See, Do, Teach

If you think that going to therapy means you can go to a shrink’s office, unload all your problems, and walk away a new man, you’ll be disappointed. You might feel better for a minute, but if you go home and do the same things you’ve always done, you’ll get what you’ve always got.

Therapy involves learning new skills. The couple who’s coming in for marriage counseling needs to learn to listen and respond differently. The anxious person must learn to relax; the depressed one, how to keep going; and the addicted one, why and how to stop using their substance. Every person must be able to observe themselves accurately and compassionately. The greater part of all this learning occurs outside the therapy hour, far from your shrink’s office.

A surgeon once told me they have a saying in medicine: see one, do one, teach one. Only when you complete all three can you say you know the procedure well enough to do it on your own. See one means you watch someone perform a surgical procedure. When you try your hand at it under supervision, you are doing one. Teach one requires you to explain it to someone else, so they can do it, too.

There’s a lot of wisdom in this method, which can be applied with variations to almost any kind of learning. It’s not enough for me to tell you how you can calm yourself down in sixteen seconds by square breathing, you must do it. Then, it’s not enough for you to do it, you must explain to someone else how to do it. I have often found that I think I know something when I start writing about it, only to be confronted by all the ins and outs of the topic before I’ve reached the end of the page. Teaching someone is how you work out the kinks in a skill and develop real mastery. Then, if you really want to learn something, learn it well enough to explain it to your grandmother.

Learning a new skill in therapy is harder than learning a surgical procedure because you really need to use the skills when you are under extreme duress. You need to learn to listen when your spouse is yelling at you, how to calm yourself when you think you’re going to die, how to go on when you wish you would die, and why and how to stop using a substance when it seems like nothing but the substance could solve your problem. You need to be able to observe yourself accurately and compassionately when you are the most ashamed. That’s hard. It’s as hard as a surgeon learning a new procedure, not on a patient, but on himself, blindfolded, without anesthesia. To be able to learn to do that is going to take more than watching one, doing one, and teaching one. You’re going to have to do ten thousand.

This is where drilling comes in, otherwise known as repeated conscious practice. No one likes to drill, but a musician who hasn’t done his scales will not know how to play. An actor who hasn’t rehearsed does not know her lines. A basketball player who hasn’t shot from the foul line countless times will not score a point when the game is at stake. The idea of drilling is to repeat something often enough so you can do it in your sleep. If you’re ever going to be able to listen when your spouse is yelling at you, listening must be automatic.

If change is ever going to occur as a result of therapy, then most of the work, and the drilling, must occur between sessions. The anxious person must take up meditation; the depressed one, action; and the addicted one must repeatedly choose not to use his substance. Everyone must practice observing themselves accurately and compassionately if they’re ever going to have a chance of doing it when it’s hard.

Rat Park

Old PostsA well-funded behavioral researcher once spared no expense to create a perfect environment for rats. No, this wasn’t a PETA scheme gone wild; it was an important study that could pay off handsomely if life was as simple as research.

The beginning of the story is well known. You take a rat and put him in a cage, give him the choice between drinking life-sustaining sugar water and water that is laced with drugs like cocaine or heroin. Many of the rats will choose the drugs and use them to the extent that they will starve themselves to death.

Those results are often cited. They’re told in every high school as a cautionary tale to discourage kids from using drugs. It’s only part of the story, though. Bruce Alexander wanted to know more.

Dr Alexander looked at the cages where researchers were conducting their experiments and said, that’s no place for a rat. Imagine yourself shut up in a wire cage with nothing to do and no one to do it with. Wouldn’t you use drugs then, if only to pass the time? What would happen if the rats were living in rat heaven? Would they still use drugs and kill themselves, doing so? He created Rat Park to find that out.

First of all, the individual cages had to go. Rats are social creatures. They need room to play and explore. Get some trees, grass, and line the floor with woodchips so they can make nests. Keep the cats away. Scatter some cans and boxes for them to hide in. Now give them the choice to use drugs.

