Narcissistic Personality Disorder

The DSM-5 lists the criteria for having a diagnosis of Narcissistic Personality Disorder as five or more of the following:

1. Grandiosity with expectations of superior treatment from other people

2. Fixated on fantasies of power, success, intelligence, attractiveness, etc.

3. Self-perception of being unique, superior, and associated with high-status people and institutions

4. Needing continual admiration from others

5. Sense of entitlement to special treatment and to obedience from others

6. Exploitative of others to achieve personal gain

7. Unwilling to empathize with the feelings, wishes, and needs of other people

8. Intensely envious of others, and the belief that others are equally envious of them

9. Pompous and arrogant demeanor

We all have a personality and we all can possess characteristics or traits such as narcissism, but one of the hallmarks of having a personality disorder such as NPD is that it usually persists throughout the lifespan and it is very difficult to effect positive change upon this individual’s internal character structure. This person externalizes all of his problems. Thus, when things go right, it is attributed to that individual’s achievements. When things go wrong, it is someone else’s fault. When people aren’t falling in line as yes men who support and boost up the narcissist’s grandiose sense of self, then slights are experienced as threats, attacks, and injuries.

It comes as no surprise that many individuals with NPD rise to the top of their organizations. The entertainment industry, politics, medicine, academia, law, and corporate America are rife with people with NPD. What is most egregious is when these individuals sexually harass, physically abuse and verbally attack those around them and never face any significant repercussions for their behavior.

It is very rare that a person with NPD will ever seek out therapy to address their problems. Again, they attribute their problems to the shortcomings of others and they need to hold fast to believing a grandiose fantasy of themselves. Therapy would be threatening. If this person ever does go to therapy, it is probably because he has encountered a life tragedy that has brought him into treatment. A threat of divorce, a loss of a job, a serious illness.

What is all too common is to see patients who have been directly and negatively impacted by the behavior of a narcissist. Children who have a parent with NPD. People who have had employers with NPD. People who have been sexually harassed or even raped by a narcissist who is incapable of empathy. Often these patients have been living with the experience of being an object to meet the narcissist’s needs, unable to see themselves as a separate individual with needs of their own. They often describe feeling guilty for disappointing the narcissist. When the child of a narcissistic parent moves away or chooses a career path that is counter to what the parent wants for them, this is wounding to the parent. For some parents with NPD, even simply developing and growing up is perceived as a threat.

It is very sad and disturbing that so many individuals inhabit this Earth with untreated Narcissistic Personality Disorders and continue to inflict harm on others. And it is incredibly infuriating to live in a world where so many narcissists are lauded and given accolades. These people are often rewarded for their narcissistic behaviors. We just lived through four years with a President who is the textbook example of this disorder. Society bolsters up these behaviors and sends the message that this is acceptable, even admirable. And so many, many lives are negatively impacted by it. Our society celebrates those who have the most wealth, the most beauty, and the most talent. We exalt celebrities to a godlike status. Donald Trump, who became famous by building a real estate empire and becoming known as a reality tv personality, then managed to be elected to the highest political office in the world and still continues to garner large numbers of followers even after leaving office. Many celebrities have come under fire for sexually harassing or even raping young men and women, only to face relatively little to no legal consequences. OJ Simpson quite possibly even got away with murder.

I wish I could feel hopeful that things will improve on this front. I do believe that it is important for us to work at not being complicit by colluding with a narcissist’s behavior. Too often people don’t speak up because they are understandably afraid of what will happen if they do. And others blame the victims instead of the abusers. This should collectively concern and upset all of us.

Group Dynamics Part III: The Role of the Scapegoat

All people take up certain roles in groups, often playing different roles at different times during the group’s development. In part, individuals are driven to take up certain group roles based on their own personal life experiences and personalities. But another way we can understand the phenomenon of why certain people play specific roles in a group is that people are unconsciously put into certain roles by the group to serve the needs of the group-as-a-whole. Thus, one’s role in a group is a combination of one’s individual predisposition to take up a specific role PLUS the need of the group-as-a-whole to unconsciously put that individual in that role. One such role is that of being a worker who functions in the group as a helper and a supportive follower of the group’s leader in support of the group task. Another role is to be a “hitman” who attacks the group leader and the primary task of the group. This person likely has a predisposition to play the role of the hitman or “anti-task leader.” He or she has mostly likely played this role before in other group settings AND the group has a need to place this individual in this role for the interest of the group.

One very common role that a group member may take up and be put into is that of the scapegoat. In the Old Testament, one kid goat was sacrificed and a second kid goat was sent into the wilderness after the Jewish chief priest had symbolically laid all the sins of the people upon that second goat. We use this term “scapegoat” to refer to a person who is blamed for the mistakes and problems of others often because it is convenient for the group-as-a-whole to keep someone in this role for the sake of the entire group. Remember, like any role in a group, the individual who becomes the scapegoat probably has a predisposition to take up this role based on his or her personal history and life experiences AND the group has an unconscious need to put someone in the role of the scapegoat. If all the wrongdoings and blame is located in one group member, then that member who is scapegoated becomes the problem and the other group members can split off their own sense of fault and wrongdoing. This is why we say that it is convenient to have a scapegoat. It is convenient to place all the blame outside of ourselves and locate it in an other. Like in the example from the Bible where this term originated, we can then expel that individual from the group. The thinking here is that if we (the group) just get rid of this one rotten apple (the scapegoat), then everything will be all good again and we can return to functioning as an effective group. And, in fact, this is often exactly what happens. Groups locate all their problems in one person. That person becomes the scapegoat. And often the group then finds a way to expel that person from the group, with the belief that the solution to the group’s problems is simply to get rid of that one person.

Think of the various groups you have been part of during your lifetime, such as in school, in your family, or at your workplace. You probably can think of experiences where this happened, where someone was the scapegoat who was blamed for all the wrongdoings of the group. Or maybe it even happened to you where you became the scapegoat of a group. And then, oftentimes, that scapegoat is expelled from the group, such as when someone is fired or let go from a work setting. Or in a family where all the wrongs are located in one child who becomes the “problem child.” Here, the person may not be expelled from the family, but it is convenient to persist in keeping that person in the role of scapegoat for the sake of the whole family. This is an all too familiar occurrence. The problem with this dynamic is that it doesn’t really solve the group’s problems because the group problems are not really located solely in any one individual. It may temporarily seem to work right after the scapegoat is expelled from the group, but inevitably the group’s problems will reemerge because they never were simply about the faults of one individual group member.

The scapegoat of a group need not be just an individual. It can also be a subgroup of the larger group. For instance, at a school it could be that the math department is the scapegoat for the school where all the problems get located. Maybe the front desk staff becomes the scapegoat for all the problems of the whole office. Or an entire family may become the scapegoat of a certain community or neighborhood, the one “bad apple” on the block. On a global scale, maybe it’s an entire continent. If each continent is a subgroup, then Africa is often the scapegoat for the problems of the world.

