Saturday, August 12, 2017

Make Yourself One of the People You Care For...

"Don't compromise yourself. You're all you've got.”  - Janis Joplin
Mary's story is not unique. Mary does not know how to say "no" to the other people in her life. Her husband and grown-up children have become accustomed to her meeting their small or big demands. Her extended family takes her for granted when they unilaterally assign her with tasks and responsibilities for family situations and events. Her friends know that she will drop everything and come to their aid and rescue in their latest crisis at all times of day and night. Her co-workers and supervisors praise her for taking on any additional roles and tasks that need to be done, without expecting credit or compensation for the inevitable sacrifice of her weekends or planned holidays. In therapy, Mary complains about the excessive demands placed on her by all the people in her life and their lack of understanding and caring for her boundaries and personal time.

Mary's story is not unique. Almost everyone knows someone like Mary in their life. In my own experience as a therapist, I have seen this issue arise in individuals from just about every culture, race, ethnicity, gender, age, socioeconomic status, among others. Mary could very well have been Maria, Miriam, Meena, Mark, Mario, Dr. Ming, Madison and so on. The fundamental issue is a very human issue. It speaks to the challenge of having a balanced approach towards oneself and those around us.

A big picture issue in this dynamic is the obvious dissonance between being a very helpful and resourceful person for others, while having a passive and helpless experience when it comes to oneself. It is like playing a board game with the only rule being that the one person you cannot help is yourself. As we search deeper for the reasons for this anomaly, we most likely encounter the tendency to view the self-other issue as all-black or all-white. If we seek the choice as only helping others versus only helping ourselves, then as "good" people, we are inclined to take the first choice. Thus, we play out the pattern of being a "good" person, who always helps others, because the perceived alternative is to be a selfish or "bad" person.

The good news is that we can learn, through therapy or in other ways, to move to a more balanced approach towards the self-other dynamic. Once we learn that helping the personal self is not always bad, we can allow help to reach us when we need it. One technique I have found helpful with many patients is helping them imagine a line of people that they are supposed to help, with each person getting a turn and then going back in the line. I ask them to imagine themselves getting a turn as well, making themselves one of the people that they are supposed to take care of. Not always first, but not always last either, getting their turn just like everyone else. This helps people to open a channel towards self-resourcefulness and allowing them to bring the considerable skills in the business of being helpful to the parts of them that could do with that help. This helps shift treatment as well as the direction of life towards more positive and self-affirming paths. Charity does indeed begin at home. 

Monday, January 30, 2017

My Own Worst Enemy

"Education is a progressive discovery of our own ignorance." -  Will Durant

The story is a familiar one.

A scorpion asks a frog to carry it across a river. The frog is afraid that the scorpion will sting it. The scorpion promises not to do so and gives a valid reason to the frog that if it stings, they will both drown. This makes sense and the frog agrees to carry the scorpion. In the middle of the river, the scorpion stings the frog. The surprised and dying frog asks the scorpion, "why did you sting me knowing that you will die too?" The scorpion said, "I couldn't help it, it is in my nature..."

This story reverberates with almost all of us. Who hasn't given valid reasons and made resolutions, only to abandon them soon after? This story especially stings, pardon the pun, in the context of mental health and for the patients who are struggling with it. A common refrain from patients is that "I am my own worst enemy."

Patients often state that even though they know what is best for them, they find themselves unable to change their maladaptive behaviors. These behaviors emerge as unhealthy habits, destructive patterns in relationships and substance abuse, to name a few. Many times, it is easy to see the problem but difficult to understand why it keeps appearing or how to resist yet another repetition of the pattern. The issue that arises from this dilemma is whether this is an innate and fixed part of the person or can this be changed to a more constructive outcome.

Entire books can, and have, been written on this topic. However, let us attempt to highlight a few key issues that surround this subject. The starting point of the inquiry is that a person is aware of a disconnect between his stated values and his actual behaviors, and is wondering why. Let us leave the topic of not even being aware of disconnects for another discussion. Also, there are various methodologies, especially cognitive-behavioral therapies, that do not focus on why there is a disconnect and instead directly attempt to help with reducing or eliminating this disconnect, and this can be a perfectly acceptable outcome in many cases. However, it may be preferable, or even necessary, to understand the root causes of the behaviors, as opposed to their immediate triggers.

