In Therapy

My Exclusive Interview With Nidhal Abaza

Ryan Howes, Ph.D. — Wed, 11 Nov 2009 18:54:09 +0000

I've been fortunate to land an interview with a Palestinian-American named Nidhal. You may have seen his name in the papers recently. In the entertainment section.

Following last week's email blast from the PT Editors (in short: Be Topical!), we've heard a few dozen perspectives on the horror at Fort Hood. When considering which unique angle I might add to the discussion it soon became obvious: I know a Palestinian-American guy in his 30's named Nidhal. Let's hear from him.

Nidhal Abaza is a popular comedian currently working L.A.'s comedy rooms. He was born to a Palestinian family in Dhahran, Saudi Arabia, a town of mostly American expatriates working in the oil business. He briefly lived in Cyprus ("some people know it's an island in the Mediterranean. The rest are American"). For the last 20 years, he's made his home in the USA. Put your hands together and welcome to the stage: Nidhal Abaza!

Ryan: So, Nidhal, how's your week going?

Nidhal: My week's been fine, why do you ask?

Maybe you didn't hear, someone fitting your description was allegedly behind a shooting spree in Fort Hood, Texas last week. I'm curious about the impact it's made on you.

Oh, right. I heard about that. Well, as the details started to emerge and it turned out that the shooter was a thirtysomething Palestinian-American named Nidal, I thought I might be in for it. And I'd like to note there are some pretty big differences between us. For one thing, he's a murderer. For another, he suffers from mental illness, and, worse, male pattern baldness.

But yeah, you'd think people would have harassed me or at the very least teased me about the similarities, but that hasn't happened. I'm certainly less self-conscious than I have been at other times during my time stateside.

What's your experience as a Palestinian-American over this past decade?

Well, in terms of me suffering any kind of backlash...I just haven't had that happen. My first reaction on 9/11 was probably the same as most peoples'- a mixture of shock, horror and anger. My second reaction was to put an American flag on my door. Seriously. Just in case anyone was thinking of tarring and feathering me.

I really thought it was going to be a nightmare, and I'm sure for some people it was, but I had no problems. What I remember most is that I must have had twenty of my American friends call to check in on me to make sure I was ok and that nobody had bothered me.

You actually had more concern and support after 9/11?

Yeah, and I think that's important to note because that was my experience, and I think it speaks well of, if not all of America, at least my circle of friends. And taking a broader view, since 9/11, it seems like things have gone the opposite direction than what I would have expected. For example, pre-9/11, there were almost no representations of Arabs in popular entertainment, and any that existed were without exception negative caricatures. Since then, there have been many more positive, or at least nuanced, portrayals of Arabs in pop culture. And that's a good thing for humanity and world harmony. Far more importantly, it's potentially a great thing for my career prospects.

Why do think things went that way?

Well, it might just be me Monday morning quarterbacking, but my guess is that all of a sudden this country was forced to engage and acknowledge that part of the world. I recently watched a show on Showtime called Nurse Jackie and one of the series regulars is this gay nurse named Mohammed. It's not commented on at all - he's just a gay guy who happens to be named Mohammed. That just never would have happened ten years ago on a major TV show, a regular cast member who was Arab. And you see Middle Eastern characters popping up all over the place on TV.

Let's go back. What brought you to America?

Freedom. Really, at the risk of sounding like a Lee Greenwood song, that was the main draw. I attended American curriculum schools overseas from kindergarten on and so I grew up pretty Americanized from the start. I remember reading in US history books about free speech, "all men are created equal," "government for the people by the people" - all that good stuff. And I thought, "Makes sense to me. Where do I sign up?" So from a relatively early age I wanted to come over here. I didn't like being somewhere where you had to watch what you said. Where the government blatantly censors expression and there's no such thing as civil rights.

You came to the United States because it's a place where you don't have to watch what you say. And here you are, a comedian. Did you experience any racism when you came here?

Sometimes people would jokingly say, "Oh, are you a terrorist?" That was their big joke. I object to this not so much because it's offensive, but because it's hacky. It's just not that funny a joke, people. Everybody's done it.

There were a couple of other instances so minor as to not be worth mentioning. My experience here has been overwhelmingly positive. My fellow Americans have been very good to me.

You've made your cultural background a central part of your act. Tell me about that.

Well, I just talk about it because as a comedian your strongest asset is your point of view. And I'm lucky in that most people haven't heard one like mine. I'm Palestinian, but I say in my act that I consider myself a citizen of the world, and I really do. I guess I think it's important for that POV to be represented, because most of the Middle Eastern comics I've seen do very obvious, lowest common denominator kind of comedy. For that matter, it seems that's the way it is with most race-based comics, whether Arab or Asian or whatever. Most of it is not real intelligent stuff. As opposed to my stuff, which is BRILLIANT. Please note that I'm being self-mocking there, mmmkay?

Noted. Is there an underlying message to your act? Any point you're trying to get across to people?

God, I'm loath to say there's a message to it because the primary directive of stand-up is "be funny." If you wanna send a message, use Western Union and all that. But I do hope that my world view is reflected in my stand-up. And part of that world view is people matter more than where they're from or what superstitions they practice.

I tell a story in my act about when the first Gulf War was about to start. I was in social studies class in Seattle and the teacher decided to do an impromptu poll. He gave us two possible outcomes to choose from. He said in both cases the American/coalition forces emerge victorious - only the casualty rate would differ. In Scenario A, we lose 100 Americans and the Iraqis lose 100,000 people. In Scenario B, we lose 10,000 and the Iraqis lose 20,000 people. And who prefers Scenario A? I think every person in the class raised their hand. Who prefers Scenario B? No hands. And that was a real eye opener for me. That's when I realized, "Man, Americans really are bad at math."

I just don't think you can be patriotic without implicitly being bigoted. How can you be proud to be an American or Palestinian or whatever without implying other nationalities are lesser? I'm not proud to be an American. I'm very, very glad to be an American, but I'm not proud. What would I be proud of exactly? I didn't have a hand in writing the Constitution. I didn't fight in the Revolutionary War. If I was proud of those things, then I'd also have to be ashamed that black people were bought and sold in this country. And I'm not ashamed, because I didn't have anything to do with that either. I'll take credit and blame for my own actions, thanks.

So, yeah, that's the world view that I hope is reflected in my act. But, you know, funnier than I just put it.