The rats weren’t interested. Who needs drugs when you’ve got wood chips.

OK, so next, they got some other rats addicted by the previous method, in the stark, isolation chambers, and then set them free in Rat Park. They’re gunna need rehab, right? They’re not going to be able to stop on their own without methadone or a rat’s version of a twelve-step program.

Not so, those rats weren’t any more interested in the drug-laced water than the others were once they became residents of Rat Park.

Some say that Alexander’s study demolishes most of the assumptions of drug addiction theory.

Rat Park suggests that the desire to use drugs is, indeed, super powerful if you are isolated, alienated, with nothing to do and nowhere to go. If you’re living like a rat in a cage you’ll be inclined to use drugs and probably use those drugs to such an extent that you’ll neglect your basic needs till you die. However, it suggests, if you are in a safe place, around supportive people you love, given the opportunity for meaningful work and creative play, then drugs aren’t going to be that interesting.

If you look at what we do to drug addicted people, limit their options and put them in cages when they violate possession laws, you’d say that we make the problem worse. If you look at the way many rehab programs are run, like impersonal boot camps, you’d say we make the problem worse. If you look at the way employers, schools, friends, and family treat the addicted person, like a pariah who you can’t trust, you’d say we make the problem worse. This is madness, you’d say.

I agree we make the problem worse that way, but I don’t think recovery from addiction is as simple as Rat Park suggests.

You see, humans are not rats. Take your typical human and put him in a secure environment with plenty of food and companionship, give him something pleasant to do, tell him that he is loved, that he is forgiven, that he’s the greatest thing since sliced bread. Will he be happy? Maybe for about a week. Then he’ll find something to be miserable about.

The truth of the matter is that not all of our drug addicts come from the inner city or depressed rural areas, both places worse than even a rat’s worse nightmare; many come from the comfortable suburbs, from loving families, enjoying every privilege, and anticipating the fulfillment of every dream. There may not be much addiction in Rat Park, but there is much in Human Park. It doesn’t make much sense, but that’s why we call it madness.

When I went to repost this old post I realized something important was missing. Why can’t humans be as happy as rats? I decided to try to answer that question. It will be in my post next week. It’ll be titled, Cranky. Sorry to anyone who was made miserable by this.

Ride the Ego Balloon

You may be amused, instructed, affirmed, chastened, enriched, or enlightened by my latest video.

The ego is a good tool if you understand its uses and limitations. The ego balloon can make you crazy, but it’s often a good crazy, a necessary madness, provided you can land the thing when it needs to come down.

A Reconciliation Case Study


Travis and Suzanne entered my office, sat down at opposite sides of the room, and immediately began to speak at once, competing for airtime. Travis was addicted to cocaine, Suzanne his long-suffering wife. The last time Travis used cocaine had been eight months ago; but at that point he had been repeatedly leading the family through a special kind of hell that included deception, lying, and unexplained withdrawals from the joint bank account. Since his last relapse, Travis had been to inpatient rehab and attended an intensive outpatient drug and alcohol program several times a week. By their account, he was doing well. Suzanne said he had been through treatment twice already, further stressing their bank account. This time he was also going to NA, had a sponsor, and was working the steps. To Suzanne, this meant he had lots of new friends, while her friends, including those at Al-Anon, all thought she was crazy to stay with him.

When I had a chance to interrupt, I asked, “Since you’re already with Al-Anon, NA, and the intensive treatment program, why did you set up this appointment?”

“She doesn’t believe in me,” said Travis. “She’s always on my case. I can’t do anything right, even when I’m doing everything right.”

She said, “All NA, his sponsor, and the program know is what he tells them, so they all think he’s doing great. I need someone working with him who listens to me.”

I was beginning to think I made a mistake advertising my private practice on my website by saying I had experience with substance use disorders and was willing to do couple’s therapy. I thought it was a good idea at the time since many providers, Travis’s program included, didn’t offer much to their patient’s spouses, citing problems with insurance coverage and HIPPA.