Looking at the bewildered frog, and even the bewildered scorpion, we encounter the limits of conscious experience. This wall is not a static entity but it stands in a fixed place at any given point in time. We only "know" what is on our side of this wall while what is on the other side is not "known," at least in the conscious sense. The problem is that even when we exhaust all the answers on the conscious side, we do not venture into the "other" side of conscious experience. We have a dim awareness that this other side is dangerous, perhaps mystical, perhaps horrifying, at any rate, to be avoided at all costs. So we keep looking in the same places, hoping to find something new and safe. 

The important idea is that the other side does not have to be a threat. Since the beginning of psychotherapy, there have been efforts to normalize the hidden parts of the self. Freud believed that if a person could say anything that came to her mind, or analyzed her dreams, and other such practices, she would realize that the "unconscious" material did not need to be cut off or "repressed" from conscious awareness. Jung illustrated many forms that hidden awareness can take, reflecting archetypes found in the cultures of the world. His idea of the "shadow" highlights the same issue of what is hidden but can be eventually seen, perhaps with the help of a psychoanalyst or psychotherapist. There have been many other contributors to this concept from all sides of the psychotherapy spectrum. Some that come to mind are Assagioli's ideas on Psychosynthesis, Schwartz's Internal Family Systems theories, Beck's notion of underlying schema, McCullough's
Affect Phobia and Bromberg's self-states. The mechanisms are cognitive and emotional in nature and utilize processes having labels such as denial, repression, dissociation or avoidance. However, all of these theories and theorists expound the idea that rather than a hostile part of the self that needs to be cut off, there is a misunderstood part of the self that needs to be integrated into conscious awareness.

The benefits of this perspective are enormous for mental health. This approach can help replace the internal conflict between unconscious motivations and conscious frustration. Our cut off parts can become more integrated and visible, and we can access more sides of ourselves in our daily lives. To extend the metaphor a bit more, we can go from being our own worst enemy to being our own best friend. As many patients can attest, it is better than it sounds.

Thursday, December 15, 2016

Mental Health Stigma and Personal Identity

"The only thing shameful about mental illness is the stigma attached to it." - Lindsay Holmes

A while ago I had a familiar experience. At the Please Touch Museum in Philadelphia, I ran into a South Asian Indian ("desi") family, who had driven down from New Jersey to the museum for their three-year old's birthday. We started talking and our conversation reached the inevitable "so what do you do?" I found out that the husband and wife both worked in IT. When it was my turn to answer, I hesitated.

I am a Clinical Psychologist. I do psychotherapy, psychological assessments, lead therapy groups and conduct evaluations for patients struggling with mental health issues. I work with individuals and families dealing with depression, anxiety, mania, hallucinations, delusions, post-traumatic stress disorder, personality disorders, substance abuse, suicidal thoughts, other self-injurious behaviors, relationship issues, adjustment issues and the task of finding self-knowledge, meaning and purpose in their lives. I work with children, some as young as four years old, to help them successfully overcome present challenges so that these do not build up and result in full-fledged disorders later on. I also teach and do research, mostly related to mental health issues.

I answered that I was a researcher. It was not a thought-through statement. Just the first thing I could come up with in my hesitation. I had a feeling of short-changing myself even as I said it but it had already been said. Later that day, I reflected on why my gut reaction had been to portray myself as a "scientist," which of course, I am, but not a "practitioner," which I am as well. With most Americans, I do not usually hesitate to present the practitioner side of my professional identity. I realized that in this exchange, my South Asian roots had played a significant part. Many a times when I have introduced myself as a psychologist, I have often observed an alarm reaction from South Asian acquaintances. There is a noticeable discomfort, as if a family secret had been revealed, or that the secrets are now threatened by the mere presence of a therapist. The mention of psychology is considered better avoided. Their hesitations are similar to mine, they come from the same place.

