CPPNJ - The Center for Psychoanalysis and Psychotherapy of New Jersey

Saturday, December 17, 2011

Sexual Abuse -- New Statistics, New Hope

The numbers are staggering.

According to a just-released government survey, nearly one-third of women report they had been victims of sexual violence — rape, beating or stalking — at some point in their lives. Additionally, one in seven men had experienced severe violence at the hands of an intimate partner and 1-to-2% had been raped.

The high numbers surprised even some experts. They point to a problem in our society that is poorly addressed and that has profound implications for its victims.

Not surprisingly, the report showed that people who survive sexual violence suffer from physical and psychological problems, including diabetes, chronic pain, difficulty sleeping, increased risk of smoking, depression and Post-Traumatic Stress Disorder.

Part of the toll comes from the fact that rape is not only an act of sexual violation, but of power and control exercised over a helpless victim. The survivor must contend not just with being brutalized physically (often by someone he or she trusted), but also with the violation to her or his sense of self integrity and safety. The experience can be overwhelming, particularly when it stirs up memories of earlier examples of vulnerability, betrayal and shame going back to childhood.

In my practice, I have worked with many such individuals. Some report anxieties and inhibitions around sex, as well as guilt, anxiety, anger and mood swings. It can take a toll on their sense of confidence and trust, and on their ability to grow close in intimate relationships. Because of shame ("What will people think of me?"; "Maybe it was my fault") many do not talk about what happened to them. Some are afraid that to speak about it — even in therapy — would leave them once again feeling trapped with the very overwhelming feelings and memories they are trying to avoid.

Unfortunately, denial rarely works. In order to shut down anything associated with the experience, the person numbs her or himself (sometimes with alcohol, food or cigarettes), reliving what happened in flashbacks or through persistent fears and hypervigilance. They are always mobilized and on the lookout for danger. Some isolate from friends and loved ones. Without being able to deal with what happened, the trauma lives on within them, and gets created with others around them.

Since my practice includes men who have been physically and sexually abused — many, but not all of them gay — I wanted to address the special challenges they face. Both male and female survivors have to battle stigma and shame, but a man who is overpowered is often deemed weak and unable to fight back. There is a great hesitation to report crimes for fear of how the police and others will react, whether they are gay or straight. Much of the abuse takes place in romantic or sexual relationships, which can lead to guilt, stigma and self blame. Women who know their attackers often struggle with this as well, although in somewhat different ways.

Regardless of the circumstances, a goal of therapy is to create a sense of safety that allows the patient to feel she or he can talk about what had happened without being judged or overwhelmed by their feelings and memories. The therapist is careful to move at a pace that feels comfortable to the patient, in a way that is respectful of her or his need to feel in control.

The ability to speak the unspeakable before a carrying, nonjudgmental other can help relieve shame and give the person a sense of control and understanding. To the degree that the experience stirs up pain from the past, the ability to shed new light on earlier experiences — and to see how they connect to the person's current reactions and coping skills — can be profoundly healing and self-esteem enhancing. Ultimately, the person can move from feeling like a victim to a survivor who might actually grow stronger from the experience.

-- Eric Sherman, LCSW

Sunday, November 13, 2011

Learning for Penn State: the Legacy of Childhood Sexual Abuse

Much has been written about the recent news out of Penn State. Throughout the country, people were disturbed by the magnitude of the sexual abuse allegations, and the negligent way that coach Joe Paterno and the administration swept aside this serious matter.

The news brought home a dynamic of childhood sexual trauma with which many survivors and fellow professionals are familiar. In fact, a number of former abuse victims in my practice again felt violated by the news that unfolded throughout the week, including the way the beloved father-figure Paterno had further betrayed the children involved by not acting on the charges more seriously. (The insensitivity of Penn State students who violently rallied on behalf of Paterno as if he, and not the boys involved, was the victim also upset some.)

It is sadly ironic that the name Paterno sounds so much like paternal. When a young person is abused, frequently a parent (or both) who should have known instead adds to the victim's trauma. Whether consciously or not, they ignore signs (including of the child's distress) that something is amiss. Worse, they may disbelieve or even blame the child, perhaps re-creating a dynamic from their own childhood. (Victims of child abuse frequently marry abusive partners to whom they cling.)

The results can be devastating. Sexual trauma -- including various forms of seduction and boundary violation -- can overwhelm the child's ability to make sense out of what has happened, leaving him or her feeling frightened, overwhelmed, and guilt-ridden. Without the support of protective parents, the child feels doubly isolated and betrayed. He or she may blame themselves for whatever small degree they enjoyed the attention. Incest and other forms of child abuse generally take place in dysfunctional and chaotic households where children feel unseen and unprotected. The attention of a seductive father can be the only form of love the child knows, leaving her to blame herself for what had happened. ("I must have wanted it.") When one or both parents reinforce this message, the child is left burdened by a sense of guilt and shame too massive to process.

And so the victim frequently employs something called dissociation to try to maintain some form of self integrity. Dissociation is a coping mechanism designed to help an overwhelmed individual cope with trauma -- although at great cost. Threatening experiences and feelings are split off from the person's conscious awareness and are experienced as if not part of the self. The unconscious is acting like a surgeon, sacrificing a cancerous limb to protect the rest of the body -- except the person is not aware of what they are missing. In severe cases, called Dissociative Identity Disorder (formerly Multiple Personality Disorder), the parts of the self associated with the trauma become autonomous personalities that take over the person's consciousness.

However, dissociation need not be so pervasive. An adult can function quite competently in the world, yet be afraid of sex, for instance, since sexual feelings cannot be tolerated due to their link to the original trauma. Or he or she may be unaware of their own anger, dating back to the original betrayal. These people present as compliant adults terrified of aggression or confrontation. Without being able to get in touch with their own healthy assertion, they attract demanding others who use them and leave them confused -- precisely the original trauma from childhood the person was trying to avoid.

This is one explanation why trauma survivors often unwittingly reenact painful situations in the present. What cannot be integrated and understood can only be lived out over and over again, seeming to reconfirm for the adult that life is in fact terribly dangerous, that they are bad and worthless and sure to be betrayed.

For such adults, psychotherapy -- particularly a psychodynamic approach -- can be a vital part of the healing process. Therapy helps the individual understand and incorporate parts of themselves that have been left behind. The analyst -- another parent-like authority figure -- creates a safe environment to inevitably reawaken the patient's hope and dread of being both recognized and helped, but also once again seduced and betrayed. It involves more than simply recovering memories, but rebuilding trust. This involves the adult being able to experience and integrate what had previously been dissociated. Rather than simply reenacting the trauma in adulthood, the person finally begins to see themselves in a new light and moves on in their lives in ways they never would have imagined.

If some good comes from the Penn State tragedy, perhaps the discussion about sexual abuse and adult responsibility may increase awareness and make it that much easier for others to come forward and get the help they need.

-- Eric Sherman, LCSW

Sunday, October 23, 2011

Contentment: What you can find in a pill

According to a new survey, the use of antidepressants rose 400% in the United States in little more than a decade. (If only I could say the same for my stock portfolio.) The National Center for Health Statistics reports that antidepressants are now the most commonly-prescribed medications among 18-to-44 year olds. Nearly a quarter of women age 40 to 59 take them.

Sadly, less than a third of people taking antidepressants, and less than half of those taking two or more, had seen a mental health professional in the previous year.

It gets more depressing -- every pun intended. According to the study, most people on antidepressants suffer from relatively minor depression (sometimes called dysthymia), and some may not be clinically depressed. And yet as many as two thirds of Americans with severe depression receive no treatment at all.

A number of experts believe that we have reduced depression, anxiety and other states of the mind into simple neurochemical disorders, failing to address the broader psychological aspects.

Psychotropic (psychiatric) medications have helped many people; I have strongly recommended them for some of my patients over the years. I do not wish to minimize their importance in any way. But their overuse, particularly without accompanying psychotherapy, is part of a larger problem. As a society, we are mired in a get-well-quick mentality that treats complex emotions like a Betty Crocker cake mix -- a right-out-of-the-box approach that's quick and easy, but minimizes the pleasure and importance of finding out what's really cooking, so to speak, to cause a person's suffering.

