Relapse Prevention, Part 2

In my last post I wrote about triggers for relapse and the importance of having a relapse prevention plan, if you’re trying to establish and maintain a clean-and-sober lifestyle. The relapse prevention curriculum I developed in at the University Hospital of the West Indies in Jamaica included modules on stress  management, anger management, and rational thinking – all topics I’ve covered in previous posts. In this post I’ll be writing about other aspects of recovery from addiction.

I’ve met people with serious substance abuse problems who were too  proud to admit that they needed help in their recovery. (“I’m man enough to do it on my own!”) I’ve also known drug abusers who couldn’t imagine talking to other people – especially strangers – about addiction-related things they’d done and were ashamed of. But I’ve never met a recovering addict who got and stayed clean-and-sober without help from others, either in the form of professional help, or peer support groups such as AA. The road to recovery isn’t a road to walk alone.

Although I never saw him staggering drunk, my own father was an alcoholic. A military man who prided himself on his self-control, he once went for a year without drinking, to “prove” his ability to control his drinking. He went for exactly 365 days without a drink, but he hated every day of his self-imposed sobriety. It’s a condition known in the recovery community as “dry drunk.” As planned, on Day 366 he resumed drinking, moderately at first. But within weeks he was back to hiding bottles and drinking at the level he’d been drinking before his year of “white knuckle” sobriety.

There are individuals, I’m told, who’ve regained control of their excessive drinking and become moderate “social drinkers” – but I’ve never met one. “Someday I’ll be able to drink again” is a dangerous thought for people in recovery. Addicts are notorious for irrational thinking and self-deception. Many a relapse starts with thoughts like “I’ll allow myself one beer on my birthday” or “I can still shoot pool with my drinking buddies at the bar, and just drink sodas.” One of the arguments for attending Twelve Step meetings is that in time you’ll come to recognize your own rationalizations, by listening to other addicts who’ve come to recognize their own bullshit. Twelve Step meetings are all about getting real with other addicts who they know won’t judge them, because they’ve been there, done that, themselves.

Some friends and family of addicts don’t want to support their recovery, for a variety of reasons. Other well-meaning people who care about an addicted friend of family member become enablers. With the best of intentions, they try to shield their friends or  loved ones from the natural consequences of their addictions. They think they’re being helpful, but they’re simply enabling the person to continue drinking or using. In order to truly help, enablers need to learn to practice tough love – to stop attempting to rescue the person, and to let them suffer the natural consequences of their substance abuse. A mother practicing tough love won’t bail her son out of jail, because she knows from experience that if she does, he’ll be shooting up again within hours of his release.

Most recovering addicts come to the realization at some point in their recovery that they not only have to stop their drug-of-choice, but all intoxicating substances. I’ve known a number of crack and opioid addicts who initially believed that they could substitute alcohol and/or cannabis for their drug-of-choice, only to find that it was just a bridge back to their preferred drug. Cravings are one of the most common triggers for relapse, and getting high or intoxicated doesn’t improve anyone’s judgment or ability to resist cravings.

In my last post I mentioned euphoric recall (addicts dwelling on memories of the good times they’d had drinking and drugging, before getting addicted) as a trigger. This is one form of rumination, but addicts can also ruminate about how much they’d like to get high right now. This kind of thinking activates cravings that lead to relapses.

I’ve had some personal experience with this, as a recovering nicotine addict. What I found was that when I ruminated on how good it would feel to light up a cigarette, I relapsed time and again. Eventually I was able to identify my ruminations as a predictable relapse trigger, and to stop dwelling on thoughts about how I’d like to have a smoke. I still have occasional situation-specific cravings for tobacco, but I no longer feed the initial thought with more thoughts, and the cravings only last for a few seconds. After years of being  nicotine-free, the long-term rewards of being a non-smoker outweigh any momentary cravings I might have to light up again.

What you’re “supposed to feel”

No matter what kind of family or culture we were born into, we got instructed on what we should feel under this or that circumstance. Some of the instructions came in the form of admonitions (“Of course you love him, he’s your father!”) and some in the form of role modeling. As children, we learn a lot from the behaviors we observe being demonstrated by those around us.