Travis added, “Every time I relapsed in the past, it was after a fight with my wife. I don’t want to use again, but she’s driving me to it.”

Suzanne answered, “If I let up the least little bit, Travis will start thinking he can use again. The only time he does well is when he’s in the dog house.”

Suzanne’s cynicism was easy for me to understand. The people closest to a person with a substance use disorder are always the last to believe they’re doing well. They’ve been burned before and have the most to lose.

I could also understand Travis, he was complaining about Suzanne’s Negative Sentiment Override, a corrosive tendency to assume the worst in a partner. No one can take a steady diet of negativity for long.

I knew what many in the recovering community and traditional treatment programs would say. They’d say that an addict is lying whenever his lips are moving. They’d say an addict’s best thinking got them into the mess; it’s not able to get them out. They believe addicts have to hit bottom, lose everything and become totally humiliated before they will ever change. These harsh views are like a two-by-four to the head for getting some people’s attention, but their effectiveness has diminishing returns. Most walk out of treatment when they’re told they can’t do anything right, as Travis may walk out on Suzanne.

I’m familiar with that approach from the many years that I worked in drug and alcohol programs before starting my private practice. Travis was a kind of dry drunk, a person who, while he is not currently using his drug of choice, was still under its influence. Despite all the help, he still didn’t accept responsibility for his drug use and was trying to blame his wife in advance for his next relapse.  Of course, he hadn’t been able to sustain abstinence, he hadn’t taken control of his life. That approach had not gotten through to him. There had to be another way.

I thought I had one.

Sometime before, I had gone for training in restorative justice. This had nothing to do with my work with addiction, but I was beginning to see how it could apply. Restorative justice is an attempt to repair the harm caused by crime. I became aware of this method when a teenager got caught spraying swastikas on the parking lot of the synagogue next to my office. The judge could have sent the kid to jail where he might have met some skinheads and been further radicalized; or he could have put him on probation, which would have been called a slap on the wrist. Instead, the judge sentenced him to work with a restorative justice counselor.

The counselor met with the teenager to check if he was ready to take responsibility for his actions and if he could imagine how spray painting a swastika on a synagogue parking lot might cause a stir. If the offender had no remorse, the counselor would send him back to the judge; but he did regret his actions. Next, the counselor met with representatives of the congregation to tell them about restorative justice and ask if they’d be willing to participate in a meeting with the offender. They were; so, they arranged a meeting.

The kid would have been prompted to speak first, to acknowledge the harm he’d done. The congregation would have replied, getting everything off their chests. If the apology was accepted, they’d move on to construct a plan to make amends. He’d scrub the parking lot, rake leaves, speak to the whole congregation, and listen to their stories about the Holocaust. A time limit is placed, and everyone shakes hands. If the offender follows through with his promise, then the judge dismisses the charges, the congregation forgives him, and everyone moves on. The skinheads look for other recruits. The world is a better place.

I wondered, could I do the same thing with Travis and Suzanne? There was clearly a break in their relationship, caused by both Travis’ drug use and Suzanne’s response to it. Could this break be mended? I believe it had to be for Travis to sustain his recovery and for Suzanne to stop being his jailer and go back to being his wife.

I knew the first thing I had to do was see them individually. Nothing could be done if they kept on talking over one another and, besides, I was getting a headache. The work I had in mind for both of them was the same, but they couldn’t do it together. Both were claiming to be the victim and expecting me to adjudicate. That’s not how it usually is in restorative justice work. There, someone already accepts the guilt and is ready to take their punishment. As long as Travis and Suzanne continued to make the case for the other being at fault, we would get nowhere. I had to get them past the blaming stage and be willing to clean up their own part of the mess.

Before we finished that day, I told them I wanted to work with them separately and confidentially for a few sessions before we met again together. I’m aware that some family therapists won’t do this, concerned that they would end up being complicit in keeping secrets from spouses. But that’s exactly what I hoped would happen; that is, I hoped that, by meeting with me individually, both parties would say things they never would with their spouse present. Later I might urge them to share with one another; but for now, I wanted to have a clear, safe space in which to work without interruption.

