Mental Morsels

The Mental Benefits of Rote Memorization

2011-03-18T08:42:00.000-07:00

Rote memorization has become the pinata for the entire field of education. Always a highly politicized area of our civilization, educational values, pedagogy and the role of modern teachers have all borne the blame for countless societal ills. Teachers today too often receive a figurative scarlet letter "F" from the public for failure to teach basic language skills, and for their seeming inability to convey appreciation for our cultural heritage. And for emphasizing "rote memorization" over "real learning." Today, we give "real learning," the moniker, "critical thinking."

In his book Doing Our Own Thing: The Degradation Of Language And Music And Why We Should, Like, Care (2003), linguist John McWhorter makes the argument that the changes in the educational system are a symptom of a larger cultural movement toward increasing informality in learning and communication. A symptom, not the cause. You can pursue Dr. McWhorter's ideas further at the link above. Here, I'd like to extend this portion of his thesis into the realm of mental health.

The fact of the matter is that the trend in the West over the past 45 years or so has been to emphasize self-expression over self-discipline. Rather than push people to learn detailed rules and traditional strictures for writing, talking, even painting, the goal has been to rid the mind of such arbitrary, stuffy, tedious, and (let's face it), plain hard rules of craft. Instead of considering such rules means for expressing erudition and discipline, we see them as bygone ways of conveying snobbery and classism. Worse, so the prevailing paradigm asserts, the rules snuff out creativity by binding up energy in their mastery, and leave little left over for true meaningful expression. It's like a mind subjected to rules must necessarily be dimmed by them; only a mind that can vent itself in every direction at once, without limit, can be authentic.

I suspect this paradigm represents too much of a good thing. To use a metaphor, it would be like saying a bare light bulb is more "real" and beautiful in its unshaded authenticity, then light filtered through a crafted chandelier or stained glass window. Which would strike you as more beautiful?

Worse, as a counselor, I fear that doing away with rote rules and making everyone focus on "self-expression" might have set many people up for failure.

Yes, there are the divergent thinkers out there, those inherently creative and rebellious types who withered under hidebound, authoritarian learning methods like rote memorization. These types likely did revel in the newfound cultural freedom to express themselves in their own, idiosyncratic ways. They could cut ties with the past and their "establishment" elders.

But what about other hardworking people? Those folks who, when you take away the rules and tell them to express, find themselves with nothing to say? Or no good way to say what they do harbor in their hearts? What if they find "critical thinking" exercises frustrating, intimidating or frankly, beyond their ability? Or worse case scenario, they express themselves proudly, believing they are profound, only to find the world beyond the classroom--friends, bosses, coworkers--responding with a resounding yawn? I can't imagine the devastation this kind of person experiences is worth throwing out the proverbial baby with the bathwater. I think rote memorization might have left them a more viable legacy.

My grandfather was poorly educated. He technically attended school through the eighth grade. But because the one-room rural schoolhouses in the Appalachia of the 1920s lacked enough teachers for every grade, he was only able to cobble together about five or six years worth of true schooling. Despite that, he had a 39-year work history that ended in management, he supported a wife and family of six children, read the bible...well, religiously, and became an accomplished folk woodcarver.

Still, he recalled his schooling with some fondness. He remembered having to memorize parts of Edgar Allan Poe's The Raven. By the time I knew him, his school years were over fifty years in his past. His recollection of the poem was fragmentary and inaccurate. But he really did love it. His one regret from his education was not that he didn't get to do enough critical thinking or self-expression. No, he always wished he could have gotten more training in spelling. That rote memorization exercise so many of us hated in school was what he desired the most.

My Baby Boomer father could still recite Shakespear's "Tomorrow and Tomorrow and Tomorrow," soliloquy from MacBeth and "The Jabberwocky," by Lewis Carroll, some thirty years after he graduated high school. These are the legacies of his education, poetry that even today I would wager he is proud to recite.

Rote memorization ended up having far-reaching consequences for both my grandfather and my father. There is a pride in holding something in your skull that is *yours,* that no one can take away from you. What seems arduous and merciless to master in youth pays dividends years later. It is even better, of course, when the effort is freely chosen. I spent the summer of 1990 memorizing "The Raven" for myself...all 102 lines of it. If asked, I could recite it in about eight minutes, at about 90% accuracy. By contrast, from my teenage years, I can recall few "critical thinking" exercises in which I did well. I felt much better about myself when I added a bit of Poe to my own being.

We can't turn back the clock and return education to its hidebound traditions. That would be as unrealistic as asking men in their thirties to put on monocles and bowler hats, and pushing women in their twenties not to shave their legs. Instead, I wonder if modern educational pedagogy is adaptive and willing enough to incorporate the best of what worked in the past with that freedom of expression they sell today? Is there a place for hidebound rules of learning and expression? Should we, perhaps let people choose their light bulbs, but still cover them with cut crystal chandeliers and stained glass?

Leave Diagnosis to the Professionals

2010-11-14T20:04:00.000-08:00

A hundred years ago, professions were impenetrable. The professional-client relationship was unequal, and the former held all the cards. Physicians wrote prescriptions in Latin and described medical conditions in dense nomenclature well above the heads of their poorly educated patients. Lawyers too relied on Latin for their documentation, so the client never knew if what was written was exactly what was discussed. Providers of various services held a virtual monopoly on them. Those they served had only the word of the professional that their best interests were being overseen. There was no way to double-check someone suspected of dishonesty, except to find a professional with the same expertise, and then there was no guarantee that he (yes, most were men) wouldn't be just as dishonest.

Those of us in the modern world might sometimes reflect upon the status of old with nostalgia, and regret that we were born in more literate times, among a more skeptical public. But the fact is that there was corruption among professionals in that Golden Age. There were incidences of sexual exploitation, overcharging or just plain nasty treatment based on snobbery and prejudice. Or sometimes, the professionals didn't know what they were doing and did more harm than good by cloaking their actions in dense language with long-tailed words. They were also known to blame the victim. After all, who could check up on them?

Today, we live in an age of the Undermined Professional. The public challenges professional judgement and refuses to be anything but an equal in the exchange of professional services. After all, knowledge, once prized, hoarded, cloaked in obscuring and secretive words, is now cheap and as easy to find as punching the buttons on the remote control or clicking the computer mouse. In this modern age, patients tell doctors what to prescribe, and clients tell mental health professionals how they want to be diagnosed.

Since I fit the latter situation, there's today's lesson.

The rash of what I call "cyberdiagnosis," or "point-and-click" diagnosis. I find myself more and more having to field requests from patients who want me to verify what they have already decided about themselves, because they found a symptom list on the Internet. In the old days, we called the symptom checklist "cookbook diagnosis." In my earliest graduate school training, we received strong warnings from the clinical faculty about the dangers of this approach. It tends to create too many "false positives," seeing something where there might not actually BE something. Second-year medical students are known for this tendency, diagnosing every cough or headache they develop as lung cancer or a brain tumor. My professors of yesteryear couldn't have foreseen the Internet, which pipes professional knowledge into any home with a computer, or pharmaceutical companies with their punchy bulleted lists of symptoms on television commercials. Not surprisingly, these developments have produced an epidemic of the very phenomenon we were being trained to avoid. Untold numbers of people now think they're sick or mentally ill. Knowledge without training and experience can be a dangerous circumstance.

Simply put, symptoms are not enough to diagnose illness. Mental illness in particular is defined as normal behavior carried to extremes. But there are more circumstances in which someone might show extreme behavior, besides having a mental illness. It is the role of a mental health professional to tease apart what is transitory from what is systemic, what is external from what is internal. Other factors have to be considered, among them, social circumstances, relationships, medical condition and childhood history. Just because someone is rundown and tearful doesn't mean they're depressed; thyroid problems can cause this. Hearing voices doesn't necessary mean someone has schizophrenia; sleep problems or medication side effects can mimic it. And just because someone has trouble focusing attention or remembering details doesn't mean they have adult attention deficit disorder (ADD); lifestyle stress can simulate it.

With regard to the ADD diagnosis, I've actually upset several patients because I disagreed with their cyberdiagnosis on this condition. My most glaring example was a young man recently, whose wife had point-and-clicked her way to diagnosing him with ADD because he was distracted and irritable toward her. Although he had no history of this condition before, she wanted me to corroborate her Internet research.

