Critical Thinking: A Therapeutic Goal

 

 

 

Critical thinking — what the philosopher John Dewey called the ability “to maintain the state of doubt and to carry on systematic and protracted inquiry,” is the goal of reflection. To modify Dr. Dewey’s quote, psychotherapy/psychoanalysis aims to help the patient develop critical thinking about one’s own mind and about the minds of those that influenced them. “I am not interested in symptoms” I say, in a provocative manner, to my class, knowing that saying that contradicts all of their previous education in psychotherapy. “I am also not interested in symptom-relief,” I say, taking it one step further. “What I am interested in,” I say, “is how the patient is thinking about his life and why those symptoms are manifesting at the particular time, and in the particular way, in which they do. ”

Karen, sixty-two, comes to mind. She has what could be called Generalized Anxiety Disorder, and I prescribe her medication, so in that sense, I am interested in symptom-relief, but mostly I am curious why she has to worry. I am helping her be curious as to why her mind is preoccupied with worry. The key words are “has to”. As I understand anxiety, it is often a symptom of a deeper issue of insecurity and loneliness  and I would like to explore that with her. I want to explore that with her in a way that makes her curious about it in a way which generates a  “systematic and protracted inquiry” and which carries on both inside and outside my office. This is what I do, and this is what I teach. Sure, I tell patients with anxiety to try yoga, meditation, and dietary interventions, but that is merely the beginning, because as time progresses, the issue becomes, “so what is really go on here?” To that question, there are endless answers, requiring a “systematic and protracted inquiry.” Dr. Dewey, may he rest in peace, is my hero.

Unconscious Prejudice: Freud Lives

 

http://www.scpr.org/news/2015/03/09/50259/police-agencies-line-up-to-learn-about-unconscious/

http://www.pbs.org/newshour/bb/biases-back-mind-affect-feel-race/

 

We treat people differently based on reasons we would adamantly deny. We live lives of contradiction and confusion. The one slight benefit to all of these racially based shootings is that we can now acknowledge that, although we do not like to admit it, first impressions cause us to make conscious and unconscious assumptions about people, which cause us to act, at times, in unkind, and hostile ways. The story in this report of a white mother with her African American son who is slowly crawling out of anesthesia, where she sees her son as scared, and the staff see him as threatening. This disparity, clearly racially driven, highlights the notion that, under stress we work off assumptions which may have historical value, but in the current context is inappropriate. The staff perceived this young man’s anxiety as potentially violent, because in their minds, agitation could result in aggression, whereas if he were female, and/or white, they may have been inclined to try to soothe, as opposed to ignoring and avoiding. The bad news is not about unconscious assumptions, since we are all “guilty” of that, but the bad news is that we, as a society, deny that we behave that way. It is only with the advent of hand-held video cameras can we begin to penetrate this denial, and say, hey, the person in authority reacted out of proportion to the situation at hand. Let’s be honest that we have prejudice, which is rooted deeply within us. Then, we can attack the problem. Otherwise, we repeat. Geez. It sounds a lot like psychotherapy. Freud lives. Here is our “evidence”.

Epistemology

 

Epistemology, theory of knowledge, is rubbing me today. What is knowing? Cara, seventy, comes to mind, as she tells me that after visiting her husband’s elderly mother, her husband sobbed. “How do you know he sobbed?” I asked, with the history that Cara often reads into her husband’s emotions, even while he denies he feels them. “He was blowing his nose a lot,” she said. “Did you ask him how he was feeling?” I asked, knowing the answer, as we have been around this bend before. “Yes, he said he was congested,” she said, still convinced that he was crying. “Why do you not take him at his word? I am not sure I am familiar with anyone who cries who is not aware of crying.” I say, trying to probe into her conviction that her husband’s report of congestion translates into her certainty that he is crying. “Well, I don’t know,” she says in frustration, with hostility and defensiveness.

I  jump to the concept of projection, that Cara wants her husband to be a feeling, sensitive person, who cries at the impending demise of his mother, but by his report, he has no such feelings. Wanting something becomes having something if one can deceive oneself long enough and hard enough, which ultimately leads to psychological pain and suffering, when one has to see that the lie is internal. We betray ourselves and then we pay.