Something is wrong when we have gone from self-examination to Prozac Nation -- a situation which has only worsened since the famous book of that title was published in 1994.

When people pop pills without also engaging in psychotherapy, they are not addressing the deep-seated problems that are caused their depression, anxiety, self-doubt and compulsions. The act of avoiding what makes them anxious about themselves likely is at the heart of their problem to begin with. Without making the effort to address how they got stuck, they are likely to only perpetuate their shame and feelings of inadequacy regardless of the effectiveness of the medication. "I am not strong enough to tackle my problems," is the message they give themselves. "I have to find an easy way out."

The benefits of psychotherapy are numerous, particularly a psychodynamic approach which looks to understand the underlying causes of maladaptive patterns and find ways to permanently alter them. The person's sense of self and ability to navigate their lives improve immeasurably. There is great joy in being able to understand and master issues which have kept us stuck. As change unfolds in the psychotherapy sessions and in the person's every day life, most people find their relationships -- with themselves and others -- and their sense of accomplishment and confidence improve in dramatic ways.

The process involves work -- more than just popping a pill. But if you really want to get to the crux of your problems, looking inside to find a sense of purpose may be more profound than anything you keep in your medicine cabinet.

-- Eric Sherman, LCSW

Tuesday, October 4, 2011

Understanding self sabotage

Still repeating the same self-defeating patterns?

Dating the same kind of controlling jerk you vowed to avoid three controlling jerks ago?

Putting off assignments until the last minute, then making sloppy mistakes in a rush to meet deadline?

Sleeping late, not going to the gym, overeating... and then hating yourself for it?

On the surface, it makes no sense. Why would anyone keep shooting themselves in the foot when clearly they can see their toes smoking?

But when you consider the unconscious -- the thoughts, feelings and motivations that "secretly" guide your actions -- even the most irrational behaviors come in to focus. Consciously, you want to complete the assignment, find a healthy romance, and stop angering friends by running late. But deep inside, conflicting desires are at odds with your conscious intentions.

Sure you want to prove yourself, but what if you unambivalently attack an assignment and then fail? What if you pursue a romantic partner who can truly nurture you -- and he walks away? It feels worse to be rejected by Prince Charming than to stick with the jerk you know isn't right for you.

I have worked with numerous people who, on the verge of important accomplishments -- or perhaps right after something good has happened -- become anxious and yank the rug out from under themselves. It may seem counterintuitive, but it sure beats getting your hopes up and having somebody else dash them -- especially if that's been a frequent experience in life. By extinguishing your own hopes, your unconscious is trying to protect you from the rejection that has already happened in the past, and that it is sure will happen again if it lets its guard down. The pain you know is familiar, and by causing it yourself, you at least feel in control. You know how things will turn out since, without realizing it, you have engineered them that way.

People often say they procrastinate because there are lazy. I like to reframe it so that they can see what they really are is frightened. They put off a daunting task because they are afraid they will not be good enough to accomplish it. Or what if they do, and still feel empty inside? Not trying is a way to keep alive the hope that things will still work out in the future.

Also, by unconsciously repeating the past -- by dating an aloof, rejecting man like father -- you hope to master the pain and come up with a new ending. If you can win over Mr. Wrong, you can finally please daddy (in abstentia) and feel worthy, powerful and recognized.

The problem is that it rarely works. Instead of mastering and changing the past, we repeat it almost verbatim. What may be required is a working through facilitated by psychodynamic psychotherapy. In treatment, you confront your unconscious belief systems and finds new ways to address them. This happens in vivo with the psychoanalyst, another parent figure likely to stir up familiar rejection anxieties, but who is also able to find new ways to respond to them. Rather than reject, he affirms. Rather than become angry, he remains curious.

So stop procrastinating and start looking inside. You may be surprised by what you find.

-- Eric Sherman, LCSW

Sunday, August 21, 2011

REMEMBERING 9/11: Four Stories

On the 10th anniversary of the unimaginable, four members of the CPPNJ community -- Sally Rudoy, Martin A. Silverman, Lillian Shaw and Eric Sherman -- share their memories of the day that changed us all, personally and professionally. We welcome your comments, including your own 9/11 reflections.

A Day, At First, So Ordinary
by Eric Sherman

The thing I remember most -- besides the images of people jumping to their deaths -- is the smell.

A stench that hung over lower Manhattan, reaching the Greenwich Village neighborhood of my New York office. It smelled like burning rubber. Everyone knew what it was, even if we didn't want to acknowledge it. The odor carried the charred remains of the World Trade Center and -- most horrifying -- the people who had perished inside.

I had loved my office because of its giant windows and sweeping view of lower Manhattan. The regal Woolworth Building and the Twin Towers in the distance. On bright days, like the morning of September 11, 2001, I kept the blinds closed. The sun would have been too distracting.

At 8:48 am, as the unthinkable happened beyond my giant windows, I was in session with the same patient I saw every Tuesday morning. What stands out for me is this -- we heard nothing, we saw nothing, we knew nothing. The session went on like any other. How could I ever trust the ordinary again?

When the session was over, I bumped into my suitemate in the men's room. "Did you hear?" he asked excitedly. "A plane just flew into the World Trade Center."

I rushed back to my office and peaked through the blinds. I saw clouds of smoke billowing from what I assumed was one of the towers. I had no way of knowing that both buildings had been hit. I assumed a Cessna or other small plane had gone off course and accidentally struck the tower. I wanted to keep looking at the scene, but I had no time. I was off to teach my first post-graduate class ever, and I was nervous as hell. So I closed the blinds to the last view I would ever have of the World Trade Center and rushed to the subway. The towers crumbled while I was underground.

My first inkling that something frightening had happened was when the train I was in, trapped in a tunnel for 20 minutes, finally pulled into the Columbus Circle station and Transit Authority personnel ran on with bullhorns shouting that the station was being evacuated. A New Yorker from birth, I was concerned, but not terribly phased. Perhaps I would have an interesting story to tell the candidates when I began class moments later.

There would be no class that day, and no return to normalcy for some time. As I walked the 2-1/2 miles back to my office wondering how I would get home (the subway and New Jersey Transit were no longer running and Manhattan had been sealed off), my mind raced. Didn't one of my patients work in the Towers? The thought that he might be dead chilled me. (He had in fact been at his desk when the second building lurched forward upon the plane's impact. When I spoke with him that evening, he was fine, though quite shaken. So was I.)

The weeks after 9/11 were surreal. At first, I needed to show a photo ID to get past the police barriers on the corner of my office building. I kept the blinds closed tight, occasionally peeking out at the sight of the giant gray cloud engulfing what used to be the World Trade Center. I could only look for a few seconds at a time. The scene disturbed me too much.

My office -- the world -- no longer seemed safe. My patients and I -- the city, the country, the world -- were in a state of trauma, and there was no escaping it. The ever-present stench. The bomb-sniffing German Shepherds and National Guard officers with giant rifles at every train station. The terror that it could happen again at any moment.

Seeing patients in the days after 9/11 was both life-affirming and traumatizing. As much as I wished to work through what had happened and be present for my shell-shocked clients, at times I had the desire to shut down and forget. I kept the blinds closed tight in my office partly so that I could pretend that when I opened them again, there would be the World Trade Center, gleaming in the sun.

But there was little opportunity for denial. Session after session my patients relayed the horrors of that day and the anguish they were going through. I tried to help them sort out their feelings even when, occasionally, I wanted to scream: "Stop, please! I can't hear anymore." Instead I listened, shared my own experience when helpful, and cried with each one. Together we healed.

I have since moved my office to another part of the Village. It's on the ground floor overlooking a courtyard. There are no tall windows with views of the downtown skyline, no need to shut the blinds. Each morning that I commute to my New York office, I walk by the now-closed St. Vincent's Hospital, where many of the victims of 9/11 were rushed. The emergency room that served as a chaotic triage center is bordered up and ghost-like. Perhaps it is fitting. It is also terribly sad.

