Programming your brain

The human brain is wired to be adaptive. We humans are “the magic animal” because we can imagine things that don’t exist and create them, and see things not only as they are, but as they could be. Our limitations as individuals are often determined by our limited thinking. As a therapist I sometimes had the privilege of working with people whose goal in therapy was personal growth, and of seeing them grow. Two fundamental questions for such clients are, “How do you want to change?” and “What do you see as hindering you from making that change?” Insight may play a role in the process of choosing to change your behavior, but it often requires learning and practicing new skills. One of the psycho-educational groups I used to teach was “Skills for Growth.”

One apt metaphor for growth psychology is upgrading your mental programming. A good therapist can help people to identify outdated or defective programs in their operating system, and to upgrade them with new “software.” There’s growing evidence of the brain’s neuroplasticity, which is to say that behavioral changes can actually “re-wire” synaptic connections in the brain, making it easier to maintain the new behavior.

We all inherit beliefs from our social environments as we grow up, whether those beliefs shape our behavior in a functional or dysfunctional manner. Clusters of beliefs about this or that aspect of life are known as schemas, and they guide our behavior for better or worse. For instance, Fred grew up in a family where his father dominated his mother, sometimes yelling at her and slapping her around. His father taught him that the husband “wears the pants in the family” and that sometimes husbands have to hit their wives, to remind them who’s boss. This is Fred’s schema – mental model – for marriage until he falls in love with Susie, who believes (like her parents) that husbands and wives should be equal partners in marriage. So Fred goes to pre-marital counseling with Susie, at her insistence, and realizes that she’ll never be a submissive wife like his mother. He comes to realize that his  “marriage programming” is outdated and needs an upgrade, if he wants to marry Susie. So he listens and learns, upgrading his schema regarding marriage.

Similarly, Angela may decide that she needs to replace her stress relief schema and stop relying on alcohol and other drugs to chill out. And Paul may decide that he doesn’t like being programmed for dependency, and install new programming for increased autonomy and initiative-taking. Upgrading your programming doesn’t necessarily require the help of a therapist, if you’re a self-starter. Once you become aware that there are upgrades for obsolete or ineffective programs, you can re-program on your own. New possibilities become visible when we change our thinking and examine our attitudes.

We can use mnemonic devices – memory aids – to change bad habits, setting rules and keeping score to systematically reinforce desired behavior changes. As an example, I decided to establish a zero-tolerance policy regarding my occasional failure to turn off stove burners or the oven after cooking. I chose as my mnemonic device turning on the stove light whenever I’m cooking. Ideally, I don’t leave the kitchen to eat until I’ve turned off the light, and I don’t turn the light off until I’ve made sure that all the burners and the oven are turned off. This works most of the time. The consequence for leaving a burner or the oven on after I’ve finished cooking is that I record it on a calendar that hangs near the stove. I don’t like having to record failures, so in the language of behavior modification this is a mildly aversive consequence. But it’s enough to shape my behavior in the desired direction, and I have an accurate record of my rate of behavior change. It’s been over six months since my last transgression, and I intend to keep on with my protocol until I’ve “extinguished the target behavior” entirely, and go for a whole year without a slip. By then I will have created a new reflex behavior and, perhaps, a new synaptic connection in my brain.

Behavior modification is all about targeted and systematic behavior change, but you don’t have to be in therapy to use the principles to re-shape your behavior. You can set goals and create your own plan. Announcing your goal to friends and loved ones, and establishing meaningful consequences for not making measurable progress toward your goals, can help. Consequences can include positive reinforcers (rewards, tangible or intangible), negative reinforcers (withholding positive reinforcers), and/or aversive consequences, like marking your calendar every time you fail to achieve your target behavior, or having to admit to your friends that you didn’t meet your goal.