What I found instead was that they had only been married for two weeks. The couple did not move in together until after they got married, so this was their first experience dealing with each other in conjugal circumstances. More, the young man was trying to work his first professional 8-4:30 job, while his wife was still in college. So while he had to be in bed by 11:00 p.m, she had an erratic schedule and was staying up until odd hours, disrupting his sleep patterns. Further, his wife wanted to talk when they got up in the morning, while he preferred quiet time to "wake up;" another feature they couldn't know about each other until they'd lived together. She was also texting him at work, distracting him and frequently pressuring him to get their new home assembled and ready for guests.

Do you see the pattern here?

She wanted him diagnosed with a mental health condition, something with a stigma that is very difficult to escape. The reality was that she was responsible for much of his behavior. No doubt, as they adapt to each other, some of his distraction and irritability will go away on its own. Some simple coping skills training might have also helped them both. But alas, the happy couple never returned for further services.

It is understandable why people try to cyberdiagnose. Life is hard, confusing and when others behave strangely, we all want to feel some control over the situation. The Internet is easy, available and chock full of information. But information without understanding, without professional experience, just creates too many false positives. So if I might invoke an old-fashioned, rather paternal perspective, leave diagnosis to the professionals.

Words Speak Better than Actions

2010-09-30T08:10:00.000-07:00

There is something quaint, even cute, about watching a long-term couple. Since they know each other so well, they don't always require words to know if the other needs or wants something. They can guess, often quite accurately, what's on the other's mind. I only have to hear my wife clear her throat, for example, to know she'll be wanting a drink of water soon. So I'll go ahead and get it for her before she expresses the need for it. For the little things in life, I think there's no concern with this benign form of "mindreading," and it can be endearing.

However, when it comes to strife and conflict in relationships, I observe more people getting into trouble by trying to "mindread" than almost any other situation. In fact, I've written on the topic before.

Recently, I got into a discussion about this topic with an esteemed online colleague of mine, because her perspective was quite different. I'm a self-described man of words, a believer that we can never know another's thoughts, only what they tell us about their thoughts. My colleague espoused a broader position, citing the old bit of wisdom that actions speak louder than words, and that the truth of someone's motive and character are more implicit in what they do than in what they say.

Mmm...okay, maybe. Sometimes.

But I think this is too unreliable to use as a basis to resolve conflict. Like my giving my wife a drink of water, a guess about someone else's thoughts is a guess, regardless of whether or not it is accurate. For the "serious things" in our relationships, I consider words and discussion a safer medium. More, I've long believed it a small conceit to start any discussion with some variant of "I know what you're thinking," or the confrontational "You think that just because I..." More, I think it rude to intrude on another's thoughts and act like we know more about them than they've disclosed.

We like to bash the use of words in the West. Which is paradoxical, because then we laude such people as Shakespeare or Emily Dickson for their "blank verse" and "slant rhymes;" elegant uses of language.

The reality is that sometimes, actions are based on irregular reinforcement, old habits, or even because of past psychological damage. As such, the person doing them might have no idea why they're doing them, or they could find themselves acting in a way completely at odds with their wishes or intentions. In that case, actions obscure motive and character, they don't elucidate them. Actions may speak louder, but they don't always speak clearer. That's where *talking* comes into play, encouraging the use of words and communication to bring motives for problematic actions to light.

As a caveat, I certainly think it's acceptable in a relationship situation to disclose what you think the other person is thinking. Exemplum: "When you don't talk to me for hours, it makes me wonder if you're feeling angry with me." This is phrased as a hypothesis, which the other person is free to confirm or refute. In my professional opinion, beginning discussion with that type of respect is the key to reducing conflict and finding solutions.

You Have All the Time in the World

2010-07-15T08:41:00.000-07:00

As I went through a lunch line yesterday afternoon, I encountered a very pleasant young woman behind the counter. As she was preparing my order, she noticed I had a rather large tome I am currently reading for entertainment. In the work week, I often read during my lunchtime. It is a meditation and a stress reliever; but mainly, I do it because I enjoy it. When I replied that my wife and I like this particular author and exchange her books, the employee innocently stated, "Yeah, it's nice to have time to read like that."

She said it without any obvious rancor and I'm sure she did not think about it again afterward. But I did. I had to consider that she made a couple of obvious mistakes. First, she was implying that I don't work as hard as she does, something she could not possibly know or understand. Second, she assumed that reading is only something that can be done if one is idle.

Reading, and any other recreational activity for that matter, isn't dependent on time so much as it is priority. To quote a friend of mine (hey, Leda!), "A reader is a reader is a reader." If someone enjoys reading, they'll find a way to make it a priority, to use part of the same 24 hours we all have, regardless of their other commitments. I was a reader as a child, as a teenager and as an adult. When I went away to college, my family promised me I'd be so inundated with reading assignments and papers to write for my professors, that I would almost certainly lose my love of reading.

Didn't happen.

Oh, they were right, I did get inundated with those kinds of assignments. But for a reader, mandatory reading is apples to oranges when compared to the rewards of recreational reading. One is draining, the other energizing. Even in graduate school, where I got hammered with that distinctively polite, egghead form of hazing, I still found the time to read my favorite authors. Sometimes, it was during lunchtime, or between classes or a few minutes at night before bedtime. A reader will find a way. In my experience, those who claim they don't have time to read or who profess to be burned out on it by their career...well, they were probably never readers in the first place. I feel bad for them, though I'm sure the feeling is mutual.

It's all about what you value and what you prioritize.

The Living Past

2010-06-18T10:06:00.000-07:00

Most of us have had the unpleasant experience of traditional history classes, in which fossilized teachers read dessicated material from dusty tomes in monotone voices to us, the indifferent students. My best pencil doodles came out of such venues, and I bet that had I kept them, they'd be on par with Picasso today. The problem with teaching history in this way is that it leaves out something very important: history is alive. It endures, persists and can still actively touch our lives in a positive way. History is the tale of people--real people--whose deeds endure the test of time. History is not a list of facts about them, like their names and birth dates. When spoken about in that dry tone that so many burned out teachers maintain, the people of the past do appear dead and disconnected from us.

The fact of history's living presence can be quite a benefit for our mental health as well. Viktor Frankl, in his work Man's Search for Meaning, introduced a unique and powerful idea that anything we do--all our achievements, relationships, creations--are "saved into the past." By this, he explained that once lived, our lives become an indelible mark on the passage of time. The truth of our being, the fact of our existence, can be forgotten or denied, even hidden. But none of these consequences can change the fact that we were. For Frankl, the tide might erase the footprints in the sand, but it can never unmake the fact that someone walked there, on that beach, in that time and for their own reasons. Whatever their story might be, the thread of it, that sequence of events, has joined the larger tapestry of the living, enduring past. I liked one of Frankl's comparisons. He pointed out that as youth-oriented as Western culture tends to be, he himself would never want to be young again (he eventually died at age 92). He observed that the story of the young person is unwritten, rife with uncertainties. For the older person, the majority of their life is a certainty, undeniable, and comfortaing in that certainty. Metaphorically, Frankl noted that our sad tendency as we age is to lament the empty field in front of us, while forgetting the full granary behind us.

I've found Frankl's notion of a life "saved into the past" to be not only personally comforting, but quite useful in working with patients who come to me with grief. Losing a loved one--human or animal--is a universal experience, and perhaps one of the most painful circumstances a human being can ever face. Usually, this is associated with death, which is the ultimate loss, though breakups can be their own form of torture. Never mind such ambiguous losses as missing children, stolen pets or MIA soldiers. And of course, relationships are not the only parts of our lives that we can lose and for which we can grieve. Job loss is another type of bereavement issue. So is the loss of a condition of life, such as the amputation of a limb or a permanent damaging of our health.