Real love is rooted in a naturally-occurring feeling we have for another person, but love is institutionalized in a variety of ways. New mothers are “supposed to” love their babies, but this isn’t always the case. It may be a hormonal thing, as with post-partum depression, or it might be that the child was conceived by rape; but a mother who doesn’t spontaneously feel love for her newborn is usually judged or blamed. Children are “supposed to” love their parents, but not all parents are worthy of their children’s love.

We all have feelings about our feelings. We may feel ashamed for having been afraid, or angry at ourselves for being depressed. A number of people I worked with over the course of my career felt terribly guilty for not loving a parent or other close relative who had neglected and/or abused them. We can’t choose what we authentically feel about anyone, and nobody has the authority to tell you what you’re “supposed to” feel. Real loving feelings either arise spontaneously, or they don’t. It’s not something we owe someone just because we’re blood relatives.

Gestalt guru Fritz Perls said that most people are socialized to be phony. Ideally, a kiss is a genuine expression of affection or love. But many times in some families, children are told to hug and kiss a relative because (s)he’s kin, whether or not the child feels affection or love for that person. Kissing may become a hollow social ritual, performed because it’s expected. In some family situations, a child may be expected to kiss someone who has abused or neglected them, or whom they find “creepy.” In some cultures a child may be required to kiss a dead relative at a funeral. This sort of thing can be a traumatic experience. It can be a perversion of what a kiss is meant to express. You can’t make yourself love someone any more than you can make someone love you. But you might be put in a position where you feel you have to fake it. When Perls called a behavior phony, he wasn’t judging the client; he was observing that the behavior wasn’t an authentic expression of feeling.

I’ve worked with couples in loveless marriages who reflexively claim to love one another, because that’s what’s expected, when they haven’t felt love for their partner in a long time. It’s not always black and white, however. Observing my father’s parents as a youth, I came to understand the term “love/hate relationship.” Love and hate can be closely allied, and it’s been suggested that the opposite of love isn’t hate, but indifference.

Relationships can be emotionally nourishing or, at the other end of the continuum, they can be toxic. People can change, and family systems can change. Often the goal of family therapy is to change the family system and to promote reconciliation between family members. But this isn’t always possible. Bad marriages can be terminated by divorce, but your parents will always be your parents – for better or for worse. I’ve worked with people who’ve tried time and again to reconcile with family members, only to find that the relationship remains toxic to them despite their best efforts. If a client had gotten to the point where they’d concluded that a family relationship would never be anything but painful for them, I’d suggest that she had the option to “divorce” that relative. It’s a sad happenstance, but it’s sometimes necessary for healing to begin.

I’ve also suggested that not all “kinfolk” need be blood-related, that you might have brothers and sisters you haven’t met yet. There are several people in my life that I consider “found” brothers and sisters. Someone who was abused or neglected by a parent might later find a nourishing relationship with an “other mother” or with a man who feels like the father he wishes he’d had. I’ve seen it happen. The mere fact of blood relationships doesn’t necessarily confer lifelong obligations, and certainly not the obligation to feel a certain way about a member of your birth family. We feel what we feel, and there’s no “should.” Rational thinking can free us from the tyranny of “shoulds.”

Dialectical Behavior Therapy, Part 1

For two years I worked in a Dialectical Behavior Therapy (DBT) program at Columbia Area Mental Health Center. The program director was Dr. Sherri Manning, trained by Dr. Marsha Linehan, who had devised DBT for people (mostly women) diagnosed with Borderline Personality Disorder (BPD). People with that diagnosis are notoriously difficult to treat, and DBT provided the first effective, empirically validated therapy for that disorder.  Working in a DBT program requires the study of Dr. Linehan’s groundbreaking textbook, Cognitive-behavioral Treatment of Borderline Personality Disorder and the accompanying Skills Training Manual for  Treating Borderline Personality Disorder.  Every clinician in a DBT program is a member of the “consultation team,” which supports the team members in their challenging work.

