Moments of Change

Alcoholism and other addictions are baffling for everyone. People who suffer from them think they are making choices. They can’t understand why things keep going awry.  “I’ll try harder next time,” or maybe it was someone else’s fault. “If only they…”  Family members and outsiders can’t imagine why a person would make the same destructive decisions over and over.

My way of understanding addiction starts with free will. We think we have free will and we really do, but there’s a catch. The catch is that evolution got there first to make sure we do things we are supposed to do in order for the human race not to become extinct. In fact the motivational apparatus that ensures our survival as a species has been getting stronger and more sophisticated since life first began. Let’s look at how this motivational apparatus stacks the cards to be sure we will use our free will to do what is best for homo sapiens.

We are supposed to eat when we need food, put on clothes when we are cold, drink when we need water, and make babies. If you think about it, you can see that the main way our motivational apparatus gets us to do the right thing is by making us desire it. We want to eat. And the reason we want to is that we get pangs of hunger and we also imagine how good it is going to be to sit down to a tasty meal or eat a snack. So evolution has seen to it that we get pleasure from doing the things that we are supposed to do. This is actually a very good system because it allows us the flexibility to attend to more pressing things. When we are running from danger, we don’t even think about the fact that we are hungry.

Sometimes we humans get the idea that we are smarter than our motivational apparatus. For example, sometimes our motivational apparatus thinks we need to eat, while we feel we should lose weight. Then what happens? Who is going to win? Usually, Motivational Apparatus turns out to be the winner. The reason is that MA has some tricks. When we try to go against her, first she makes us obsess. If you are told not to drink anything for the next 4 hours, first you will feel very thirsty. Then if you still don’t drink, you will begin to obsess about water. MA will send messages to your mind to try to get you to drink. If that doesn’t work, then she can control your thoughts as well! She will send you rationalizations. Think about the food rationalizations that pop into dieters minds. “It tastes so good. You deserve a snack.” “Just one little bite.” “Well, you blew your diet, so you might as well have the rest and start your diet tomorrow.” “You will never succeed, so you might as well give up this diet idea altogether.” And so on. Not only does she know how to talk you out of your resolve, but she understands how one thing leads to another. It all started with one bite, then step by step, she knows how to lead you to utter defeat.

What happens with addiction is that in some poeple, the motivational apparatus has a switch. Once it is switched, your motivational apparatus starts to think that getting “high” is necessary for the survival of the species. Now MA goes to work to find ways to get you to a drink or drug. When you resolve not to, she uses all the tricks she has learned over millions of years. That is the way I make sense of the power of addiction to destroy lives and families.

The switch is what gives addicts a completely different relationship to substances of abuse than others. How can you tell the difference? It isn’t quantity alone. There are people who drink a lot and don’t lose control. The best way I know to tell the difference starts with a look at self-preservation. MA normally makes sure that we don’t make the same mistake twice. Think about driving a car. At any moment a small movement of the steering wheel could cause death, yet we don’t make those small movements. Something very powerful keeps us from putting ourselves in danger. Many poeple have made a mistake once with alcohol. You may have thrown up, or even had a blackout where you couldn’t remember what happened the night before. The normal reaction is the same as when you let the car wander over the line. You don’t do it again. When I see a person who has had one chance to learn a lesson about substances, yet makes the same mistake again, then I am alerted. It is quite likely that this person has had the switch so that MA sees their getting high necessary for the species. That is, to me, the essence of alcoholism or drug addiction. Once the switch has happened, then despite the promises the addict may make, the situation will continue to get worse until he or she comes to an awakening often called, “rock bottom,” even though it doesn’t always have to be so terribly bad.

I put the focus on “getting high” for a reason. Even though most addicts have a drug of choice, when that one is not available or if they abstain, MA will not give up. If she can, she will substitue the next most desirable way of getting high. That is why I think of people as being addicted to getting high rather than to a particular substance.

How, then, is it possible to recover? Do you remember what I said about putting yourself in danger? Normally we simply don’t. So what force could be strong enough to motivate soldiers to put their lives in harm’s way? We know that the strongest motivating force for heroism is loyalty to the people in your platoon. The social bond is one of the few things that is strong enough to make us choose to put ourselves in jeopardy. In effect, we are pitting one biological force against another, the social bond versus preservation of the species. This is the single most powerful force for recovery.

There are different ways to bring the social bond to bear against addiction. In my experience, the one that works the most consistently is the 12 step model. AA and the other 12 step programs don’t just teach techniques for not taking the next drink, they build close social bonds between sponsor and sponsee, with one’s home group and with other groups. Fortunately these are free and available everywhere. There is a reason why they tend to work better than bonds with family or friends. Family members and friends don’t understand addiction and are easy to argue with or manipulate. Therapists and counselors may understand better, but a single person is also easy to question. Groups of peers who understand you, and have been there themselves are the hardest to ignore. There are many other helpful activities and strategies and research shows that the more you make use of, the better.