The majority of people lack the knowledge and awareness that the role of the scapegoat is not entirely about that one person’s individual issues and predisposition. When we don’t see that there is also a group need to scapegoat that person, we assume that all the problems lie simply with that individual and we may unknowingly participate in scapegoating that person and possibly expelling that person from the group. In this way, we are unconsciously participating in attributing all the “bad” of the group on that individual and we are perpetuating in keeping that person in the role of scapegoat.

Working with individual patients who have been predisposed to be the scapegoat in groups, it is important to explore and understand that person’s individual history -- family-of-origin, school, friend groups, work settings -- to come to a deeper understanding of what has contributed to this person having been placed in the role of scapegoat and oftentimes taking up that role as a very familiar life experience of theirs. In this way, perhaps we can effect a positive change for that individual so that he or she needn’t continue to take up this very painful role. Once we become conscious of what was previously unconscious, we then are more empowered to make choices that can lead to positive change.

Group Dynamics Part II: The Powerful Defense of Splitting

In my last post I introduced the group dynamics concept of the collective unconscious. I want to follow up on that post by elaborating on some other key concepts that are applicable to groups. In my next post, I will discuss the role of the scapegoat that often emerges in a group. But first I want to focus on the defense mechanism of splitting as it pertains to the group level.

On an individual level, splitting is a primitive defense observed in infants that can persist into adulthood for some people. Infants are not yet able to make sense of the complexities of human behavior and so they need to split people into being all good or all bad. It is too hard to understand that the same individual one idealizes can at times behave in ways that are very hurtful. We often talk about splitting as black-and-white or all-or-nothing thinking. I tend to believe that the concepts of "good” and “bad” or “right” and “wrong” are man-made constructs that are limiting and simplistic. It is false to believe that any individual can be all good or all bad.

When we apply this concept of splitting to the group level, we observe how subgroups adopt an “us vs. them” stance. Republicans vs. Democrats. North vs. South. These groups often get polarized. Each subgroup believes that they are the good guys and the other subgroup is the problem. In my last post about the riot on the Capitol, I spoke about how Trump supporters believed that they were defending America and democracy while Democrats were the bad guys who illegally stole the election away and were undermining democracy. Democrats believed that Biden won the election fairly and that the riot was an insurrection that threatened our democracy and American values. Both subgroups truly believed that they were in the right.

It is easy to see how this is an example of splitting on a group level. The group in this instance is America, and the group members are all the U.S. citizens. One major subgroup is called Republicans and another Democrats. And we have been tremendously polarized, illustrating the “us vs. them” split I described. What is less easy to see is the connection between splitting and authority. Splitting is a defense mechanism. It protects the group against expressing uncomfortable feelings towards the group’s leader. It is safer for the group as a whole if one subgroup expresses anger towards another subgroup rather than for the entire group to express negative feelings directly toward the group leader who has power and could potentially use it in dangerous ways against the members. It is far less scary to allow the split to occur between the subgroups and to have the negative feelings located there. Now, we know that many individuals and the subgroup of the Democrats expressed negative thoughts and feelings towards Trump, the group leader at the time. But on the group level, on the level of the collective unconscious, it was much scarier for the group as a whole, that is, the entire group known as Americans, to be conscious of and express how utterly terrifying it was to have a leader who was so emotionally unstable and unable to effectively lead. Many people need to cling to the belief that Trump was a protective authoritarian figure that they could idealize. The split defended the group from having to access such terror.

I find it helpful to consider the members in a group as being either on-task or anti-task. The on-task subgroup consists of members who support the group leader and the task of the group while the anti-task subgroup is made up of members who are essentially attacking the leader by avoiding the task of the group. This can be understood as a split between the two subgroups which serves as a defense that protects the group as a whole against its deeply held unconscious feelings toward the group leader. These buried feelings may range from hostility, envy, and mistrust to dependency longings and sadness. I know that these are difficult ideas to digest and synthesize. I invite you to think about the various groups you are a part of, such as an organization or your family. Begin to consider ways in which there has been splitting that occurred between different members or subgroups. Perhaps these splits are operating as defense mechanisms that serve as a protection from negative, uncomfortable feelings - often unconscious - that exist towards the group’s leader.

January 6, 2021 and the Power of the Collective Unconscious

Like many people, I experienced Wednesday’s storming of the United States Capitol by Trump supporters as deeply disturbing but not really surprising. If anything, the seeds of insurrection have been brewing for the last four years and quite probably have been simmering long before that. I’m specifically thinking about the collective unconscious of our nation and even our entire world from the perspective of group dynamics theory.

We all have an unconscious, that part of ourselves that is inaccessible and entirely out of our awareness. Sigmund Freud brought the concept of the unconscious to our attention and believed that a primary goal of psychoanalysis is to make what was previously unconscious conscious, thereby empowering ourselves around the choices we make that can impact our futures. While things remain unconscious, we can do little to effect change, but once we become aware of these previously unconscious pieces of self, we then are empowered to make conscious choices about our behaviors to improve our lives now and into the future.

But this concerns the individual level of behavior. There is also the interpersonal level of behavior, which is focused on the relationship between two people. When I am conducting couples counseling, I am mostly attending to the interpersonal level and sometimes the individual level of behavior. What most people do not know about or fully understand is a third level of interaction, the group level. When I first learned about this third level, that of unconscious group dynamics, it was like seeing something in 3D for the first time. It was, and still is, an utterly fascinating lens through which to see the world. This concept takes time to really click and make sense. It is very complex. It is easy to confuse this unconscious group phenomenon with the individual or interpersonal levels. And it is not either/or. All three levels exist. We all have personal responsibilities over our behaviors. Keep in mind that I am talking about processes that are out of our awareness. They are unconscious. This third level is ubiquitous to all groups, no matter the size or affiliation. No exceptions. Just like every single one of us has our own individual unconscious, every group, whether it is three people or a million people, has a group level unconscious. It is this third level which has been on my mind since Wednesday. And it is this third group level that addresses the phenomenon known as the collective unconscious.

If you have been swept up in the excitement of a large crowd at a rock concert, a protest rally, or a sporting event, this may help you get closer to what it can feel like to experience the power of the collective unconscious. Mobs of people rioting like they did on Wednesday is another example. Obviously, lots of people are not Trump supporters and never have been, expressing sentiments such as “Not my President” from the time he was elected. But this is individual and group behavior which is conscious, not group behavior as it applies to the collective unconscious. All Americans are a part of the “group” known as the United States and the larger “group” known as the world. Even if as individuals we are not in support of Trump or if we are members of subgroups such as Republicans, Democrats, or Independents, this is separate from what it means to be a part of the collective unconscious. Within any group, there are always subgroups that are in support of the group leader and there are those that are in opposition to that leader. But again, on an unconscious group level, we are all participants in what occurs. From this perspective, we are all complicit in electing this President. We are all complicit in creating the events that occurred Wednesday.