Borderline Personality Disorder is characterized by extreme emotional dysregulation, or imbalance. Personality disorders are  diagnosed on Axis II of the DSM (the “Bible” of psychodiagnosis), apart from Axis I diagnoses like depression, anxiety disorders and schizophrenia. According to Dr. Linehan, all people with BPD have an underlying Axis I pathology, but have also experienced trauma that has shaped their behavior in persistent, dysfunctional ways. People with the disorder are often suicidal, and frequently engage in self-destructive behavior, including drug abuse and/or self-mutilation. They go to extremes in over-valuing and then rejecting significant others – sometimes in the same day. Dr. Linehan describes them as living in Hell and not knowing there’s a way out.

In order to be accepted in a DBT program, the client has to sign a year-long treatment agreement, to be renewed at year’s end if the client wants to stay in the program. She agrees to keep a daily diary card, charting moods, thoughts, and behaviors; and agrees to keep individual and group therapy appointments. Participation in the program is contingent on living up to the terms of the treatment agreement, and the client also agrees to other specified contingencies, which I’ll write about later. In the DBT program I worked in, patients were seen once a week for individual therapy and twice a week for skills training group sessions. Although individual therapy plays an important role in DBT, the skills training groups are at its heart. There’s no processing of issues in these sessions, but rather the presentation of skills by the group leaders, and coaching in their use.

One of the skills taught to DBT therapists is radical validation. Whereas I might equivocate if someone said I’d yelled at them, under normal circumstances (i.e. “I didn’t yell, I raised my voice because I felt frustrated.”), if a client in the program accused me of yelling at her, I’d validate her perception and immediately apologize for yelling. People with the BPD diagnosis are frequently blamed for things they can’t control. Many have never heard validating messages like, “You didn’t choose to be like this. If you knew better ways of  dealing with your pain, you’d use them. I believe in you and your ability to create a better life for yourself.”

Four modules are taught in DBT skills training groups: Core Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Group leaders are trained in specific techniques to facilitate skill acquisition, strengthening and generalization. There are a lot of handouts and homework assignments. The groups reinforce what the clients are learning by keeping their daily diary cards. DBT is a cognitive-behavioral therapy in that it helps clients to learn the connections between emotions, thoughts and behaviors, and to apply that knowledge. A primary goal of the therapy is to help the clients achieve balance in their lives.

Marsha Linehan studied meditation with a Buddhist roshi (master) and a contemplative Catholic priest, and mindfulness is at the core of DBT skills training. Group members are taught that there are three primary states of mind: reasonable mind, emotion mind, and wise mind -the last of which is an integration of the first two. That they have a wise mind is a revelation to most clients. Being in the state of wise mind adds intuitive knowing to emotional experiencing and logical analysis. It’s explained as, “learning to be in control of your mind, instead of letting your mind control you.” One of the skills taught in the Core Mindfulness module is how to be mindful without judging.

The Interpersonal Effectiveness module helps clients to learn how to ask for things they want and how to say “no.”  It teaches them to prioritize and self-validate in setting relationship boundaries. It teaches “what” and “how’ skills for getting reasonable things you want and not caving-in to pressure to do things you don’t want to do. The Emotion Regulation module helps clients to learn the role of emotions, positive and negative, and to deal with them in a balanced manner. It teaches them how to build positive experiences and avoid negative experiences, and to feel a sense of agency in their reactions to emotions. The Distress Tolerance module teaches such skills as distraction, self-soothing, and improving the moment. It includes thinking skills and physical techniques for tolerating stress without responding in extreme, self-destructive ways. It teaches the concept of “radical acceptance” of things that can’t be changed.

After finishing the Distress Tolerance module, the group starts on Core Mindfulness again; so group members get multiple exposures to all four modules. I personally think that the skills taught in DBT groups can also help people with other diagnoses. I’ll continue to write about DBT in my next post.

 

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.

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.

 

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.

 

 

 

The Gloria sessions

I’ve written posts about my education as a psychotherapist in the humanistic psychology program at the University of West Georgia, and my exposure to a variety of therapeutic modalities. These included Rogerian (client-centered), gestalt, and cognitive behavioral therapy. I remember watching a videotaped film titled “Three Approaches to Psychotherapy” that I’ve always thought of as “the Gloria sessions.” For many years this film was only available for viewing by professional therapists, faculty, and students of psychotherapy; but now all three sessions can be viewed on YouTube.