When I met with them individually, I said to both, “I hear you’re hurt by what your spouse has done or is doing to your relationship. What I want you to do is create a complete inventory of how you were hurt. Make a list. Don’t leave anything out. While you’re at it, put down the positives about your relationship, as well. That’s only fair. There must be a reason you’re still together.”

I have to first take their pain and resentment, as well as their continued commitment, seriously before they will ever let me look at their part of the problem. So, when Travis said he was hurt when Suzanne didn’t trust him to see friends on a Friday night, that was something he needed to say. He needed to say it and he needed me to receive it with congruity, empathy, and unconditional positive regard. When Suzanne shared her long list of his broken promises, lies, and betrayals, I had to receive it differently than her friends had done and not second guess her decision to stay with him. Any counselor schooled in Rogerian Person-Centered Therapy ought to be able to do these things, even when he wants to break out the violins or perform a good swift, pseudo-therapeutic kick in the butt.

I took a look at some things Travis and Suzanne wrote about. Some were major betrayals such as Travis smoking up the money they had saved for a down payment on a house. Others seemed petty. It’s important to ask a few questions about the apparently petty ones, like Suzanne not trusting him to see his friends. What I found was the petty injuries picked at open sores that have never had a chance to heal. The reason Suzanne’s monitoring was so galling to Travis was because his parents were domineering helicopters that he always resented. Cocaine embodied freedom that he craved and Suzanne’s action, which might have been fine in its own right, was the very thing he was the most allergic to. Travis was able to see this and acknowledge that the real beef he had was with his parents.

Next came the most delicate part of the operation. When a person feels safe after talking about their pain, almost inevitably they will show me their guilt and shame. I’ve learned to look for them. The guilt will become useful to energize the work that lies ahead; but the shame will get in the way. In common usage, guilt and shame are synonymous, but I like to make the distinction between the two. Guilt is when we feel bad for what we did; shame, when we feel bad for who we think we are. Guilt motivates empathy; shame just makes us want to strike back or hide.

At one point when I met with Suzanne, she called herself codependent. This is what I was looking for. Codependency is a very useful concept when it describes behavior, but Suzanne had turned it into a shame statement. The shame statement was not helping her change, it was convincing her that change was impossible. I had to do some quick work to clean off the shame and preserve the guilt that would motivate her to improve. I set about trying to ennoble codependency. I told her she was a hero.

“Heroes do things that are called impossible. Trying to prevent a cocaine addict from smoking cocaine when you are not the cocaine addict is an impossible thing. Your friends will try to warn you that trying to do the impossible is grinding you down. They say you’re codependent; but, I think this is what you do to have a meaningful life. Your friends want to see you happy; but you don’t want to be happy. You want to do something that matters. You do that by trying to do the impossible.”

Whenever I give a long speech in a session, I end up afraid I lost the client. I get carried away sometimes and when I come to, they’re looking at me funny. Suzanne was looking at me funny.

“I guess trying to do the impossible turned me into an impossible person.”

I had to laugh, half from relief that she understood the fine, tortured point I was trying to make. But she was still making shame statements. I had her break down how she was acting like an impossible person.

“Oh, just like he says. By getting on his case and not giving him a chance to prove himself again.”

It was much easier for Travis to talk with me in a shame-free way. Perhaps all the treatment helped. One thing rehab, group therapy, and NA do well is, by bringing together people who have made the same mistakes, they enable them to look at their guilt without shame encumbering. Without Suzanne around, he was able admit that, whenever he and his wife had a fight and he relapsed, the relapse was actually his choice. He didn’t have to do that. He even confessed to utilizing the threat of relapse as a means to defend himself from her. I explained that I was still concerned it might lead to relapse, for no threat is believable if you are not ready to use it.

He admitted several close calls. He still regularly indulged in the fantasy of use and had recently driven out of his way to go past his old spot. I asked if he had told anyone about this.

“Heck, no,” he said. “I told my sponsor, but not my program or my wife. That’s not what they want to hear.”