Most often, of course, it is the loss of a relationship that creates the most heartache in our lives. And usually, it involves death. So I begin grief counseling by challenging the very idea of "loss." Certainly, when a loved one dies, the permanency of that situation is inarguable. But only if one looks at the empty field that is the future of that relationship. What about the full granary of the past? Can one deny that the relationship with the loved one existed? No. Are all those good memories, those wonderful stories, erased by the incoming tide of grief? Nope. Have all the wonderful experiences, the laughter, the hope, the shared moments, become unmade? Uh-uh. As painful as the loss may be, the fact of the matter is that the story of the relationship has not changed. In fact, when speaking to someone who has lost a family member, like a parent, for example, I remind them that they didn't stop being a daughter or son, merely because of the loss.

Along with the permanence of the loved one's story and place in a patient's life, I work with them to realize that that person's wishes and expectations often live on, too. One of the best ways to deal with grief is to put one's energies into something productive. Bringing the loved one back is not possible. But making sure that what survives of them is not forgotten *is* within our power. One of my most memorable grieving patient encounters was with a middle-aged woman who dedicated herself to gathering all of her recently deceased mother's original food recipes from all the disparate family members. Apparently, some of these recipes were only written down once. Only one copy existed. This patient made sure to assemble every one she could get in one place; a cookbook she had published at her own expense. Then she gave copies to all her family members, so that the totality of her mother's legacy could be shared by all. Or as I later phrased it, "Mom was in every kitchen."

Often, when prodded, patients will admit that the lost loved one hoped their family and friends would accomplish this or that goal. Why not continue to work on it? Wishes don't die. In fact, the fulfillment of a lost loved one's expectations can be the most concrete way to show that they still have an influence, that a part of the relationship is still there, still capable of making us better.

Try this thought experiment. Think of someone you cared about who has died. What do you do each day to keep their story alive? How can you act now to bring their part of your own history forward, maybe even share it with the rest of us? Can you do something today to make yourself better, because they wanted it for you?

Energy Drain From Personality Disorders

2010-05-02T13:27:00.001-07:00

In the previous entry, I talked about personality disordered people as those who drain off our energy in our encounters with them, and give little back. Managing them takes energy from our other relationships and can cost us effectiveness on our jobs, hobbies and general happiness.

What to do?

Well, unfortunately, there is no uniformly satisfying answer. Even among mental health professionals, personality disorders are considered barriers to successful treatment. The prognosis is poor. Such clients come to us distressed, but rarely show much progress from the energy invested in them. Despite this, some dedicated and admirable counselors do still work to change the personalities of these people. Most are pessimistic about it, though. Instead, they focus on teaching difficult clients better ways to behave and cope with the vicissitudes the person her or himself so often creates. Intervention is, in short, a "damage-control" philosophy. Help them reduce the bad consequences of being what they are, but be resigned to the fact that the client will always be what they are.

Counselors have one major advantage, though. We get to go home after interacting with an energy draining person. But what about living with them? How should you handle them when they're a part of your social circle or family unit? Well, the answers there are even less satisfactory and often harder to implement. Most of us are caring, and legitimately don't want to see someone close to us suffering if we think we can do anything to help. But when do you cut off the energy drain, and say "enough?"

The secret lies in knowing when and how to set limits. A great deal of psychotherapy, in fact, goes into teaching beleaguered people to put limits on what their loved ones do to them in the name of love or loyalty. I personally spend much time on what I've referenced here several times, interpersonal strategy; the planned use of words and responses to difficult people.

The first step in setting limits involves self-monitoring. Each of us has to be attuned to our own level of energy and we have to draw the line as to how low we're willing to let it go before we clamp down on the outpouring. One of the most salient lessons to learn about people who habitually drain energy is that trying to reason with them is usually ineffective. Getting your energy is what they desire the most, even more than escaping whatever is causing them pain. They don't want your wisdom, and will likely be resistant to even your most well-reasoned and helpful advice. So don't blame yourself if you have tried your hardest, only to find you haven't been able to make their lives better, or get past their rationalizations for victimhood. If they keep calling on you, despite your frustration and sense of futility, you can begin setting limits by telling them they most likely need professional mental health assistance beyond what you can continue to give them. Make the topics they keep bringing up "off limits" if you want the person to remain a significant relationship in your life.

Other ways of setting limits might be not answering the phone every time they call, or holding them to a pre-set time in which you will listen to their woes. Insist on communicating by email or other asynchronous medium on certain conversation topics, so you have more control over the time you invest in them.

Eventually, the person will seek a more cooperative source of energy. Unfortunately, that might only happen after the personality disordered individual becomes angry and accuses you of "never really caring." In fact, you might find yourself lumped into a pool of past people who have allegedly mistreated the energy-draining person, a "you're just like all the rest of them" category. Be prepared for such emotional outbursts, and remember that anything they say to you, even if it is the truth, is calculated toward feeding on your energy again. Guilt can be a strong motivator to buckle on your limits. Don't. Keep to them, and make it clear you aren't going to change the rules, even though you're sorry they feel so negatively about you. You might have to be prepared to lose the relationship. That's a sad outcome, but the fact of the matter is that relationships can and do end. Sometimes, they just can't survive the test of time, and you have to cut your losses and reflect on what you gained. The ultimate test, as this article originally maintained, is in how much energy it cost you and when the price becomes too high.

Energy Drain in Personal Relationships

2010-04-19T13:05:00.000-07:00

In the previous entry, I used as a metaphor the psychodynamic idea that the mind operates via energy, and that a drain on our energy makes it harder to think, control our emotions and be happy. Sigmund Freud himself said that the main job of our mental activity is to love and to work, and I spent some time talking about the pitfalls of when the workplace siphons away energy from our personal lives.

On the other side of that equation, our personal relationships--be they familial, romantic, sexual, platonic or casual--can also tie up our energy. When this happens, the loss can make us unable to give what we need to other types of relationships and to our jobs.

My experience has been that mentally healthy people in healthy interactions will circulate energy back and forth, in the form of attention and empathy. Walking away from such an encounter makes us and the other person(s) feel like we've given something of our energy, but we've gotten something back from it as well. It is much like a fountain, which cycles the same water over and over, but creates a never-ending froth of stimulation and beauty.

By contrast, there also exist what mental health professionals call "personality disorders." Such people draw many unflattering and pejorative names in popular press: psychic vampires, dysfunctional people, bottomless pits, as well as a bevy of four-letter epithets inappropriate for a professional blog. Whatever one calls them, personality disorders are people who are damaged in some way, chronically unhappy and incapable of keeping up their end of the circulation of energy. They give nothing back, they just take and take. We walk away feeling drained, lessened by trying to engage such people. More, the draining party doesn't benefit from the encounter either. They just get reinforced by the attention, such that they keep seeking out more attention--more of our energy--but they don't use it to help themselves get any better or happier.

The Diagnostic and Statistical Manual of Psychiatric Disorders offers up descriptions of several different types of personality disorders. Although you should leave clinical diagnosis to the professionals, the following deliberately overgeneralized criterion might help you recognize when you're dealing with an energy drainer:

Their lives always seem to be in a tumult, one crisis after another. They might have multiple accidents leading to injury, have conflict with myriad people, lose jobs frequently or have legal/financial troubles on a regular basis.

They have more interest in getting sympathy for their suffering than changing the situation causing it.
Such people will often talk about themselves and their own problems, but seldom ask about yours.
They have inconsistent and contradictory attitudes and seem unaware of it. Such statements as "I'm the kinda person that," can be a red flag, especially if what follows contradicts what they told you hours, days or weeks ago.
Often, they rationalize mistakes or poor judgement, and blame elements of the external world for their suffering.

But one of the best ways to measure whether you're dealing with someone like this is to reflect for a moment on your own energy level when you're around them. Do you feel tired? Frustrated? Despairing? Does your mood plummet or become irritable when you hear their voice on the phone? For all that, do you feel like you're pouring time, money, attention, sympathy and hope into someone who shows no improvement or motivation to help themselves? Or who might even be unappreciative and defensive about their own misery? Do they play the victim's role, no matter what the situation?

We've all had such relationships in the past, or at least had encounters with such people in the public. The shaky data at present suggests 5-10% of the general population is diagnosable with a personality disorder. Statistically, that's one to two people out of every twenty we meet. In medical populations, it can climb considerably. Among patients needing daily medical treatment (like opioids) for benign chronic pain, for example, some studies show as much as 50% have a personality disorder. I'll admit I haven't seen data on populations of other chronic illnesses, but I suspect they might have higher-than-average incidence of such people too. We've all encountered the person who seems to gain something from the "sick role." If you've ever dealt with a doctor, nurse or hospital worker who was overly surly or churlish with you, it might be because they interact daily with so many energy drains, and function with depleted energy by the time they *get* to you. Politeness and empathy take resources they might not have.