In 1965 a courageous young woman named Gloria – a divorced single mother – agreed to be videotaped in brief therapy sessions with three of the most influential American psychotherapists of the twentieth century: Dr. Carl Rogers (client-centered therapy), Dr. Fritz Perls (gestalt therapy), and Dr. Albert Ellis (cognitive behavioral therapy). Watching the sessions again, I was reminded of Gloria’s courage and candor. The production quality isn’t always good and following the Perls  session takes concentration, due both to poor sound quality and Perls’ thick German accent. But if you want to see three masters of psychotherapy at work, this film is a treasure trove. Their approaches to working with Gloria are very different.

In each segment, the therapist briefly describes his approach to therapy, then works with Gloria, then comments on the session. In the first segment Carl Rogers says that if the therapist can establish certain conditions in relating to the client, “therapeutic movement” will predictably occur. The first condition is genuineness, and the second is congruence – meaning that your non-verbal communication is congruent with your verbalizations. The third condition is transparency , meaning that the therapist hides nothing and can be easily “seen through.” Rogers states that if these three conditions exist, and the therapist can be in tune with the client’s “inner world” (how she experiences herself in the world) insights and growth will follow.

During the session Gloria keeps trying to get Dr. Rogers to give her advice about making a decision, and dealing with guilt feelings related to the decision. He never accedes to her request, but keeps accurately reflecting on what she’s saying, allowing her to eventually take ownership of the issue, and to trust her own judgment. (Contrary to popular belief, good therapists seldom or never give advice.) Rogers is comfortable with silences, and at one point asks, “What do you wish I’d say to you?” She gets it. In his commentary, he remarks on how her “then-and-there” orientation at the start of the session quickly becomes a “here-and-now” focus. He highlights the “I-Thou” quality of their experience, rejecting Freud’s intellectual concept of transference/counter-transference in favor of Martin Buber’s term for authentic relating. He concludes, “Gloria and I really encountered each other” and says he thinks that both of them benefitted from their brief encounter. Watching again, I can’t help but agree.

Perls puffs on a cigarette while he describes gestalt therapy, and Gloria lights up at the beginning of the session, admitting that it’s a response to anxiety. In his introduction Perls, like Rogers, endorses the I-Thou relating essential to the therapeutic relationship, and the idea that therapy should not dwell on the then-and-there, but should always focus on the here-and-now of direct experience. He states that a gestalt therapist never offers interpretations, but provides clients with experiential opportunities to discover things about themselves, often by interrupting the client’s verbalizations and calling attention to automatic behaviors that the client is usually unaware of. Early in the session Perls labels some of Gloria’s behaviors as “phony” – which has a specific meaning in gestalt therapy. She’s initially bewildered and angry, feeling judged. She’s very defensive, but Perls doesn’t back off, and Gloria appears to catch on to what he’s saying by the end of the session. He was never judging her; he was giving her an experiential lesson in her automatic, typical defenses. It’s known in gestalt therapy as “being on the hot seat.” It was Perls who wrote what became known as the Gestalt Prayer, which starts with: “I am not in this world to live up to your expectations and you are not in this world to live up to mine.”

In his introduction, Albert Ellis expounds upon the notion that – contrary to Freudian psychodynamic theory – the past isn’t the primary determinant of present-day distress or dysfunction. The past may have a role in its formation, but it’s present behaviors that maintain the problem – specifically, the irrational things we tell ourselves about our experiences and their consequences. As I’d remembered, Ellis came across like the  stereotypical pushy, fast-talking New Yorker, but his words were precise and logical. In his short session with Gloria he manages to convey the principles of rational thinking, by applying them to Gloria’s anxieties about dating and seeking a life partner. She appears to grasp the notion that she makes undesirable situations worse by catastrophizing. “Don’t beat yourself over the head or convince yourself you’re a no-goodnik, just because you didn’t get the outcome you wanted.” He explained how he gives his clients behavioral homework assignments to complete between sessions, and suggests that Gloria should set up opportunities to take some small risks, instead of holding back in social situations. Its a behavioral technique called exposure, and Ellis was one of its early proponents.