At some point this September 11, I will watch as much TV coverage as I can stomach. I will pause to think about trauma and bravery, finding meaning in what seems too much to bear. It is what I do every day as a psychotherapist. It is what gives life purpose.

First Responders
by Sally Rudoy

One memory I have of 9/11 and the few days in the aftermath was a feeling of wanting to be useful – to do something to help others. Somehow providing succor to others’ fear and shock would mitigate my own. I wanted to run toward Ground Zero, not away.

I heard from a colleague of mine that the next day there would be a coordinating meeting in the High School library. The board of education had put out a call for therapists in the community who would be willing to volunteer time to counsel traumatized students. When I arrived at the meeting in the library, it was standing room only. Around every table, packed against the book carrels, and perched along the length of the check out desk were psychotherapists of every discipline. Clearly, I was not alone in my need to do something: to make order out of chaos, return the world, now forever changed, back to its pre-9/11 predictability.

Somehow I thought this impulse to run toward disaster might be unique to those in the “helping” and first responder professions. However, as I counseled students and patients throughout the weeks following, I heard echoes of the same impulses. Teenagers wanted to go to lower Manhattan and help dig in the rubble, make casseroles for the families who lost parents, or sign-up for military service and go get the guys who “did this to us.” Younger children wanted to raise money or hold a bake sale for…for…for somebody, for something.

Early psychoanalysts discovered the phenomenon of the mind’s use of defense mechanisms to protect the self from disturbing thoughts, feelings and behavior. In those early days after 9/11, enveloped as I was in the same trauma as the ones I sought to help, I began to recognize a universal defense of keeping helplessness at bay by helping others. On the face of it, this seemed adaptive and a testament to the resiliency of the human spirit. Now, from the perspective of the tenth anniversary of 9/11, I also see my response as more nuanced. The person most helped by my actions in those dark days was myself.

PTSD Hits Too Close to Home
by Martin A. Silverman

Our daughter, 2000 miles way, called us that morning to tell us that an airplane had crashed into the WTC. We turned on the TV and watched the second plane hit the other tower and the two towers collapse to the ground. A few hours later, a woman called me and asked me to see her son, who was very upset about the incident, which he too had watched on TV. I helped her son deal with his agitation and distress -- and I helped HER to deal with it as she was even more upset than he was. I saw them a few more times, but my main preoccupation, as president of the Association for Child Psychoanalysis at the time, was that of working together with heads of many other mental health organizations to help children and families across the country to deal with the emotional impact of that terrible occurence.
Exactly six months after the 9/11 terrorist attack on the WTC, on 3/11/2002, I had left my home office and was in my kitchen getting an apple, when I heard a roar that sounded like it was coming from the engine of something gigantic racing up my driveway. Then I heard an explosion and saw debris flying up into the air. I realized suddenly that what I saw were pieces of my house. A woman, in a huge SUV, with her children in the back seats, had started to use my driveway to make a k-turn. Then she lost control of her vehicle, raced up my driveway, plowed into my station wagon, crumpling it like an accordion, and pushed it into the back porch of my house, demolishing the steps outside the kitchen, sending the pillars holding the roof up over those steps flying into the air, and knocking a hole in the side of my house!
When I stepped outside, I found that it was that same woman who had come to me with her son after the World Trade Center attack half a year earlier. "I'm so sorry," she exclaimed; "I don't know what happened!" But I knew what had happened. She had returned to me, and to my dismay, had re-enacted, at my expense, what had upset her and her son so much on 9/11! I am glad to help children and their parents who are emotionally distressed, but this clearly was over and beyond the call of duty, don't you agree?

September 11, 2001, Ten Years Later
by Lillian Shaw

The morning of September 11, 2001 dawned easily with the bright sun in place, a warm and welcome visitor, cool breezes, and billowy clouds dotting the sky-scape. As I walked into the day room of the hospital where I worked, to gather together ten patients for their ongoing twice-a-week therapeutic group, the television was on and the New York panorama looked crisp and bright.

“We will have our group now” I told the patients. It was 9:15 AM. The patients were accustomed to joining together and talking about their illness, themselves, their struggles and even current events. Especially loved was the topic of the baseball playoffs, and the World Series, set to begin in September, 2001. Groups, I had told them, allow you to change. You sit together and come to understand your thoughts and behaviors, responses and reactions to others, and theirs to you. You learn about yourself, in a group. Nothing could be truer for the close-knit September 11 terrorists, who planned their activities well, and were self-supporting, and increased their functioning and resolve, through their network.

One patient moved quickly into my personal space, and said “Did you see? Look at the TV”. I looked and saw the instant-replay of a plane smashing into the World Trade Center tower. The announcer was saying something about a plane off course. It was quiet in the room. I stood there and saw the replay three times in quick succession. Inside I felt as if raw nerves were being hacked, producing feelings of numb, and helpless abandon. Vulnerable and overwhelmed America, I thought, already had experienced atrocities resulting from the Achille Lauro, the Gulf War, the Unabomber, Oklahoma City, Atlanta Summer Olympics, the USS COLE, and others, and I felt the pull. The Twin Towers were icons, and all the people who would die that day had left home in the morning never to return. I had never been in either Tower, or navigated to the top.

After the group, I went back to the day room and watched the replay of the second plane hitting Tower two. America’s blood, tears and tissues were being poured onto New York’s pavement, I thought. And then came the horrible, terrible stories of untimely death, unasked-for and unsought bravery, and running to escape, running to save self and to save others, running for your life. The Tunnel-Run race honors Stephen Stiller’s brave run through the Battery Tunnel with 75 pounds of fire gear on his back, to help. And we watched heroes live, and we heard of heroes dying.

A socials worker on the next unit left the building in tears. Her father worked in the World Trade Center and she could not get him on his cell phone. My son Tom was out of work and had several interviews the previous week in the WTC section of the city. Does he have any meetings scheduled today, I thought? The cell phone was dead as I tried to call. No cell tower transmission, I was told. I later found out that Tom had no interviews that day and that he and my nephew Ted, each living in Hoboken, had met at the fence surrounding a waterfront park, after the first impact. They saw the second plane hit, and heard the whoosh of the fire as it enraged into a red and orange ball, and witnessed the changing of the New York harbor line, and our secure feelings, our concept of freedom, and many lives, forever, in a quick few seconds.

Then the towers came down, and New York looked like a ghost town in black and white, as the world was riveted to the television. The firemen, police, ambulance workers, hospital workers and nearby workers, all pitched in and ran and helped, and we saw an unfolding of life in goodness. It was butted against evil. Mayor Giuliani was there and it felt terrifying

We heard about the crash of a plane into a field in Pennsylvania. More heroics and bravery from people who stood up, never thought of themselves, and wanted to save others and stop the terrorists’ attack. Todd Beamer’s “Let’s roll” has become a mantra for action-oriented goodness and Mark Bingham and Tom Burnett’s bravery, and that of others on flight 93, an inspiration. Then more desperate death. And you began to worry if we will ever understand the trauma of that day, the inconceivable and despicable acts of a few, and then war. The Lord’s Prayer and Psalm 23 were prayed on board, in those last minutes, and over the phone.

The rebuilding continues. Much the same as individuals rebuild lives after emotional illness, mental illness and physical illness, trauma and abuse, and it takes time. Our nation continues to build and grieve, and to know that life matters, our lives matter, and our freedom is worth fighting for.

Saturday, August 6, 2011

Psychotherapy 101: A Who's Who In Mental Health

Thinking about seeing a therapist but confused about all the different titles? Psychiatrist, psychologist, psychoanalyst, psychopharmacologist, psychotherapist -- what a perplexing preponderance of "p-words!" So, as Richard Nixon used to say, let me make things perfectly clear. (Admittedly, Richard Nixon was not the best person to turn to on issues of mental health -- or clarity.) Here is a (remarkably incomplete) guide to the world of the mental health:

Psychotherapist -- This is an umbrella term for any professional who is trained to treat people for their emotional problems. Depending upon their academic degree, a psychotherapist can be a psychiatrist, psychologist, or social worker (among others), and work with individuals, couples, groups, or families.