So, what is knowing? Why doesn’t Cara believe her husband when she says he is congested? Why does she get defensive if I wonder aloud about her misperception, about her possible wish? Generally speaking, wishes and fears dominate our mental landscape, and we are forced to integrate those with external validators of experience. As we cross a bridge in the wilderness, we say “it is safe” but then we fall from the bridge and we have to revise this notion to say “I thought (and wished) it was safe.” If we encourage others to go on that bridge and they get hurt, then we are vulnerable to guilt, as our “knowing” betrayed us and harm ensued. Forgiveness must enter the scene as we understand that there are different levels of “knowing” and, as such, we are subject to error and negative consequence.

Returning to Cara, my challenge to her that her “knowing” may, in fact, be “wishing,” leading her to anger, thereby creates our struggle  to determine what her husband’s tears might mean to her. Knowledge, meaning, wishes and fears, all wrap together to create our inner being. The more we can open up to our mental fallibility, the more we can hold on to equilibrium and mental fiber. Epistemology keeps us humble.

Reverie In Psychotherapy

 

 

Thomas Ogden describes psychotherapy and/or psychoanalysis as an opportunity for reverie. He quotes R. M. Rilke, 1904…

 

“I hold this to be the highest task of two people; that each should stand guard over the solitude of the other.”

 

He also reminds us that Debussy felt that “music is the space between the notes.”

 

Dr. Ogden reminds us that not only do we have sexual body parts which are private, we have mental processes which are also private, to be shared or not, as we see fit. This idea that psychotherapy promotes a reverie, a private internal world, argues against Freud’s fundamental rule that we must instruct our patients to tell us what is on their mind. No, Dr. Ogden says emphatically, we must help our patients expand their reveries and then choose what they want to share with us. Freud issued a demand that Ogden sees as counter-therapeutic when our goal as therapists is to encourage and guide whether than dictate. Depressed, anxious, obsessive, and hysterical patients do not have a reverie, because their symptoms hijack their brain such that they are constricted in what they “choose” to think about. Here, the word choice implies an unconscious choice, where for mysterious reasons, the patient’s brain is on shut-down, and as such, they are limited in their ability to access their own brain. It is as if they have a very large house but all the rooms are locked, and the patient is afraid to find the key, because she fears what she will find, so she limits herself to one very small room, where she knows where everything is located.

 

Dr. Ogden says get that key and have the patient see the exploration of the house, the brain, as a reverie, as a source for more thinking, rather than a place in which they fear will be so painful they will get stuck in the pain. The irony here, is the patient is stuck, but they fear moving forward because they might get stuck in a different way and that change is frightening. The concept of the reverie is that nothing sticks, and all ideas are free-floating, a place of interest and curiosity, rather than pain and suffering. To be curious is to think, whereas to feel pain is to constrict and be self-centered. Guiding patients to curiosity, away from their symptom focus, is the heart of psychotherapy, Other kinds of psychotherapy work the other way. They focus on the symptoms and discourage curiosity. One could say that they complement each other and patients can benefit from both. To that, I would agree, but long-term relief comes from thinking about thinking and challenging our patients to question what their symptoms mean to them; to use the symptom as a spring-board to reverie.

Marissa, twenty, in times of stress,  picks at her skin. At first, I focus on symptom-substitution and I encourage her to wear a rubber band around her wrist, so she can pull at that in exchange for picking at her skin. Second, I get curious with her about why she thinks she picks, and what this means for her. With time, Marissa begins to talk about painful physical abuse she experienced as a child, and how when she thinks about that, she has the urge to pick, but that she was not aware of this dynamic for many years. Marissa begins to take her urge to pick as a sign that she is floating into childhood memories of abuse, and she is slowly able to feel and experience these memories, as she would a movie or a dream,  fulling knowing that she is part of her reverie (as opposed to dissociation), with the ego strength to understand that although she was a victim as a child, her adult self is not a victim. If I had only offered her the rubber band, and if I had only focused on her triggers, I would not have helped her learn to tolerate memories, very painful memories, as a reverie, important parts of her history, but only part of her present in the form of recollections, and not new experiences. This work of embracing the past, without it being brought forward into repetition in the present, is the hard work of psychotherapy.

see also…https://shirahvollmermd.wordpress.com/2012/09/07/the-play-space-a-place-to-be-thought-about/