When you heard about Fort Hood, what did it make you think about or feel?

Well, at first when we didn't have a name or know anything about the shooter, the first thing I thought was, "I hope it's not an Arab." I just immediately remembered that a few years ago there was an Arab or Muslim guy in the military who threw a grenade in a tent of sleeping soldiers, and I was hoping it wasn't another one of those kind of things. Then, sure enough, it turned out it was, only much deadlier. People sometimes go crazy and shoot people, it's not necessarily racial or religious. This time it seems that it was, but to me the takeaway from that is not "Islam is bad", so much as it is "religion is bad."

Anything people should know about Palestinians or Arabs that they don't know?

We're all really well-endowed.

Backseat Drivers & Therapy, Part IV: What to Do

Ryan Howes, Ph.D. — Thu, 05 Nov 2009 08:37:54 +0000

The point here is pretty simple: it's your therapy, you can share with others as much or as little as you want. Here's what to do with the unsolicited opinions.

This is the fourth and final post in the series to help you manage intrusive loved ones in your therapy. It builds on posts highlighting the pitfalls of backseat drivers (Part I), some real-life accounts of this problem (Part II) and eight common types (Part III). By the way, I found a great post on handling actual backseat drivers. Most of what they say applies here minus the references to GPS, riding shotgun and new car smell.

Most of the time, backseat drivers aren't really an issue in therapy. Loved ones generally care about your wellbeing, respect the work you do in your therapy and offer support if you need it. But there are good reasons to cover this topic thoroughly: when backseat drivers are a problem, they're a real problem. The impact can range from minor annoyance to total annihilation of your therapy.

In the words of a real client from the PsychLinks forum:

the trouble with friends and family is they don't necessarily fully appreciate the therapeutic relationship and don't understand how it works unless they've been in their own therapy. it's easy for them to criticize and say how your therapist is wrong. i think it's tough, i think if you know you have a good therapist and they are a good fit for you, that you need to take the comments with a grain of salt. however, if you are still in a very vulnerable place (dealing with depression and anxiety), it becomes a lot harder to know if their feedback is on target or not.

It's a dicey issue, one that can be difficult to navigate. As we therapists repeat ad nauseum: trust in the relationship is essential for successful therapy. When trust exists, therapy tends to progress. That's the ideal. But the trust is challenged when:

The therapist behaves unethically. I suggest you peruse the APA Code of Ethics to see what I'm talking about. This is not when the therapist upset you because he challenged you to face a fear or forgot your dog's name or suggested something that didn't work. I'm talking about the big boundary violations - inappropriate sexual behavior, extortion, needlessly breaking confidentiality, etc. If these issues occur or are about to happen, talk to someone in a position of authority. The therapist's boss, the police or their licensing board come to mind.
The client rehashes everything they do in therapy to their friends. Everyone you talk to will have an opinion which may result in more confusion. Sometimes it's best to keep this material between you and your therapist. For example, if you didn't understand what your therapist suggested last session, this is a good thing to talk about in therapy. If your therapist reminds you of your creepy aunt, this is prime therapy material. If you feel like therapy is the only interesting thing in your life to share with friends, you've got a topic for therapy. I invite you to risk trusting the therapist to see if the process and relationship can answer some of your questions, rather than running everything by the committee.
Loved ones undermine and sabotage therapy. Even well-meaning friends may not realize their comments can stall or derail your work. This is sensitive, personal work, and one harsh critique can do plenty of damage. If you know your minor concerns about therapy will be met with "I told you so" and "she's a quack," maybe it's best to save your questions for your therapist. A friend may ask "how's your therapy going?" and you can answer with "good, I'm learning ___ about myself." No one can dispute what you're learning, and you can keep the nitpickers at bay by giving them less to criticize. Someone hounding you with questions you don't want to answer might be quieted with "my therapy is very personal, if there's something I'd like to talk about I'll let you know." And if we're talking about a really toxic opponent to your therapy, you may need to say something like "it looks like we disagree about the value of therapy. I hope you'll respect my wish not to debate this with you. If not, I'll need to leave."

Clearly, trust comes at a high cost. If there's something terribly wrong with the therapy, report it. If there's a minor conflict, talk it over with your therapist. And if loved ones are intruding, tell them to back off. As it is with many issues in therapy, this is not a black and white issue. There are certainly times when eliciting support or discussing questions about therapy to a friend is a great thing to do. These might be times when you:

had a breakthrough and want to share it with someone
wonder how to bring something up to your therapist
want to talk about what it's like to be in therapy
talk through a concept or technique you learned
want someone to hold you accountable for a new behavior
look for objective feedback on changes you've been making

And so on. The intersection between therapy and loved ones will always be a little messy, such is the nature of relationships. It's important for you to know that you have plenty of control over that intersection. You can keep the two at their stoplights or mix it up between the crosswalks.

Two final notes about backseat drivers:

Parents and Teens

Backseat driving takes the front seat when working with children or adolescents. Occasionally, kids or teens seek out therapy on their own, but most of the time concerned parents bring their child to therapy to address issues they believe are problematic, and the kid may not agree. Parents might have specific ideas for the goals, procedures and session-by-session topics within the therapy. While these suggestions can be helpful, the teen may have a different goal, and the therapist a different approach. Problems are inevitable.

Here's one possible solution. When working with teens I meet with everyone to clarify the goals of therapy and how we'll work to reach them. I'll tell the parents I prefer to keep the material between me and the teen unless the information includes potential harm to the teen or anyone else. In order for the teen to feel safe, they need to know I'm not acting as a double-agent for the parents. Otherwise, they won't trust me and therapy is a waste of time and money. Whatever the parents say to me is fair game for me and the teen to discuss, whatever the teen says stays between us (with the above caveat). When everyone is clear on that arrangement, therapy runs fairly smoothly.

Note to Loved Ones

So what if you are Sally? How can you best support someone going through therapy? I'd suggest a blanket statement like: "I don't want to get in the middle of your therapy, but if you ever want to discuss what you're learning about yourself, I'll listen." If she takes you up on it, do just that: listen. If your friend or loved one seems to be experiencing roadblocks or has questions about the process, avoid chiming in with your own advice or opinions about the therapy. Instead you might tell her to "be sure to mention that to your therapist."