Mental rehearsal is part of programming ourselves – positively or negatively – for the achievement of goals. We rehearse for upcoming events in our minds, sometimes encountering anticipatory anxiety. Sometimes we reflexively rehearse for failure, ruminating about everything that could go wrong in our upcoming performance, whether on the stage, in the bedroom, or in the conference room. Sometimes we give up and stop trying because we convince ourselves that we can’t succeed. Rule number one in rehearsing for success is not to ruminate on failure scenarios, or to focus on your doubts and insecurities. Rule number two is to actively rehearse for success, behaviorally and attitudinally. If it’s a public performance of some kind, practice, practice, practice until you’ve got it down to a reflex. And then harness the power of your imagination to rehearse for success. If it’s a public speaking engagement you’re nervous about, perform it in front of a mirror repeatedly and imagine the enthusiastic applause you’ll get – or even a standing ovation!

Teaching psycho-educational groups, I used to cite a psychological experiment I’d heard about in which two groups of ten people with average basketball free throw skills were to have ten free throws for record, to see whether Team A or Team B would score more baskets. Team A got to have ten practice throws before throwing for record. Team B was told to relax and visualize ten perfect throws in front of a cheering crowd. Obviously, Team B scored higher. While the members of Team A sunk some baskets and missed others while practicing, the members of Team B had a mental set of 100% success. I can’t give you a reference to this particular experiment in motivational psychology, but I can tell you that visualization of optimal performance and success is an important element in sports psychology. Visualizing positive outcomes – rehearsing for success – can help anyone to perform at their best, if they’re well-prepared.

If we discover that one of our mental programs/schemas is obsolete and limits our potentials, we can upgrade to an improved program that allows for new possibilities. Our past is not our potential.

 

Anger Management II

My father was an Army officer and a strict disciplinarian, but he was a gentle man by nature and never spanked me when he was angry – except once.  When I committed a spanking offense such as lying, he might get angry, but would order me to go to my room and wait. By the time he came to administer the punishment,  he’d have calmed down, and would hug me soon afterward, to let me know all was forgiven and that he loved me. He did the same with my brother and sister. Spankings were few and far between in the Koob household, and none of us children were ever called “bad” or “stupid.” None of us were ever slapped or beaten.

I’m extremely grateful to have grown up in a loving family, with minimal use of corporal punishment. But I’m also grateful that my father slipped that one time and spanked me, not because of something I’d done, but because he was angry. I still remember the feelings of helplessness and rage that accompanied the physical pain. I’m grateful because my father’s slip gave me a taste of what it’s like to be physically abused, and it heightened my empathy for victims of abuse. In my career as a therapist I would work with many men, women and children who grew up in families where physical and emotional abuse was commonplace. One of the most common “invisible scars” of abuse is  residual anger.  Sometimes a reservoir of accumulated rage erupts as angry or destructive acting-out; sometimes the rage is repressed, and manifests as depression.

People who have temper problems usually came by them honestly. If some – or many – of the adult role models in a child’s social environment are physically and/or verbally violent, violence can become normalized. Violence is a sad legacy in some families, passed on from generation to generation. But it only takes one generation to break the chain of family violence, and I’ve been privileged to work with parents who were determined not to do to their children what was done to them by their own parents.

I’ve taught anger management to many parents who were ordered into counseling by family courts, as well as people who entered counseling voluntarily because they had anger issues to deal with. I’ve also taught anger management to groups of cops, parents, teachers, and Marine Corps drill sergeants. I started my group presentations by talking about the origins of anger control problems, the importance of parents role-modeling the non-violent resolution of conflicts, and my guidelines for spanking.

It is sometimes possible to raise a child well, without using physical pain as a teaching tool. But if a parent finds it necessary to use corporal punishment, it should be the punishment-of-the-last-resort. If you have to spank a child frequently, it’s not working; find out what does. Finally, never inflict pain on your child when you’re angry. All you will teach him or her is to role-model that it’s okay to hit when you’re angry. After a calmly-administered spanking, make sure the child understands why you felt the need to spank in this instance, and express your love, verbally or with a hug. If you slip, like my father did, you owe the child an apology.

Learning anger management doesn’t mean you won’t get angry anymore. Everybody gets angry sometimes- except maybe the Dalai Lama. My definition of practicing anger management is that you can still make good decisions, no matter how angry you are. You don’t do or say things you’ll regret later. As with stress management, the first step in learning to manage your anger is a self-assessment. Knowing the “why” of your anger problem isn’t as important as knowing the “whats.”