One phenomenon that has been observed by people who study this group level of the unconscious is the incredibly strong pull to uphold White male authority, even by people who are not White men. Trump has many supporters who are female and/or identify as coming from races other than Caucasian. There are many possible ways to understand this, one of which is that on an unconscious level, aligning ourselves with a straight Christian White male in authority may be the closest we can get to having power ourselves. We have always upheld White male privilege, long before there was a United States of America. In America, White men have firmly held onto the role of President until Barack Obama took office in 2009. In 2016, Hilary Clinton was preparing to be the first female U. S. President. Globally, there have been relatively few countries that have had a female leader and even fewer that have had more than one, and even fewer where that one female leader stayed in office for a significant amount of time. Now we have our first interracial, female Vice President elect in Kamala Harris and Joe Biden is intentionally appointing people who identify as other than straight, White, and male to make up his Cabinet. If the unconscious pull -- not just from White people but from us as a whole -- is to uphold White male authority, then the intense backlash to this authority being threatened is not at all surprising.

This is why I said that the 2016 election of Trump and the recent events to overturn the 2020 election have been simmering for a long, long time. Obama, Hilary, and Harris represent threats to our deep-rooted, unconscious need to preserve White male privilege. What we see are violent displays of aggression like what took place Wednesday. But I believe that much deeper down, these actions are motivated by primal, unconscious anxieties that our lives are in danger -- that these are threats to our very survival. While there are certainly Republicans who do not believe the election was taken from them, there is an enormous faction of people who genuinely believe that it was. They believe that they are defending America and democracy. We cannot convince them otherwise. Denial is an incredibly powerful, primitive, unconscious defense mechanism. And here it is being employed on the group level by a large subgroup of our country. This is different from people who are lying or playing along to protect themselves. This is how so many people believe that we don’t need to wear masks and why there is such a large anti-vaxxer movement. Denial is protecting people from those primal fears and anxieties that are buried deep, deep down. I know I sound like a broke record, but this is operating on the unconscious group level. So even if many of us do not believe these things as individuals, we are all a part of the collective unconscious that needs to uphold the status quo.

Please bear in mind that these are very complex concepts to absorb and not easily understood right away. What I attempted to propose here is obviously much more complex than can be addressed in a short blog post, but it is food for thought and perhaps an introduction into a different lens with which to think about what happened on Wednesday. More so, what has been happening in this county and in this world since the beginning of humankind.

Be Empowered to be Powerless

The words “powerless” and “victim” can be triggering. One patient of mine even has a hard time with the word “resilient,” despite the fact that the definition of this word is “tending to recover from or adjust easily to misfortune or change.” Some people see these words and their implications as signs of weakness. They conclude that if they view themselves as a victim or see themselves as powerless, then they must be weak. On the contrary, any one of us can find ourselves in a situation where we are powerless to help ourselves. Any of us may experience being victimized, such as when we are the victim of a crime. The situation we find ourselves in does not make us weak. People who are considered to be empowered, resilient people can fall pray to acts of violence and aggression and be powerless to prevent them.

I believe that part of this misconception has to do with the phenomenon of “blaming the victim,” in which people are considered somehow at fault for the terrible things that happened to them. This is most commonly seen in cases of sexual abuse, where women (and some men) are blamed for inviting the abuse upon themselves. This blame may take the form of accusations that the person was behaving seductively, dressed provocatively, and/or was drunk. In turn, many people who are abuse survivors internalize these messages and blame themselves for what happened. One male patient blames himself for not standing up to his father when he was being physically abused, even though he was just a small child at the time and could not have done anything to prevent the attacks. A female patient who was raped blames herself for not “knowing better” than to let her guard down and enter her perpetrator’s apartment. These people become hypervigilent, scanning the horizon for any potential dangers, operating under the false assumption that if only they had remained alert, then the abuse could have been averted, and therefore, at all costs, they need to prevent it from ever happening again.

One thing I have observed in these instances is that the individual who was abused may behave in self-punitive ways, even much later in life, as an unconscious defense against feeling powerless. In other words, despite how damaging it is to punish oneself with all kinds of negative, critical self-talk, it is still preferable to opening yourself up to how utterly terrifying it would be to acknowledge that you were powerless in the face of traumatic events. In other words, believing that you could have done something to prevent the abuse gives you a false sense of control. The woman mentioned above chooses to blame herself for the rape rather than acknowledge the sheer helplessness of that situation, because to do so would be to open herself up to feelings of intense fear were she to recognize that she was powerless to prevent an attack. She conducts her adult life by coming down hard on herself for every small error or lapse in judgement. To see things in any other way would be an acknowledgment that there are times when things are out of her control, and therefore it would be an acknowledgment that she could be powerless and could be victimized again. The man described above who was beaten by his father would sooner tell himself that he must have been a bad kid who deserved being punished rather than see himself as an innocent child who did not deserve the abuse that was inflicted upon him and which he could not stop. To do so would also open him up to all the rage toward his father that he has been holding onto and turning against himself, because to direct this rage toward his father would be profoundly terrifying. He experienced his father’s rage in the form of physical abuse, so he has learned to equate his own rage with the potential for physical violence.

Perhaps naming oneself as an “abuse survivor” is seen as a more acceptable label to many than “victim.” It implies that one is resilient, that he or she overcame traumatic circumstances and maybe even became stronger as a result. Still, I think that we can neutralize the negative views of words like “victim” and “powerless” if we shift our thinking to see that you can find yourself in a situation where you are being victimized even when you are a strong, resilient, empowered individual. What’s most important is what you tell yourself about what happened and the person you are as a result. We can reclaim these words if we see that there needn’t be anything shameful in having found ourselves in a position where we were powerless to prevent being victimized.

Election-Induced Anxiety

A mere two days before the 2020 Presidential Election, the anxiety people are experiencing is palpable. Many of my patients have been talking about their fears about the election and what may happen immediately following, with much anticipation of riots and acts of violence and aggression. The news is reporting a significant increase in the number of purchases of firearms. Add to that the fact that we are in the midst of a global pandemic. Cases of COVID-19 are surging as the temperatures are dropping and it is getting darker much earlier as we approach the winter months. People are struggling to keep afloat with devastating numbers of unemployment, work stress, and profound isolation. So many of these stressors are out of our control. Such powerlessness is at the root of our anxieties. When people feel helpless to enact positive changes for themselves, they become fearful.

The antidote to this powerlessness, then, is to practice ways to control the things that are within our power to control. I would be naïve to expect people not to watch the news this week, but perhaps people can choose to limit the amount of time they spend doing so. If the news is contributing to a rise in anxiety, then it would be a good idea to consciously limit one’s exposure to the things that are triggering anxiety. Setting boundaries, in this case time boundaries, is a very empowering act of self-care. There are also a large number of concrete activities that people can do to help manage their anxiety. These often involve changing one’s heart rate either by slowing it down or speeding it up. I teach many patients suffering from anxiety disorders deep breathing exercises that help them take in vastly more air and slow down their breathing. With some patients, we start our sessions with ten minutes of a guided meditation, which can help people focus on the present moment and be more aware of their internal emotions and physical sensations, which may have the added benefit of providing some relaxation. Alternatively, you may choose to speed up your heartrate with any number of cardiovascular exercises. Physical exercise, in addition to keeping your body in good health, can help reduce anxiety. One patient who suffers from anxiety told me that she finds it helpful to focus her attention on activities that she enjoys, such as knitting and trying new recipes. And some people find it helpful to engage in activities that require some type of repetitive motion, such as scrubbing a pan.