Making Ideas Stick

Sand slipping through my patient’s hand, is how I often think about ideas which we discuss, but for powerful unconscious reasons, never seem to materialize into action. Or, as my colleague says, “people pay us money, not to take our advice.” The key here is to penetrate the patient’s brain, so the new way of seeing the world, is not merely cognitive, but also visceral. Without this visceral component, people tend to relapse into their old habits, their old defenses. Milly, for example, thirty-six, continually has relationships which ultimately make her feel used and worthless. All of the men in her life have ended their relationship by having an affair, which upon revelation, was lasting for most of their time together. This pattern, Milly sees, is a result of her not acting on her deep suspicion that the men she chooses to be with, are disloyal and sensing Milly’s desperation for a relationship. Although she understands this dynamic, she feels powerless to change it. We discuss the repetition in her mates, and how it reminds her of how she was treated by her mother, dismissed and overlooked. Yet, to her frustration, she continues this pattern. “You must need to continue this routine, perhaps with the wish that you will finally get a better outcome.” I say, highlighting that within the repetition is a wish. Milly begins to see that if the wish were more conscious, then she could see that instead of wishing that these men would take a different course, it is she who has to change. Still, even with that insight, the pattern continues. The depth of her initial pain lives on in the persistent repetition. As we spiral inside her unconscious, there is hope for relief from that pain, freeing her to use better judgment for her suitor. The deeper we go, the more likely it is that Milly will break the cycle of degradation.

Oedipal Eye

http://www.complex.com/pop-culture/2013/07/justin-bieber-new-tattoo

In light of my review of “The Way, Way Back” I am drawn to this article about Justin Bieber. His mother’s eye is tattooed on the inside of his elbow, leaving me to speculate as to the meaning of this drawing. I imagine a boy who wanted to please his mother, along with a boy with musical talent and showmanship, leading him to a life with great public success, but perhaps with deep ambivalence towards his mother who led him down this road. The eye represents his attachment to his mother. He has externalized his internal experience of keeping her in the forefront of his mind. He can bend his arm and pretend she is gone, but then, inevitably, he is confronted with her, yet again. The symbolism and the poetry of this artistic creation is moving, and perhaps sad. He cares what his mother thinks, or so I assume, but is this at the expense of what he thinks? The challenge of both attaching and then separating comes to my mind. This is the Oedipal struggle, the struggle of life,  that all attachments are temporary.  Yet, the internal connection remains as long as one can keep the significant other alive in the internal world. Perhaps Justin Bieber wanted some insurance for this attachment, in the form of a reminder memo. Wild speculation-that is what this is! Mental fun!

Scary Feelings

“How are you?” I ask, Whitney, fifty-seven. “I don’t know,” she responds, as she says each time I see her. “You need not to know your feelings,” I say, changing her words slightly to give her more of a sense of agency. It is not that she does not know her feelings, as she believes, as she takes a passive stance, but rather, it is more that she NEEDS not to know her feelings, since she is scared by them. Whitney’s husband of twenty-two years passed away two years ago. Her kids are grown and independent. She has a boyfriend. She works as a therapist. Yet, her feelings remain “not knowable” to her as she walks in my office. She then agrees. “Of course, I need not to know my feelings. I miss my husband terribly and so if I get too close to those feelings, I will hurt my boyfriend’s feelings, and my kids think I should be over that by now.” She says, defending her position of detaching from her feelings. “Yes, but you can feel them in here,” I say, pointing out the obvious, that my office, this play space, enables her to be free to talk about her feelings without fear of judgment or hurt feelings. “Yes, but then I have to leave, and my feelings do not just zip up as soon as I leave your office,” she reminds me that the transition out of my office can be quite challenging and she has to be mindful of that. “Yes, I understand that, but the price you pay for being detached from your feeling is also a large one.” I say, pointing out that there is a challenge in  both feeling and not feeling her inner world. “What do you mean about the price?” she asks, wondering about my choice of words. “The price of not experiencing the texture of life.” I say, even though I know she knows that. “I think it is worth the price,” she responds, keeping my choice of words. “Well that is where you are today, but you might not feel that way tomorrow.’ I say, pointing out that the ‘price’ might change for her with time and distance from her husband’s passing. Making her aware of the “price” is making her more conscious of her unconscious decision not to feel her feelings. The word price is carefully chosen to suggest that she is deciding how she interfaces with her world. Agency is established. Victim-hood recedes.