How does your anger typically manifest? Aggression, passive-aggression? Physical harm to self or others? Verbal aggression? How does your anger management problem affect your life? What are the predictable triggers  for your anger reactions? What are your cues? (Physical signs that you’re angry, such as a rapid heartbeat or a flushed face.) Once you’ve completed your assessment, you’re ready to try out whatever physical and mental anger management techniques you think might help you to change your behavior.

Physical anger management. If one of your cues for anger is rapid breathing, you can learn breath control. If muscle tension is a cue, you can learn to relax the muscles you typically tense when you’re angry. The key is becoming mindful of your triggers and cues. You can learn to physicalize your anger in a non-threatening and non-destructive manner, jogging, or doing pushups, or working out on a punching bag. If you can walk away from the situation that triggered you, you might be able to regain your cool quickly. Other factors in physical anger management are  adequate sleep and good nutrition.

Mental anger management. I’ve already written several posts about rational thinking, and think it’s the key to mental anger management. If I give situations and other people the power to “make me mad,” I’ve placed the locus of control outside of myself; I blame externals for my anger and for my behavior when I’m angry. If my locus of control is internal, I understand that I generate and sustain my own anger in response to things that happen (or don’t happen) in my life, and can control my behavior no matter how angry I am. If I know that someone is trying to trigger me, I can deny him the satisfaction. People who don’t rise to the bait can’t be hooked.

I’ve had the advantage of going through a “plebe system” at The Citadel – a military academy – which is like nine months of boot camp in the armed forces. I’ve had the experience, multiple times, of having an upperclassman scream in my face, or make me do pushups until I collapsed in a pool of sweat. Although I wanted to punch some of my antagonists, or curse them and walk away, I had to remind myself that this wasn’t personal. If I wanted to graduate from The Citadel, it was something I had to endure for my freshman year. I now see that, like boot camp, it was a stress inoculation,  and a preparation for combat.

Anger is a universal experience, and isn’t necessarily a bad thing. It’s fully justified in some situations, and may even help us to survive, as with a soldier in combat. Practicing anger management means knowing that you’re in control, even when angry.

Hypnosis

Hypnosis isn’t just one thing, but describes a range of mental states in which one is receptive to suggestions. Stage hypnosis and clinical hypnosis aren’t the same phenomenon. There are a number of popular myths and misconceptions about hypnosis, and several models to explain hypnotic phenomena. I learned the basic techniques of hypnosis in grad school and practiced on friends. But since I never got certified as a hypnotist, I limited the use of hypnotic techniques in my clinical practice. I usually only did one “trance induction” per client, when it seemed appropriate, with the goal of teaching them self-hypnosis while they were “in a trance.” Outside of work, I’ve hypnotized friends at their request, for such things as pain relief.

I put quotation marks around trance because trance induction is only one model – the best known – for hypnosis; but no model is perfect for all occasions. (See my past post on the Model Muddle.) Traditional trance induction involves a verbal induction, which may start with something like “You are getting very sleepy . . . .”, sometimes accompanied by a visual stimulus such as a pendulum, whose motion the subject is told to follow with his eyes. But some verbal inductions suggest that the subject’s eyelids “are getting very heavy” and will soon shut. A technique called guided fantasy can also induce a trance, as can a well-told story.

Stage hypnosis is another thing entirely. The silly on-stage behaviors  of the “hypnotized” volunteers from the audience appear to be best explained by a social role model of hypnosis. This role-playing proceeds from one of the popular myths about hypnosis: that the hypnotist can control his “subject’s” behavior. Anyone who comes forward when the stage hypnotist invites volunteers is a wanna-be performer, predisposed to do whatever he’s told. The hypnotist “auditions” the crowd to see which people are the most suggestable, weeding out the less suggestable. The volunteers he selects to go on stage know they’re absolved of all responsibility for any silly  thing they may do, because they’re seen as being under the hypnotist’s control. He earns his paycheck before his subjects are on stage, because he knows the people he’s selected will act-out the role of hypnotic subject, as it’s popularly understood.

