about women who have never had a relationship with their fathers or any father figure while growing up.  In the field of psychology, we call this ‘father alienation.’  Even adult women who were raised with their fathers can still experience father alienation if their father was not available to them emotionally.  Whether the reason is that a father was not around or available to his little girl, for some adult women it has left a social and relational deficit when dealing with the opposite sex.

The adult woman from a family where she experienced father alienation can go without answers to some of the most difficult questions such as:  why did my father leave, and why did he not try to make any contact with me; why was he emotionally distant; and  how am I like my father?

She might also struggle with questions that can change the landscape of her relationships.  Those questions might be:  who will walk me down the aisle;  how do I relate to a man if I have never had a man in my life; and, where does he fit in my life?  For many women the answers to these questions have set them on a journey of unhealthy relationships, self-doubt, low self-worth and body image challenges.  The internalized pain of being abandoned and never being affirmed by the first man in a female’s life can take on the appearance of  biological and psychological disorders.

In addition, the unconditional positive regard that a little girl did not get from her father sets in motion a social, relational and psychological development trajectory that can result in that daughter growing up to be a woman who lives a co-dependant, unhealthy lifestyle.  Most women would like to believe that the impact (or lack of impact) of a father has nothing to do with the type of woman they have become, but most researchers and psychologists believe otherwise.  As a father shows unconditional positive regard to their daughter, that daughter observes her father on a deeper level with expectations of the future.  These futuristic expectations are grounded in four fundamental principals.

  • Positive Self-concept
  • Feeling confident in male-female relationships
  • Comfortable with showing affection
  • Healthy interpersonal skills

Each one of these principals are essential for raising healthy daughters who then turn out to be healthy women.

Have you experienced father alienation?  Let’s talk about it.  You might be surprised to find that you are not alone in living with the residue that father alienation has left like fears and self-doubt in your current heterosexual relationship.

What is Personality Reconstruction?

Saturday, March 26th, 2011

A term I use frequently in the work of therapy is “personality reconstruction”.  This term can cause a lot of misunderstanding.  I am not saying that I do not like people the way they are; I’ve always found something to admire in every patient I’ve ever counseled.

When I say personality reconstruction, I mean repairing the damage a person sustains through life. That damage is different for each person: trauma, loss, or some other set of events. This damage has prevented the person from actualizing their full potential self. For example, maybe a past trauma has stunted their progress towards his or her native talents and gifts; now, they are in an unbearable state because they aren’t living the life they were meant to.

The term personality reconstruction refers to the process of accompanying a person through whatever process they need to become the best person he or she can be.  Now the crafty among you are saying, “You’re mean I’m not being myself!”  To that complaint, I respond with a resounding YES!  Too many people walk through life not being the self they truly are; they are bagged by symptoms and know deep in their hearts that they are living some kind of false self.

In short, they are living a lie of some sort.

To borrow a term from Martin Heidegger, they are living an inauthentic existence, giving way to desires that are not truly their own.  They are living as if they are  part of the “herd”,  borrowing their ideas, affections, and even sense of self from everyone else but themselves.  What analytic psychotherapy does is afford a person the chance to become the person he/she most truly and deeply might be.   This process and even way of life is not easy;  it can put one at odds with former friends and lovers.  But as the French writer put it well, “Better to be hated for who one is than loved for who one is not.”

About client relationships: who is the alliance really with?

Sunday, March 20th, 2011

It happens not all that often, baruch Ha Shem, that one will have a young person in treatment that the parents decide needs to attend therapy less often than is clinically indicated. This is a real ethical dilemma.

On one hand, you are committed to the young person and their process. And they usually see the value more than the parents do, especially when the parents are not aware of whats going on in their life. On the other is the commitment the therapist made to the patient, to not demean oneself or one’s services. Even worse, one does not want to model how bullying works.

All too often, the discounted and diminished analyst becomes the object lesson in “This is how you don’t get walked on” and other misguided notions. Worst of all, though, is how the continued work with the therapist creates a rift in the young person’s attachment to the parents. Although this might seem like a good idea at first, creating and living with this kind of rift can only become the source of other attachment problems that will manifest later.

So the question becomes this: is some treatment better than none? In some cases the answer is a resounding YES. If the young person refuses to see any other clinician, and the problems are not set in the personality structure, then some short-term work might be ethical and acceptable. But if the problems are set in the personality structure; have had real-time consequences in his/her life; live in the disturbed attachment field (more on the attachment field later!); and have an inevitable quality to them, then perhaps the clinician has to have the humility to bow out. In this situation give referrals if that is possible. But be sure to keep the door open should some crisis emerge.

Oddly in these situations, crises have a way of rearing their ugly head. The act of setting the boundary with the parents can serve as a model for the patient; although boundaries might look odd and feel weird, they are necessary and help to keep everyone safe. To be on the safe side, document your decision and make sure you have assessed for safety. In this situation, it is the clinician’s job to worry about suicidality more than the parents, who will NOT hesitate to call counsel.

Most of all, trust your well honed clinical instincts, talk with other clinicians, and make sure your decision does not come from any other place but concern for the young person and good boundaries.  Our own unanalyzed counter-transference can always get us into trouble!