Backseat Drivers & Therapy, Part III: Types

Ryan Howes, Ph.D. — Tue, 06 Oct 2009 22:03:20 +0000

Backseat drivers take many shapes and forms, from helpful to hostile. In Part I we discussed why backseat driving is a problem, in Part II we looked at why people backseat drive and gave several real-life examples. Today we're breaking down the most common backseat drivers.

***Before getting started, I'd like to clarify: I do think it's helpful for clients to talk about therapy. What I was clumsily trying to recommend in (now revised) Part I is clients with a specific question or concern for the therapist will ideally take it straight to her instead of triangulating, diffusing, etc. When among trusted friends or loved ones, clients should feel free to talk about what they're learning in therapy, what they find difficult and what's confusing. They can discuss how hard it is, how they're growing and whether or not it's worth it. I'm glad PsychLinks and other support forums exist; I want people to share their experiences and learn from one another. But when it comes to direct conflicts or misunderstandings, I hope the support system suggests you: "ask your therapist about that." I addressed this issue in a previous post called Say Anything, which I hope clears up any confusion. More on this in Part IV.

Back to the issue of the day. Backseat drivers are any influential people with opinions about your therapy. As loved ones, they have some power and can use it to help or harm. Many fall in the "help" category, but not everyone. As far as I can tell, there are eight types of backseat drivers. Here's what they do, what they want and what you might hear them say:

Threatened: On the lookout for negative evaluations about them from the therapist. Wants to know what the therapist thinks about their role in the client's life.
"I suppose your therapist sided with you regarding our argument?"
"Is she going to tell you to break up with me?"
"Now you start exercising?! I told you to do that months ago!"

Curious: Fascinated by the mysterious world of therapy. Wants to know what happens in intricate detail.
"So what kind of things do you talk about?"
"And then what did he say?"
"Call me right after your next session."

Hostile: Uses participation in therapy as a weapon. Shames the client about being in therapy. Wants control.
"You're nuts. You need some serious therapy. Now."
"There's another thing you should talk about with your therapist."
"You know what? I don't care. I'm not the one in therapy. Tell it to him."
"When do I start reaping the benefits of your therapy?"

Freeloader: Fears going to their own therapy so they mooch off yours.
"So did you tell your therapist about my anxiety? What does she think?"
"Yeah, this is a confusing problem for us. Maybe your therapist can figure it out."
"Can I come to a session with you?"

Peanut Gallery: Psych major, therapy client or other bystander who knows how to help you better than your therapist. Wants to say "I told you so" or "my therapist is better than yours."
"She's using reflective listening? This is an empty chair situation if I've ever seen one."
"I could teach you CBT techniques. You need him to address your father wound."
"My therapist hugs me and tells me it'll be okay. Does yours?"

Avoider: Won't acknowledge therapy due to their own shame about the issue. Wants therapy to go away because it makes them uncomfortable.
"You have your (finger quotes) appointment at 6pm, correct?"
"You'll be done after six sessions, right? I think maybe our insurance only covers that many."
"I deal with problems privately. Why don't you?"

The Parent: Wants help. Wants a different perspective. Wants their kid to be healthy. Wants to trust the therapist. Afraid to hear they've done something wrong.
"Yes, I tried that already and it didn't work."
"So maybe this is just a normal phase that she'll grow out of?"
"If you don't stop that right now I'm calling your therapist."

Helpful: Has a sincere desire to support and assist your process. Wants to aid, not interfere.
"So what are you learning about yourself?"
"If there's anything you'd like to talk about, I'll be here."
"If you feel that way about your therapist, maybe you should talk to her about it."

Stay tuned for Part IV, where we'll look at what you can do about backseat drivers, and what to do if you are the backseat driver.

Backseat Drivers & Therapy, Part II: Why & Examples

Ryan Howes, Ph.D. — Wed, 30 Sep 2009 07:17:06 +0000

In Part I we covered what backseat driving is and why it might disrupt therapy. Today we'll ask why people backseat drive and give a few real-life examples.

It's an inevitable issue in long-term psychotherapy. Therapists are ethically and legally bound to keep information confidential, but clients can say whatever they want. Those close to the client are curious about the therapy, especially if the outcome has personal relevance for them. They'll ask how the therapy is going, show interest in the therapist's interventions, even suggest topics for the client to discuss. Once in a while, this is helpful. Sometimes it complicates the work.

So why do loved ones kibitz on your therapy? There are many possible reasons. Maybe the interested party wants to be included in your life. Some have a sincere desire to help. Others may have a fascination, a fear or a fundamental disagreement with the process. Or they believe they could do it better. They wish to be involved, but whether it's as an aid or a hinderance is sometimes difficult to discern.

Some would say backseat drivers have control issues. Maybe that's true, but I think it's more about the fear of the unknown. Therapy is a mysterious black box. While our lives open up on Facebook and Twitter and reality TV, therapy maintains a shroud of secrecy. It's tantalizing for outsiders to imagine what really happens during those 50 minutes. They want to know what you really think, how you really feel, and how those thoughts and feelings are handled. Particularly if that hour has an impact on their life. The exclusion can feel like rejection. Underlying the comments are questions: "What aren't you telling me? Don't you think I can help? Am I not enough for you?"

There's an online forum called PsychLinks where clients, therapists, students and others gather to discuss all things related to psychology. A few weeks ago I solicited the experiences of clients and backseat drivers. Several were kind enough to share their stories, which span the helpful/harmful spectrum. Their revealing responses helped me understand these issues on an even deeper level. Here are a few quotes:

People that meet me and find out I'm in therapy are often shocked and tell me I have no problems and I just need to hang out with them more.

Throughout the process, my mother in particular wanted all the details of those sessions (to the point that I was expected to call her after each session to recount the session) ... she would tell me that my psychologist was an idiot ... my psychologist was making this into a bigger deal than it need be. The psychologist was aiding me in staying in the 'victim' role.

I have a friend who [says] that I just need to get over myself, I have nothing to be depressed about, it's all in my head (I suppose it literally is - ha!), etc etc. Needless to say, I mention NOTHING to her anymore.

i don't much talk about being in therapy because it would be too hard to explain to people. i guess it depends on who it is.

I think in one sense, it is reassuring to us, but also gives us an opportunity to further process a therapeutic experience and gain other perspectives. I also like to brag about my therapists because I think they are simply the best and absolutely amazing : )

i've been asked if maybe therapy is just making me dwell on things and maybe it's not necessary - that i'd do better without.