Some people are better hypnotic subjects than others, and clinical hypnotists have ways of assessing “depth of trance” before making therapeutic suggestions. They don’t exert control over the behavior of their clients, but help them harness the power of their imagination and will, to bring about desired changes in behavior. A good hypnotic subject is one who wants to experience a trance state, and expects something good to come from it – if only a feeling of relaxation. It helps if the subject thinks hypnosis can help them achieve a desired goal, such as pain control, quitting smoking, or losing weight.

A good subject can be taught self-hypnosis, and learns that any power she’d thought resided in the hypnotist in fact resides within herself. When a placebo pill works to relieve pain, it’s because the person taking it wants and expects it to – another example of how motivation affects perception. People can learn to use trance to re-direct their mind away from pain,  or from nicotine cravings. Naturally occurring events can  temporarily result in relief from pain. If you were flying in an airliner while you had a splitting headache, and the plane experienced extreme turbulence for two minutes and seemed to be falling out of the sky, it’s likely that you’d lose all awareness of your headache for those two minutes. If panic can re-direct the mind away from pain, so can other things.

Post-hypnotic suggestions can help people to change behavior, but there’s nothing magical about their power. A hypnotist working with a client on smoking cessation will give positive suggestions while he’s in trance, then may give post-hypnotic suggestions that he won’t feel like smoking after the session, and if he does smoke, the cigarette will taste terrible. What the hypnotist can’t supply for the client is willpower. If the client takes a puff after the session and throws the cigarette away because it tastes awful, this experience may help him to fight cravings and stop smoking. But if he resumes smoking despite the initial bad taste, the post-hypnotic suggestion quickly fades.

The only “magical” element of hypnosis is the magic of the human imagination. Hypnotic subjects don’t lose control in trance, and can’t be hypnotically forced to do things they don’t want to do. People can’t get “stuck” in trance. While positive hypnotic suggestions can help people marshal their inner resources to change chosen behaviors, there’s no truth to the notion that it can improve memory or sharpen the recall of details of past events. Indeed,  it can encourage the development of false memories.

In a later post I’ll be writing about Ericksonian hypnotherapy, which revolutionized our understanding – and the practice – of clinical hypnosis in the latter half of the twentieth century. Dr. Milton Erikson was a genius psychotherapist, whose influence on the profession is evidenced by the fact that the Milton Erikson Foundation sponsors the Evolution of Psychotherapy conferences – the world’s largest convocation of psychotherapists.

Stress Management

We’ve all heard that prolonged stress negatively impacts our health, but stress isn’t necessarily a bad thing. Dr. Hans Selye, one of the pioneers of stress management, said that stress can be “the spice of life or the kiss of death.” He labeled negative stress distress and positive stress eustress. If we choose to ride a rollercoaster, or to scale a cliff, or watch a horror movie, we’re choosing to experience stress. Stress is an unavoidable fact of life, and a stress-free life would be an uneventful life – boring. Sexual excitement is a form of stress, and we all enjoy an adrenaline rush from time to time, especially if we chose the stimulus that triggered it.

Our autonomic nervous system, which regulates automatic behaviors, has two branches: sympathetic and parasympathetic. Both are involved what Dr. Selye called the “fight or flight” response. Activation of the sympathetic response gears us up, preparing us to fight or flee, whether or not we’re in danger. Heartbeat and breathing instantly become more rapid,  delivering more oxygenated blood to the brain and the extremities. Blood pressure and blood sugar rise, muscles tense in anticipation of action, and you may experience a jolt of adrenaline. After the event or situation that triggered the sympathetic response is past, the parasympathetic branch kicks in, reversing the fight or flight response and allowing us to “rest and digest.” We’re told not to go swimming right after eating a meal, because our blood flow has been re-directed from our extremities to our gut, increasing the possibility of a muscle cramp.

The fight or flight response evolved to help our ancestors to avoid being eaten and to hunt dangerous prey. If you’re a soldier in a combat zone, or a cop, or a firefighter, you may experience it on a regular basis. But although only a few of us in modern society frequently face physical peril – other than heavy traffic – we respond to perceived existential threats, even if we’re not actually in immediate danger. Combinations of financial, social and environmental stressors (How am I going to pay the rent? Is my wife being unfaithful?) can result in a high level of distress, sometimes manifesting as anxiety.