Before 12 step programs can work, there are two lessons that usually need to be learned. The first is that the addicted person needs to learn that he or she can’t succeed with controlled use. “Can’t I just have one or two and then stop?” Every addict would like to succeed at this, and sometimes it takes years to realize that it just won’t work. While the results of the experiment are still unclear, the addict won’t be able to identify with the 12 step group. The members will look like losers who’s lives are unmanageable. Only when the addict hits rock bottom and realizes that his or her own life is unmanageable, will the people in the 12 step meeting look like winners.

The second lesson is realizing that you can’t succeed alone. Many alcoholics and addicts want to be in sole control of their lives. They like to solve their problems on their own. It is hard for them to come to realize that their brain is owned jointly by themselves and MA. She has at least 50% of the shares, and will regularly win a vote. Once you understand this, you can see that you need outside allies to build a majority and start to win the decisions.

One final reason for hope. There are no guarantees, but this is as close as one can come: When alcoholics and addicts are willing to do as much as is necessary to get well, they will generally succeed. They may have to escalate their investment many times but, if they survive, their efforts will eventually pay off. The ones who don’t succeed are usually those who are only conditionally willing.

These are some of the key concepts that I use in working with people with addictions and their family members. They help me make sense of things that just don’t make sense. I hope they are of help to you as well. Of course, there is much more to doing a full evaluaton and developing a plan of action. Consulting an addiction professional is strongly recommended. For family members, please see also my post on codependency and look up Al anon and Nar anon, the 12 step programs for family members.

Control

We all want to have control. Well, the illusion of control, since we don’t have full control of anything. We feel in control when we drive a car, but the truth is there are severe limitations. We are limited by the car’s abilities, by the laws of physics, by laws passed to protect us, and by our own concern for ourselves and others. There is no end to the things we might want to do with a car and can’t. That means we don’t have full control, only a limited partial control. But it feels like control and that is one of the pleasures of driving. That’s what I mean by illusion of control. It is really a state of mind, not a fact.

Even though it may be an illusion, every day we see people doing terrible and wonderful things in order to give themselves the feeling of control. Dictators want absolute power and control. Family and intimate relationships are ruined by one person’s need to control another. Some use drugs and other behaviors in order to control what they have to feel. On the other hand, people seek out challenges and push themselves to new heights of real achievement at least in part to gain a feeling of control over their world.

So why is this state of mind so important to us? The answer is both philosophical and psychological, but the best place to start is very early in life. Around age one, we discover that we have control. That is why one-year-olds are so elated, even triumphant. We have discovered the world and that we are its emperor. When we are uncomfortable, someone guesses what we want and takes care of it. When we are dissatisfied, we cry, and someone takes fixes the cause of our discomfort. The fact that not every need gets addressed doesn’t dim our belief in our ability to control. Perhaps this is because our emotional equipment is not capable at that age of dealing with mixed feelings. Perhaps it is that the mind can’t process a negative, something that doesn’t happen, as opposed to something that does happen. Whatever the exact reason, the times when needs are not met don’t count. These disappointments are felt, but don’t affect the feeling of elation that the world is responsive to our wishes.

Then, suddenly the “terrible twos” arrive. Just when we are sure that we are in perfect partnership with Mom and whatever we want will be granted, she says, “No!” By this time, development has progressed to where a positive “No” does topple us from the imperial throne. The shock and pain are terrible. From the height of triumph, we plunge instantly into the depths of pain. Coping with defeat takes experience and skills. The two-year-old has none of these to buffer its stark impact.

Predictably, two-year-olds do what they know how to do, they test their ability to control. They do the most powerful things they know to regain control over their world, they have a temper tantrum. The screaming and kicking are both an expression of extreme distress, and a means of forcing the caregiver to make it right again.

Then we come to a fateful fork in the road. To me, this is a philosophical watershed moment. There are ultimately only two solutions, but they are very different. *** good control vs. bad control here!!  *** One is to focus on getting control over others and the other is to adapt to the world the way it is, to “live life on life’s terms.”

Hardly a philosopher, the two-year-old must make this most fateful of decisions. He or she is not without some power and abilities. First there is the power to command others. Two years of experience have given the child a good deal of skill in getting others to comply with her wishes. On the other hand, Schore tells us that by 18 months, the brain has developed enough for the child to form ideals and to feel shame when he fails to live up to them. This rudimentary conscience is essential equipment for feeling good about adapting to the needs of others.

The healthiest solution is a balance between controlling and adapting. There is nothing more costly than trying to control things we can’t, while adapting to the needs of others without taking care of ourselves soon leads to emotional bankruptcy. This is the essence of the famous serenity prayer, “God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.”