In the next entry, I'll talk about limit-setting and how it can help curb the amount of energy other people can take from you.

Having the Energy to Love and to Work

2010-04-15T07:17:00.000-07:00

My wife, a university-level journalism teacher, would probably grade me off here for "burying the lead," but I think a meandering approach to today's topic would be more useful.

Once, in my early adulthood of the mid-1990s, I was listening to my grandmother talk about hardships of her own youth. In that conversation, I observed how so many people hearken back fondly to "the good old days." My grandmother rolled her eyes and shook her head in that distinctively "Geneva way" (Geneva being her name), and gave me a memorable response: "Well they can have'em!" In her rustic, Kentucky accent, she explained that until you've used an outdoor privy at night in sub-zero temperatures, or had to pound your laundry clean on an old corrugated metal washboard, you can't appreciate what the modern world offers.

Her words from all those years ago, highlight a piece of wisdom I once heard: you truly know an Age has ended when people start to have nostalgia for it. The brutal realities have begun to fade from living memory.

Mental health professionals can be guilty of nostalgia too. In fact, I personally have a closet respect for the ideas about people and relationships from Sigmund Freud's old psychoanalytic theories. Once, the field of psychotherapy was dominated by Freudian "psychodynamic theory" as it later came to be called. Not everyone followed directly in Freud's footsteps, and many of his colleagues and students tweaked one part or another of his theories. Subsequent research has outright contradicted some of his ideas, such as the importance of tension reduction, or the flakier "psychosexual stages of development." But still, his perspective once permeated so extensively into Western culture that even his critics reflected him back in a reactionary manner.

Irvin Yalom, in his book The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients (2002), includes a chapter called "Freud Was Not Always Wrong." In it, he states:

"Freud bashing has become fashionable. No contemporary reader can escape the recent scathing criticism condemning psychoanalytic theory as being as passe as the bygone culture from which it sprang. Psychoanalysis is attacked as pseudoscience based on an outmoded scientific paradigm and eclipsed by recent advances in the neurobiology of dreaming and the genetics of schizophrenia and affective disorders."

But Yalom goes on to show how Freud had to single-handedly invent the field of psychotherapy in an age when emotionally suffering people had nowhere else to go. He notes that Freud "wrote an amazingly prescient chapter on psychotherapy that prefigures many of the major developments that were to occur over the next one hundred years."

I have to believe there was something of value in Freud's beliefs about the mind. And that brings me finally to today's topic.

Psychodynamic professionals, though often in disagreement with each other, usually keep Freud's assumption that a person's personality is an energy system. Like a hydraulic or internal combustion engine, the mind needs energy to do what Freud called "psychological work:" making thoughts, feelings and behavior. The more that energy gets "tied up" creating defenses against our own impulses or the demands of other people, the less energy is left for normal decision-making, healthy feelings and productive behavior. To paraphrase Freud, one needs a generous supply of energy that she or he might properly love and work. Freud's mode of treatment was all about freeing up energy for that purpose.

This model was based on antiquated, mechanistic nineteenth century physics, to be sure. But as a metaphor, I think it remains an apt description of our psyche, if not a viable explanation. We still speak of being "on" when dealing with people in a public or social setting, an activity that leaves us exhausted afterward. Most of us welcome the chance afterward to be "off," the better to recharge some kind of symbolic battery. We retreat from public, and fall into mental seclusion with such activities as sleeping, taking bubble baths, staring blankly at the television, reading a good book or walking alone.

What happens when there is an imbalance of energy between love and work? You've been depressed before, haven't you? You've dealt with a difficult person at your job or in your family, right? Do these experiences not take a toll on some kind of "energy," leaving you feeling drained?

In employment circles, there is literature aplenty on what is called burnout, a term that easily ties together with energy; something "burned out" has lost the fire, the "oomph." It is cold, eroded, reduced, diminished. What causes it? Well, that would require an entire entry unto itself, but the short answer here is that employees just run out of energy. Perhaps they use too much too quickly, trying to accomplish a large task all at once. Or they might be involved with dysfunctional co-workers or difficult employers, either one of whom requires a constant energy drain to stay polite, diplomatic or to otherwise build a facade that can mask true feelings that would have bad consequences if they leak out.

Where does that energy come from?

It gets bled out of one's personal life, out of loving relationships, friendships and personal interests. We find it harder to push ourselves to do the things that once gave us pleasure. Patience wears thin and the foibles of others become less tolerable. Unfortunately, such costly buttressing strategies in one domain, at the cost of energy from other, will still fail. Spending energy without recouping energy leads to a bankruptcy of sorts. In fact, the term "bad attitude" might not be so much something in its own right, as what happens when we run out of energy and can no longer fuel positive attitudes.

Of course, the workplace is not the only domain where energy can get "tied up." Next time, using this model, I'll introduce what happens from the other side: when energy is consumed by a taxing personal life.

When is a Friend Not a Friend?

2010-03-23T09:40:00.000-07:00

Having conducted thousands of counseling sessions, I am always struck by how few of my patients make the distinction between "a friend" and "an acquaintance." They paint all significant relationships in their lives as "friends." This was a trend even in the early days of my career, but the recent proliferation of social networking sites like Facebook or MySpace, seem to be encouraging the practice. Unfortunately, such sites treat our relationships like something that can be collected, akin to baseball cards. More, they've even contributed to a change in our language. Not only do the sites stretch the meaning of the word "friend" to include pretty much anyone we meet, but they have led to "friend" being turned from a noun into a verb: "friending."

My professional experience is that applying the rules for one type of relationship to another usually results in miscommunication and feelings of betrayal. So often, a tearful patient reporting on their mistreatment by a person they thought a friend was from a relationship with considerably fewer obligations than a friend would observe. People who aren't friends will not behave like friends, no matter what we call them.

The Difference Between Friends and Acquaintances:

I intend to list here my personal opinion about the qualities of friendship. Before doing so, however, I want to say in advance that I heartily invite those with dissenting opinions to please express them! Now, I think friendships are characterized by being longstanding, cross-situational, durable and finite.

True friendships tend to be established in youth, which I consider to be anywhere from childhood through the point in life when one begins to commit more resources to house, marriage/family and career. Usually, the ages will range from 5 through 25, though I myself suspect the normal cap is probably the late teens or early twenties. So such relationships will likely be at least a decade strong by the time one is a functioning, productive, autonomous adult.

In our youth, before other commitments take over, we have the time and emotional energy to invest in deepening friendships, and exploring them in multiple situations. For that reason, friends tend to share many different kinds of experiences with us. Anything from ballgames to tea parties, church sermons to roleplaying games.

Friendships might go through periods of waxing and waning. We might draw apart from a long-term friend for months or years at a time, but we find that they have a durability in the face of the ravages of time. When we reconnect, we can re-establish old ties by sharing those previous experiences, and perhaps reinvigorate the relationship with our newer experiences.

And finally, since they do take time and energy, friends are necessarily limited in number. Which is why those people on Facebook who proclaim to have hundreds or thousands of Friends, aren't really talking about true friendship.

Now let's contrast this with acquaintances. These are relationships of lesser depth. In contrast to friends, they are of shorter duration, situational, fragile and more numerous.

Since we tend to meet them later in life, we're more likely to find them in our workplaces, or connected to our extracurricular activities. Such a person might come to a BBQ for coworkers, but is unlikely to attend a parent's funeral or child's graduation. It isn't that they don't care. But after all, they've got parents and children of their own to worry about now. Acquaintances don't often persist beyond a given workplace or situation. People promise to "keep up" when life changes, but then new acquaintances come with new venues, and there just isn't time and energy to maintain them all. So they're more fragile and tend to fade more easily.

Finally, it is possible to have dozens of acquaintances, because each only gets a piece of us, and not our entire selves. But I still don't think one can have hundreds of acquaintances, and cultivate any meaningful, consistent encounters with them.