Anxiety is similar to fear, although the causes might be multiple and may not be immediate physical threats. A person having an anxiety  attack may experience their fight or flight response as paralyzing. Once you’ve had one, your fear of having another one becomes yet another stressor in your life. If you only occasionally have fight or flight reactions, stress may not be a significant factor in your health. But if you have them frequently, your health may be affected. But frequent fight or flight reactions aren’t the only stress-related threat. Chronic overstress – having more on your plate than you can handle – can kill.

Stress management doesn’t mean eliminating stress. It means controlling the amount of stress in your everyday life and, where possible, eliminating stressors. There are both physical and mental aspects to stress management. But first you need to identify the sources of stress in your life, your triggers for stress reactions, and how stress affects you.

If you need to practice stress management, start with an inventory of your stress factors: job security and satisfaction, finances, safety, residential issues, and personal relationships. Think of how you might be able to reduce unwanted stress in each area. It may mean some tough choices. Then list the kinds of situations and events that tend to trigger stress reactions. Being aware of your stress triggers may help you to prepare for them or learn ways to avoid them. Become more aware of how you typically respond to stress triggers and overstress. Do you somaticize (physicalize) it into headaches or bellyaches or backaches? Do you stay angry or depressed? Do you worry excessively? Anxiety has many faces , including free-floating (generalized) anxiety, panic attacks, and phobias – including social phobias. After doing this analysis of the role of stress in your life, you’re ready to look at physical and mental stress management techniques.

Physical stress management techniques include breath control, learning to relax your muscles, meditation, self-hypnosis, yoga, exercise, good nutrition, and adequate sleep. Avoid self-medicating with alcohol or other drugs. If you’ve listed rapid breathing as a stress symptom, you can learn to slow your breathing when you’re under stress. This helps to bring the fight or flight response under your control. There are many techniques for relaxing tense muscles, and relaxing the body tends to simultaneously relax the mind. I used to teach clients a method of focusing on the sensations in each of the muscle groups of the body in turn, tensing and relaxing each muscle group until they became aware that they could relax them at will by focusing on the changing sensations. It’s a form of mindfulness.

Learning time management or anger management might be part of your stress management plan. The best single mental stress management I’m aware of – besides meditation, which calms both body and mind – is rational thinking. (I’ve previously published several posts on rational thinking as a learnable skill.) Any stressful situation can be made more stressful by the way we think about it, and the effects of stressors in our lives can be minimized by thinking about them rationally. Failing to achieve something you wanted to achieve doesn’t make you “a Failure.”  Telling yourself that you’ll never get over a loss can be a stress-inducing self-fulfilling prophesy. Thinking that they “can’t stand” something has never helped anyone to cope with distress.

Some stressors can be minimized or overcome, others can be tolerated until circumstances change, by developing coping skills. We can all learn to manage our stress to some degree, if we understand it for what it is and make a conscious effort to control its effect on our lives. Coming up with your own personalized stress management plan and implementing it can help you to become more resilient in times of adversity, and might add years to your life.

 

What I learned in prison

Hey, I only worked in prison, honest! I’ve been inside many jail and prison cells during my years working in community mental health and Corrections, but I’ve always been able to leave them at will. Correctional institutions are as close to Hell as I’ve ever come, or want to come.

My first job at a correctional institution was at South Carolina’s largest juvenile prison, where I did counseling, clinical and psychological assessments, worked on a treatment team, gave testimony at parole board hearings, and co-led treatment groups in the sex offender treatment program. Years later I worked at two maximum security prisons for males, with visits to the women’s prison to co-lead groups. During my three years as a psychologist at the Intermediate Care Unit (ICU) – the “mental health” unit of South Carolina Corrections – I routinely visited the Administrative Segregation Unit (solitary confinement) and the prison psychiatric hospital, and even went on the Supermax Unit, where the worst-of-the-worst criminals in the state are housed. I’ve had career criminals, rapists, murderers, and other violent felons on my caseload. I was once sucker-punched by a legless man on the prison yard, but I’ll save that story for a later post. One thing I learned was that incarcerated people know two distinct worlds, with totally different sets of rules: Inside and Outside.