Once they were identified, I had them both write up a statement of responsibility for all the mistakes they thought they made and the impact they had on others. It’s important for a person to be able to tell his story, narrating the depth of dysfunction, all the way to his redemption. But, if they talk about it only in terms of their own suffering and leave out how it affected others, then they have a limited understanding of the costs of their choices.

I tried to be clear that this was a document Travis and Suzanne didn’t need to show each other. I explained, when it comes to marriage counseling, we never know how it’s going to turn out; it’s the type of counseling that has the lowest success rates, if you measure success in marriages saved. My main objective is for both parties to follow their true values. If that saves the marriage, and it often does, that’s great and the marriage is saved with both being true to themselves. But, even when it doesn’t, following your true values gives you a better chance of meaningful happiness in the future. To that end, I ask them to admit what they think they could have done better; not what their spouse would want them to say.

This is often harder to do than it sounds. Most people are thoroughly indoctrinated into believing that they want what others want. Here’s where all the emotions they’ve been feeling lately come in handy. Being a victim brings up lots of emotions; and emotions, I explain, tell you what your values are.

Fortunately for Travis and Suzanne’s marriage, it turned out they both highly valued honesty, as indicated by the depth of their emotions whenever they had to lie or hear a lie. Travis wanted to be able to say he missed his friends without Suzanne reacting so strongly, and Suzanne wanted Travis to tell her how he really felt. This lucky congruity made the next step easier because they would have to share their statements of responsibility with each other in a conjoint session. There are many times when partners write a personal statement of responsibility that contain elements they don’t think is wise to share with their partner. Often this is because they don’t want to take their medicine, but sometimes they have a legitimate concern that the truth will needlessly hurt their partner. When these thorny ethical dilemmas come up, I generally ask them how important openness is in their relationship. When it comes to marriage, most say it’s quite important.

During the reading of the statement of responsibility, often called an apology, I’m on alert for common errors. There are lots of ways to screw up an apology. They could be vague, apologize without confessing to anything, focus more on their pain than the victim’s, or fail to ask questions and listen. But the most frequent error is in thinking that once they make an apology, the whole matter should be done with. No forgiveness should ever, ever be extended immediately following an apology, or expected. Ever. Apology is the start of the process, not the end.

The next step is to decide how the offender can make amends. Remember, they were both offenders in their own way. Suzanne said, let me monitor your every action and I will believe in you when you get enough clean time. But that wasn’t going to work.  Getting overly involved in his recovery was the very thing Suzanne had to apologize for; and besides, there was no way she could monitor him effectively. The other problem was that, even though Travis’s use of cocaine was disastrous whenever he did it, he never did it very often. He could abstain from his drug for months or years and Suzanne would never know if he was going to relapse tomorrow. The best way to make amends was by some action that can be performed every day that would prevent them from repeating the harm they each caused to the other.

For Travis, this meant that he had to talk to Suzanne every day about how he felt regarding his recovery. We set it up in terms of a ten-point scale. Zero meant he had no desire to use and ten meant nothing could stop him. Suzanne would know that he was being honest because sometimes he would say things she didn’t want to hear. Travis had thought that by reassuring her that he wasn’t even thinking about using cocaine, he was helping her feel better and winning for himself some freedom from scrutiny; but she wasn’t believing any of it and his strategy was backfiring. She would feel far more secure in knowing the risk level than Travis being evasive about it.

For Suzanne’s part, she would receive these reports from Travis with more composure. We set up a ten-point scale for her, too; with zero indicating a lifeless response, and ten a total freak out. The scales made it easier to identify and talk about degrees. We expected that as she got better at accepting his reports, he would get better at making them, and vice versa.

It’s vitally important that, once all parties arrive at an understanding, they document it and set up a system to review progress at regular, frequent intervals. By regular and frequent, I mean every day or two at first. Far too many transformative plans whither away from simple inattention. I felt so strongly about this that I set up a system where they reported to me how they and their partner were doing, both in making amends and in giving positive reinforcement when their partner did so.