Psychiatrist -- This person has a medical degree and, unlike most psychotherapists (with the exception of nurse practitioners), they can prescribe psychotropic (psychiatric) medication. Many psychiatrists -- referred to as psychopharmacologists -- provide only prescriptions and medication management; you would need to see a psychotherapist additionally for talk therapy. Traditional psychiatrists continue to practice psychotherapy, however.

Psychologist -- This person has a PhD in psychology. In addition to performing talk therapy, they have training in psychological testing (i.e., the Rorschach test, among others). They can also perform research protocols. (Psychologists who concentrate on research generally work in academic or research settings.) Some psychologists who are trained specifically to do clinical work (rather than research) have "PsyD" (Psychology Doctorate) as their academic degree, rather than PhD.

Social Worker -- When people hear "social worker," they think of professionals who provide social services in hospitals and agencies. However, some LCSWs (Licensed Clinical Social Workers) also practice psychotherapy. Their education is somewhat similar to that of a psychologist (although they may have a master's degree rather than a doctorate), but they are usually more attuned to the individual in their environment, and they do not provide psychological testing.

Psychoanalyst -- After receiving a professional degree, some psychotherapists go on to get extensive special training in this in-depth therapy modality that helps people get to the root of their problems. Psychoanalysis, as first invented by Sigmund Freud, is the only method that works with the unconscious -- motivations and defense mechanisms that are out of our awareness, and therefore cause us to repeat harmful patterns. The couch, free association, dream analysis, and transference (originally defined as the patient transferring his or her feelings toward their parents onto the analyst), are all exclusive tenets of psychoanalysis. The unfortunate stereotype of the silent therapist who only wants to talk about people's childhoods (rather unfairly) comes out of this model.

Today, many psychoanalysts are drawn to more contemporary models that build on, but also diverge from, Freud's original thinking. These therapists -- sometimes known as "relational analysts" -- are more active in the treatment and interested in people's current-day problems and how they are influenced by past experience. We look at how people interact with others in ways that only reinforce existing fears and patterns, and we look to create new experiences and ways of seeing oneself, including within the therapeutic relationship. Contrary to the stereotype, psychoanalysts sometimes do give advice and opinions, but we also do much more than that.

Traditionally, psychoanalytic patients came to sessions at least three times a week and lay on the couch. Today, many people in psychoanalytic (or psychodynamic) psychotherapy attend only once or twice a week. The couch is optional; some relational analysts never use it at all. Psychoanalysis differs from other forms of psychotherapy (like cognitive-behavioral therapy) in that it is more comprehensive and emphasizes getting to the bottom of problems, rather than simply alleviating symptoms.

Sunday, July 17, 2011

The Monogamous Marriage and What To Do About It

A recent article, “Married with Infidelities,” by Mark Oppenheimer was published in the New York Times a couple weeks ago. And yet, many people are still talking about it! Don’t know if you’ve had a chance to read it, but it seems to have triggered significant feelings about monogamous relationships, here’s the link: http://www.nytimes.com/2011/07/03/magazine/infidelity-will-keep-us-together.html. The author interviews Dan Savage, a pop writer whose column is entitled “Savage Love”. Savage began his column years ago helping folks learn how to cope with their sexual proclivities, and now attempts to help people with their love lives.

The article makes the point that we often assume that monogamous relationships must remain so and suggests that couples who are open about infidelities they may have happier marriages. I think if he is talking about saving peoples individual sex lives, this might make sense. But it doesn’t sound like a remedy to help one’s, or the couple's love life. Savage suggests that there are couples, or one part of a couple, who need more than one partner or periodic extra-relationship sexual experiences. This is called an open marriage. It’s been around for quite a while, perhaps saving many marriages.

Though there are some folks who want to be able to desire and be desired by their partner with whom they have a commitment and many years invested in each other. Some are skeptical about this being a real possibility in a long-term relationship. Long-term monogamous relationships can get stale and perhaps boring and can begin to feel restrictive and limiting to one or both partners. These feelings can translate into thoughts about remedies. An obvious and easy one is to have a fling or two, but the problem may remain. Trying to avoid those feelings of limitation is a missed opportunity to create something new and satisfying.

An interesting point that arises from the article is the emerging need in our society for a “quick fix”. There are tons of claims to have the right formula for being thin, wealthy, more attractive, you name it, someone can tell you how to do it. Treating individuals and couples with issues around intimacy and sex is not necessarily formulaic; each person has a different set of histories and life experiences. And we know that people’s sex lives are directly related to their love lives and vice versa. Therapy helps people understand themselves and their uniqueness so they can make difficult life-choices that work for them.

Psychoanalytically and attachment informed couple’s therapy helps people experience uncomfortable feelings and more importantly expands their ability to make use of them. Being bored in a relationship can mean a whole host of things about each person and the couple that may be remedied by using each other in the service of extinguishing boredom without involving an extra-relationship fling. All relationships and individuals in relationship change over time. Desire can wax and wane in long-term relationships as can love. Finding the ability to be vulnerable with each other and recognize each other’s (and one’s own) needs and limitations actually produces growth. Each part of the couple can find within themselves some part that meets the needs of the other and themselves without having to substitute.

The suggested solution for couples to avoid feeling bored in a long-term monogamous relationship by having affairs “above board” is one way to avoid feeling the loss that inevitably comes with choosing one thing over another. Another way of dealing with that loss is to face it head on, be honest about it with themselves and the one’s they’ve committed to and find ways to deepen and enjoy their experience of being human, with all its limitations and flaws.

Saturday, July 9, 2011

What we can learn from Betty Ford

By Eric Sherman, LCSW

With her death at 93, Betty Ford leaves behind a legacy of grace and courage that can be a lesson for us all.

Her ability to overcome cancer, depression, and, addiction -- and to turn these personal struggles into a public commitment to help others -- is nothing short of inspirational. Few of us will ever be thrust into the public spotlight the way the former First Lady was, but there is much we can learn from her unflinching honesty in struggling with, and ultimately overcoming, adversity.

Mrs. Ford became a role model when, in 1974, she underwent a radical mastectomy for breast cancer. She used the opportunity to speak openly about her experience at a time when such a topic was taboo. As a result, tens of thousands of women sought out breast exams in the months after her surgery, undoubtedly saving many lives.

But she is best known for her decades-long battle with addiction to alcohol and painkillers, a problem that began in the 1960s.

"From the outside, (my) life looked like a Norman Rockwell illustration," she said at one point. But despite her seeming fairytale life and public outspokenness, privately she harbored debilitating feelings of loneliness, self-doubt and shame. She questioned her intelligence, and began to feel useless and empty as her children left the house and her husband became more successful in his career, and later was defeated for reelection. "I'd lost my feeling of self-worth."

Like many others, she turned to alcohol and painkillers to numb her insecurities. The more she drank to escape her self doubts, the more they intensified -- a spiral well known by many addicts, as well as to others who suffer from insecurities that seem too overwhelming to combat.

"Now I know that some of the pain I was trying to wipe out was emotional," she wrote in her autobiography, "Betty: A Glad Awakening." "I was convinced that the more important Jerry (her husband) became, the less important I became."

Ultimately, after a painful family intervention, she chose to face her problems by entering rehab, a decision that would forever change her life and sense of self.

These days, public figures entering rehab are about as common as humidity on a summer day, but at the time to go public about one's battles with personal demons was largely unheard of. Mrs. Ford did more than just gain and maintain her sobriety. She found a sense of purpose by using her experience and influence to found the non-profit Betty Ford Center, a rehab facility, and to speak openly about her struggles.

Hers is both a cautionary and inspirational tale about the corrosive nature of self-doubt and what it takes to overcome it. Low self-esteem leads to anxiety, depression and, often, avoidance. Overwhelmed, many people turn to substances, sex, food, shopping and other obsessive-compulsive behaviors to fill the emptiness within. This may work temporarily, but soon leads to greater shame. Some, like Mrs. Ford, put on a brave face and keep their pain a secret. Others retreat from family and friends, while some wield their insecurity as a weapon, proclaiming their victimhood as loudly as possible in a misguided attempt to be rescued. Unfortunately, they end up feeling all the more isolated, fraudulent and hopeless.