... no real back seat drivers for me, thankfully :-) at the first sign of it i would just shut down about the subject, and it would become a no go zone with me.

... my therapist encouraged me to make brave steps into the world, and when I talked about this to the 'friend' she discouraged me. e.g. I would talk about a new project for my work, the friend would tell me all the reasons not to do it, thus puncturing my enthusiasm.

I'm very, very fortunate. It appears that finding the right therapist the first time around is not necessarily typical, and somehow I managed to do it. Frankly, it's probably more fortuitous than winning the lottery.

My gratitude to the members of PsychLinks for their candid responses. I was struck by how subversive the "support system" can be. In my practice I've certainly seen helpful aid, annoying intrusion and invasive butting-in, but the enmity represented here is an eye-opener. This is a small sample of what happens at the intersection of loved ones and therapy, please feel free to share your own experiences. In Part III I'll delineate the types of backseat drivers.

Backseat Drivers & Therapy, Part I: Introduction

Ryan Howes, Ph.D. — Thu, 17 Sep 2009 18:03:53 +0000

Well-intentioned loved ones can butt in and screw up a perfectly good therapy. Or they can give needed support. Or they can lend perspective to a harmful therapy situation. How do you tell the difference?

Jane has something brewing:

"I've been talking with Sally about our sessions. She thinks exploring my past is a waste of time and that my whole problem started with my ex-boyfriend Jim. She says Freud was misogynistic bigot and no one believes in him anymore. She also thinks I have ADD and wants to know your opinion about Ritalin."

Boy, it appears Sally and I are really at odds. Our treatment plans, theoretical orientation and therapeutic techniques are diametrically opposed. Sally and I have locked horns in a bitter ideological conflict. We could debate some of these points for hours and never come to a peaceful resolution.

Wait a minute. Who is Sally? Why does she have such a say in what we talk about? And most important, how does Jane feel about our work?

Of course, Sally is Jane's friend. They've been friends for many years and Jane trusts her opinion. They share everything. Sally's been in therapy several times and majored in psychology, so Jane looks to her for advice. Sally wants to help Jane get the most out of her therapy, so she's kibitzing - looking over her shoulder, backseat driving. This well-meaning gesture can complicate and disrupt Jane's therapy.

As stated before by me and my fellow bloggers, the therapeutic alliance is extremely important for successful therapy. Jane and I working together on her issues in an atmosphere of trust and collaboration is the backbone of our work. When a Sally enters into the picture, the alliance can be undermined. Jane may start questioning our work and feel torn - to whom should she listen? Now, rather than getting down to the business of working on herself, she's sidetracked by divided loyalties.

Some of the people I've worked with report feeling awkward, annoyed and irritated when those close to them ask about their therapy. Others feel the questions convey love and interest in their life. And some clients actively solicit opinions about their therapy to help them know what their feelings about it should be, or to validate what they already feel. Therapy doesn't exist in a vacuum - it's tantalizing to talk about this hour with others during the week. If you do, you'll inevitably hear their feedback. Everyone has an opinion.

Before I dive too deep into this series, I'll state the big caveat: if something unethical or illegal is going on, please tell someone. Discuss your concerns with your therapist first, and if that doesn't resolve the issue, call your therapist's boss or licensing board and let them know what's happening. If you're not sure what's ethical and what isn't, take a look at their professional Code of Ethics. If a boundary is being violated, it's probably mentioned there.

In this brief series I'll try to address what happens at the intersection of therapy and loved ones. I hope to leave you with an understanding of what is helpful for clients to disclose to others, what isn't, and what to do about overzealous backseat drivers. I'll cover the confusing area of adolescents in therapy as well as give tips to those with loved ones in therapy.

I'll be working from one general thesis: as long as the therapy is ethical and effective, it's best to discuss conflicts or concerns directly with your therapist. Why?

Diffusion of energy: I've heard this from clients before: "something you said last week really ticked me off (or got me thinking, or confused me), but I talked to my friend and I feel better. So, what should we do today?" We just missed a great opportunity to dive into juicy material. Because you blew off steam outside the session, we are deprived of the opportunity to learn and grow in this room. You may feel better, but I don't have any greater understanding of the problem and we don't have the shared experience of resolving it.
Assertion: No matter how collaborative the therapy, it's still a challenge to confront the therapist in the here and now. Many clients come to therapy wanting to work on their ability to confront. Why waste this opportunity?
Therapist growth: Your therapist is a human and a professional, always growing and evolving in her work. If she made a poor choice, it would be great for her to hear about it. It's not your responsibility to educate or train your therapist, but she should be willing to learn from her mistake and provide better service to you.
Developing self: I've mentioned people who tend to live life by committee. Rather than exploring and trusting their own opinion, they'll survey friends and family and adopt theirs. While occasionally helpful, making most decisions this way is disempowering. I'm interested in Jane's opinion of our work, not Sally's.
Avoiding triangulation: In too many families, direct communication is replaced by a triangle: A tells B who tells C. This is a very common but ineffective way of communicating. Sometimes it's repeated in therapy (especially with teens): client is upset with therapist, client tells loved one and loved one leaves a stern message on therapist's voicemail. The therapist, bound by confidentiality laws, can't even acknowledge the client is in treatment without consent. When the client speaks directly to the therapist, it eliminates the triangle and gives the client a chance to deal with the situation directly.

In Part II I'll discuss why backseat driving happens and give real-life examples. Stay tuned.

Four Elements of Forgiveness

Ryan Howes, Ph.D. — Sat, 05 Sep 2009 00:43:07 +0000

Theories of forgiveness are like LinkedIn accounts - everybody has one but they never really use it. Today I'll let you in on my theory.

The mental and physical health benefits of forgiveness are well established (here, here and here). But for some reason, it's much easier said than done. Why is this?

From experiences personal (several) and clinical (too numerous to count), I've seen a lot of forgiveness. Many failed attempts at forgiveness, I should say, and some satisfying ones that seem to last. The effective attempts tend to share four common elements:

A. Express the emotion
B. Understand why
C. Rebuild safety
4. Let go

The alphanumeric bullets are intentional. These are elements, not steps, as it's not a completely linear process. People need to go through points A-B-C in whatever order they deem necessary, even repeating them until satisfied. They may need to understand why or acquire safety before they let themselves feel. Or maybe they need to revisit the facts several times before they understand. But those three elements need to be achieved before letting go (point 4) is possible. A lot of people want to leapfrog the feelings and rush to letting go, that's a problem I often see. But bypassing the emotion doesn't allow a deeply satisfying process to take place.