When I first saw “Three Approaches to Psychotherapy,” I remember that there was a brief interview with Gloria after the sessions; but I wasn’t able to find it online. As I recall, Gloria said that she liked Carl Rogers the best, and learned some valuable things from Albert Ellis; but her session with Fritz Perls was the one she most benefitted from. If you don’t understand the basics of gestalt therapy, what Perls says and does in the session won’t make much sense. It shook Gloria up; but that’s what good gestalt therapists do, and Perls was one of the best. I highly recommend the Gloria sessions to social science students, psychotherapists in training or practice, and people who want to know more about psychotherapy.

Little did I know when I first watched the film that I’d actually meet Rogers and Ellis. I’ve already written about my brief meeting with Carl Rogers. In a later post I’ll describe my encounter with Albert Ellis.

On not giving away your power

Quite a number of times during my years in community mental health I had public school students (mostly boys) referred to me for counseling by their schools, due to fighting. These students definitely did not want to attend mandatory counseling sessions, so I used that as a lever, saying “Let’s see if you can learn to control your temper in two or three sessions. It’s up to you how long you have to come in for counseling.” I fully understood that when a teenager is being taunted in front of his peers, it feels more powerful in the moment to start swinging than to stand there feeling humiliated. So I framed their problem as one of giving away their personal power when they let themselves be goaded into losing their temper and fighting. Before I got into teaching anger management skills, I had to convince these students that I could help them. I often used set-up “punchlines” and strategic metaphors in therapy.

My first therapeutic hook was to show them a hand-lettered cardboard sign on a loop of string, which I’d hang around my neck. The sign read “If you want to make me mad, call me a _______.” I had a number of smaller signs that  I’d hold over the blank: “retard” “punk” “homo” “Mama’s boy”. With a straight face I’d offer to give the signs to the student, to wear at school. Of course he’d decline my offer, confused as to why I’d think he’d want to wear it in the first place. Then I’d give him my punchline: “You may as well wear it. Your behavior already tells people the same thing the sign says. The guys who give you a hard time just have to find out which of these things to call you, to make you lose control. It only makes you feel strong when you fight, but you’re actually giving away your power. When a bully goads you into throwing the first punch, he’s gotten what he wants. He knows that you’re the one who’s going to be suspended.”

My second hook was a metaphor that actually involves fishing. I’d ask the student if he’d ever gone fishing, and most had. I’d ask if they’d ever tried fishing without bait. Of course they’d say they always used bait. Then I’d say, “Because you know that a fish wouldn’t bite a bare hook, and the bait hides the hook. And that’s what happens when your enemies at school make you lose your cool. Their words are the bait that hides the hook. Once you bite, they’ve got you.” I’d pantomime reeling-in a fish, then suggest that keeping control of your behavior when you’re angry is a strength. (I realize that there are times when a cool-headed decision to fight is an appropriate response to bullying, but I won’t get into that circumstance here.)

There are other ways that people frequently give away their power to other people or to circumstances beyond their control. An event such as a traffic jam doesn’t have the power to make you mad, unless you invest it with that power. It’s one thing to say that you became angry when you got stuck in traffic, and quite another to say – as many people do – that being stuck in the traffic jam “made you” angry. The traffic might have triggered your anger, but it didn’t cause it.

Sometimes people blame their feelings or actions on others: “I wouldn’t have hit him if he hadn’t dissed me!” People who attribute their anger to other peoples’ behavior (i.e. “You make me angry when you contradict me!”) are making an indirect demand: “Don’t contradict me, or you’ll have to deal with my anger.” As with blaming circumstances for one’s anger, there’s a big difference between “I get angry when you _________” and “You make me angry when you _________.” The difference is in locus of control. Does control exist within me, or outside of me? Owning your anger is a strength.