Another thing I learned was that all too often prisons are dumping grounds for mentally ill people who should be housed and treated in more humane institutions. The ICU housed some of the sickest psychiatric patients I’ve ever encountered. If one of the inmates in the unit needed hospitalization, he was temporarily transferred to Gilliam Psychiatric Hospital (GPH), on the prison grounds. Sometimes when I went there to check on a patient, I was reminded of the origin of the word “bedlam,” which was derived from Bethlehem Asylum, in Old London. The bay in GPH was often filled with a hellish cacophony of shouts, shrieks, and men banging on their metal doors. And this was where inmates were sent to recover from psychotic episodes.

I learned that when people have their freedom of movement restricted to a tiny cell and almost everything is taken from them, as in solitary confinement, they can become very creative with such things as their body fluids. I won’t elaborate here, except to say that self-mutilation is not uncommon in Administrative Segregation (“admin seg”) units, and that a colleague had a “corrections cocktail” of urine and excrement thrown in his face. I’ve known guys who could hide a razor blade in their mouths, or conceal a straightened paper clip beneath their skin. I knew an inmate artist who painted with his blood. Admin seg units are where you get housed if you need protection from other inmates, violate certain prison rules, or present a danger to other inmates or staff. Only inmates in admin seg, the psychiatric hospital, and the Supermax Unit have a cell to themselves. Part of my job was to help formulate behavior management plans for inmates who were engaging in extreme behaviors, or were suicidal.

I learned about “lifers” – inmates with life sentences. They’re only a small percentage of the prison population, but having a life sentence confers a reputation for violence. Many lifers have the attitude that they can do whatever they want, short of murder. “What are they going to do, give me another life sentence?” In prisons, the strong inevitably prey on the weak. I learned that some inmates have genuine regrets or remorse for their crimes, while others only regret having been caught.

I learned at a deeper level something I already knew: that you can’t rehabilitate a person by treating him like an animal. Some people think of prisons as correctional institutions, with the goal of reforming criminals, knowing that most of them will return to free society someday. Others think of prisons as penitentiaries, whose goal is to exact legal revenge, to make the inmates suffer for their crimes. I was glad to resign from my job as a prison psychologist, because I’d come to see the prisons I’d worked in as misery factories. There are evil people in the world, and we need prisons. The temporary deprivation of liberty can be a powerful incentive to reform, for those who have a conscience and good judgment. If we, as a society, deprive a person of his liberty, we are morally responsible for his humane treatment. Jesus taught that we should love our enemies; he never said it would be easy.

One of the things I learned in prison that makes me saddest is that when prison systems aren’t adequately staffed and don’t succeed in habilitating or rehabilitating criminals, they often return brutalized people to the streets, and institutionalize many inmates who could have been prepared to return to society. I’ve known inmates who, upon release, weren’t prepared to make it Outside and committed crimes in order to return to prison, where they understood the rules.

 

 

Peace Corps service in Jamaica

I only met one Jamaican psychologist during my two years living in Kingston, serving as a Peace Corps Volunteer. She told me that there were only a few psychologists on the island. The University of the West Indies, on the outskirts of Kingston, didn’t have a psychology department. When Maria and I applied for Peace Corps service after our marriage in 1990, I never dreamed that I’d be employed as a psychologist in whatever developing country invited us to serve. (The more open an applicant is to serving wherever his/her services are needed, the higher the likelihood of acceptance.) With a bachelors degree in English, I thought I’d end up teaching English somewhere near where Maria worked. Maria was a psychiatric nurse – easy to place – and our Peace Corps recruiter initially referred to me as her “ball and chain” – not so easy to place. Maria was selected by Jamaica to serve as an instructor at the University Hospital of the West Indies (UHWI) School of Nursing. It just so happened that UHWI had just opened Jamaica’s first detox/rehab ward (mainly for alcoholics and crack cocaine addicts) and was in need of a ward psychologist. So from 1991-93 I wound up being one of Jamaica’s few practicing clinical psychologists.

The ward was initially run by a young psychiatrist who had just finished his residency at Johns Hopkins, and the staff consisted mostly of nurses, none of whom had experience working exclusively with substance abusers. When I reported for duty I discovered that the 8-bed ward had no treatment model (other than the medical model) and I had no job description. The only thing resembling treatment was several Twelve Step meetings  a week.