FDR famously said, “There is nothing to fear but fear itself.” It seems more and more that politicians and many news sources are intentionally playing on our fears with the thinking that this fear will help them earn votes or make them money. In thinking about all the aggression that exists in the world, it seems to be fear that is at the root. Fear can cause people to act in ways that are almost unimaginable. Often, people aren’t even aware that they have these fears; they may simply be in touch with the anger that is fueling them to behave in dangerous ways. If we look closely, we may uncover deeply buried fears, such as fears of scarcity and fears of mortality. As we head into what is predicted to be a difficult week ahead, I invite you to take a moment to reflect on how you can approach the week by being kind to yourself and considering ways you can stave off feelings of powerlessness by taking charge of the things that are within your power and the ways you can actively manage your anxiety.

How to Manage Coronavirus-induced Anxiety

While people with an underlying anxiety disorder may be experiencing a heightened sense of panic or dread during this pandemic, pretty much everyone is grappling with some amount of unease as life as we know it is unhinged or even uprooted. Many people are staying home, which can disrupt our markers of daily life and leave us feeling disoriented and discombobulated. And as of right now, there is no end in sight, adding to our sense of powerlessness and confusion. Here are some simple things one can do to help manage this anxiety.

One course of action to combat anxiety is to slow down one’s heartrate using various relaxation techniques. There are a variety of useful tools such as guided visualization and progressive muscle relaxation. However, the simplest anxiety management technique I teach my patients is deep breathing. Many people have picked up faulty habits and have adopted shallow breathing patterns. Such breathing can actually exacerbate anxiety and panic. I work with patients to retrain their natural breath so that they develop diaphragmatic breathing. This allows the individual to take in vastly more air and slows down the whole process from inhalation to exhalation.

Think of our chest and stomach cavity as a cylinder. Put one hand on your rib cage and the other on your stomach. On a count of three breathe in, first fill your belly, and then, when that is full, expand your chest. You can fill the entire cavity, all the way around the back. Do this in reverse for the exhale. On a count of three, first exhale the air from your chest, followed by your stomach. When you feel that you’ve exhaled all the air in your chest and stomach cavity, pull up from your groin to get the last of the air out. Repeat this cycle three to five times. Try this a few times during the day. This is easy to do because you can do it anywhere and it takes very little time. With practice, this can eventually retrain the way you breathe so that it will be there automatically when you are most anxious. Remember, this is like opening a parachute: you wouldn’t wait until you are in midair to learn how to open it. You need to practice it over and over so that it will be there when you need it. After enough practice, try increasing to a count of four or five for each inhale and exhale.

Slowing down one’s breathing may prove a useful way to manage anxiety, but some people prefer to accelerate their heartrate as another anxiety management skill. The thinking is that changing one’s heartrate is the key, whether that means slowing it down or speeding it up. Any type of cardio activity can work: running, jogging, biking, jumping rope, dancing, swimming, and other athletic activities.

Another activity I personally find helpful with managing anxiety is to engage in some repetitive motion. Cleaning is an excellent example of this. Try scouring a pan or cleaning a floor. Something about the physical movement and repetition lends itself to getting the anxiety out of the body. Besides, you can benefit from having a clean surrounding!

This is not one size fits all. Experiment with some of the suggestions here and see which work best for you. You might come up with ideas not mentioned. What’s most important is that you find things that help lessen your anxiety and that you are actually likely to do. And remember, we are all going through this together. You are not alone.

Life in the Age of COVID-19

Everything feels rather upside down as we try to adapt to this new normal of life with the coronavirus pandemic. Most people seem to be at least a little bit unsettled by this outbreak. It’s not at all surprising for us to feel unease when there are so many unknowns and things are so up in the air. Many therapists are grappling with these feelings ourselves as we work to help our patients best manage their anxiety, restlessness, isolation, and relationship difficulties. The following are some initial thoughts I have on these subjects.

Most people are likely to feel some amount of anxiety but people who already struggle with underlying anxiety disorders or depression are particularly vulnerable to having difficulty coping. I recommend trying doable actions such as taking walks, running, meditation, deep breathing, guided visualizations and talking to friends and family for support. I strongly encourage people to limit the amount of time they spend listening to the news, as this can spike anxiety exponentially. In some ways, this crisis is similar to what it was like after 9/11 in terms of our collective anxiety. At that time, as now, limiting one’s exposure to tv was essential to maintaining health and wellness.

Many people are living alone and therefore quite isolated. Reaching out to people is crucial. Perhaps you have one or two close friends who are in a similar situation. Try making an agreement to connect with each other daily. Meeting via an online video platform such as Skype or Zoom is a great idea. I’ve been doing this for all my therapy sessions. While meeting in person is preferred, this is the next best option. Seeing a person face to face goes a long way. Having a pet is another great way to combat loneliness. Reportedly, there has been a rise of the number of people buying pets for this very reason. Now is also a good time to call your therapist if you have one. People need not wait for their appointment to reach out for help.

While some people are having a hard time with so much solitude, others are struggling with having their nerves frayed by spending so much time at home with their partners. Many of these couples were experiencing difficulties before, but even in the healthiest relationships “sheltering in place” can be a true test. If possible, I think it’s vital for individuals to find time alone by getting outside or going into a separate room. I’ve encouraged couples I work with to come up with a code word to signal to a partner they need a time out if things get too heated. Is it possible to call a “truce” to not bring up loaded discussions or arguments while we are bunkered down? Now is the time for us to be extraordinarily gentle with ourselves and others.

It may be hard to structure one’s time when trapped at home. I think it is important to treat one’s life much as you would if you were going to your job. Try getting dressed much as you might if you were going into the office. If working from home, try setting clear time boundaries. Make sure you have start and end times, schedule breaks, and aim to only address personal matters outside of these time boundaries. I suggest scheduling your personal time as well. You can break these down into chores, family time, and personal time. Children obviously require a lot of structured play and learning, but we also may benefit from scheduling our days so that we don’t find ourselves ruminating, festering with anxiety, and struggling to get anything done.

Thankfully, Blue Cross Blue Shield is allowing us to practice online psychotherapy during this pandemic. I foresee more people needing our services due to this crisis. My hope is that people won’t hesitate to reach out in such a trying time. While it certainly doesn’t take the place of seeing patients in the office, I am pleasantly surprised to see how effective remote psychotherapy can be. How very fortunate we are to be living in a time where such a thing is possible! Best wishes for health and calm as we navigate this unknown territory together.