I'll expand on this:

A. Express the emotion: Whatever the crime or injustice or violation, the forgiver needs to fully express how it made her feel. If the transgression elicits anger or sadness or hurt, those feelings need to be deeply felt and expressed. If it's possible to express it to the perpetrator, great. If not, a stand-in, empty chair, heartfelt letter or yelling in the car with the windows rolled down might suffice. Are you expunging all the feelings? Probably not, but enough to allow you to focus on the other areas.

B. Understand why: Our brain will continue to search for some explanation until it's satisfied. Maybe we won't agree with the rationale, but we need some schema that explains why the act took place. In some situations, even an acceptance of randomness can be a sufficient paradigm.

C. Rebuild safety: The forgiver needs to feel a reasonable amount of assurance the act won't recur. Whether it comes in the form of a sincere apology from the perpetrator, a stronger defense against future attacks or removal from that person's influence, safety needs to be re-acquired. To a reasonable amount, of course, because we are never 100% safe.

These three elements help us process the event. It's how I feel, how I understand what happened, how I know it won't happen again. On to the fourth:

4. Let go: This very difficult step is a decision. Letting go is making a promise to not hold a grudge. In the case of a relationship, it means one partner won't refer to that past transgression again: "I'm forgetful?!? Well, you forgot our anniversary once!" It's resolving to refrain from lording the transgression over the other in the future. When it comes to forgiveness, the victim holds all the power. I've even seen a smile creep over the face of someone who has been trespassed upon: "You screwed me over? That gives me a whole year of guilt-tripping." Letting go means surrendering this dominant role; a stepping down from the powerful position of victim to allow equality again. In addition, letting go is making a promise to yourself that you'll stop dwelling/replaying/ruminating/perseverating on the injustice. If letting go feels impossible, it's probably because A, B or C weren't sufficiently completed.

For example: I loan you my car and you return it with an empty gas tank, Arby's wrappers everywhere and an N'Sync bumper sticker. That's bordering on unforgivable, but I'm going to try:

I let myself feel the anger about the car and tell you about it (A). I say something like: "Dude! I'm livid! I hand you my car keys and this is what you do? I can't believe it! And who listens to N'Sync?"

Then I ask you why you did this (B). You tell me you were in a hurry and didn't have time to clean it out or get gas, but you meant to leave me $30 for gas and a car wash. And the bumper sticker was a bad joke. Lol? I don't like it, I don't agree with it, but it does help me make sense of the situation.

Now I need to rebuild safety (C), so I decide I won't lend you my car anymore or I ask you to promise not to do this again or I start charging you a $100 deposit for car borrowing. Something like that, something that helps me gain assurance that it won't recur. Then maybe I need to express anger again or set another boundary. If I've gone through these three elements; expressing feeling, gaining understanding and working toward feeling safe, then the last step is a little easier.

I make a decision to let go (4), so I won't hold this over your head in future conversations or conflicts. I'm also letting go of my rumination and perseveration about the issue. That's where the real benefits of forgiveness lie.

By the way, you're gassing up my car and taking off the bumper sticker, too. If it's possible/reasonable to make these reparations, it should be done. And when I find your Celine Dion cassette in my tape deck, it's mine to dispose of how I please.

Of course, many situations are more complex than this example. But in general, forgiving means returning to a place of equality. It promises health benefits, relational perks and emotional strength, as you know, but it also means relinquishing power. Maybe that's why it's so difficult for so many people.

600 Ticks

Ryan Howes, Ph.D. — Wed, 19 Aug 2009 20:53:21 +0000

I live a significant portion of my life in the ten minute gaps between clients. I've gotten it down to a science after a dozen years in practice:

"Good work today, see you next week."
Write session notes
Check voicemail
Check email
Grab keys, walk 18 paces down the hall to the restroom
Find sports drink/Diet Coke/lemon Arrowhead sparkling water in my refreshment drawer (bite of Power Bar optional)
Return urgent messages, put the others on my to-do list
Pull out file for next client, review previous sessions
Gather myself, collect my thoughts, take a deep breath
Listen for the waiting room door close
"Hi, welcome"

It looks so utilitarian in writing. The list doesn't do it justice. Those ten minutes are golden.

Don't get me wrong, I thoroughly enjoy the 50 minutes I'm on the clock - exploring uncharted territory, learning how people think and cope, sharing in "ah ha!" moments. Each work day gives me opportunities for growth, challenge and reward. But those ten minutes between the 10 and the 12 on my clock are vital.

They're my time to reflect, reset and reload.

As soon as the door closes, I'm at my desk putting into writing the gist of the past 50 minutes. Thorough yet concise, I'm summarizing and evaluating what just happened. Sometimes it's an emotional breakthrough. Other times it's gathering data or the client just needed to vent. I'm using a few moments to take stock: where did we go today and where might we go next time, and furthermore, determining how today fits into the overall case conceptualization.

I hit the commode (if nature calls), check messages and evaluate my food/liquid intake because don't want these needs to intrude upon my sessions. I don't want to be thinking how much I need to go to the bathroom when a client is grieving his lost childhood. I don't want to daydream about dinner when someone is deciding whether or not to get a divorce. During sessions, I usually have something to drink on the coaster to my right. Not that I'm dying of thirst, I just don't want the desire for something to draw away my attention. If it's there, a muscle-memory away from my right armrest, that much more of my brain can attend to the issue of the moment.

I'm resetting: allowing the last session to pass away, attending to my own needs, re-calibrating my instruments and preparing myself to enter the psychic space of another. It's like a boxer going back in the corner for some water, a pep talk and a possibly a styptic pen, getting ready for another round. Minus the violence and spit bucket.

Then I reload. I review the file for the next client. I get familiarized with our last few sessions, placing myself back in that mindset. Where are we headed? How did we leave off last time? What unresolved issues are waiting to be addressed? I've been blessed with a good memory, so a couple sentences usually trigger all the relationships, events, defenses and assets we're working on. I have an idea of what we can cover today, but it's up to the client to chart that course. I find myself eager to get started.

The waiting room door closes. I wait for the big hand to reach 12, and I'm up to open the door. I'm not sure what the next 50 minutes will bring, but I'm excited about the opportunity to reconnect with my client and curious about where we'll go.