If I blame external triggers for my anger, I’m giving them power over me. If I own my anger, I’m more likely to control its duration and its influence on my behavior. I’m not stating this as an absolute. If someone were to sucker-punch me, I’d certainly attribute my anger to his behavior. I’m just making the point that if I own my anger, I’m less likely to reflexively hit him back. (Which may or may not be the best response.) Thinking that I generate my own anger in response to external triggers is more rational than thinking that others can pull my strings, and that external triggers cause my anger.  Staying in control of your behavior and making good decisions while experiencing a strong emotion is a strength.

Another common habit of people who can’t differentiate between their rational and irrational thoughts is catastrophizing or awfulizing. When something inconvenient, unpleasant, disappointing or hurtful happens, there’s nothing to be gained by mentally labeling it as “terrible” or “awful,” or saying that you “can’t stand it.” Of course real tragedies and major losses can truly be terrible and overwhelming , but exaggerating the negative impact of an unwanted, unpleasant experience just makes it all the more unpleasant. Each of us has the ability to assign meaning and give weight to events, and catastrophizing is another way that people diminish their own power. Sometimes we spend ten dollars of adrenaline on a ten-cent problem, because of the way we think about it.

 

Trains of thought

In my last post I said I’d explore how an initial irrational thought can lead to a train of connected irrational thoughts, expanding from incident-specific to generalized irrational thoughts. Thinking this way doesn’t help you to feel the way you’d like to feel, or to act wisely.

I used to lead a psychoeducational group (as opposed to a process group) called Skills for Recovery at South Carolina’s largest psychiatric hospital. When I taught my module on rational thinking and irrational trains of thought, I’d draw a crude train on the whiteboard as I taught the concepts. I started by drawing a rectangle on “wheels” on the right-hand side of the board, adding a smokestack and a triangular cowcatcher to distinguish it as the locomotive. Then (right-to-left) I’d draw several more rectangles on wheels – boxcars – behind the locomotive. Inside the locomotive rectangle I’d write Activating Event, then I’d write Thought 1, Thought 2, Thought 3, etc. in the boxcars (right-to-left). My standard rap on trains of thought went something like this:

Trains can take you places, hopefully places you want to go. Trains of thought can also take you places. If your thoughts remain rational, your trains of thought  will take you in positive directions. If they’re irrational, they’re likely to take you places you don’t want to go. Take Luke for example. He’s between girlfriends and looking for a new one. He fancies himself a pretty good dancer, and likes to hang out at dance bars and clubs. He’s attracted to Lucy and has seen her out on the dance floor with different men. He works up the courage to approach her at the bar, introduces himself, and asks her if she’d like to dance. She says “No thanks,” gives no qualifiers or explanations, and walks away. Luke isn’t sure how to read her Mona Lisa smile.

Luke’s first thought is rational. “I’m disappointed that she doesn’t want to dance with me.” If he remains rational, he might think “I don’t know why she turned me down. I probably never will, and that’s okay. It may not have anything to do with me, personally. I’ll find someone who wants to dance with me before the evening’s over. And even if I don’t, it’s not the end of the world.” If, instead, Luke has a gut reaction and starts thinking irrationally, his thinking might go in either of two directions: what’s wrong with her, or what’s wrong with me? If he boards the former irrational train, he might conclude that (T1) she’s either a lesbian, or that (T2) she’s stuck-up and thinks she’s too good for him. After another drink, he might start to generalize that (T3) all women are like that, thinking they’re better than us, and that (T4) they’re all stuck-up bitches who don’t know a real man when they see one. Luke’s behavioral response to these angry thoughts is to get hammered.

Luke may instead think of his rejection by Lucy as proof that there’s something wrong with him. He might jump to the conclusion that (T1) she turned him down because she doesn’t find him attractive – which may or may not be the case. He’ll probably never find out, but irrational thinkers with low self-esteem tend not to give themselves the benefit of the doubt on such self-judgments. Luke may think that (T2) he was foolish to ask Lucy to dance in the first place; he should have known she’d turn him down. He may convince himself that (T3) there’s no point in asking any other woman to dance, because she’d just turn him down like Lucy did. Riding that irrational train of thought, he might generalize that (T4) he’s just not attractive to women. From there he might label himself (T5) a pitiful Loser who will never find love, and leaving the club thinking suicidal thoughts.