Unconscious Messages

Lela, forty-two, is mostly concerned with what her dad thinks of her. Lela is married with two kids, but she does not seem to care for her husband too much. “I tolerate him,” she tells me. By contrast, her emotions rise as she discusses how her dad has mistreated her for years. Her persistent refrain is that he loves her siblings more than he loves her. Lela understands that she was probably a “mistake” given that she is ten years younger from her youngest sibling, and twelve years younger from her older sibling. Lela’s narrative was that her dad wanted her mom to have an abortion, but her mom refused and hence she was born. Lela believes this based on one argument in which the mom suggested that was true, but she was indirect about it. Lela and her dad have a weekly lunch date where they are both faithful to this date, but when there are family functions, Lela is notoriously late and scattered. She often “forgets” the time or location, causing the other family members to wonder where she is. “Maybe you are sending an unconscious message to your dad that when it comes to family functions, you are painfully reminded that you were unwanted, but when you and your dad meet alone, then you feel special to him. As a result, you are on time for your weekly dinners, and late for family gatherings.” I say to Lela, thinking about how timeliness, or lack thereof, communicates huge unconscious messages of respect and motivation. “I just don’t see it that way,” Lela protests. “I mean, I do agree that the family gatherings usually work on everyone else’s schedule and not mine, and that makes me angry and hurt, but I am not sure that is why I am often late.” Lela says, reflecting on her family dynamics and her reaction to them. “Although that could explain why you were late. It is possible that you were mad that you were not included in the original planning, and so you express your anger by making everyone wait for you.” I say, explaining that this scenario could be an unconscious communication to her family that she is upset with what she perceives to be a lack of respect. “Yea, it could be, but I don’t think so,” Lela continues to protest. Her protest feels to me like a way of saving face. She feels guilty about her behavior, but she also dislikes how she feels with her family. I know she will think about our discussion, given our long history of struggling with her self-sabotaging behaviors. Lela wants to be loved by her dad. That seems to be her life’s goal. Now, that is a bit more conscious.

Unconscious Living

Arthur, fifty-eight, goes to work every day. He works in the financial industry and he helps people build wealth. He is single, never married, and profoundly self-centered, as his “friends” report to him. Arthur’s closest relationship is to his mother, an elderly woman who is cognitively intact, but physically frail. Arthur’s father is in a skilled nursing facility, dying from Parkinson’s Disease and Dementia. Arthur reports to me that he is “desperate” for a girlfriend and yet, he feels completely clueless as to why he can’t find a mate. “Maybe it is hard for you to listen to other people,” I say, pointing out that communication skills are important for human connection. “I do listen,” Arthur protests loudly and angrily. “Well, sometimes I notice that you have a hard time listening to me. I begin to speak and you interrupt and change the subject back to how hard your life is given that you are so lonely.” I say, trying to gently point out that he may think he is listening, but the point that he hears for a few minutes and then changes the topic to his own concerns, demonstrates that it is hard for him to stay present with the other person’s thoughts or feelings.

Arthur is not aware that he has poor listening skills, even though he has been told this by multiple important people in his life. Arthur believes that he does listen, so he is confused as to why he is getting this feedback. “Maybe unconsciously listening to others makes you anxious, so in a deep way, you have to refer the subject back to yourself in order to calm yourself down. Maybe all of this is happening at such a deep level that you are not aware of being so self-referential.” I say, trying to talk about how unconscious anxiety can lead to behaviors that one is not aware of. “You are confusing me,” Arthur says. “Yea, I can see that, but maybe if you mull it over, you will begin to understand how one’s mind can work on such deep levels that some parts of communication become outside of your awareness. “I don’t know if that is interesting, or I am just not getting it, but it seems way too abstract for me.” Arthur says with a tone of deep frustration and anger. “Maybe you need to relax a bit so that you can allow yourself to consider these ideas. Your anger may be getting in the way of your understanding.” I say, noting that his low frustration tolerance is another barrier to working deeply. Considering unconscious processes requires a frustration tolerance, since these ideas are uncertain and fuzzy. Arthur leaves abruptly, showing me his discontent. “See ya tomorrow,” I say. “Yep,” he responds without a smile. His anger is conscious. His anxiety is deeper.