The Importance of the Therapeutic Relationship

Until the past several decades, psychotherapists believed they were a blank canvas onto which their patients projected all their unresolved issues from their childhood and their internal relational experiences with their parents. Nowadays, we believe that there is a close, real relationship between the patient and therapist that develops over time and may become the most important agent for change in the patient’s treatment. Both the patient and therapist bring to the relationship their own unconscious past relational patterns that originated in early childhood experiences, often between them and their parents.

It is crucial that the therapist monitor the nuanced interactions and enactments that occur over the course of the therapy. The danger in not paying close attention to the shifts between them and their patients could lead to serious negative consequences, such as repeating unhealthy relational patterns or driving the patient out of treatment. I recently encountered one example of such an enactment in my practice. Twice I mistakenly got the time wrong for one patient and I either had booked someone else during his time slot or I forgot to come to my office to see him. If I wasn’t monitoring the shifts in our relationship, I may have dismissed this as a simple error on my part instead of an interaction between us, and it could have well marked the end of his therapy. Luckily I was aware of how unusual this behavior was, as I have never mistaken a patient’s time slot in my 20 years of practice. This signaled to me that there must be an enactment between us that tells us something essential about the patient’s relational experience in the world. Sure enough, after exploring this together, we discovered his experience of feeling like an afterthought to his parents and friends most of his life. Instead of driving him away from treatment, this enactment elucidated something important about this patient’s relational dynamics and became an essential part of his healing.

I sometimes think that if a patient and I focus on nothing else but the twists and turns in our relationship, we still might be engaged in the vital process of therapeutic action that enables the patient to make long-lasting positive changes to his or her life. This relationship is unique in that I am a part of it, unlike all other relationships that I only hear about through the lens of their point of view. I can help patients come to understand deep-rooted relational patterns and have a positive experience of a relationship that might be unlike any other past or current relationships they have ever experienced. Such a healthy relationship can be a “corrective emotional experience” that can have everlasting changes for the patient.

Feelings 101

I occasionally think how backwards it is that we go to school to learn math, reading, and science but we didn’t take classes on feelings or relationships, things that will impact us for the rest of our lives. Many of my patients struggle with identifying and expressing feelings. Often, they grew up learning that certain emotions were “bad,” and they received little to no help from their parents in educating them about affect management. Nowadays, many children are learning in school and at home essential skills to help them identify and regulate their feelings, something of which most adults today could definitely make use.

When working with patients who need help developing a language for their emotions, I encourage them to begin with what I label “primary feelings,” akin to primary colors. They start by learning the basic emotions of anger, sadness, happiness, and fear. Or as some therapists say, “Mad, sad, glad, and scared.” These are the red, blue, and yellow of feelings. If we put each of these feelings on a scale from 1 to 10, with 1 being the mildest degree of the emotion and 10 being the most intense, we can start to differentiate the varying degrees of an emotion. For example, if we have a scale for anger, we put “angry” in the middle at 5. Along the anger scale, we can put feelings such as irritated and annoyed at the low end of the scale - around 2 or 3 - and a feeling such as enraged at a 10, on the high end of the scale. These feelings all are different forms of anger, just to varying intensities of this emotion. On the “happy” scale, with “happy” a 5, we might label a 1 or 2 “satisfied” or “content,” while a 9 or 10 might be “ecstatic” or “exuberant.” Additionally, some feelings are a combination of primary ones. For instance, “hurt” might be a combination of sad and angry. “Surprised” may be a mixture of fear and happiness. When we peruse lists of feelings, we start to see how most labels for feelings can be either a degree of a primary feeling and/or a combination of multiple primary feelings.

The other skill that most patients need help with is differentiating feelings from thoughts and behaviors. If we stick with the core emotion of anger, then anger is the feeling, while slapping is a behavior used to express this feeling, and “I hate you” is a thought that is attached to this core feeling. Most people confuse these and think that “getting angry” is the same as hitting and screaming. We have choice about which behaviors we want to employ to express a feeling; even when it feels “out of control,” we can choose not to hit or scream. We do not have choice about the feeling itself. Feelings are neither good nor bad, they simply “are,” the same way thirst and hunger simply are physiological states. People rarely judge themselves for being thirsty but people often judge themselves for being angry or sad. We cannot choose if we are angry or not, but we can choose how we respond to that anger.

Much of my work with patients around feelings is to educate them about the differences between thoughts, behaviors, and emotions and to help them learn that emotions are not something “bad” they need to run from. I can help them learn various healthy and effective ways to express feelings, in contrast to unhealthy, maladaptive expressions of emotions they may have learned up until now. Most importantly, I help my patients learn that feelings are not something they need to avoid at all costs, but rather essential parts of being human.

Actions Speak Louder Than Words

One of the greatest lessons that I’ve learned which I try to impart upon my patients is that actions speak louder than words every time. This applies whether we are discussing another person in the patient’s life or the patient herself. In other words, one can deceive themselves and others, either intentionally or not, but if we pay attention to an individual’s behavior, we get a much clearer picture of what is really going on. The unconscious is incredibly powerful and one’s behaviors cannot help but betray one’s true sentiments. We can train ourselves to pay more attention and become better attuned to the non-verbal cues that are being expressed.

These non-verbal cues include subtle facial expressions and body postures as well as more obvious behavioral patterns such as perpetual lateness and cancellations, continued inaction, or repeated substance use. I encourage my patients to “turn off the volume” and pay attention to the non-verbal signals they pick up on from others, rather than the words they are being told. One patient who is having problems in her marriage is continually frustrated and upset when her husband says he wants to fight for their relationship but his actions indicate otherwise. This spouse has taken little to no steps to start individual or couples therapy, has not done anything to improve his health through diet and exercise, continues to drink alcohol excessively, and does very little to help out with the household chores. Another patient often arrives for her appointment ten to twenty minutes late or cancels a day before and asks to wait until the following week to meet. Yet another patient consistently arrives for his appointment thirty minutes early yet “forgets” to pay his co-payment every other week. Therapists have learned to track these behavioral patterns, for they provide a wealth of information about the individual’s unconscious motivations.

I caution my patients not to interpret the behaviors of others. We may hypothesize about what the non-verbal behavior tells us, but we are not mind-readers and we cannot know with certainty the meaning of these behaviors. For instance, the patient who is consistently late for her appointments may be unconsciously expressing anger toward me and/or may be acting on her fears about accessing painful emotions in therapy by attempting to regulate the amount of contact we have to ensure that she not come in contact with these feelings.

Interpreting another’s behavior can lead to confusion, anger, and faulty assumptions; simply paying attention to what the patterns of behavior are is safer, as it is almost always non-disputable. If I point out to the female patient above that she frequently arrives to her sessions late or cancels her therapy appointments, this data is merely observable fact that is indisputable. If I interpret the meaning of this behavior as an expression of the patient’s anger toward me, then I have crossed into the murky territory of attempting to guess the reasons for her behavior. The patient may disagree with my interpretation and a therapeutic rift may occur or my deductions may be incorrect. I caution my patients to stick to the observable behaviors without interpreting the meaning of said behaviors. By strengthening our ability to “mute” another’s words and tune into behaviors, we can develop our ability to accurately pay attention to the incredibly powerful non-verbal communications that are being expressed before our eyes.