I know some colleagues who see clients back-to-back, no break. They must know something I don't, because that would never work for me. I believe those ten minutes between sessions are essential for client care and my own mental health. Sometimes clients wonder if they can go overtime a few minutes to finish their thought, or they might want to know if I care enough to bend the rules. What they might not understand is by keeping that ten minutes sacred I am caring for them. I'm modeling good boundaries and self-care, reflecting on their session and making time for the tasks that keep my practice rolling.

Without those 600 ticks, I might not be able to help them as much.

Music Genre vs Theoretical Orientation

Ryan Howes, Ph.D. — Mon, 10 Aug 2009 21:13:10 +0000

I'm not a music therapist, just a shrink who strums a guitar. The similarities between music and psychotherapy have long intrigued me: both explore mood, expression, emotional catharsis and the balance of art and technique. Each have subfields with zealous disciples. We go to music and/or therapy seeking answers, relief and understanding. Our darkest days and dreams to be better people are the catalyst for many of the best therapy sessions, as well as the best songs ever performed.

A while back I attended an ISTDP workshop. The modality is direct and forceful, they don't mince words and time is of the essence. It reminded me of a punk rock concert: therapist and client, slam-dancing in the psychic space. I wondered if the two might even have similar theoretical underpinnings, and furthermore, if there were correlations between other music genres and therapeutic modalities, what might they be?

After much deliberation*, here are a dozen music genres and their corresponding theoretical orientations:

Top 40 Pop ~ Cognitive/Behavioral Therapy - Popular music tends to follow a stable, predictable formula that produces results. It may lack in edge and depth but it delivers the goods - that's why it's the Top 40. Same with CBT - popular, effective, formulaic, doesn't go too deep.

Frontmen: D. Meichenbaum, M. Carey, D. Burns, M. Jackson
Supporting Lyric: "I just can't get you out of my head, boy your lovin' is all I think about" - Kylie Minogue
"There is more to the surface than meets the eye" - Aaron Beck

Rock ~ Psychodynamic - According to Freud, our basic instincts drive us toward sex, aggression and death. Rock music plugs these themes into a 100-watt amp cranked to 11. Throw in a shared history of scandal, drugs, groupies and narcissism, and these two are a perfect match.

Frontmen: S. Freud, J. White, R. Greenson, Led Zeppelin
Supporting Lyric: "Daddy didn't give attention to the fact that mommy didn't care" - Pearl Jam
"It is always possible to bind together a considerable number of people in love, so long as there are other people left over to receive the manifestations of their aggression." - Freud

Adult Contemporary/Easy Listening ~ Humanistic - Unconditional positive regard, congruence and empathy are the wheels of the humanistic tricycle. What else would you want to experience in your dentist's waiting room?

Frontmen: C. Rogers, M. Bolton, A. Maslow, K. Carpenter
Supporting Lyric: "Up, up and away, in my beautiful balloon!" - 5th Dimension
"The good life is a process, not a state of being. It is a direction not a destination." - Carl Rogers

Classical ~ Family Systems - Orchestras rehearse to create a product greater than the sum of its parts. Family therapy has a similar goal in its quest for the mythical "functional family." Also, about 27 minutes into a classical concert or a family therapy session, people may begin losing touch with reality.

Frontmen: V. Satir, W. A. Mozart, M. Bowen, J. S. Bach
Supporting Lyric: "Duh Duh Duh DUM" - Beethoven
"Human experience of identity has two elements; a sense of belonging and a sense of being separate." - S. Minuchen

Techno ~ Neurofeedback - For readers who are either too nerdy or not nerdy enough, techno is a movement in popular music harnessing technology to create powerful, futuristic, eclectic sounds. Neurofeedback is a relatively new modality that utilizes technology to improve upon existing theories and techniques. Who says you have to understand it for it to work?

Frontmen: Prodigy, F. Shapiro, Daft Punk, J. Lubar
Supporting Lyric: "You're unaware/You keep moving/You're unaware/You keep moving" - Crystal Method
"I use Neuroguide for QEEG and both Neuroguide and Eureka for LORETA." - Lubar

Punk ~ ISTDP - Punk uses short, loud, no-frills songs to convey a strong message or emotion and they don't care how you feel about it. ISTDP is known for breaking through defenses and getting to core issues in a single-digit number of sessions, but it's criticized for trying to pick a fight with the client in order to elicit emotion. They're both Intense, Short-Term, Dynamic, and for many, Psychotherapy.

Frontmen: H. Davenloo, W. O. Williams, P. C. Della Selva, I. Pop
Supporting Lyric: "I like taking Tuinal / It keeps me edgy and mean / I'm a teenage schizoid / I'm a teenage dope fiend" - The Ramones
"It is the experience of intense anger against his mother that is most likely to lead to therapeutic effect." - David Malan

Emo ~ Existential - Emo appeals to the kids who are too shy to be punks but still have plenty of anger and anxiety. Fits right in with the school of therapy that derived from the German and Swiss philosophers so mindful of death as humanity's final boundary. Both emo and Existentialism teeter on the boundary of banality and optimism agreeing that life is temporary, just unsure if the appropriate response is whining or acceptance.

Frontmen: V. Frankl, Good Charlotte, I. Yalom, Fall Out Boy
Supporting Lyric: "As time passes by, regrets for the rest of my life." - A7X
“Ever more people today have the means to live, but no meaning to live for.” - Frankl

Gangsta Rap ~ Kleinian - The theories of Melanie Klein revolve around envy, breasts, death and hostility. Need I say more?

Frontmen: M. Klein, T. Shakur, J. Grottstein, Eminem
Supporting Lyric: "Today I didn't even have to use my A.K. I got to say it was a good day." - Ice Cube
"...when in the baby's mind the conflicts between love and hate arise, and the fears of losing the loved one become active, a very important step is made in development." - Klein

Blues ~ Jungian - Carl Jung's work highlights archetypes, symbols and the collective unconscious. In the blues, women are heartbreakers and men are longsuffering (archetypes), rain is sad and trains bring hope (symbolism) and we all look for something down at the crossroads (collective unconscious). When B.B. says: "I've been down hearted baby, ever since the day we met," he's talking about the anima, right?