Suicide is a mood-specific behavior; people never try to kill themselves because they’re elated. Some impulsive suicide attempts are triggered by a train of irrational thoughts, culminating in the irrational belief that suicide is the “solution” to the present conflict or problem. This kind of irrational thinking can be fatal. Suicide hotlines have saved innumerable lives by engaging people who are in crisis in compassionate dialogue until the suicidal mood passes.

Trains of irrational thought are perpetuated when we don’t recognize them as such, and ruminate on them. Situational depressions can be drawn out by dwelling on negative thoughts. If you should catch yourself ruminating on negative thoughts, learn to identify and challenge them. Luke might challenge his persistent thoughts that he’s a pitiful Loser in this manner: “Is it a fact or do I just feel that way? If it’s a fact, what’s the proof? Some pretty women have been attracted to me, and I don’t even know if Lucy turned me down because she doesn’t find me attractive. I have friends who believe in me and don’t think I’m a Loser. Loser is just a word, anyway. I’m not a Loser! Like everyone else, sometimes I win and sometimes I lose. Anyway, sitting here staring at the floor and feeling sorry for myself isn’t helping anything. I need to go for a run.”

Negative, irrational thinking and ruminations can be a “rehearsal for failure,” while riding rational trains of thought can be a “rehearsal for success.” People  who become mindful students of their own thinking can eventually become experts on their own thinking and where it typically takes them. They can avoid the traps of irrational thinking and ride trains of thought that take them to chosen destinations. Cognitive and cognitive behavioral therapies resonate with the buddhist teaching that all suffering arises from our attachment to things – in this case to irrational thoughts and expectations. Irrational thoughts often lead to irrational decisions and behaviors, based on false assumptions. Becoming a rational thinker means learning to spot and challenge your irrational thoughts before you act on them. It gets easier with practice.

 

Rational thinking

My therapeutic orientation was existential and I was trained in a humanistic psychology program, but as I told both clients and colleagues, if I had a Gospel to preach in my clinical practice it was the Gospel of Rational Thinking. It’s a learnable skill and I wish it was a standard part of the public school curriculum; but the corporate state wants the public education system to turn out conditioned consumers, not independent thinkers. Independent thinkers are as hard to herd as cats. I’ve practiced and taught rational thinking for decades. Being able to spot my irrational thoughts before acting on  them has kept me from making innumerable mistakes and spared me a lot of unnecessary pain over the years. (I actually met Dr. Albert Ellis, creator of Rational Emotive Behavior Therapy, at a professional conference. I’ll tell you more about him in a later post.) Rational thinking is an important component of cognitive and cognitive behavioral therapies, whether irrational thoughts are labeled as thinking errors or as irrational self-talk. The wisdom of rational thinking correlates to the teachings of buddhism and to the Serenity Prayer. It’s a learning program that teaches people how to think rationally, without telling you what to think. It’s the opposite of  – and the antidote to – indoctrination.

We all engage in self-talk, our constant mental monologue, judging and labeling and making choices throughout our waking hours. Some self-talk is innocuous, but other self-talk carries a lot of weight and guides our subsequent behavior. Some of it is rational, but some is irrational – for all of us, even psychologists. In my experience most people can’t always tell the difference between their rational and irrational thoughts, and sometimes suffer painful or destructive consequences from their irrational thinking. Rational self-talk helps us to feel the way we want to feel and accomplish what we want to accomplish. Irrational self-talk leads to avoidable negative emotional states (anxiety, depression, anger) and undermines our ability to function at our best.

Many irrational thoughts are characterized by the words “always” and “never,” “should/shouldn’t” and “must.” Some examples: “I should always make a good impression on people.” “Things never go my way.” “I’ll never succeed in life.” “I shouldn’t ever let down my guard around people. They always take advantage of you.” “Life should be fair.” “I must get this promotion!” When people think irrationally, they set themselves up for disappointment, or worse, when things don’t go as they’d hoped.