How does a toddler make the decision? I think it depends most on two things.  First, how easy it is to manipulate your grown-ups, and second, how safe it feels to give in to them. This is the time of battles of will between caregiver and child. The philosophical issue is certainly critical for the child, but how many of us adults have comfortably found the solution? Parents and caregivers are tested, too.

Let me tell you a story. I once worked with a young woman who had a great deal of trouble with this issue. She had tremendous difficulty saying no to anyone. She didn’t have the security or self-esteem to feel she had a right to her own needs, so she took care of other’s. Partly as a result of her strong leaning towards caretaking, she loved small children and found work in a school for troubled toddlers. She loved them and was naturally sensitive to their needs and wishes. Soon she learned that if she gave in to the children they would rapidly get out of control and begin to kick and bite. She found by experience that these children needed to learn to lose battles. They needed her to say no and mean it. As she learned to do this for professional reasons, she began to be able to stand up for herself in her adult relationships as well. The experience was absolutely necessary in her relationship with her boyfriend. Without a balance between her own needs and his, any real intimacy would not be able to develop.

So, for the most part, “control freaks” are those who, at that early age, were either too afraid to lose battles, or  too easily able to control their grown-ups. The result is the same either way. Those children begin a lifetime of practice at increasing their control in order to remove any discomfort. It should not be a surprise that along the way, their ability to empathize can get lost, as can their sensitivity to others’ needs. There are all degrees and combinations of these characteristics, but in the extreme you may recognize the elements of a manipulative, narcissistic or sociopathic personality.

Normally, I think sports analogies are bad form, but there is one I come back to over and over.  Life is like baseball and you are the batter. The pitcher (life) throws all kinds of pitches at you. They are not calculated to be nice, to the contrary, they are as hard to hit as possible while still being in the strike zone. This rather closely approximates life. All kinds of things happen and some are best avoided, while others represent opportunities. Good hitters can connect with one in three pitches. If they are able to do this consistently, they will be great ones. So we have no control over what kinds of pitches are thrown but some control over which ones we chose to engage with and how we handle them. If we make use of the partial control we do have, and learn to handle the two out of three that we miss, then we will most likely be able to feel as if we are in control, and that will be good enough.

I hope this post raises some questions. Please feel free to comment and if you do have questions I will try to answer them.  JS

An important question from Louise:

“I have a question about how to know if my psychiatrist is right for me. He appears very knowledgeable and generous, but he is never warm and never says anything positive. After a year of weekly psychodynamic psychotherapy, I feel like I am a worthless person (I did not feel like this when I started). I feel traumatized by each session and spend the following days crying. I really believe he is trying to help and I feel guilty about going to someone else.”

Answering this question is a little scary for me. Who am I to criticize another therapist knowing that I am far from perfect, myself. Then there is the danger of not knowing Louise or her therapy from direct observation, but only from her brief description. So I’ll talk in general, recognizing that the reality may be different, and that ultimately Louise will have to make her own decisions.

Let’s look at how so many well meaning and ethical therapists, by withholding feeling and feedback, end up frustrating their patients and often, in my view, reducing the effectiveness of their work by trying to follow the principle of “neutrality.”

In the dawning days of talk therapy, Freud’s idea was that gratification would kill desire. As a good 19th century scientist, he equated all the “drives” with thirst, hunger and sex. He pictured a hydraulic system where pressure builds up till we satisfy the need, then there is a release and the pressure of desire drops.

Applied to therapy, the model predicts that if the therapist withholds emotion, information, support, etc., it will increase desire and motivate the patient to reveal more and make more progress. Unfortunately the model is too simple.

Before we take a look at the complexity, we must consider the effect of shame. New therapists are taught about “neutrality.” They learn that it is not good to reveal too much or show too much feeling. Maybe the explanation is actually more rounded and complex but, when you are just beginning, what comes through is “Thou shalt not…” Students identify with the simple and powerful prohibition, even more because it is unnatural and hard to do. A senior colleague who retired and had to refer his patients, confided that  the hardest part was that his colleagues would learn the shameful truth that he had been friendly and giving. In my view, this was one of his best characteristics. You can see that neutrality has cast a huge and dark shadow on the profession of psychotherapy.

So what about the real complexity?  First, as I said in the post on Attachment to Your Therapist, the most powerful source of energy and drive to move therapy along is the need for connection. We want to feel closeness. We want to be special. We want to share a common understanding. These needs are powerful and inborn, coming from our evolutionary roots as social beings. They make us willing to reveal things to ourselves and our therapist that are hard to admit and carry painful feelings, just so we can be understood and feel close. What creates a tipping point is hope. When we have hope of getting close, we desire it more and work harder for it. When we lose hope, we give up and turn elsewhere. This is why too much deprivation turns our hope and desire off, while just enough energizes our efforts to get close.