The Role of Meditation Practice In Psychotherapy

In recent years I have begun implementing meditation practice during the first ten minutes of a session with some of my patients. The choice whether to meditate or not is always at the discretion of the patient. The purpose of such practice is to help bring awareness to one’s internal world in the present moment. This encompasses improving one’s attunement to emotions and physical sensations that can be detected in the body. I have found that many people are initially uncomfortable being with themselves in the here-and-now, and thus they flee being in the present and resort to living in the past or future, allowing their thoughts to distract them from what is right before them.

Most people do not need my help accessing their thoughts; they can fairly readily identify what they are thinking. It can be a different matter when they are trying to identify what they are feeling. When an emotion is intensely felt, it is likelier that the individual will notice it and be able to describe it. One is more apt to recognize that she is enraged than to recognize that she is mildly annoyed. But if we believe that all people have thoughts, feelings, and physical sensations at every moment, whether we are aware of it or not, then we can begin to see how difficult it can be for many people to access feelings when felt to a lesser degree. This concept that people have thoughts, feelings, and physical sensations at every moment is similar to breathing. Once an individual is encouraged to focus on his breathing, he usually can do so easily. We are all breathing at every moment but often we are not paying attention to our breathing. The same applies for thoughts, feelings, and physical sensations. Some people may find identifying and accessing physical sensations challenging. Still more may struggle to identify and stay with their feelings. Trauma survivors in particular may struggle in this way, given that one of the ways they learned to cope with the trauma they experienced was to numb themselves and dissociate from their internal world. This serves a protective function. As adults many of these individuals have difficulty knowing what they are experiencing when it comes to emotions and physical sensations.

Meditation seems to assist people in building their awareness of what is happening internally. Furthermore, it can help people learn to stay in the present moment and tolerate inhabiting their own internal world without feeling threatened by unpleasant emotions. I’ve witnessed people who initially had trouble sitting still because they were so anxious learn to relax into a ten minute meditation practice and open themselves up to the present. With most patients we start and end the meditation practice with four deep breathing inhalations and exhalations. This seems to help people relax and prepare themselves for the meditation. During the meditation itself, patients are instructed to focus on something simple, such as their breath, that they can keep returning to when their minds start to wander. They simply can notice and be curious about the thought that distracted them and then return to their breathing. With some patients, it is preferred to scan the body from head to toe during the meditation as a way to tune into what is happening internally. By conducting a body scan, one might become aware of tension and other physical sensations that are being held in various body parts. Another option is to draw one’s awareness to the sounds around them, both near and far. I invite my patients to focus on their breathing or to do a body scan, however, because these are ways to increase awareness of one’s internal space, whereas sound brings the individual to something that exists outside of them. Over time, most patients tell me that they have found that the meditation helps them be more aware of what is going on inside them, both with emotions and with physical sensations, and these skills can transfer to the their lives apart from the meditation. For the purpose of developing these skills during psychotherapy, I find that the term “awareness building” rather than “meditation” may be a better fit. People can get confused by what is meant by meditation practice. When we agree that we are working on improving their awareness of their feelings and body sensations, they can best understand how such practice can be of value to them. After the ten minutes, I find it useful to briefly discuss how the patient experienced the exercise and what she became aware of during the time. I also attend to whether starting with this practice has a positive shift for the remainder of the session and can help the patient feel more present and connected to me while engaged in the therapeutic endeavor.

The Role of Attachment Theory in Psychotherapy

Although attachment theory has its origins in the research of infant development and is not a model for how to conduct psychotherapy, I have found it increasingly useful as a therapist to consider attachment style when sitting with a patient. In a healthy development children develop a secure attachment with their primary caretaker, usually the mother. More often than not an insecure attachment develops. John Bowlby outlines three types of insecure attachments. An avoidant attachment style is one in which the child adopts the attitude that he/she is fine without the caretaker and maintains this “I don’t need you” stance throughout life. An individual with an ambivalent attachment style responds to an unpredictable parent by either becoming angry or exhibiting helplessness. And an individual with a disorganized attachment style can present as scattered and disoriented, especially when the attachment figure is unavailable.

These attachment styles originate in infancy and persist through adolescence and adulthood. We find that these are transmuted generationally, with children often mirroring the attachment style of their caretaker. It is imperative for a clinician to be aware of one’s own attachment style as well as to attend to one’s patient’s unique attachment style, as these will emerge in the treatment as the relationship between the therapist and patient evolves. It may well inform the clinician and patient about what is being enacted in the therapy, and if a clinician is not paying close enough attention, the danger is that things get acted out in the therapeutic relationship without being addressed.

Attachment styles are not set in stone. Through the work of therapy, someone who previously had an insecure attachment style can learn to develop healthy attachments in their closest relationships. It may not replicate the experience of one who was born with secure attachments, but it is still possible for the individual to establish and maintain close, meaningful interpersonal relationships. As a therapist who works relationally, I view the therapeutic relationship as the primary agent of change. By focusing directly on attending to what occurs in the relationship between therapist and patient, we can afford the patient the opportunity to experience a healthy attachment, possibly for the first time. The real relationship between therapist and patient offers the patient the chance to learn and practice developing true closeness with a nonjudgmental parental figure with whom one can reveal their authentic self without repercussion of rejection, abandonment, or wrath. Over time, the hope is that by modeling a healthy relationship between therapist and patient, this experience will transfer to other close relationships outside of this dyadic relationship. In this way, the bulk of therapy happens in the room by addressing the ever-changing landscape of the real relationship between therapist and patient. The therapeutic relationship thus presents a unique opportunity for emotional intimacy that may endure as one of the closest and healthiest relationships the patient has known.

The Plight of the Performing Artist

The gratification of a standing ovation, uproarious laughter when you land your joke just right, the sense of mastery you can experience at reaping the rewards of your hard work and preparation…these are just some of the allures of being a performing artist. Inherently, nothing is wrong with basking in the limelight for a job well done. But when the measure of one’s sense of self-worth is determined by external validation as opposed to internal validation, it may drive that individual into a nonending chase after that all too temporal adoration.

Children develop self-worth by the age of five. In a healthy development, the child learns an intrinsic sense of self-worth and is internally validated. Such a child comes to believe that he is a valuable individual merely because of his existence on this planet, as opposed to because of how good his grades are, how popular he is, how attractive he is, or any other of the numerous false markers of “worthiness” that may be prescribed at a young age. Often when one is seeking elusive validation of their self-worth, that individual may feel incredibly insecure and “less than” on the inside. If that person then pursues a career which is so closely intertwined with the response of an audience, as would be the case of a performing artist, then often the need for external validation becomes the thing that drives the artist’s performance above all else. When one’s primary motivation for one’s art hinges on the accolades of an audience, it is likely that this individual at his core has a depreciated sense of self.