At times we all wish the world was fair. But it isn’t, and thinking that it “should be” doesn’t help anyone. You might not always succeed at things you really want to succeed at, but that doesn’t make you a “failure” or a “loser.” If we tell ourselves that we’ll “never” get over a loss, we’re programming ourselves to suffer endlessly. If we expect to “always” perform optimally in interpersonal situations, we’re not allowing for the fact that we’re all flawed human beings. To err is human, and to expect perfection, or to always succeed at everything we do, is to court disappointment. Great expectations can lead to great disappointment, and moderate expectations to moderate disappointment. But if you engage in an enterprise because you feel it’s the right thing to do, with no specific expectations pinned to the outcome, you can’t be disappointed.

Here are some categories of typical irrational thoughts: Catastrophizing is imagining that worst-case scenarios are likely outcomes. Minimization is wearing blinders that don’t let you see your own strengths, or the positive potentials in a situation. Grandiosity is feeling superior, having an exaggerated sense of self-importance or ability. Personalization is when someone thinks “It’s all about me.” Thinking you’re the center of the universe. Magical thinking is characterized by acting ritualistically, as if a ritual behavior will bring about a desired outcome. Leaps in logic have to do with jumping to conclusions not based on evidence. Mindreading means attributing motives for a person’s behavior without evidence. “I know why he did that!” All-or-nothing thinking is the inability to see any shades of gray between poles of black and white. Paranoia is characterized by unjustified suspiciousness and feelings of persecution.

I’ll be writing more about mindfulness over time but, suffice it to say for now, one kind of mindfulness is paying close attention to your self-talk and where it takes you, emotionally and behaviorally. With practice, you can learn to immediately distinguish your irrational thoughts from your rational thoughts. In cognitive therapy, when you identify an irrational thought, you learn to frame a challenge to that thought. An example: “I may have lost out on that promotion, but that doesn’t mean I’m a loser.”

I used to teach clients a method called a “4-Step Check” to help them learn to spot and counter their irrational thoughts. After an upsetting event, you analyze it in writing. (1) Event. Describe what happened. (2) How I felt. This might include multiple emotions. (3) What I did.  What would a videocam have recorded? (4) What was/were my irrational thought(s). With enough practice writing 4-Step Checks, spotting irrational thoughts eventually becomes automatic, and you don’t have to do them on paper anymore.

Here’s an example of a 4-Step Check by Charles, an alcoholic in early recovery: (1) Jim, my new AA sponsor, promised to pick me up at 7:30 sharp for an 8:00 meeting across town that he knew was important for me. When he hadn’t shown up by 7:45, I hailed a cab. (2) I felt desperate and alone in the world. I got angrier every minute Jim was late. (3) I kept looking at my watch, sometimes several times a minute.  I paced back and forth on the sidewalk, cursing. I kicked a dog. (4) I should never have asked Jim to be my sponsor. He’s doesn’t really care what happens to me. He’s a selfish, unreliable bastard! You just can’t rely on anyone. I should just go to a bar instead of paying for a taxi to get to the meeting.

As it turned out, Jim showed up late to the meeting and afterwards apologized sincerely, explaining why his tardiness had been unavoidable. So Jim did his 4-Step and was able to spot his irrational thoughts and how they were related to his emotions of the moment. You may have noticed that Charles’ initial irrational thoughts were specifically related to Jim’s failure to show up when he said he would. But then he starts to generalize, telling himself that people aren’t reliable and that working on recovery is useless – a rationalization for relapse. This is an example of how an irrational thought can lead to a progressively irrational train of thoughts, going from specific to generalized irrational thinking. None of these thoughts can help Charles to feel the way he’d like to feel or to help him achieve his goals.

Any irrational self-talk statement can be challenged by asking, “How do I know that to be true? What is my proof?” In my decades as a therapist I urged many clients to “become a student of your own thinking.” Every day holds new opportunities to learn about yourself, if you pay attention. In time you start to see the patterns of your own irrational self-talk, and you internalize the 4-Step Check. Spotting irrational thoughts becomes a learned reflex and voila!, you’re a rational thinker. In my next post I’ll get into “trains of thought” that take people to places they don’t need to go.