Therapy and Money

Wednesday, March 16th, 2011

Now this is a topic that usually gets A LOT of attention.  My approach is pretty simple.  Many times I envy my British colleagues; the government simply gives them a living wage for the year and basically says, “Take care of as many of your fellow citizens as you can.”

I wish I had that arrangement.

Unfortunately, I have to do things like billing and that is clearly NOT where my talent lies. My affection, regard and love for my patients are free.  But the basic needs of living – rent,  food and Bucke’s kibble – are not.  So what’s to be done?  The need is so great I could work 24 hours a day and still not make a dent. I’d burn myself out and ultimately be no good to anyone. Plus people are sometimes resistant to analytic therapy, and the process could become a mess that no analyst could untangle.

Why must people pay for therapy?

Paying for these services is standard and certainly beneficial to both the therapist and the patient.  Why?  A number of reasons:

  1. The therapist brings an objectivity to the encounter that NO friend or family member can. Sometimes that objectivity allows the analyst to say things that appear tough but are actually necessary.
  2. The therapist brings training and experience to the encounter.  This affords the patient greater expertise in how to deal with the issues that he/she is working on.
  3. The therapist also brings a focus on the patient that is unique.  Think about it:  how many times in a day does someone pay attention to you and only you for an hour, thinking only of ways to help move you from one place you don’t like to another you’d like more?  In this distracted society, that does not appear to happen too frequently.
  4. The therapist is available 24/7 – especially at SPARK.  Most people don’t want to “disturb” their friends and family at 3:00 a m.  But that is what the therapist is there for!
  5. The clinician should have no other agenda in the helping relationship.  There should be no thought of “if I do this for this patient, what can I expect from him/her?” I emphasize “should” because, unfortunately, some do not.

This kind of thinking leads to boundary violations and injuries to the self.  In this way, the fee requested for therapy allows the patient to know what should be the only “selfish” concern of the analyst.  The fee helps set a boundary that should help everyone feel safe,  or at least safer.  Once the payment of the fee breaks down, unless the analyst has excellent boundaries, the door is open to all kinds of trouble. And its usually of the sort that leaves permanent psychological scars

Finally, the old saying “that which comes too easily we esteem too lightly” appears to be true.  Every clinical study has shown that people who pay for therapy get better while those who get it with no cost tend to either stay stuck or get worse!  In this way, the little bit of “skin in the game” that therapists asks for is not that much in comparison to what the analytic relationship has to offer.

At SPARK we attempt to make therapy as affordable as possible.  But all too often, I have had patients attempt to manipulate a “bargain” or simply default on their obligation.  This can only make one wonder about that patient’s boundaries.  And if they are parents, as some would say, Oy gevalt!  (It’s Yiddish….Google it.)

One final example

If one had (Ha Shem forbid) cancer, one would not argue with the oncologist about the rads of radiation therapy.  Hopefully, one would trust that doctor’s experience, training, and wisdom.  The same holds true for psychotherapy.  As I have always said, psychotherapy is a relationship. Like all relationships, it is built on trust.  With no trust, there can be no relationship, and thus no true healing of body, mind, and soul.  And wouldn’t that be the point of going to therapy in the first place??

At the end of the day, it’s been my experience that everyone that goes to work expects to get paid a competitive wage for their work.  That seems fair.

The Pace of Therapy

Monday, March 7th, 2011

All too often, I hear people comment on how long therapy takes.  Having submitted to years of therapy myself I can appreciate the “When will this end??” feeling. But having sat with people in the process for as long as I have now, it becomes all too clear why the process of therapy takes as long as it does. There are many reasons, and I want to touch on a few of them now.

Finding and recognizing the symptoms

First off, it takes time to recognize what symptoms are and what those symptoms are doing to one’s life.  One has to maintain hope that change is possible. All too frequently, people live with these symptoms for a long enough time that they begin to identify with them; they think of themselves AS their symptoms. They subsequently forget that there is a symptom-free, optimal life.

Family and Friends that enable us

On top of all this, there are all the usual suspects of family and friends who, consciously or not act, as enablers for people’s symptoms. For example, many addictions specialists will tell you that recovery often involves a total rearranging of a person’s social spheres.

Eventually for the patient to live that symptom-free life, they must let go of ALL the things that hinder them from getting there. And “things” can very well include people.

The fear of recovery

Finally, there is the fear. We all react differently to our fears. Some work hard to burst past them, while others succumb to it. Some of those in therapy have a fear of recovery, of becoming well.  And this can take many shapes including the fear of the unknown to fearing that people will not love the new person that emerges from treatment.

Coping with that fear is done at the patient’s own pace. Once they have dealt with the emotion in a healthy way, the process can continue to move forward. But there is no race; the therapist wants the patient to understand that these things take time and no one is judging.

These are just a few of the factors that can slow down the pace of therapy, not to mention the usual interruptions that can get in the way.  Thus, perhaps therapy moves a lot more quickly than we give it credit.  Or perhaps the real secret is:  therapy moves at the pace for which we’re ready, and no faster……or slower.