Until these patterns can be addressed, they are likely to intensify. Ironically, in the midst of such shame and despair, the person may need to find whatever hope and strength they can muster to risk looking at their problems, often through therapy. I say risk because the process is uncertain and at times can be painful -- the very feelings the person is trying to avoid. But facing our shame and fears can not only detoxify them, it could make us feel stronger and more confident. Therapy can help us find our voice and a sense of purpose.

That is the legacy of Betty Ford -- a woman who found a way to use her triumph over pain to not only find personal meaning, but to help others in their struggles as well.

-- Eric Sherman, LCSW

Friday, July 8, 2011

Presence: Meditating On The Gift That Keeps On Giving

By Mitchell Milch, LCSW

Meditation is perhaps the most important “best practice” I employ each day in the service of warming my self up so I can develop, apply, and identify obstacles to being present in an emotionally intelligent manner. I’m defining emotional intelligence as a measure of one’s facility to apply experiential learning to understanding and accurately predicting one’s influence on the outcome of new situations. I label meditation a “best practice” because it is a quality control measure in the same way a chef will codify cooking processes to ensure that the quality of dishes are consistently maintained. My use of meditation is the psychological equivalent of a ballet dancer rehearsing movements on the barre to stimulate his muscle memory or a tennis player volleying before a match to hone the timing and rhythm of his hand-eye coordination. It’s about finding an optimal level of emotional arousal conducive to the effective employment and coordination of our experiential and observing selves. On a neuro-physiological level this translates to the maximal recruitment and coordination of the left and right hemispheres of the brain.

Meditation anchors us in the present. It’s a mindful orientation to a bodily awareness. We drop anchor in the present moment by slowing and deepening our breathing. Our bodies are integral parts of our information storage and retrieval systems. We may liken our brains as coordinated and interactive multi-processor networks. Our stored intelligence is dispersed throughout our bodies. I have borrowed many times from a colleague of mine who might ask a patient: “If your stomach could speak right now what tale might it tell?”

The wisdom of “reliable“ intuition is distilled from thoughtful investigations into what we learn from trial and error and how we apply these lessons to more accurately predict and influence future outcomes. I place reliable in quotation marks because as a case in point, the unconscious intuitive false alarms of a traumatized brain are easily tripped by unreliable and invalid innocuous stimuli. The onset and impact of such stimuli may be as random and unpredictable as the fluctuations of the stock market. An intuitive “gut feel” that can be relied on must be applied to events that cohere in some logical fashion. Such intuition is the direct consequence of processed experiences resulting in the ever expanding growth of anatomical structures supporting the increase of ever sophisticated decision trees. We stretch our knowledge by discriminating and making sense of sometimes minute anomalies in patterned behaviors. Let’s call this the evolution of best tailored practices. As a former supervisor once pointed out to me, the “right feel” on how to engage a patient in a timely manner may not be understood on a cognitive level until it’s too late. If you’ve ever been tested by a patient on his way out the door with the alliance hanging in the balance, you know exactly what I’m talking about. It’s a matter of now or never in terms of accessing the correct response. One is operating strictly from what feels like the right thing to do or say. There’s no time to make cognitive sense of this pivotal moment.

What slow, deep breathing does is to open us up psychologically speaking as permeable interpretive containers of bounded space. To anchor one’s self in the moment is to set the conditions for being a sensitive tuning fork to a patient’s multi-leveled communications. Some of us call this meditative state the empty brain- open heart consciousness of being. Others prefer such conventional Freudian terms as “being neutral without memory or desire.” In the fields of arts and athletics this state of consciousness is labeled as “flow,” or “being in the zone.” Meditation is the multi-faceted operations of self-monitoring, disciplined attentive focus, and the modulation of states of emotional arousal. It is the optimal state of arousal that permits our brains to work in the most coordinated and effective manner. We know that the tragic flaw of the traumatized brain is that it is seldom if ever “cool under pressure.” Equally important is how meditation offers us the awareness that we are resistant to anchoring ourselves in our bodies. We may struggle on any given day to contain and observe parts of our selves. Any awareness of anxious pendulum-like swings between the past and the future may indicate a need for some self-analysis before we return to the challenges of our day.
Practicing meditation can be as easy or difficult as your level of resistance to being with yourself. I liken it to starting an exercise program. You can convince yourself that to begin exercising you need the right outfit, the right gym, the right trainer, the right comfort looking in the mirror etc., to begin. The same could apply to meditation. It can be as simple as using deep breathing to anchor yourself in your body while you are washing dishes, or it can be as difficult as deciding that you can’t start meditating until you research the most effective technique, pick a mantra, and figure out when and where you have 30 minutes each day to sit quietly.

Eckert Tolle, the world renown spiritual teacher and author defines presence as the moment you are aware that your mind has been on an excursion elsewhere. The father of mainstream meditation in the west is probably Dr. Herbert Benson of Harvard University. Benson in his book “Beyond The Relaxation Response” suggests that one can learn to be present any time and any where. It’s a matter of attending to your sensory experiences as anchors. You can create conditions for flow or being in the zone while walking down the street. All that is required is slowing and deepening your breathing and paying attention to the sensory experiences of your foot falls. It only takes the creation of bounded space and one degree of separation between our experiential and observing selves to open us up to new possibilities for being with ourselves, our loved ones and our patients.

Benson doesn’t know he is preaching to the analytic choir when he touts the indispensability of breaking free of our habitual non-learning ways of thinking to access the creative transformative mind. There may have only been one Mozart but there’s a little bit of Mozart in each of us to tap into if we design the conditions for our artistry. Enjoy!

Saturday, June 25, 2011

Gay pride (and prejudice)

At 11:55 last night -- only days before New York's Gay Pride Parade commemorating the 42nd anniversary of the birth of the gay rights movement -- the state became the largest in the nation to approve same-sex marriage.

Gay men and lesbians throughout the country rejoiced at a further recognition that they are equal to any other person regardless of whom they love. What a victory for all those individuals who grew up being told that there was something wrong with them.

Well, yes and no.

Here are some of the comments gay men and lesbians read or saw continually during June, the month of pride:

Same-sex marriage is "unjust and immoral" and poses "an ominous threat" to society (New York Archbishop Timothy Dolan). It will lead to "anarchy" (former New York Giants receiver David Tyree). We should not encourage "sodomites" who are "spreading sin, disease, deviancy, and a higher suicide rate" (Torah Jews for Decency, oblivious to the fact that comments like theirs are what lead to a higher suicide rate). And let's not forget comedian Tracy Morgan's infamous rant that he would stab his son to death if he were to come out as gay.

Imagine being a gay man or lesbian and hearing these comments from religious leaders, celebrities and sports heroes. Or walking in the Gay Pride Parade past "godly" people carrying signs proclaiming that AIDS is God's punishment for homosexuality. It's easy to dismiss these outrageous rants, but what about the subtle messages LGBT individuals get every day.

Imagine the guilt and hurt of knowing your parents, though accepting, blame themselves for your sexual orientation -- since, clearly, someone must be to blame. Or steering conversations at work away from what you did over the weekend for fear that coming out might hurt your career. Or to be a gay man who is afraid to hold his son's hand in public for fear of being reported for child abuse.

Remarkable progress has been made in the 42 years since the Stonewall riots. Yet nine out of ten LGBT students report experiencing harassment and nearly two-thirds of them feel unsafe in school. The incongruities are astounding -- young people are coming out far earlier then ever, yet suicide related to homosexuality remains the second leading cause of death among youth. For the first time, public opinion polls show that a majority of Americans support same-sex marriage and New York joins five states and the District of Colombia in allowing it. Yet 39 states and the federal government (through The Defense of Marriage Act) specifically ban same-sex marriage. Several more outlaw gay people from adopting or becoming foster parents because of the "risk" they pose to children born to crack addicts and dangerously abusive parents. And the Tennessee State Senate recently passed a bill that made it illegal to even discuss homosexuality in any school prior to ninth grade.

The more things change, the more homophobia remains ingrained.