Frontmen: C. Jung, R. Johnson, J. Campbell, M. Waters
Supporting Lyric: "I went down to the crossroads, tried to flag a ride. Nobody seemed to know me, everybody passed me by." - Eric Clapton
"The least of things with a meaning is worth more in life than the greatest of things without it." - Carl Jung

Contemporary Christian Music ~ Mindfulness - Critics slam CCM for rehashing pop music from five years ago and adding a religious spin. Mindfulness has been described as old CBT techniques reloaded with spirituality. Funny thing is: fans of either won't like this comparison.

Frontmen: J. Kabat-Zinn, Hillsong, T. N. Hanh, A. L. Grant
Supporting Lyric: "Looking for a reason, roaming through the night to find my place in this world" - M. W. Smith
"Love is a state of Being. Your love is not outside; it is deep within you. You can never lose it, and it cannot leave you." - E. Tolle

Opera ~ Lacanian - Both are nearly impossible to understand, they speak to a particular crowd and are not for everyone. The true believers are fanatics. Lacan has been called the Freudian's Freud. Opera appeals only to the most devoted audiophiles. Both require subtitles.

Frontmen: J. Lacan, R. Wagner, J.A. Miller, R. Strauss
Supporting Lyric: "For the signifier is a unit in its very uniqueness, being by nature symbol only of an absence." - Lacan
"L'amour est un oiseau rebelled Que nul ne peut apprivoiser" - Bizet

Country ~ Narrative Therapy - The narrative approach states the personal story is at the core of the development of self. Country music has always been about the story - heaven knows it's not about the music.

Frontmen: J. S. Bruner, D. Parton, T. Sarbin, H. Williams, Jr
Supporting Lyric: "Is this work better defined as a world-view? Perhaps it's an epistemology, a philosophy, a personal commitment, a politics, an ethics, a practice, a life, and so on." Michael White
"I've got friends in low places where the whiskey drowns and the beer chases my blues away and I'll be okay" - Garth Brooks

Shuffle mode on your iPod ~ Eclectic

* Disclaimer: No science here, just having fun. I'm not suggesting fans of a particular musical genre should seek out the corresponding therapeutic modality - or vice versa. I know of no research to support this idea (but I wish I could have chosen it for my dissertation topic). Feel free to disagree or contribute your own ideas.

The Definition of Insanity is...

Ryan Howes, Ph.D. — Mon, 27 Jul 2009 19:06:00 +0000

I hear this every week, sometimes twice a day: "The definition of insanity is doing the same thing over and over and expecting different results." No, it isn't.

To be clear, insanity is a legal term pertaining to a defendant's ability to determine right from wrong when a crime is committed. Here's the first sentence of law.com's lengthy definition:

Insanity. n. mental illness of such a severe nature that a person cannot distinguish fantasy from reality, cannot conduct her/his affairs due to psychosis, or is subject to uncontrollable impulsive behavior.

Insanity is a concept discussed in court to help distinguish guilt from innocence. It's informed by mental health professionals, but the term today is primarily legal, not psychological. There's no "insane" diagnosis listed in the DSM. There's no "nervous breakdown" either, but that's another blog.

Where did this saying come from? It's attributed to Albert Einstein (probably not), Benjamin Franklin (probably not), Mark Twain (probably not) and mystery writer Rita Mae Brown (probably so) who used it in her novel Sudden Death. It's not clear who said it first, but according to at least one blogger it's "the dumbest thing a smart person ever said." The catchy saying has gathered steam in the past few years (example I, II, III), and regardless of the source, it's gotten a lot of mileage.

I'm not in the habit of slamming cute sayings (with one exception), but I think there's a dark underbelly to this one. I've started hearing people use it in the service of avoidance, which is a defense mechanism. Rather than facing their fears, they grab on to this saying for protection against possible failure, pain or rejection. Some examples:

"I've asked out two women and been shot down both times, and you know the definition of insanity..."

"I jogged for a week and actually gained weight. They say the definition of insanity is ..."

"It's been a month and I'm still crying about his death. I'm living the definition of insanity."

The definition of insanity doesn't have anything to do with jogging. It's important to keep grieving, jogging and asking people for dates because these are areas of life that require some repetition and are quite sane. As a therapist, when I hear these statements I can collude with the protective bubble of the socially accepted catch phrase or challenge it. When met with the examples above, I'll challenge.

I think the confusion behind this statement is best illustrated by these two words:

Perseveration: the pathological, persistent repetition of a word, gesture, or act.

Perseverance: steady persistence in a course of action in spite of difficulties, obstacles, or discouragement.

Some forms of dementia, traumatic brain injury, anxiety and OCD can cause people to perseverate. They repeat words and tasks or try repeatedly to solve problems, but are left frustrated and unsatisfied. They're not necessarily insane, but stuck in a non-productive pattern due to a glitch in brain function. Some medications or CBT tools may prove helpful.

There's also the psychodynamic construct called repetition compulsion where people unconsciously repeat past conflicts in an attempt at mastery. We want to finish unfinished business, so sometimes we re-create old, unresolved problems for the potential of a better outcome. A typical example would be a guy who desired closeness with his emotionally unavailable mother as a child and therefore seeks out unavailable women in his adulthood. Or a woman who feels it's always her duty to invite her selection of apathetic friends to socialize. Or someone who is drawn to crowds of wealthier/smarter/prettier/etc. people where they always feel left out. They're all trying to finally conquer some old feelings of rejection. But even if they do succeed today, it doesn't erase the pain from the past.

Let's not confuse perseveration with perseverance. A persistent quest against a fear or toward a goal is often the best course of action. Repeating the same constructive behavior over and over, hoping (one day) for a positive result is a difficult but virtuous. It's the effort made by eating oatmeal every morning, brushing your teeth after every meal and daily journaling. It's weekly therapy, consistent workouts and taking time for spirituality. It's Rudy trying over and over to get into Notre Dame. Or Mother Theresa tirelessly serving the poor. Or someone working to systematically overcome shyness, build healthier habits or communicate better with their spouse. It's a 12-stepper taking it "one day at a time." The qualities of perseverance, consistency, loyalty - these are beneficial to health and definitely not insane. And they're doing the same thing every day, hoping for some measure of progress.

So how do you tell the difference? Perseveration feels compulsive, hopeless, helpless, automatic and unsatisfying. There is a desire to stop, but stopping doesn't feel like an option. Perseverance feels like striving toward a noble goal, and whether or not it's reached it there is virtue in the effort.