Growing up in India, it was not difficult to see the shame of mental illness. The stigma of mental illness casts a net wide and deep. As it is a society driven by family reputation, members of families commonly hide their own symptoms of mental illness or of their family members. Denial is the default coping mechanism. There is a strict demarcation between "normal" and "mental", and nobody in their right mind would allow any identification with the latter. Statements such as "mad or what?", or in Hindi "paagal hai kya?" and derivations thereof are common parlance. And if a little "mad" is a problem, then a lot is a disaster. The treatment of severe mental illness is abysmal and the outcomes for those suffering from it are horrendous, The problem itself is not acknowledged, therefore never solved.

South Asian culture is hardly unique in having stigmatizing attitudes towards mental illness. Western culture tends to have greater individual stigma based on the concepts of independence and self-determination. Other cultures exhibit greater social stigma towards mental illness. However, this is not a litany of any culture, it is a reflection on my experience within these two cultures and the questions that emerge from that. What can we all do to change our default attitudes towards mental illness? It is quite a task to eradicate the stigma of mental illness from a culture but we can all take small steps. For my part, I decided to make the conscious effort to always introduce myself as a clinical psychologist in the future. I hope that people at the other end of that introduction can examine their attitudes towards the "mad," "paagal" or "mental" people, and those who work with them, and respond not with labels and stigma but with tolerance and acceptance.

Monday, December 5, 2016

Love Thy Enemy - Melanie Klein and the 2016 US Presidential Election

“When there is no enemy within, the enemies outside cannot hurt you.” - African proverb

In the weeks before and after the US Presidential patients and colleagues alike have been drawn into the incessant pull of a partisan political climate. The United States has just witnessed a bitterly fought presidential election laying bare the fault lines of divisiveness within this nation. What has been striking has not been the divisiveness per se, but the extreme, one-sidedness of each camp, as exemplified by the notion of living in “bubbles,” impervious to contrarian influences. Witnessing this isolation of viewpoints in Facebook feeds and self-selected news sources, a question arises in my mind about what can the study of psychotherapy provide as a guide to the current predicament of this divisiveness. President Obama in his State of the Union address in January 2016 expressed his regrets about the increased divisiveness of the politics in the country. Things apparently did not improve in the rest of the year as well. As President Obama pondered about the politics of this chasm, we can attempt to understand the psychological underpinnings of it.

This election defied logic. Apparently during the election, there were rule-breakers on both sides but the people who were absolutely shocked at the rule-breaking actions of one party’s nominee were unperturbed by the rule-breaking behavior of their party’s nominee. There was also the strange phenomenon of people being absolutely shocked by the statements and behaviors of a candidate in the primaries but miraculously becoming unperturbed by those statements and behaviors after the candidate became their party’s nominee. The election cycle teemed with rage, disgust, the propensity of seeing the world as black or white. Partisan news organizations and social media accounts repeated portrayed the “other” as the object of the hate and ultimately, destruction. The permeating belief was that MY nominee was a human being of good intentions, but with human flaws, but YOUR nominee was the devil incarnate, needing to be erased from the planet!

As this point, anyone familiar with the history of psychology hears a few familiar notes on a theme. Anyone who took an Intro to Psychology college course might recall mentions of the development of psychoanalytic thought and within it, the development of object relations theory, attributable to the work of Melanie Klein. In the 1930s, Klein formulated important ideas in psychological maturation on the basis of her work with young disturbed children. Klein postulated that infants begin to internalize caregivers as objects. These objects are mental representations of an actual other, primarily a caregiver, whom they perceive as good when the other fulfills their needs, and bad when their needs are not met. Eventually, the child internalizes this split between good and bad, and comes to perceive herself as good or bad at different times. Healthy psychological development occurs when the child is able to integrate the good and bad aspects of self and others (love and reparation) and move from a fragmented, anxiety-driven state of good versus bad (paranoid-schizoid position) to a more nuanced, reality-based appreciation of the good and bad aspects of the same person, including oneself (depressive position). The children who do not successfully make this transition remain trapped in a state where they have a constant need for self-validation, to be seen as a  good object, with a corresponding constant need to expel the bad object from within themselves and locate it in another person or entity. Freud had described a process of painting others with the disowned aspects of the self (projection). Klein went a step further and described a process where a person takes actions to not only project unto others but to engage with others in a manner so as to evoke a confirmatory response of their badness. She called this process projective identification.