It is my belief that after young adulthood, it is nigh impossible to create really close friendships. Once life takes over, we're limited to acquaintances. We can strive to resurrect long-lost friends, and certainly cultivate the ones we've had for decades. But finding new ones is just too hard when home, hearth and career intrude. Social networking sites can help, but they're only good for "keyhole" approaches to the lives of others; they aren't windows, and they certainly aren't doors. For that, there's no substitute except time and energy.

Make no mistake, acquaintances are as necessary in the adult world as friends. They make our jobs easier, more pleasant, and can be a source of support during an acute crisis. A kindly coworker can be an emergency babysitter, for example. Spending hobby time with people of like interests can stave off career burnout, maintain motivation and keep us in touch with the outside world. But these benefits must be garnered with caution: acquaintances are not the same as friends, and mistaking them as such causes pain.

To Be Free, One Must Be Chained

2010-03-17T10:33:00.000-07:00

When I first heard the words in the title, well over a decade ago, it was phrased in a rather more friendly way: "To be free, you must submit yourself to a set of rules." I cannot remember now who first said this piece of wisdom, and the World Wide Web is strangely silent on the issue. So I'll simply acknowledge here that it is not my quote, but it is one I like. I see the observation as an issue of good mental health, and therefore, as grist for today's Mental Morsel.

Our American culture in the present is very rigidly individualistic. That is, we're very sensitive about "doing our own thing," or "dancing to the beat of a different drum" and going "against the grain." Of course, there are numerous studies demonstrating that Americans tend to be far more conforming to trends and counter-cultural values than we like to admit, but this doesn't change the fact that if asked, we tend to express a belief in ourselves as free-thinking individuals. More, we don't like to change our ways just because the Generalized Other says we should. Taken to its extreme, this cultural value begets self-absorbed, "me first" rudeness, a phenomenon I've addressed in other posts.

So everywhere you look today, you see emphasis on freedom, on living by one's own idiosyncratic impulses. "If it feels good, do it" was a slogan of yesteryear, but it is alive and well today. Just look at the wishlist section at Amazon.com, where there are beguiling encouragements to "treat yourself." It's as though we deserve limitless self-indulgence, like we're special by sheer virtue of being born and being who we are. Rules, limits on our behavior, are conceptualized as stuffy, arbitrary things, the province of little old ladies with their hair in buns, crossing bony arms over the chests of their faded floral dresses, and tut-tutting us.

Here's the problem with pursuing freedom for its own sake: What comes next? As the movie Serafina (1992) indicated, freedom is only the beginning. It doesn't work very well as a goal unto itself, it is a means to an end. The value of freedom is measured by what you do with it after you have it.

The fact of the matter is that absolute freedom leads to failure to thrive. It is synonomous with aimlessness. Some of the early developmental psychology research indicated that in terms of child development, the ones who grew up the most dysfunctional and ill-prepared for life's vicissitudes, were the ones given the most freedom. They became obsessed with their own will, with seeing their desires and wishes enacted, and not being told what to do. Such children were loud, angry and demanding, and had little regard for others. Such a description is all too easily recognizable among many adults in the America of the 21st century.

Margaret Atwood and Viktor Frankl, among other writers, discriminated between "freedom from" and "freedom to." The former refers to the state in which one is not subject to sanction from other people for their decisions. If I want to wear floppy red clown shoes to work, I should have "freedom from" life-threatening consequences; I might be heckled or even disciplined, but not beaten or killed. By contrast, "freedom to" refers to the ability to choose one's own meaningful, standards with which to live by. To be constructively free, we must subject ourselves to rules, even if they are rules of our own making or governance. Everyone who functions well in a society is doing this. They enact rituals and self-expectations to which they adhere with reasonable discipline. Such individuals realize life isn't about doing what they want when they want it; it is about setting goals and making a plan to accomplish those goals. And doing it might mean delaying gratification.

Here's an example. I like beer. I like beer a great deal. But...I have rules about it. I can only have so much per week, and only on certain days. And only at the same time on those days. More, it is always in the same proportion. Why? Because beer is an indulgence, as well as a responsibility. We all know its dangers. I get heckled by peers sometimes for my rather rigid take on it. They ask me, "Why don't you just let yourself have a good time?" Because I have rules about having indulgence without first having worked throughout the week, either at my job, in my hobbies or at the gym. Who makes me live by these conditions? No one, but I have rules. I won't say I am perfectly compliant with these rules--I'm human, after all--but I can say that I feel better and accomplish more when my compliance outweighs my laziness.

Those of us with rules tend to value the anticipation of enjoyment as much as the enjoyment itself. Nothing gets me through a busy day of patients or past the burning in my weight-lifting muscles like the thought of that one beer on Thursday night. I particularly love my vacations, for what are they if not an escape from one's regular routines? A chance to do things in a different order or proportion? But how would a vacation contrast with everyday experience if we lived every day as a vacation? All experience would run together, and the only differences would be higher body weight, drunkenness, laziness and malaise. Hedonism, like freedom, cannot be a goal unto itself. It is incompatible with a meaningful life and good health. Pardon the somewhat cliche statement, but rules are the rungs on the ladder of success. A sense of achievement, of pride and ultimately, of contentment, are contingent upon playing by the rules; freedom comes in deciding whose rules.

Avoiding Loutish Behavior

2010-03-04T06:20:00.000-08:00

I've referenced Lucinda Holdforth's book Why Manners Matter in a previous post, but found it worthy enough a read to use it as a springboard for today's topic as well.

Holdforth introduced me to a name for a concept I really like, "cocooning." She defines this as a lifestyle choice of insulating oneself from the public, of keeping other people at a discrete distance. She cites the increasing use of technology to accomplish this, whether that technology be the cell phone that lets one loudly broadcast conversations to put off other people, to music players, to huge and intimidating SUVs with their onboard televisions, DVD players and surround sound. Holforth asserts that this type of lifestyle has become more prevalent in the 21st century, because so many of us have become sensitive to that sizable portion of the population "out there" who has no ability to restrain themselves for the benefit of others. They lack courtesy. Her conclusion on the topic is that the cocooning lifestyle is a sad commentary on society, since so many now feel the need to wall themselves off from discourtesy and unpleasantness. By using their gadgets in such a way, cocooners risk themselves being discourteous and unpleasant. She also indicates it is a huge and wasteful expenditure of resources, citing the gas-guzzling, space-hogging fortress that is the SUV as one significant example.

While I can see how such a state of affairs can happen among cocooners, I'd like to take issue with her suggestion that it is a thoroughly negative lifestyle choice. Indeed there is a population of unpleasant people out there, whether they are rude through lack of awareness and seeming cluelessness about how to behave in public, or whether it be through outright loutishness. We can't fight with them without becoming one of them, and the stress of confrontation, even when one is polite and in the right, can often make the entire experience of being in public not worth the effort. I believe the choice of cocooning, if approached appropriately, can have several mental health benefits.

As an aside, one must admit the option is not available to everyone equally. Generally dependent upon technology (with exceptions, discussed below), cocooning as a lifestyle will necessarily be available mostly to those on the positive side of the so-called "digital divide." One needs financial and temporal resources, as well as technical know-how, to have access to technology.

Second, the term "cocooning" implies insulating oneself against the environment, in a hidden and reclusive sort of way. So I discriminate between Holdforth's loudmouthed public cell phone users, and the unimposing user of a digital player. The former actively pushes people away with their noise pollution, while the latter wears quiet headphones and passively listens while waiting for the bus. They intrude on no one. I can see the difference between aggressive use of an oversized vehicle to take up two parking spaces (to push others away), and a person at Starbucks, who is unobtrusively typing on their laptop. Cocooners need not be dismissive of others' rights; they merely minimize the negative impact of the public on their attention and peace of mind.

Cocooners also reduce frustration and risk in public by restricting their presence from it. Simply put, they stay home more. They avoid the crowds, the dangerous traffic, the noise, the waiting in lines required of interacting with public services. Increasingly sophisticated home entertainment systems and DVDs have been stealing the magic from a night at the cinema for the past ten years. They give good entertainment without large coronas of hair in front of the screen, or those disgustingly sticky floors. It is now possible to do a great deal of shopping online, getting anything from bras to boob-tubes, jock straps to golf balls, music to marmalade. Internet connection speed and product availability allows downloading of movie rentals, which makes even a painful drive to Blockbuster unnecessary. There is a serenity to watching the newest movies without dealing with red-light runners, or people who bumble through the aisles, acting like they've never been in public, or those who like to show creative hand gestures to their fellow citizens.