In addition to seeking constant adulation, performing artists may attempt to compensate for a lack that is at their core. Numerous behaviors may be employed to this end: substance abuse, eating disorders, anger outbursts, depression, anxiety, self-harm, and sexual acting out, to name a few. Such behaviors often are attempts to manage underlying feelings of low self-worth.

Psychotherapy can help a performing artist uncover the previously hidden unconscious motivations that have been operating, thereby assisting her in increasing her awareness of underlying relational patterns that get repeated if not addressed. By becoming aware of how one has exhausted herself with this constant drive for validation, one may be better positioned to shift things so that one can learn to derive satisfaction from one’s intrinsic sense of self-worth. Such a person will still have ups and downs, losses and successes, like any individual, but one’s identity can remain solid and intact even during times of hardship because one’s sense of self-worth is no longer dictated by some outside validation over which we have no power.

The Collective PTSD of a Nation

Since the Presidential election of 2016 - even prior to it - there has been a spike in the number of patients who are reporting experiences of anxiety, powerlessness, restlessness, fear, difficulty sleeping, and being more scattered and disoriented than they previously have known themselves to be. This is particularly jarring when their sense of self is shattered and they are exhibiting symptoms that have not materialized before in their adulthood. Still more concerning is when, given the changes in health insurance in recent years, patients can no longer afford their deductibles and therefore opt to discontinue treatment at a time when they might most need to be coming in.

Not long ago I attended a seminar in which the speaker addressed how in ways not previously seen to this extent or magnitude, people seem to be responding to a collective trauma brought on by our current political climate. Clinicians, in addition to our patients, are struggling to manage their own levels of anxiety and powerlessness. Many of the people in our country show a complete dismissal or disinterest in facts, choosing instead the ease of not having to think for themselves and diminishing their personal fears by taking comfort in entrusting those in authority who are disseminating lies and "fake news." On a national (if not global) level, this is incredibly terrifying. Many of us are reeling from the continual onslaught of political egregiousness. This constant bombardment of one horrific incident after another is a form of trauma and the very thing that can disrupt us to such an extent that we are left in the position of having to always be in a reactionary stance, having to brace ourselves for further trauma.

For people who have a history of trauma in their childhood and adolescence, the current political landscape is all the more fraught. It is like walking through a landmine that presents us with ongoing triggers which reawaken those early traumas which may be deeply entrenched. One might react internally in much the way they did when they were young, defenseless children. 

I encourage patients to limit their exposure to the news if it is interfering with their ability to function. Given that it may be crucial to have a safe relationship such as the one that can develop in a therapeutic relationship, I think it is important to work together to figure out how people can continue coming in if their insurance is the barrier that is preventing them from seeking the help they require. Having a support system and appropriate self-care is of the utmost importance for both patients and clinicians during this highly chaotic time. 

Suicide Survivors Part Two: The Parallel Process

In my last blog post, I addressed the topic of suicide survivors, i.e. people who are impacted by the loss of an individual who has taken his or her life. In light of the recent news of the suicides of celebrities who are in the public spotlight, I wish to follow up on my last post by focusing on the issue of "parallel process."

One of the common themes that most survivors will speak about is how powerless they feel in the wake of such a tragic event. Often they feel guilty that they were not able to do more to prevent the suicide. In the presence of the survivor's grief, others can feel powerless as well, not knowing how to best provide support or comfort to the survivor. They may feel compelled to help but are not sure how. I believe that in this particular circumstance, this response differs from other types of losses. We frequently can find ourselves in situations where friends, family members, and colleagues are impacted by the death of someone close to them. Many people have experienced these types of losses themselves and/or have witnessed others who are in mourning.  Yet this may not be as frequent when it comes to suicide. Especially if the person has never experienced a suicide or known a suicide survivor, they can feel ill-equipped to know how to respond.

In psychological terms, we can refer to this experience of helplessness or powerlessness as a "parallel process." It is often the case that the people left behind can experience in themselves a parallel experience to the person who took his or her life, namely that of feeling powerless. We can imagine that the person who saw no alternative to suicide must have felt incredibly helpless, powerless to do anything to improve their situation and feeling utterly hopeless that things can get better. Many of these people have tried multiple things to alleviate their symptoms, such as therapy, medication, meditation, yoga, body work, nutrition and exercise. At the end of the day, none of these things have alleviated the depression, shame, negative sense of self, and other feelings underlying their suicidal ideation and intent.

When others are caught in a parallel process, feeling powerless ourselves, our instinct is often to try to "fix it," to find solutions for the people who are grieving. This stems from the discomfort they have tolerating their own profound sense of powerlessness. I encourage people to sit with this discomfort. Sometimes the most we can do is to simply offer support, communicate that we are thinking about the person who is grief-stricken, and let them know that we care about them. Depending on the specific situation, we may spend time with the survivor, bring them food, and check in with them. It's different for each person. To ask the survivor what would help them can even feel like too much for them; it puts the burden on them to have to respond or even know what they need. Our intentions are coming from a place of a sincere wish to help. It's good to remind ourselves that sometimes just the simple things are a form of help. 

Someone once told me that hearing a friend say, "I'm thinking of you" felt a lot better than if the person asks them, "How are you doing?" or "How can I be helpful to you?" A simple "I'm thinking of you" conveys that you care without requiring anything in return.  

Suicide Survivors

The term "suicide survivor" is unfamiliar to most people. They assume it refers to people who have attempted suicide themselves; in fact, it refers to people who have lost someone to suicide. Whether it is a family member, partner, friend, patient or colleague, losing someone to suicide is incredibly challenging to those who are left behind to grieve. It is a far more complicated type of death that may take a longer time to grieve and can stir up a variety of feelings such as sadness, shock, anger, and guilt. Many survivors feel very isolated, experiencing that those around them cannot understand what they are going through. Also, there is a stigma attached to suicide that often causes people to keep this information a secret. 

Working with suicide survivors is one area I specialize in, although many patients come to me for other reasons and it often isn't until much later in their treatment that I learn they've lost someone to suicide. The impact of this loss can be tremendous. We need to take into consideration the specific relationship to the patient. Losing a friend or sibling is quite different than losing a parent. Losing someone the patient had a close, loving attachment to is different than losing someone where the bond was more fraught. We also want to pay attention to the method of suicide and the patient's unique experience around the death. For instance, the trauma of a survivor who witnessed or discovered the person who committed suicide varies from that of those who were distanced from this immediate visual and auditory trauma. The experience of someone who had a loved one who had previous attempts or threatened suicide for years varies from that of the patient who was completely caught off guard by the loss of one whose death was spontaneous or unexpected. A health care provider who loses a patient to suicide may experience a particular type of guilt, as their colleagues or the institution they work for may consciously or unconsciously fault them for the death. 