Three decades after the psychiatric Diagnostic and Statistical Manual belatedly removed homosexuality as an illness, I still sometimes treat men and women tormented by their same-sex attraction; adults and adolescents disowned by family or forced to go to counselors not to treat their shame and depression but to change their sexual orientation. I also see many lesbians, gay men and bisexual patients who are out, open and proud, and supported by friends and family.

Homophobia will never be eradicated. We all grow up in a heterosexual society usually in straight families. Sometimes we forget to examine our own subtle fears and assumptions. A couple of years ago, I taught a course in Gender and Sexuality to a group of open-minded psychotherapists. Several people wanted to know what caused homosexuality. Could it be the result of childhood sexual abuse? I noted that no one wanted to know what caused heterosexuality. Could sexual abuse make someone straight? As psychotherapists, when we are sitting with heterosexual patients, do we ever think to wonder about how their sexual orientation affects them?

We should. The difference between homosexuality and heterosexuality is not that one is normal and the other not, it is that one is the unquestioned norm and the other can be a frightening threat.

So let's celebrate the actions of the New York Legislature and Gov. Mario Cuomo. But let's also remember the words of a man celebrating outside the Stonewall Inn where the gay rights movement began: "We are there, finally, but we are not all the way there; this is only one step."
-- Eric Sherman, LCSW

Monday, June 13, 2011

Ain't It Peculiar...Ain't It a Shame?

by Sally Rudoy

As I was on the treadmill at the gym the other day I was listening to my iPod. Set on random shuffle mode, the iPod tossed up a sequence of songs remarkable for their coherence of theme. To my aerobic mind, the internal DJ of my iPod that day was moved to comment on the perplexing irony of couple-hood. Why do we hurt the ones we love? Why do we stay too long in relationships that are no good for us? In short, why does love stink?

Working with couples psychoanalytically I look for themes, patterns of interactions, attachment styles, and the ways in which a couple interpersonally regulate affect. I try to communicate these observations to the couple with a jargon free, lively language that, I hope, will reverberate with the deepest levels of their experience of how they give and receive love.

iPod-tethered as I was there on that belt to nowhere, I realized I could never articulate the conundrum of love more viscerally than those that were serenading my aimless journey. Two "ainty" songs coincidently played in a row. They captured the pattern familiar to songwriters and couple’s therapists alike of loving someone who is depriving or downright cruel.

For your consideration, I submit Marvin Gaye’s version of "Ain’t that Peculiar" and the B52’s, "Ain't it a Shame.” Click on the links below to hear the songs. Read along with the printed lyrics. Ain’t they got it right?

AIN’T THAT PECULIAR sung by Marvin Gaye

(William "Smokey" Robinson/Marvin Tarplin/Robert Rogers/Warren Moore)


Honey you do me wrong but still I’m crazy about you

Stay away too long and I can't do without you

Every chance you get you seem to hurt me more and more

But each hurt makes my love stronger than before

I know flowers go through rain

But how can love go through pain?

Ain't that peculiar

A peculiar ality

Ain't that peculiar baby

Peculiar as can be

You tell me lies that should be obvious to me

I've been so much in love with you baby till I don't wanna see

That the things you do and say are designed to make me blue

It's a dog gone shame my love for you makes all

Your lies seem true

But if the truth makes love last longer

Why do lies make my love stronger?

Ain't that peculiar

Peculiar as can be

Ain't that peculiar baby

Peculiar ality

I cried so much just like a child that’s lost its toy

Maybe baby you think these tears I cry are tears of joy

A child can cry so much until you do everything they say

But unlike a child my tears don't help me to get my way

I know love can last through years

But how can love last through tears?

Ain't that peculiar

A peculiar ality

Ain't that peculiar baby

Peculiar as can be

Ain’t It a Shame B-52s


(Cindy Wilson, Ricky Wilson, Keith Strickland)

Flying saucers could land

And it wouldn't make much difference to my man

I could walk aboard and thank the lord

And leave this damn town in seconds flat

Check my bags and never come back

Oh, our love is

Like a fuse that's burned out

Oh, our love is

Like a fuse that's burned out

Oh, I've been unkind

Not like you

Ain't I ashamed

Being misused

Oh, our love is

Like a fuse that's burned out

Oh, our love is

Like a fuse that's burned out

I liked your Chevy Duster

I liked your brand new trailer

I liked your color TV

But you looked at that color TV

More than me

More than me

Oh, our love is

Like a fuse that's burned out

Oh, our love is

Like a fuse that's burned out

Saturday, June 11, 2011

Weinergate -- and America's problem with sex

What is it with politicians and their... you thought I was going to say "wieners" didn't you?

When Anthony Weiner joined a growing list of sextroverts that includes Arnold Schwarzenegger, John Edwards, Bill Clinton, Eliot Spitzer, John Ensign, Newt Gingrich, Larry Craig, Mark Sanford -- help me out, I feel like I'm forgetting 20 or 30 -- it said a mouthful about men, power and our society's complicated relationship with sexuality.

What fascinates me is not the fact that each man strayed; I care a lot more about public policy than private peccadilloes. Rather, what stood out was the stunning poor judgment, the hypocrisy, the insensitivity to loved ones, the belief that each man was somehow too powerful to be caught, and especially the ridiculous denials.

And it's not just politicians with roaming eyes and stunning lies. Sports stars (hold that Tiger!), celebrities, musicians and other outsized rich and famous folk are forever being caught with their pants down in the most stunning fashion. And America can't get enough of it. What does this say about men, power, powerful men, and our country's contradictory Puritanical/pubescent attitudes toward sex?

The fact that the laundry list Lotharios is made up exclusively of men says as much about both women's continued exclusion from power, as it does about the attitudes of the genders toward sexuality. At the risk of getting all "Men Are from Mars" on you, for many males, sex is a way to exhibit potency, prowess and control. The phallus is the ultimate symbol of masculine power. Rape, as we know, is not so much a sexual act as one of domination, aggression and humiliation.

While for many women sex is a vehicle to express vulnerability and foster intimacy, for men, it can be a means of denying those same potentially shameful feelings. (Women, for their part, may shy away from the more healthfully aggressive sides of sex, although I hesitate to make pathologizing generalizations.)

Just like anger can be vitalizing for someone riddled with depression or insecurity, I have worked with many sex addicts (the vast majority of whom are men) who report that sexual conquests, particularly with someone with whom they do not feel warmly attached, can temporarily abate feelings of emptiness.

Professions like politics and sports that thrust men into the spotlight attract those starving for power and adulation. In a word: narcissists. Their hunger for power and acknowledgment must be fed with the regularity of penguins at the zoo. Admiring young interns, groupies and hangers-on not only fit the bill, but are eager to have their own needs for recognition met by attaching to powerful others, which may be why so many political wives stand by their husbands.

Additionally, America has a hard time talking about sex. More than ever, titillating messages bombard us through an ever-expanding world of media -- from Twitter to tabloids to sexting. Sex sells and makes us squirm at the same time. And so we talk about sex (when we talk about it all) out of both sides of our mouths. It makes us giggle because we equate it with being dirty. And it's pretty hard for many couples to bring what's dirty into the bedroom -- instead it gets acted out outside. The message: sex in relationships is loving but boring. Outside, it's girls gone wild!

Any pre-adolescent can log on to a porn site, yet try to introduce sex education into the schools and parents become livid. Despite its being all around us, sex remains taboo. How else to explain why so many men have affairs and sexual dysfunction at the same time.

As a psychoanalyst with an interest in sexuality, I understand the importance of psychodynamic psychotherapy in this area. Sex -- dirty, clean, and in between -- should be a healthy part of life. When complicated, shameful feelings can get put into words rather than actions, they can be better incorporated into our everyday existence.

And that can be pretty sexy.

-- Eric Sherman, LCSW

Wednesday, May 11, 2011

3 minute video explaining the benefits of Psychoanalysis

This little movie, composed by Australian artists and circulated around the world, is a good way of describing briefly how psychoanalysis can be helpful beyond medication treatment. We hope you’ll forgive its awkwardnesses, and listen to its earnest plea for treatment that goes beyond symptom remission.