We can view the communication between the two parties and their allied media bullhorns, for the most part, as projective identification. If all statements and actions become attacks, and all defenses and counter-attacks are confirmations of the other’s badness, then we start living in a fragmented sense of reality, perpetually winning or losing the sense of self with every news cycle. This is why a question in the second presidential debate regarding an appreciation of the other candidate seemed prima facie ludicrous to so many observers. How is it possible that there is anything redeeming about the other? That is after all the bad object, unidimensional and expendable. How can you ever support THEM?

The media supported this split as it does make for entertaining reality TV. Headline after headline proclaims the newest confirmation of the other’s depravity and disgusting behavior, while validating the self as all-good, suffering, enduring and above all, beyond reproach. The fragmented self looks outside for confirmation of its views of the good self and bad other and the media and the politicians are eager to provide it. The fragmented self makes for reliable votes and higher ratings. It does not matter which side the other represents, as long as there is an other.

It is important to note that integration does not mean a blanket tolerance of the other. When the other treats another as the other, then it should be met with proportionate resistance. The danger lies in the adoption of Klein’s paranoid-schizoid position in the face of either victory or defeat, refusing to accept that the other even exists or the unthinkable, the other now prevails! Not all ideas are created equal but all human beings are, and recognizing the complexity and nuances allow both a child and a populace keep themselves grounded in reality. The antidote, as Klein put it, is love and reparation, the ability to have respect for the separate other, that you can argue with a part without destroying the whole. Voting in an election, as well as living in a democratic society, should be about subjective identification, not projective identification. Ironically, we really are all stronger together.

Saturday, November 26, 2016

Pain is pain

"Be kind, for everyone you meet is fighting a hard battle." - Plato

An idea that people in therapy and outside often struggle with and that can help gain perspective on emotional distress is: pain is pain.

In therapy groups that I lead, people are helped to share stories of the pain that they have experienced in their lives. Sharing the burdens we carry is therapeutic, as is providing support to others as they share them. However, as we listen to each others' stories, our analytical parts of the self begin to evaluate and categorize. We find ourselves tuning into the judgmental voices comparing others negatively in relation to our stories. We think of examples such as:

“Is that it? Your mother just shouted a lot at you?”
“You were just bullied in school. Give me a break.”

This perspective is not helpful. Emotional abuse, such as constant  shouting, can be equally traumatizing as physical abuse. In fact, some research has shown that counter-intuitively, emotional abuse alone is more damaging that emotional abuse coupled with physical abuse, presumably due to the relational aspects of physical abuse. Similarly, a person may only be able to verbalize only one set of abusive experiences at this time, such as being bullied. Looking down on others’ pain can give a feeling of superiority, but it is likely to be unproductive in the long term.  
The same experience can occur from the opposite standpoint of viewing our experience as less negative as compared to others. Examples include:

“Oh my God! She was sexually abused as a child AND a victim of domestic violence. I have gone through nothing as compared to that.“
“His father and brother BOTH committed suicide and he is struggling with a drug problem! What right do I have to be sad about my life?“

Looking down on our pain can be just as unskilled. Listening to the traumatic stories of others and consequently minimizing our own, can only provide temporary relief. This only contributes to masking our own struggles and is of no help in the moments when we do encounter our own pain. In the end, both types of comparisons are unhelpful and possibly misleading.

Modern neuroscience tells us that emotional pain is not even different from physical pain. The same regions of the brain appear to be involved in both types of pain. The differences in pain may be considered more due to their frequency, intensity and duration rather than their causes. However, in most cultures, we are taught that somehow physical pain is “real” but emotional pain is “all in your head.” We commit, in clinical psychology terms, what is called a fundamental attribution error in social psychology terms. We attribute external causes to physical pain but internal causes to emotional pain, as if we bring only one of these on ourselves.

It can be concluded that rather than differentiate categories of pain, it would be skillful to focus on the ubiquitous prevalence of pain. Comparing one person’s pain with another, emotional or physical, takes away more than it gives. The Buddha’s first Noble Truth is that “Life is suffering.” Plato exhorted us to be kinder, as he saw everyone fighting a hard battle in life. Nothing much has fundamentally changed on this subject in the millennia since these observations were made. Pain is still built into the human condition. In fact, all pain is pain. Let us respect that, and then we can go about alleviating it.