As you might imagine, this is a very complex topic that has so many variables that one may have never even considered. In working with survivors, I try hard to not make any assumptions about their experiences. I allow for the space and time for them to tell their story and express their feelings about their loss. Many of my patients have described how I am the first person they talked to at length about their loss because of their shame and their experience of feeling misunderstood by others. I sometimes will encourage survivors to seek out a support group where they can hear other survivors tell their stories so that they can feel less alone with their grief. 

One good resource for more information is The American Foundation for Suicide Prevention, which has information that can be useful for suicide survivors: https://afsp.org/ 

How Women Dis/empower Themselves

I have been struck by how many of my female patients have been incredibly empowered to take action in the world and stand up for social justice issues and causes that are important to them. Yet, when it comes to their personal lives, they struggle to assert themselves with their partners, their families, and their friends. Somehow the strengths they can tap into "out there" fall away when it is much closer to home. Men may also have difficulties with asserting themselves, but in this post I want to focus on the phenomenon I am seeing with so many women. 

Many of these women will talk about how difficult it is for them to ask for what they need and to establish and maintain healthy boundaries. Often they find themselves "over-explaining," which actually is much more disempowering than being simple, direct, and firm. Or they don't even attempt to assert their needs. Some patients have expressed a fear that the response they will get will be an angry one. Or they will disappoint someone and then feel bad. Or they will be ignored and dismissed. Or the other person could leave them and they will be all alone. 

When we consider the ways boys and girls are socialized to express and manage their feelings, typically it is acceptable for boys to be angry but not sad or scared and girls aren't supposed to get angry. Of course this is ridiculous; all people feel the whole gamut of emotions and this is entirely natural and part of being human. Furthermore, when we explore with the patients their specific family and peer experiences growing up, we come to learn more about why they have developed the beliefs and behaviors they have. It is probably much riskier then to express anger toward the people they are closest to and it is safer to express anger and righteousness in situations in which things are a bit removed and there is a distance. 

In treatment with me, these women can have the experience of working with a male therapist who will offer a different alternative by not responding to their anger in the ways they expect and have experienced before. Focusing on our relationship can thus be of utmost importance to their healing process and to helping them practice assertiveness skills, emotion regulation and boundary setting. Over time, they can grow into being strong women who take themselves seriously and are taken seriously by those around them. 

Couples Counseling From a Psychodynamic Framework

I often reflect on how the skills we need to navigate our lives through adulthood were not taught to us in school. Most of us did not get taught how to identify and express feelings. We didn't take classes in how to nurture healthy relationships and how to sustain these throughout one's lifetime. While a great deal of effort may be given to one's career, an equal amount of effort might be missing when it comes to the relationships that we consider most important.

When the issues that bring people into treatment seem to center on their primary relationship, then couples counseling may be warranted as the preferred treatment modality. Unlike individual therapy where we delve into a patient's psyche to understand how one's unconscious processes inform current behaviors, in couples counseling the couple is the patient and the focus of our work shifts to attending to how the partners communicate, manage conflict, and show empathy for each other. Often my role is to teach specific skills along these lines. I might help them learn active listening and empathy skills. Perhaps I may teach effective ways to deescalate fights and constructively handle arguments. I may encourage partners to talk to each other and not simply to me so they can practice communication, thus bringing their relational issues directly into the room so that I can observe and intervene as needed. As the therapist, I am in the unique position of watching how they interact and I can pay attention to the moment to moment shifts in their conversation to see where they might get stuck or how conflict escalates. 

As a psychodynamic therapist, I also place importance on understanding each person's individual history and how these intersect in their relationship. It is not arbitrary when two people find each other and embark on a journey to form and maintain a relationship. Each person brings to the table their individual relational dynamics that they learned as far back as childhood. Often people reenact in their current relationship patterns that they experienced in their parents' relationship or in their own relationships to their parents. These relational patterns continue to get repeated and played out in their subsequent relationships throughout life. When we can identify these relational patterns and how they are reenacted, then we can set about to shift these in healthier directions. When we come to understand how each individual is triggered by their partner and how that may be connected to experiences they had in childhood and adolescence, it helps each person develop a deeper understanding of their partner, an awareness of how their own behavior is impacting their partner, and the potential for greater emotional intimacy. 

Relational patterns tend to get passed from generation to generation until someone takes the initiative to work through these in the context of psychotherapy. One can imagine how complicated this can be when each member of a couple is bringing to the relationship specific patterns that can be traced back to their own early relationships and those of the generations that came before. So a husband's behavior may trigger his wife in ways that are similar to how one of her parents triggered her or similar to how her parents and grandparents related to each other, and the same can be true for how the husband experiences his wife's behaviors. Usually these patterns aren't easily identifiable at the start of couples counseling, but over time, with the help of a trained therapist, they can be elucidated and worked on. The hope is that by working together in this way, each partner can come to experience a more rewarding and intimate coupling into the future. 

The Relational Nature of Shame

In the play (and movie) Proof, the character Hal asks, "How embarrassing is it if I say last night was wonderful?," to which Catherine responds, "It's only embarrassing if I don't agree." This is a great example of illustrating how shame is relational in nature. As Catherine points out, Hal's question might have been met with a variety of reactions. If Catherine were to respond, for instance, by saying she wishes it hadn't happened, Hal might experience shame about what he said and may even regret that they spent the night together. But Catherine agrees with him, they kiss, and he is elated. Without our even realizing it, our experiences of shame are often closely tied to other people's reactions. The key component to hold onto from this illustration is that one may say or do the exact same thing yet have a completely different self-experience based on the reaction of the other.

From a very early age, children may develop positive or negative self-experiences based on how the people closest to them (parents, siblings, peers, teachers) respond to them. If a young boy is expressing excitement and vitality about what he is doing, for instance, his father might respond by mirroring the boy's enthusiasm and encouraging him to engage in the activity. This could lead to the boy developing a healthy sense of himself and his own agency in the world. If the father, on the other hand, were to respond by telling the boy to knock it off, then the boy is likely to believe that what he was doing displeases his father and is wrong. Often, the reaction of the other is much subtler. In this example, the father might simply give a lukewarm response, ignore the boy, or register discomfort on his face. These more nuanced, less apparent reactions can be incredibly impressionable on a child's sense of self. Even if it is not conscious, the boy might come to learn that expressing his vitality is something to be ashamed of, and this might continue to be confirmed by subsequent, similar experiences. Once the boy reaches adolescence and adulthood, a lifetime of such experiences may have led him to squelch his own excitement and dampen his vitality.

I find that by helping patients understand how closely linked their shame is to the reactions of others, it helps them to shift how they view their past experiences. Others' reactions could lead either to greater acceptance or greater shame about the part of self in question. If a female patient comes to learn that her shame about her appearance is tied to comments and reactions she has gotten from other people throughout her life and to images that our society has held up as an ideal, she might begin to reevaluate her own beliefs and self-perception. In this way, having the awareness of just how powerful is the relational nature of shame, one might be better positioned to change one's own deeply held views and challenge distorted beliefs about oneself.