Sunday, May 1, 2011

Men -- and women -- behaving badly (or: Trumping Charlie Sheen)

Just when the train wreck that is Charlie Sheen finally pulled out of Crazy Town, along came an even bigger loco-motive bearing down on our national sanity like ants on a speck of hamburger.

Here he is, the man who hired shamelessness and gave it a comb-over: Donald Trump. He rants! He raves! He announces how very, very proud he is for being caught lying! Like a spoiled child, he wants attention -- lots of attention -- and we give it to him! The more he hogs the spotlight, the more the media throws it on him. Are they reacting to our voyeuristic need to see others getting away with behaving badly, or are they creating it? (Most likely the answer is: c--all of the above.)

The Donald did not give birth to narcissism. In fact, crassness has become a cottage industry.

Take Snooki from "The Jersey Shore" (please!). Or the table-flipping "Real Housewives of New Jersey." (I'm sensing a geographic trend here, and as a resident of The Garden State, I am none too happy.) To paraphrase Charlie Sheen, why are these people winning?

When I was a kid, I would be punished for the kind of behavior reality shows and Fox News now encourage. Today, parents not only tolerate temper tantrums, they indulge them. And their pampered kids grow up to be MTV gawkers -- and reality "stars."

For most of us, poor behavior still has consequences (although in our angry, YouTube society, the bar for what constitutes bad behavior keeps getting lower). Which may be why we reward Snooki, the Kardashians, corporate scoundrels, and pampered music stars. We don't punish them, we idolize them. We applaud their getting away with outlandish behavior, even as we complain about it.

Unconsciously, perhaps we wish we could be Snooki, indulging in whatever we want without getting ostracized, fired, or humiliated. We live vicariously through her, deriving pleasure as she flaunts the rules we can't. We get to feel superior as we mock her crudeness and reassure ourselves of how much smarter, classier, and better coiffed we are. As we laugh at her behind her back, finally we feel like we are getting away with something, since Snooki will never hear us. We get to be bad, too! All the while, we project our own shameful feelings of not being acceptable or smart enough onto her, thereby not having to experience our insecurities ourselves. There is something nice about feeling holier than thou. Just ask The Donald.

And if our strange-haired antiheroes ultimately get their comeuppance, all the better. We get to transfer our envy and insecurity onto the next train wreck who hogs the spotlight. For when Trump's tantrum finally fizzles, you can bet another outrageous
narcissist will come along for us to shower with attention.

-- Eric Sherman, LCSW

Saturday, April 9, 2011

Fat Stigma: What It Is, How It Hurts

Researchers call it "fat stigma." The disapproving glances from complete strangers. The prospective employer who suddenly loses interest when he meets you face to face, or the person who squeezes into the seat next to you at the movies with evident disgust. And of course: "You would look so nice if you just lost some weight."

According to a recent article in the New York Times, the Western prejudice against fat people is now spreading to developing countries. The article quoted a Mexico City man who groused about riding the city's crowded buses.

"The fatties," he said, "take up a lot of space."

Imagine what it's like to be on the receiving end of that kind prejudice every day. As a person who lost 50 pounds a few years ago, I have some understanding of what it's like to be heavy in a society where you can never be too rich or too thin. The sense of shame a fat person feels when they look in the mirror is only intensified by the negative reaction of others.

As our society continues to get heavier, our fashion models -- and our tolerance -- keep growing thinner. Tabloids drool over the weight fluctuations of the Kardashians and other celebrities with relish (excuse the food pun). TVs "Biggest Loser" and its many copycats exploit the obese for ratings while women's magazine covers trumpet "the last diet you will ever need" next to photos of luscious chocolate cake. Love yourself as you are; now lose 30 pounds.

Why do we live in such a fat phobic society? When people respond to the obese with disdain ("Why don't they just exercise?"), it is likely because they themselves feel threatened. Many people look at the overweight and see laziness, poor self-control, and weakness. We all have sides that feel out of control and shameful, self-defeating habits we cannot tame. We may look at fat people and see unpalatable aspects of ourselves. And so we project our fears onto them. I'm not the one who is lazy or out of control, you are. I am not insecure about my looks. By binging on sanctimony, some people get to (temporarily) feel better about themselves -- precisely the kind of solace other folks find it in food.

Body image issues often begin in childhood, with parents who criticize their children's weight and appearance while sometimes giving conflicting messages about food. ("You're not leaving this table until you eat everything on your plate!") Frequently, parents project their own insecurities around body image onto their children, calling them fat and lazy even as they overfeed them.

Because these self-images are so deeply ingrained, all the diets in the world may not be helpful. Physiological and other practical factors are also crucially important, but many people avoid the psychological component because of the fear that lies under the fat. Better to stuff down insecurity than stir up what they fear could be a lot of pain. And so the pain -- and the pounds -- remain.

In therapy, the patient will need to trust the therapist. Particularly if the clinician is thin and appearance-conscious, the person struggling with weight issues may worry about being judged. After all, many overweight people stop seeing doctors because they are lectured and condescended to. In a Yale University study, more than half of the primary care doctors questioned described obese patients as “awkward, unattractive, ugly, and unlikely to comply with treatment.” And these were the sentiments they were willing to share openly.

In order to help the patient feel safe and understood, the therapist must be willing to examine her prejudices and her own issues with weight and body image. She must be attuned to the patient's fears and shame, and any experience of being judged in the treatment.

As the patient continues to feel trusting and supported, the work deepens. The psychoanalytic therapist helps the patient understand and work through his or her feelings of shame and fear. Many people learn early on to find comfort and self-soothing food, the very things they may have needed but didn't get from their parents. In many households, feeding is the only way children feel loved.

One of the goals of therapy is not simply a healthier lifestyle, but helping each person feel good about themselves no matter what the scale says. As a person who has dealt with weight and self-esteem issues, I can proudly say that I've been fat and and I've been thin. And happy is better.

-- Eric Sherman, LCSW

Sunday, March 13, 2011

Analyze This II: A Look Inside a Treatment

Linda was distraught. She desperately wanted to get into a fulfilling relationship, but kept ending up with critical, rejecting boyfriends.

"No one wants to be with me," she said, her eyes welling with tears. "There must be something wrong with me."

Linda (a fictitious person for purposes of illustration) was referred to me by her physician, who knew I work psychoanalytically and might therefore help her get to the root of her depression.

I could quickly see why Linda was depressed -- in addition to feeling rejected, she was quite down on herself. As she spoke, she criticized her weight, which she was forever trying to control without success. She also presumed she must not be smart enough for the men she dated. As she spoke, I noticed she said things like, "I know this sounds stupid but..." and "You're going to think this sounds crazy but."

I told Linda that what she said struck me as neither stupid nor crazy, but that the way she put herself down sounded more critical than any of her boyfriends. Linda agreed, yet she looked slightly injured. "Of course," she said. "I knew this was all my fault."

And so we were off. In our very first session, we had already re-created an aspect of her relationship problems, now between the two of us. She had experienced me as a little like her rejecting, critical boyfriends, and she had responded by accepting the blame ("this is all my fault"). From a psychoanalytic perspective, it is not only expected that people re-create their problems in treatment, but that these reenactments are welcomed and utilized. They provide patient and analyst with a unique opportunity in vivo to work through the very unhelpful patterns that the person has come to solve.

With this in mind, I told Linda that I had a sense that she had felt criticized by what I had said, and had blamed herself. How had she experienced my comment? It soon became clear that she had heard me saying she deserved no better than her boyfriends, that I felt it was all her fault. It would never have occurred to her to tell me this, and without even realizing it, she had instead accepted the blame so that she would not upset me. As we continued to explore this, Linda was amazed. She had never considered that she not only attracted, but put up with and maybe even unconsciously (without realizing it) encouraged critical men by taking on both person's insecurities herself.

What was wonderful was that Linda could now recognize this without attacking herself or feeling criticized by me. I noted that she had stopped saying her feelings were
crazy or stupid. She had gone from unconsciously experiencing me like her critical boyfriends to whom she had no choice but submit, to someone who could help her feel better about herself -- precisely what she wanted from a relationship, but on some level felt she did not deserve.