One might argue that increasing Internet use negatively impacts local economies, and insulating oneself from the public creates an increasing lack of community spirit. To the first, I would respond by saying that rudeness and loutish "me first" attitudes do not really engender much loyalty to the local public. As for community spirit, that seems like an irrational belief that one should have loyalty to a geographic region, merely because circumstances put them there. That seems pretty random to me. By contrast, cocooning puts control of one's social encounters back into their own hands. Instead of dealing with a line-cutter or someone begging for change in public, we can instead have our online shopping done and stay home to talk on the phone with a person of choice. In my own life, anyone who is talking to me on the phone knows that I value the encounter, not that I'm superficially tolerating them until they tell me what they want. I'm giving freely of my time, not having it imposed upon.

Although technology has allowed cocooning to be possible, it should be mentioned that it isn't the only way to shield one's time and attention from encroachers. Reading a book in public can distract one from noise, nosy people and the tedium of waiting amongst a hoard for a seat in a restaurant. Instead of driving somewhere for dinner on Saturday evening, take a walk and get something nearby to eat at home. Walking is slower-paced, quality time, and can be a nice social experience if shared with a spouse or friends. More, walking generates negligible air or noise pollution, and is less likely to result in an automobile fatality in busy traffic.

In short, cocooning isn't for anyone all of the time, but is highly beneficial for everyone, some of the time.

How do you cocoon?

You Never Know What Time Means

2010-02-25T12:57:00.000-08:00

My wife inspired me to write about today's topic. She advised me recently, that when I have a hard day at the office, I need to come back and tally up the "little things" I have accomplished with my patients. Burnout is a constant companion to anyone in a helping profession, as is compassion fatigue. Why? Because we deal with human suffering daily, along with free will, and the intractability that comes of trying to help another human being change meaningfully. More, the people we serve often go home to bad environments, where they face negativity, arguing, unsupportive family and rough neighborhoods. Changing in such circumstances would be trying for even the most hearty individual. Counselors must come to grips with exactly how small their role in a life tends to be.

Prominent psychiatrist Irvin Yalom has long written on the topic of differing expectations between counselors and the persons they work to help. In his books Everyday Gets a Little Closer (1974) and Existential Psychotherapy (1980), for example, he documents the shock of realizing that what his patients valued from their therapy was very different from what he expected. In fact, so different were their experiences, that he writes he is uncertain he and the patient shared the same 50-minute hour! They weren't "wowed" by his advice, his prodigious knowledge of behavior or his insightful psychoanalytic interpretations of their daily experiences. In fact, the blow to his ego (and to the egos of us all), is that very often, the patient doesn't even remember most of the intellectual or learned parts of counseling. Instead, they'll report on how nice it was to have someone listen, to give them support and let them be themselves.

In my professional work, as I reflect on it, I do recall some occasions when I had similar surprises as those of Yalom. I've had patients I'm sure I've done nothing to help, and I wonder what else I can say to them. Then they'll walk into my office, and exclaim something like, "Oh, I look forward to coming here, this is the calmest place in my life!" What the patient gets isn't always what I think I'm giving. Yet they benefit all the same.

I'm reminded of my grandmother. On June 11, 1998, my grandfather passed away, after 63 years of marriage. In the short interval that followed, I wrote a couple of snail-mail letters to my grandmother, showing my support and giving my take on how crappy it is to lose someone so close. I even made sure I boosted the font size in the letters, so her poor eyesight wouldn't force her to have to struggle to read them. She herself passed away on November 7, 2000. In the process of going through her things, my parents found and brought to me, a sandwich baggie. Inside it were those two letters folded up. Apparently, long after I'd forgotten about them, she'd preserved those letters and come back to them when she needed comforting. You never know what is meaningful to someone.

These two examples--my patients and my grandmother--are good reminders. If we share our time and attention, whatever we use to fill that time and absorb the attention, it might do more good than we think. Even if we don't get to be bastions of intellect or fountains of wisdom in the process.

The Masculine Mystique

2010-02-18T07:20:00.000-08:00

The Moderator of Atticus, my mailing list at Yahoo Groups, recently sent out the following article at BBC.com:

http://news.bbc.co.uk/2/hi/health/8505641.stm

It is an interesting study, but I found that it seems like another plug for the simplistic paradigm that assumes all women use sex to get love, and all men use love to get sex. I was struck by how quickly the alleged "scientist" quickly degenerated from objective research findings to a blatant judgmental position. At one point, he concludes, "Men are very egotistical and see themselves as the sun in their own world." That's hardly a "scientific" finding, it is a judgment of character, and a sweeping generalization at that.

The study started me thinking about how much we tend to assume that men--both traditional "tough guys" and less traditional easygoing individuals like myself--are simplistic beings when compared to women. If shows like Sex and the City are to be believed, women's lives are filled with complexity, richness and a "female experience" unrivaled by anything in the life of the brutish man. I'm always struck, for example, by the contradictory attitudes our culture has about birthing children: it is a special experience no man will ever understand, and also no man could ever sustain the pain of childbirth. If no man could ever understand it, it means no man has ever had it. So how do we know whether or not men could endure childbirth? We could cite other types of pain and perhaps extrapolate, but the research indicates that regarding acute pain (which is considered to be pain of less than six months), men cope better. In the chronic pain situation, the differences disappear entirely; both women and men do equally poorly when pain is present all the time.

Men certainly have their flaws, but I do not believe simplicity is one of them.

A particularly salient yet hidden part of the "masculine mystique" is that men are propped up for success. Pushed, prodded, forced to show "pluck and guts" in the face of any adversity, masculine mystique is exactly the opposite of the picture painted for women by rabid feminists; they always complain that they're held back, not allowed to have opportunities. Men are pushed toward them whether they want those particular goals or not. Or whether or not they feel up to the challenges.

Underneath every man trying to lay down the law and be that success, is a little boy who always fears he's going to be found lacking, that others will think him a fraud. That's the classic fragile male ego. Many men build large, billowing clouds around that core of uncertainty, obfuscating its location, and exaggerating its size (yes, size matters when it comes to ego). That's the bragging, the self-centeredness, even the narcissism one sees in the more blatant "manly man" types. It is misdirection, pure and simple.

More, nothing sets off a man's defenses--his "bad temper" or antagonism--faster than a situation that stokes those fires of uncertainty. I've worked with enough women who were survivors of spouse abuse to believe that's where such abuse originates...she intentionally or inadvertently makes him feel small, and he's quick to deny it to himself by physically assaulting her; exerting his manliness. It isn't to "teach her a lesson," because she's incidental; it's more about keeping himself from facing a harsh reality. And make no mistake, there is no excuse for one partner in a marriage to physically harm the other one; everyone has a responsibility for finding alternatives to "smallness." Not every man becomes violent, so obviously, it is possible. Even among nonviolent men, though, you'll sometimes see arguments, antagonism or brooding in the face of uncertainty. Just ask my wife (*snicker*).

It is my conviction that men aren't truly arrogant. They'd just rather be thought that way instead of as uncertain and fearful. To borrow a metaphor from George R.R. Martin, women are like steel: sturdy, but malleable, capable of being stretched and folded without cleaving. Men, by contrast, are like cold, black iron. Harder, more durable, but brittle. They break before they bend.

Unfortunately, that inflexibility of their defenses tends to make them poorer candidates when I work with them in my office. They don't ask for help as well as women, they take research-based advice much less often and become more antagonistic when encouraged to self-reflect. I find much of the time that the men aren't coming to see me to learn to help themselves. They're too often hoping for a pill--usually Xanax or another benzodiazepine--to help them "deal with it." Which usually translates to "give me something for my nerves, so I can keep staring out the window stoically, and no one will know I have a problem." That's a very passive approach, and unfortunately, a largely ineffective one.

Hey, I said men were complex, I never said we didn't have problems! Anyone out there have two cents to kick in on this one?