Travis and Suzanne were able to make these changes and did very well for a while. Travis eventually relapsed; but it was a far more contained and less destructive relapse than previously. We were able to go over the chain of events just prior to his use and see what had gone wrong. He had underestimated the influence one of his cocaine-using friends had on him. Travis was able to admit he was wrong about seeing this friend. Suzanne was able to accept this without saying all his friends had to go. They were better able to collaborate on future risk assessment because two heads working together were better than one.

Travis and Suzanne were, of course, a relatively uncomplicated example that I have used to illustrate how restorative justice can be a part of treatment. There are obvious applications in cases of infidelity as well as how an adult can resolve childhood abuse. Restorative justice can even play a part when mental or physical illness causes inadvertent harm to another.

I should note that no two people can work through their victimization and arrive ready to take responsibility at exactly the same time. More often, one is prepared before the other. Sometimes it’s unsafe and toxic to remain in the relationship, waiting. Authentic reconciliation is not possible as long as the partner is not ready, and some never are. The best anyone can do is to find safety and pursue personal peace by understanding the context of how they were harmed and doing whatever they can do to prevent it happening again with other partners.

I can only take a small part of the credit due for success. Travis and Suzanne did the hard work, as well as the treatment providers, and NA and Al-Anon groups before I ever came along. However, reconciliation with the people they’ve harmed is an essential but often overlooked part of recovery. It should not be left up to chance or delayed indefinitely. Therapists can easily play a part if they know how.

The ACE Study

shrinbks-links-photo1Bringing you the best of mental health

It makes no sense, but one of the most remarkable and important findings in recent psychological research hasn’t gotten the attention it deserves and still has not had much impact on the practice of psychotherapy. I’m talking about the ACE Study.

In the 1990’s, the CDC and the health care giant, Kaiser Permanente, teamed up to recruit more than 17,000 adult research subjects, who filled out a short questionnaire, asking about their adverse childhood experiences. That’s what ACE stands for: adverse childhood experiences. They then compared their answers to a list of common ailments. They found a very strong correlation between the degree of adverse childhood experiences and a decline in both physical and mental health for the person later in life. Continue reading

The Opioid Crisis

Bringing you the best of mental health

Considering how serious the opioid epidemic has become, and how many people have needlessly died, wouldn’t it be nice if there was a medication that people could take that could control their addiction to the substances?

Funny, but there is. Federal law limits its availability. Continue reading

Learn to Walk

Stand with your feet comfortably together. Take one foot and stick it out in the direction you want to go until you throw yourself off balance. Then, at the last instant, when you’re about to fall on your face, bring the other foot forward to stop yourself from falling. Repeat this dangerous operation as long as it takes to get where you’re going.

When you think about walking this way, it’s a wonder anyone would try it. Why would you throw yourself off balance and risk injury when you could stand in one spot?

Because you want to get somewhere. Continue reading

If You Can’t Find Help

Let’s face it, it is a whole lot easier to acquire a Problem than it is to get help in eradicating it. In many localities, there are drug dealers at every corner, but to get your loved one to a clinic, takes two buses. Intake coordinators will make him wait in a room with old magazines and ask him a million questions; but bartenders will serve him right away and leave him alone if he doesn’t want to talk. Insurance companies will seek to deny him coverage, but he can play the horses with his credit card. He can get narcotics from every doctor, but it’s tough to find one who prescribe a medication that can assist him in getting off narcotics. There’s even an Act of Congress that limits doctors from prescribing it. Like I said, it’s a lot easier to get a Problem, than it is to get help getting rid of it. However, that’s not the same as saying that help is far away. Continue reading

Get Help to Defeat the Problem

When a Problem takes over a relationship and hurts people, the people in the relationship disappear and the needs of the Problem consume everything. If you’re the person with the Problem, your job is to recover and get your self back. If you’re the other person, your job is to recognize the problematic portion of the relationship, stay connected with the healthy parts, and get help. Continue reading