So I told the staff what I was qualified to do and they encouraged me to write my own job description: I would interview each new patient, review his/her medical record, and write a clinical assessment, with recommendations for the treatment plan. I would serve as a member of the treatment team. I would conduct group therapy sessions (psycho-educational and process  groups), and do individual and family therapy as needed.

I knew the program really needed to be based on a valid treatment model if it was to be effective. Other than the ward psychiatrist, I was the only treatment team member to have had training in substance abuse treatment. I knew that my first task as a Peace Corps Volunteer (PCV) was to listen and observe and learn, and to win the trust and confidence of the rest of the treatment team before I started making suggestions. However, I also started to work on a relapse prevention model that I’d introduce once I’d earned my place on the treatment team. I wanted to co-lead my groups with staff nurses, but they repeatedly declined. They were content to monitor the sessions from the nursing station.

I initially felt somewhat anxious at the prospect of leading groups. I was confident that group dynamics would be the same in Jamaica as in the U.S., but I knew that I had things to learn about Jamaican cultural norms, and I hadn’t yet developed an ear for Jamaican patois. English is the official language and all educated Jamaicans speak it clearly, with that unmistakable accent. But all Jamaicans also speak patois, and “deep patois” is initially unintelligible to English speakers. An effective group leader has to stay on top of not only everything that’s said in group, but also the non-verbal communication within the group. My initial test came early-on.

In a group session with all males, after a heated exchange between “Clarence” and “Desmond,” I thought, Did I just hear a death threat? Indeed I had, and I did an immediate intervention: “Threats of violence are not allowed in group, gentlemen. I know it’s almost lunch time, but we’re not leaving this room until Clarence not only takes back his threat, but means  what he says.” Before the end of the session, Clarence had retracted his threat, and shook hands with Desmond. Jamaican men tend to be macho, and it took all of my group leadership skills to stay in control during some contentious sessions.

The nurses were relieved to learn that I could stand up to angry Jamaican addicts. They never had to call Security, no matter how heated things got in group. More than once I had to break up fights. Most of the addicts I worked with came to respect me, and most seemed to like me. Some requested that I work with them individually. My psycho-educational group sessions focused on the relapse prevention skills that I was incorporating into my treatment model.

I soon “earned my spurs” with the ward staff, and began to feel like a valued member of the team. Everyone seemed pleased with the quality of the clinical services I provided, and in my second year of service I introduced my relapse prevention model. I’d written a relapse prevention manual with workbook exercises such as “Identifying your triggers for relapse.” I printed and assembled it at the Peace Corps office, and provided copies to all staff and patients. The model and the manual were approved by the treatment team and adopted into practice. When I left, after Maria and I had completed our two years of service, I felt a sense of accomplishment. A fellow Returned Peace Corps Volunteer (“Once a PCV, always a PCV”) later told me that when he’d served at UHWI, a few years after my service, the manual was still in use.

Peace Corps service can be very challenging, and many PCVs aren’t able to accomplish what they set out to do in their assignments, due to circumstances beyond their control.  The Country Director said to our training group, “If you feel like you’re ‘giving up’ two years of your life to serve in the Peace Corps, Jamaica doesn’t need you. You’re here to live two years of your life among the people of Jamaica.” The Peace Corps Mantra is “I got more than I gave.” Our lives were enriched by our two years in Jamaica. You can read the whole story in my first book, Two Years in Kingston Town: A Peace Corps Memoir, available online at Amazon and Barnes & Noble. For those with an interest in cross-cultural therapy, the book contains vivid descriptions of some of my clinical interventions in therapy groups. But it also describes places on the island that tourists seldom see, daily life in Kingston, and encounters with all sorts of interesting people.