Help Save Common Courtesy

2010-02-14T17:30:00.000-08:00

Every counselor has their strengths, and mine happen to be with patients or clients who have assertiveness issues. These are the people who can't say "no." They're afraid significant friends and family will withdraw love or respect if they don't do whatever is asked of them. By the time such patients get to me, they find themselves beleaguered on all sides by entitled, demanding adult children, critical elderly parents and manipulative friends, all of whom have gotten accustomed to getting what they want from said patient. The family takes and takes without empathy or consideration. The patient is stressed, depressed and horrified at the monsters they have unwittingly created.

Most of the time, patients with poor boundaries and limits admit they "just don't want to make anybody mad." I address this by pointing out to them that it is absolutely impossible to live and function in a civilization 300-million strong, and not get on someone's proverbial nerves. If you think about it, how many people do we irritate or alienate in traffic, just by taking our turn at the stop sign when they'd rather go before us, or by skirting around them in a department store, when they're stopped like a bulwark in the middle of the aisle, looking unfamiliar with the concept of shopping in public? As long as we're alive, someone somewhere is going to resent us just for being ourselves at a time and place that overlaps theirs.

In the context of counseling, or "interpersonal strategy," as I brand it, the goal is to teach the patient the words and phrases they need to help them take back their independence and ameliorate the inevitable anger that will result. I want patients to make their families and friends angry. Everybody needs to learn the lesson that as adults, they don't get to just take what they want and be ungrateful about it.

Still, I think it important to note that the inevitability of angering others doesn't give us a license to just actively say and do whatever we please in public, either.

Quid leges sine moribus vanae proficiunt?

The heading above is Latin, a phrase by Horace, that means, "What use are laws without morals?" The question is just as relevant for us today as it was for a Roman poet of the first century in the Common Era. The problem with laws is that they are so often a desperate, stopgap measure to halt behavior already out of control. In her book Why Manners Matter: The Case for Civilized Behavior in a Barbarous World, Lucinda Holdforth notes how the laws for driving an automobile have exponentially increased since the early 1970s. She points out that operating an automobile hasn't really changed that much, nor has the basic process of going from point A to point B. So why so many more punitive measures to control drivers? Her answer is that the common courtesies that were assumed and automatic thirty years ago have degraded to the point that public driving behavior has become increasingly disrespectful, dismissive and downright dangerous.

As a society, we're trying to legislate with threats of punishment, what courtesy once did on its own. It isn't very successful. Why? Because such laws are simply not enforceable. Common courtesy handles many more little day-to-day interactions than can reliably be policed by people with badges and guns.

My own two cents on the topic is that technology is partially to blame for the deterioration of basic manners. Technology itself isn't bad, it's just that it has created unprecedented ways to focus our attention, and at a very fast rate. What is missing are the basic rules for how to behave with these new gadgets and capabilities. Rules about shaking hands, waiting your turn in line and not interrupting someone while they're talking are based on thousands of years of human socializing with each other. We've had time to develop those folkways and mores (pronounced MOR-AYZ), the common rules for guiding our behavior in social circumstances. But the mobile phone has been available at affordable rates for only about a decade, and the texting technology on them is less than half that age. As a result, our social folkways and mores haven't caught up yet, and people don't know how to behave with their toys.

In two weeks, my Mental Morsels print publication will say a great deal about cell phone use in cars, a dangerous and irresponsible behavior that is proliferating at a frightening rate. Even at a less threatening level, cell phone users are intruding on the rights of others with brazen disregard and disrespect. You've witnessed them having their loud argument with their significant other on their phone in line at a restaurant. Or they yak loudly in the public library, and stand in the way at the movie rental store, trying to get someone on the other end of their phone to make a selection. I've had patients take calls in the middle of sessions, and then act angry at me when I react with impatience. Perhaps they're just boorish and ignorant of common courtesy. But I suspect it is also simply a case that no good etiquette rules have evolved yet to cover the recent appearance of cell phone technology. Even as we speak, there are bills in our state legislature to control cell phones. Once again, we're trying to legislate common courtesy.

The secret is to innovate folkways that govern how we use technology. For now, the solution might be to apply existing rules for public behavior to unfamiliar situations. A colleague of mine on a mailing list called Atticus (you can look that up at Yahoogroups), once gave an excellent example of this: you shouldn't use a cell phone anywhere in public where you wouldn't pick your nose. Instead of texting while someone is talking to you, think of the rules about proper eye contact. And if you must listen to your music on an iPod at work, remember the courtesy about not disturbing others; please don't sing or dance in your workspace when others would be intruded upon.

It's a start, huh? Any other suggestions out there?

Understanding What Doctors Mean

2010-02-11T10:30:00.000-08:00

In my previous entry, I applied Sartre's view of the human condition to chronic medical patients. Now, let's look at the other side of that coin; what responsibility does the doctor bear for shaping how patients see themselves?

We all know doctors speak a language of their own. Long words, mined from Latin and Greek, provide intimidating horns and spurs on even their simplest explanations of what's happening to our bodies.

Would it surprise you to learn, however, that complex medical vocabulary isn't what really causes the most difficulty? No, most good physicians eventually learn to work around that. It's their ordinary language that can sometimes do more harm. The wrong words used at the wrong time.

Let's face it, when it comes to the possibility of physical health problems, even the most upbeat, adaptable person is uncertain, scared and primed for bad news. Clinical hypnosis literature even speaks of a "spontaneous trance" patients might enter in emergency situations. As stated in the Handbook of Hypnotic Suggestions and Metaphors (Hammond, 1990):

...patients typically enter spontaneous trances, fixated in their attention on their body and immediate environment. Unfortunately, negative suggestions are often made in emergency situations by bystanders, ambulance attendants, police and medical personnel (pg 234).

So in this vulnerable state, patients listen as their physician presents worrisome results. The health care situation being what it is, doctors too often find themselves forced to spend limited time on negative information, and can't deal at all with how that information affects the patient afterward. It is an all-too-often occurrence, that communication between a nervous patient and harried doctor can result in a wrong and harmful message getting sent to the patient.

One could play the "blame game," and cite insensitive doctors, or say it is because patients are simply overwrought. But it seems better to me to get past that and focus on raising doctor/patient awareness that words matter, and help patients translate the doctor in their own minds.

The difference between fact and opinion:

In matters of fact, an ethical physician is duty-bound to be completely forthright. However, a "straight" presentation would include only the details of diagnostic tests. Facts, numbers. However, medical consultations are as much about two people talking as they are presenting results. Ergo, it is inevitable that the physician is going to stray from straight facts into personal opinion. Ideally, the doctor would tell patients when they are making this transition. That isn’t always going to happen. So make yourselves aware by listening for changes in the physician’s language. Facts are explained using numbers and measurements. Opinions come across in metaphor, values or prediction. Some examples (scroll on down):

FACT:	OPINION:
The tests were inconclusive.	"There's nothing wrong with you."
You've got some arthritis in your joints.	"You'll probably end up in a wheelchair."
The disk is putting some pressure on the nerve.	"It's like a big vice squeezing the spine."

Remember, opinions, unlike facts, can be inaccurate, overstated or flat wrong. A physician’s professional opinion will certainly be an informed one, but that doesn’t mean it is stated well or it's the end of the story.

Be aware of unintended negative suggestions:

If the physician uses those long, Latinate words, it's for a specific reason. The bigger the word, the fewer uses it has. Smaller, "normal" words are the real danger zone. They might seem more straightforward, but common words tend to become more vague in how we use them (think about all the ways we use the word "stuff.") Vague words and phrases might have very different--and unintended--suggestions behind them. For example:

“I'm gonna be honest with ya.” The implication with this type of statement is that the physician hasn't been honest until now! Or that they're going to unload a negative opinion on you. A better way to think of this statement: “You've trusted me so far.”

“There's nothing more I can do for you.” Physicians are fond of this statement, but look what can happen. When the all-powerful doctor says there is nothing to be done, the patient can feel their situation is hopeless. This is usually the farthest intention from the physician’s mind. If asked, most doctors would say it isn’t that there’s nothing that can be done, but rather, that what can still be done isn’t here. So referral to another practice with more options is the next action.