Perseverance is a strong, valuable quality. Perseveration is a troubling issue needing clinical attention. Don't let a quaint saying blur this distinction.

The Seven Questions Project: Conclusion

Ryan Howes, Ph.D. — Thu, 16 Jul 2009 16:47:52 +0000

Seven questions for twenty people produced 140 answers. In this 18th and final post I'll try to pull it all together and see what we've learned. (If you haven't heard of this project or you're foggy because I've dragged it on for so long, you may want to read the Introduction and Summary first.)

The Seven Questions Project was inspired by Three Approaches to Psychotherapy, a 1965 training film where celebrated therapists recorded sessions with a 30 year-old single mother named Gloria. I've been reading the entertaining and very well-written Living with the Gloria Films by Pamela Burry, Gloria's daughter. Intermingled with engrossing anecdotes about Gloria and the therapists, Pamela shared some of her own story and opinions of therapy. In this quote, she equated her experience in treatment with her mother at the time of the film:

Similar to most who seek counseling, we were both unnerved by the instability of our circumstances, and unmoored by the inapplicability of the standards and goals by which we had previously navigated our lives. We were hoping that the therapist - sitting on the chair just opposite - might recognize this foreign place within us and help give it voice. (p. 89)

Well said. This point is drilled home in her book, the films, this blog and everywhere else therapy is mentioned: a good fit between client and therapist is crucial. Today, with hundreds of theories spread among one million therapists, an uninformed client could search a long time to find a match.

Hence this project. I wanted to give readers a sense of the diversity within the field and show how a therapist's personality and theory influences therapy. I sent seven open-ended questions to today's celebrated clinicians to see how (and if) they would respond. Here are some results, conclusions and assorted musings:

Responses: I thought the up-and-coming authors and theorists would jump at the opportunity for free publicity and wide exposure, while the more established authorities in the field couldn't be bothered. I was exactly wrong. Most of the hotshots were too busy, so they politely declined, sent repeated "write back in a month" messages or simply didn't respond. The seasoned clinicians were happy to participate and seemed to enjoy sharing their wisdom and experience. Those involved in the governing bodies were the first to write back; this type of PR is probably in their job description. There was a 40% response rate overall (14 for 35), which is respectable for a soft science.

Similarities: Most everyone from Glen Gabbard to Harville Hendrix to James Bray to Thomas Szasz emphasized the primary importance of therapist/client rapport. Many stressed the need for therapists to set boundaries and practice healthy self-care. They griped about managed care and encouraged clients to leave bad therapy. Most underscored the client's right and responsibility to determine where they'd like to focus their therapy. And in my opinion, some had a similar approach to question 4 (ultimate goal of therapy): they phoned it in. Rather than getting their hands dirty by unveiling their model of health, they played it safe with "we set goals together."

Differences: As expected, dynamic types focused on working through pain from the past and CBT types emphasized interventions for changing thoughts and behaviors. Theoretical differences were fairly obvious, but personality differences were more subtle. For example, Judith Beck and Donald Meichenbaum are both pillars of CBT with similar viewpoints, but their delivery was incredibly different. Relationship experts John Gray and Harriet Lerner had answers dancing on different planets. David Burns felt good about a 2948 word response, while Hendrix gave the love in 113. Jeffrey Barnett returned his complete answers within hours of my request, while others took weeks or months or never responded. Personality is not just about what they said, but how they said it.

Mudslinging: Respondents weren't shy about criticizing one another's theories. Meichenbaum warned therapists of "questionable psychotherapeutic ‘BULLSHIT' that pervades the field." Irvin Yalom wondered if CBT therapists would really want to take their problems to another CBT therapist. Stephen Diamond's depth psychology response was a direct rebuttal to Beck. Daniel Amen jabbed at psychiatrists for ignoring the organ they treat. Burns critiqued all mainstream psychotherapy and several of my questions. Szasz knocked the entire field of mental health, but we wouldn't expect anything less from him. Apparently, these therapists empathically collaborate with their clients but they don't mind slamming the competition. Maybe that's why they're famous.

Best Question: I thought it would be questions one, four or seven, but question five (the toughest part of being a therapist) turned out to be the most revealing. The very honest and personal responses included concerns about self-employment, awkwardness at cocktail parties, staying awake in session and holding clients' pain.

Best Surprise: I invited any and all therapist bloggers to write responses to the questions and had a few takers. I found many of their answers to be less inhibited and more compelling than my big name guests. Also, I love being able to do a side-by-side comparison of the American Psychiatric Association president, a yoga instructor and a music therapist in an inpatient facility. Each has a unique, valuable viewpoint worth hearing.

Limitations: No research is complete without the author owning up to its shortcomings. The most glaring is a lack of theoretical, ethnic and gender diversity. A broad range of modalities are represented here, but the field extends far beyond psychodynamic, CBT and existential theories. I asked, but unfortunately didn't receive responses from therapists who represent some of the newer modalities (mentioned in the Summary). The project would also benefit from more diversity in the respondents to reflect the spectrum of modern clinicians.

Highlights: There are so many. The series spent a week on the APA homepage. A website for psychology students now includes it among their resources. Therese Borchard from Beliefnet's Beyond Blue interviewed me about the series. One interviewee sent me a couple of his books. A Polish psychology magazine is now asking Seven Questions to their own countrymen. Several other websites helped get the word out (here, here and here). But the biggest thrill for me was corresponding with dozens of clinicians who shaped my theory and practice in some way, several of whom became pen pals. Of course, the Yalom interview will always be a career highlight.

So what did we learn? Therapists appear to share beliefs about the fundamentals of therapy, but beyond that, they're enormously different. Some emphasize the science of therapy, while others focus on relational aspects. The governing leaders and popular icons are thoughtful, passionate people who are generous with their time and wisdom. They're also human: some have big egos and theoretical rigidity. Hopefully, through persistent dialogue and research that emphasizes our client's wellbeing (and policies that allow for such discourse), psychotherapy will continue to evolve and thrive.

Thanks again to each of the participants for their generous donation of time and effort. I typically find it difficult to get 20 people to do anything together, especially for free.

----

Want some more? Not from me, I'm done with this topic for a while. But if you have a burning interest in the theory and practice of therapy, might I suggest you look into the Evolution of Psychotherapy conference. Several of the Seven Questions participants are featured speakers as well as many other prominent clinicians. I'll see you there.