As Linda and I continued to work together, her depression began to lift. It soon became clear where her negative self- image and pattern of choosing contemptuous men had come from. Linda's father was a loving man, but he could be critical and short-tempered. If he had had a bad day at work, he might lash out at Linda, as if his burdens were her fault. This seemed to only reinforce her view that she was lovable only so long as she was perfect, and that she had to work very hard to please men, even if it meant accepting their criticism. Linda's mother, although well-meaning, only reinforced this view. When she knew her husband was in a bad mood, she would become anxious and implore Linda not to provoke her father, also implying that his bad moods were somehow Linda's fault, and that she had to walk on egg shells to make him feel better.

I told Linda that her pattern of diminishing herself before critical men now made a lot of sense. Unconsciously, she still felt she had to agree to make herself the bad one to prop up a critical, insecure man in order to win his love.

By pointing this out, I provided Linda with insight into her own unconscious beliefs -- an important aspect of psychodynamic treatment. Psychoanalysis is the only modality that works with the unconscious -- the way we perpetuate problematic views of ourselves without even knowing we are doing so. Being alert to how we are contributing to our own unhappiness is vitally important. But insight alone is not enough. Psychoanalytic psychotherapy offers something even more important -- opportunities to work through these issues, often re-created with the therapist.

By attending to Linda's relationship issues as they also emerged between us, Linda had a powerful experience of creating a new dynamic with me the midst of familiar expectations. When I sensed that Linda might be injured by something I had said, but felt safer blaming herself than telling me about it, I would tactfully inquire about this. I would wonder if Linda had felt angry with me, and had instead turned the anger against herself through self-blame. Linda was often quite moved at these moments. She learned that she did not have to put her needs aside in order to maintain our relationship, and that is okay to feel angry -- something many women struggle with.

This is how psychoanalytic psychotherapy works -- and what makes it uniquely effective. No other treatment works with unconscious motivations, or utilizes the therapeutic relationship in such a specific, active way. Without recognizing and working through long-standing unconscious patterns, we are doomed to repeat them.

Psychoanalysis provides new experiences within the therapeutic setting that also take hold in the person's outside life. It offers new ways of seeing yourself that can make you feel more in control of your life.

-- Eric Sherman, LCSW

Friday, February 25, 2011

Analyze this: What's so dynamic about psychodynamic therapy?

The prospective patient was aghast when he heard that I was a psychoanalyst. "Do you expect me to spend the next 30 years on the couch blaming my mother and poor potty training for all my problems?" he asked, rolling his eyes. "I've got real-life issues to deal with. I am not interested in any Freudian crap." (He may have used a different word than "crap.")

Like Lindsay Lohan, trans fats and the state of New Jersey, psychoanalysis has an image problem. Which is a shame, because the way psychoanalytic psychotherapy is taught and practiced by many of us today couldn't be further from the Woody Allen caricature. I don't even consider myself Freudian. Like many of my analytic colleagues, I practice in a way that is contemporary, interactive and deeply effective at treating real-life problems.

And so, with apologies to Woody (Freud would have had a field day with that name!), I would like to clear up some misconceptions about psychoanalysis, and to show how it is a uniquely transformative way to dismantle deep-seated patterns that keep people stuck in life.

In traditional Freudian analysis, the therapist was a neutral, removed expert who spoke little so as not to contaminate the process. When he did interject, it was to offer an authoritative interpretation of what the patient was inaccurately projecting from the past onto the analyst. Insight -- the imparting of knowledge from therapist to patient -- was what cured. To overcome the patient's resistances to recognizing aspects of his or her unconscious, it was necessary to attend sessions at least four times a week, and to lie on the couch so as not to be influenced by seeing the analyst. (Actually, Freud invented the couch partly because he didn't like patients staring at him all day.)

Over the last few decades, a much different analytic model, called Relational Psychoanalysis, has transformed the field. Influenced by infant research and the influx of women into the profession, relational analysts believe all people are uniquely shaped by social interactions, beginning in early childhood and continuing throughout life. We still value unearthing the unconscious, but we believe it is the therapeutic relationship, as much as insight, that is healing. The analyst is no longer a removed interpreter, but an active collaborator utilizing his or her unique personality to understand and reach the patient. The therapeutic relationship becomes an important means to working through the person's hopes and fears. Insight is still important, but only if the patient feels deeply understood.

As a result, the stereotype of the silent, bearded analyst has been replaced by the warm, flexible practitioner -- empathic, but also challenging, eager to give and receive feedback and to be adaptable to each patient's changing needs. The couch is still sometimes used, but most people sit up. More than one session per week allows the work to deepen more quickly, yet many people see great benefit at once a week.

Psychoanalytic psychotherapy can sometimes provide immediate relief from symptoms like anxiety, depression or phobias. But unlike any other treatment modality (including cognitive-behavioral therapy), it addresses and permanently loosens the very personality structures that caused these symptoms in the first place. Psychoanalysis, therefore, is the most in-depth form of psychotherapy. New research confirms it can have the most lasting, long-term impact.

What specifically goes on in a psychoanalytic treatment? In a forthcoming post, I'll show you what's so dynamic about psychodynamic treatment.

Monday, February 14, 2011

From Egypt: A triumph of the human spirit

Friday evening, I watched the news from Egypt and cried.

I sat in my expensive leather chair enraptured by the site of hundreds of thousands of people -- many of them young and poor -- as they erupted in ecstasy.

The reporter from Tahrir Square had to shout above the delirium. At times, he was literally swept up, pulled into the undulating masses around him. Tears rolled down the cheeks of some of the men and women in the crowd. Others shouted with unbridled pleasure. It was all so sudden. So unexpected. Surreal.

A man older than many around him suddenly walked up to the reporter and kissed him on the cheek. "Thank you!," shouted the elated older man. "Thank you to everyone! Thank you to the world!"

The reporter tried to maintain his composure and his footing. Within seconds, a woman held up her baby so that the infant, too, could offer a tiny kiss to the journalist. This time, the reporter lost his composure. He turned toward the baby thrust in front of him and planted a kiss on her lips. It was impossible to hear over the bedlam, but I imagined that the baby, like her mother, was squealing with joy. Surrendering to the moment, the reporter smiled broadly.

A young woman in a head shawl was next to be interviewed. The shawl highlighted her face and drew attention to its glowing features. Her dark eyes shone, her smile pure rapture. Her accented English was excellent. "I never thought I would live to see this day," she said. "I cannot tell you the pleasure I am feeling." She didn't need to; I could feel it myself.

It was at that moment -- watching the serene joy on the woman's face as delirium engulfed her -- that tears began to roll down my own cheeks. I remembered the ecstasy I felt at a party on election night, 2008, in front of the TV in somebody else's comfortable living room. The several-dozen people assembled erupted as the television announced that Barack Hussein Obama had been elected the first African-American president of the United States -- an event I had never expected in my lifetime. The feeling of accomplishment, pride and hope was palpable, just as it was in Egypt.

I thought back more than two decades, when I was a reporter myself and spent a week in Egypt on vacation. I had not expected to confront such poverty. The horses were so emaciated, they were too weak (or defeated) to swat flies that swarmed around them. Wherever I went, gaunt children tugged at my clothes, their fingers to their mouths in a gesture for food. I was appalled that a fellow tourist threw a cheap Bic pen at them, entertained by the sight of famished children diving for a trifle they might be able to sell.

In Cairo, I had been affronted by the noise and the mass of people, some hanging on the outside of packed, filthy buses, their faces grim. As a taxi drove me back to my hotel -- luxurious by Egyptian standards -- I passed military guards stationed on street corners, threatening machine guns in their hands. (My reaction to them would be recalled in the days after 9/11, as I walked uneasily by soldiers in camouflage and threatening machine guns in New York's Port Authority.)

My memory of the squalor and military presence made it all the more powerful to see unarmed Egyptians -- perhaps some the begging children I had seen when I visited -- rise up and do the impossible. And now there was a feeling of hope, a sense that destiny had played its hand.

And so I cried, like I do when I work with people who have been beaten down -- sometimes literally, more often psychologically by traumatic experiences beyond their control. I am moved by their strength and persistence. I am moved by the human spirit.