 

 

 

 

 

 

 

 

 

 

Attributions and the blame game

Part of the human condition is that we tell ourselves stories that help us to make sense of our lives. Making sense of things is a subjective process, but in our stories, we objectify. We often make ourselves the Good Guy, and others the Bad Guy(s) in our personal mythologies. I ran into Good Guy versus Bad Guy interpersonal conflicts innumerable times in my career as a psychotherapist. Of course there are bad situations that are entirely attributable to other people or to some external factor, but it’s often easier to blame some person or some external thing than  to examine your own co-responsibility for finding yourself in an undesirable situation. Instead of working on ourselves, we can attribute our problems to external factors.

I’ve written  previously about avoiding the “monofactorial hypothesis” that A caused B. (“He became an alcoholic because he stopped going to church.”) The monofactorial hypotheses is simplistic, whereas human behaviors and relationship dynamics can be very complex and multifactorial. I’ve also written about the way people give away their own power when they blame other people for their emotional state or their behavior. (“I wouldn’t have hit him if he hadn’t dissed me!” or “She ruined my life when she ________.”) In another post I wrote about Dr. Erik Berne’s book The Games People Play, in which he identifies interpersonal “games” such as Wooden Leg. This game involves statements like “But for my ‘wooden leg’ (i.e. family history, shyness, unpopularity, bad luck, etc.) I would/would have _________.” There may be an element of truth in a stated belief such as this, but there are likely other factors at play.

Many people come to therapy because they feel out of control in some area of their lives. Frequently they have pat explanations of how people and circumstances are making their lives difficult or intolerable, without factoring their own contributions to the problem into the equation. But before I go on I want to be very clear that I’m not blaming anxious or depressed people for their symptoms, especially people suffering from clinical anxiety and depression. However, even people with these chronic conditions can worsen their symptoms by the way they think. Some people attribute their anxiety and depression entirely to external factors, but to some degree they’re unconsciously “doing” anxiety and/or depression.

Many people with anxiety disorders and phobias come up with unique behaviors or rituals that subjectively help them to cope with their symptoms. These behaviors can affect relationships in minor or major ways. The only explanation for the symptom-relief is the person’s belief in their efficacy. I worked with one highly anxious woman who’d “discovered” that crunching on shaved ice cubes temporarily relieved her anxiety. That meant that her lifestyle was restricted to situations where she had constant access to ice, every waking hour. Most people in her life found her persistent ice crunching very annoying. In therapy I got her to see how she was, to some degree, “doing anxiety,” by convincing herself that she had to constantly crunch ice, and worked with her to find better ways to cope with her anxiety. Eventually we got past her exclusive focus on symptoms, and examined the root causes of her anxiety.

Some depressed people “do depression,” or exacerbate their clinical depression, by the way they think. The deep sadness we feel when we experience a significant loss is a natural response. But we can block the natural healing/recovery response to a tragic loss by our thinking, i.e. “I’ll never get over this.” or “I deserve this suffering because I ______.” It’s only human to attribute blame or responsibility onto externals, and sometimes there are  external factors – things we can’t control – that are understandably heartbreaking or discouraging or infuriating. But attributing blame and responsibility can be an excuse, or a distraction from choosing to change yourself in positive ways.

We are, by our very nature, subjective in the way we convert our perceptions – our experience – into cognitions. Some people are more objective than others, because they strive to be fair and objective, and to pay attention to the role of their own thought processes in their experiences. Having witnessed and dealt with countless interpersonal conflicts as a psychotherapist, I’m quite aware of the tendency of people to think of things in in Good Guy/Bad Guy terms. I try to practice what I preach when I’m having a relationship conflict. I ask myself, “How much of this is him/her/them, and how much is me?” This has helped me to resolve conflicts, so it’s become a reflex.

Often there’s a third important factor in the equation – the situation or context. Sometimes that situation or context is a major determinant in what’s going on, and has to be taken into account and given due weight as a relevant factor. In such situations the analysis can be two-sided (“How much is me and how much is IT?), or when others are involved, three-sided (“How much is me, how much is him/her/them, and how much is IT?”) Both as a therapist and in personal relationships, I’ve found this way of thinking to be helpful in coming to terms with problems in my life, without creating new ones by the way I think.

If I blame external factors as the only things holding me back, I have to wait for them to change before I take action. If I take my share of the responsibility for being in an undesirable situation, I can start working to change it immediately. In situations that are entirely attributable to externals, all we can do is work on our attitudes and coping skills.