“I'm surprised you're still walking.” I'm rather baffled as to why any physician would say this, but I've gotten the story second-hand from many a patient. Perhaps well-meaning physicians are trying say how impressed they are by the patient's fortitude. My experience is that it usually backfires. Patients walk away believing their health problems are so horrid, so overwhelming, so crippling, that they can expect to lose their ability to walk. Their hopes of getting more functional, or at least of maintaining function, get snuffed. Translate it in your mind as “I'm pleased you're continuing to do so well with this.”

“There's nothing wrong with you.” This suggests to the patient that the physician either doesn't believe them about their health, or that the problem is exclusively "in their head." In either case, anger, resentment and despair can result. Again, remember the difference between fact and opinion. There's no way to know factually whether a patient feels bad or not. Absence of evidence in a diagnostic test doesn't mean evidence of absence. That's an opinion. Some physicians might put too much faith in a particular test. Or it might suggest the patient does need to look at their lifestyle and relationships to help with their problem.

The final lesson here? I'll let the Roman Emperor Marcus Aurelius summarize: "Never forget, that all that is said and written is merely opinion. Just get out of it what you feel to be true."

On Being Condemned to Freedom

2010-02-10T11:05:00.000-08:00

Existential philosopher, Jean-Paul Sartre once said we are "condemned to be free...left alone, without excuse." That is, we have free will to the point that we are totally responsible for our own decisions about how we live our lives. In his book, Existentialism and Human Emotions (1957), he pointed out, for example, that when we ask for the advice of friends on what we should do about our problems, we've already decided what we want to hear by choosing the friends most likely to say that very advice to us. Even when we pick a friend we know will disagree with us, we're really just looking for a chance to argue for what we already want to do; or to talk us out of something we really don't but know we should. Think about it...how many times have your friends or family asked you for advice, only to turn around and ignore all your magnanimous wisdom? Or vice versa? Sartre would most likely argue that we pick trusted people to ask in the first place, not to learn what we should do, but to have someone to blame afterward if all does not go well when we act. We all do it, though the existentialist would say that by doing so, we aren't living authentically, or being fully human. We're not exercising our freedom of choice productively.

I have worked as a counselor with medical patients for the better part of a decade. From December 2006 until June 2008, I conducted an interesting little personal study. I tallied data on over 1200 long-term treatment patients I evaluated, and my findings indicated that 78% of those in my workplace have what we call an External Locus of Control. That's a fancy way of saying that they go to the doctor and say "fix me, doc," rather than "show me how to fix myself, doc." They're looking for a pill to eliminate all their woes, and are impatient with recommendations for changes in diet and activity level. These are the patients who have probably already went from doctor to doctor, looking for different medical opinions until they get the one who tells them, what they want to hear: "sit down, don't exercise and take this pill." Then they'll cite that advice in hidebound fashion for the rest of their lives. Certainly, doctors bear some responsibility for how they present information to patients. I'll speak to that more in a future article.

The fact of the matter is that NO CHRONIC HEALTH CONDITION is made better by sitting around or staying in bed all the time. The flu? Sure, get some rest. Broken bone? No problem, stay off that area and don't strain yourself. But those are acute ailments. Healing is the goal, and strain will make healing harder. For chronic problems, like high blood pressure, chronic pain, diabetes or irritable bowel, the goal isn't healing, but management. Stay busy, and work around the problem. Taking it easy, waiting for it to heal up, chasing after the magic pill or the unequivocal diagnosis...well, none of those tactics will work. Patients just get more deconditioned, weaker, fatter, in short, sicker. And true to Sartre's prediction, they often blame the doctor, the health care system, the pharmaceutical companies, the government, or anyone else's recommendations they themselves sought and chose to follow. Why do they do it? Sometimes because illness is the only way they can relate to other people. Other times, there might be secondary gain, like need for attention, or wanting to get out of working a productive job. The "sick role" certainly has its advantages, though I personally don't think any of them balance feeling better, living more fully and doing more.

Acting "As-If"

You've met those types of patients, right? You try to urge them to help themselves, and they cite their genetics to blame for their condition, or the unsafe workplace that ruined their life, or they reference ol' Uncle Thaddeus, "who smoked and drank his whole life and lived to age 103." These are the same people who will find the one person who burned up in a car accident because they got tangled up in the seat belt the law required them to wear. Or talk about the newspaper article from hundreds of miles away, in which a person lived healthy every day and got killed by an oncoming caribou. But you know what? Name five others. There are extremes in any data pool: the tallest person on record was over eight feet tall, the loudest belch was enough to rival a chainsaw. Have you witnessed anything like that? Probably not. Is it really smart to bank on the unlikely extremes?

I believe in acting "as-if." I choose to believe as if 99% of the time, an active lifestyle--diet and exercise, and getting out of bed everyday--are going to be the better path for me. Maybe I won't live any longer, but it isn't about the life span, it's about the health span. Wouldn't it be better to live 60 healthy years, then to have 80 years, in which 40 of it involves gulping pills, using oxygen, lingering around on the couch and feeling miserable? What's to be gained by believing all health is the fault of the uncontrollable, like genetics, freak accidents and rare diseases? I personally can't see that such a belief leads anywhere useful. It makes one a burden on their loved ones and on society at large. Such an attitude is a choice. The better choice is to be proactive.

In a nod to my brother-in-law, I sign off this entry with a sentiment from him: It is better to go to your grave with blown-out knees and pulled muscles, than with hardened arteries and morbid obesity. One comes from revving the body up to its fullest...the other, to parking it in perpetua.

What's This Blog All About?

2010-01-01T17:39:00.000-08:00

Welcome to Mental Morsels! Now...what is it?

Let's start with who am I? The short answer is, "I'm a mental health professional." I practice psychology at the Master's level. By the laws of my home state, my recognized title is Licensed Psychological Practitioner (one must have a Ph.D. to use the title "psychologist.") In addition to mental health training, I have considerable exposure to medical psychology, also called "behavioral medicine." This field is dominated by doctoral-level providers, and I am thankful to several of my doctoral colleagues, who took me under their proverbial wings and shared their knowledge with me. Because of them, I am a Masters-level professional with an above-average amount of experience with this population.

I also see myself as an "Interpersonal Strategist." In my dealings with patients, I find that what comes up just as often as mental distress is social distress. That is, patients have difficulty negotiating relationships with their friends and families, and need help developing ways of managing those important people. I happen to believe that words matter, and that how people use words makes the difference between functional and dysfunctional relationships.

"Mental morsels" are little bits of psychological wisdom, most often interpersonal strategies, which I have accumulated in my years as a real-world counselor. I would like to disseminate those bits now through media channels for the general public, for you , my readers. This is an initiative that aims to "de-mystify" psychological topics, so you can more easily digest it and ask questions of those of us practicing the profession. Mental Morsels is the next stage in a process that began with my my volunteering to be part of the Kentucky Psychological Association's Public Education Campaign. My first contributions early in 2009 led to the a generous offer by the editor of the Richmond Register of my own column in one of their "special sections" called Health Beat. That is where I coined the name "Mental Morsels," and it is with the permission of the Register (and my gratitude), that my articles they published appear on this site.

Health Beat restricts articles to approximately 500 words, which was something of a "culture shock" for me when I first began. However, I eventually came to appreciate the challenge of compressing my thoughts and (dare I claim it?), my wisdom into a smaller package where every word counts. I chose the designation "morsel" to reflect the small tasty package I hope each of my entries, both here and in print, will eventually become.

DISCLAIMER: As with most blogs, the material here is my opinion, and should be taken as such. While I hope it will stimulate your thinking, it should not be confused with the intensive experience of professional psychological treatment. If you have an personal issue of some considerable distress, my suggestion is for you to seek the services of a counselor in your area. That being said, even in matters of opinion, I like to think mine are informed by both academic research and my professional clinical experience.

So, if you agree with me that state of mental and physical health is more than an absence of illness, that it is influenced by our personal motivations, relationships with others, our unifying philosophy of life and our spiritual beliefs, then my friends, you have come to a place where you can explore those opinions! It is my hope that Mental Morsels can bring to light some of the topics of mind and body, and sensitize you, my readers, to what changes you can make in your own lives, the better to improve your physical and mental health.