For each individual, the tipping point between hope and discouragement is different. Perhaps Louise was traumatized in her early attachment experiences. Perhaps this is why a high degree of withholding from her therapist is actually re-traumatizing. Whatever the reason, when we lose hope of connection we lose our enthusiasm and energy. We become defensive or depressed. We lose our willingness to take risks and try new things. Think of the difference between children who feel safe and secure, versus ones who are frightened. The ones who are not afraid are full of energy. They jump and point and talk about what they see. Kids who are not feeling safe are low keyed, vigilant and quiet, or perhaps desperately active in a stereotyped and non-creative way. This is not the atmosphere you want in your therapy.

Is there a phenomenon of satiety? Does giving turn off motivation? If a therapist is more passionate and genuine, can this turn-off of desire? Moments of closeness bring a peak of good feeling, then a something of a letdown, but soon the need for closeness again asserts itself and we find ourselves driven to seek some new way to connect. There is, however, one important dynamic that can look like gratification leading to loss of motivation.

As mentioned in the post on Attachment to the Therapist, a second motivation that drives therapy is a childhood agenda of changing the therapist, motivating him or her to solve unfinished business from childhood. As therapy progresses, these “young” feelings and desires become more insistent, more explicit, and as a result, more obviously childlike. Freud learned very early in his work that there is always shame in expressing these wishes verbally and a preference for acting them out silently. This is what often makes patients want things rather than understanding. We want extra time, or special attention to our material needs. Medication is perfect for this, especially the benzodiazepines that make you feel warm and fuzzy and taken care of. These do not lead to growth. What helps people grow is the hard process of becoming aware of the long ago pain and going through the feelings in a context of safety and understanding.

Again, there is a tipping point that is unique for every individual. Too much encouragement of acting out of wishes as opposed to insisting on conscious awareness of them is sending a bad message to the patient. That therapist is, in effect, implying that he or she can fix the unfinished business from the past, which is not true. Extra time or medication can never repair the pain of an early experience of deprivation. Marvin J. Ashton said, “You can never get enough of the things you don’t need, because the things you don’t need can never satisfy.” This really applies to the things that substitute for love. So when this happens, the therapist is sacrificing real hope of growth in favor of short-term good feeling. A devil’s pact is formed where both patient and therapist are taking the easy way out, and progress stops.  This can look like Freud’s hydraulic model. It can seem as if too much gratification caused a loss of motivation. What really happened was that both patient and therapist have given up.

But there is a tipping pint. Zero willingness to give may be so discouraging that it stops progress. Early in my career, a young woman whose father had died during childhood came to session and confessed that she had forgotten to bring money for the bus fare home. Being young and trying to do the right thing, I tried to explore the possible underlying wish to have me take care of her as a father would have. In the end, she had another way home and I didn’t lend her the small amount of money she needed.  In the following weeks, the therapy lost its momentum and eventually she stopped coming. I should just have given her the bus fare.

Decisions of when and how much to be helpful are not really so hard. Parents make them every day. When a child asks to have his shoes tied even when he knows how, there are times, like after a big day, when you should tie them for him and other times when it is right to say, “You can do it.”

So, Louise, I don’t think it is good for your therapy that you feel so bad after each session. What I would strongly recommend is that you make this issue the central primary subject of your therapy. Talk about it, and see if the two of you can resolve it. He should be very willing to look at the matter, and, I hope, willing to look critically at his role in it. It is possible, even likely, that tackling it out in the open will actually help you learn about yourself and perhaps open his eyes to things about himself.

A reader submitted this wonderfull comment:

Anyway, I’ve been in therapy, on and off, for about 12 years. Dealing with “neurosis” I guess – trust issues, attachment issues, etc. Anyway, I’d love to see something about attachment, and more specifically, attachment to your therapist. I have a very strong attachment to my therapist and have come to see him as a father. I struggle with this on a constant basis, because he’s not my father, he is my therapist and is one hell of an ethical one at that and would never ever stretch the boundaries (which of course are some of the things that I wish for…). Anyway, anything on those issues, would be incredibly useful. And yes, I do talk to him about it as well, but having a more detached view of it would be really helpful for me.

The consulting room is an emotional candy store. It is a place where you are the only person in the world and it’s all about you. The therapist has no other mission but to understand you just as you are and help you heal and grow. It is as close as you can come in adult life to the one-way relationship of childhood where you receive but don’t have to give back. In the case of psychotherapy, you do give back, but in a different currency, that allows for all the feeling of being taken care of. One therapist said, “you buy my time, but the rest is free!”

So it is no wonder that patients get attached to their therapist. Is that bad? No. It would only be bad if it caused harm. Anything this powerful can cause harm, but not if it is handled right as it seems to be in our reader’s comment.  I think it is the main source of energy to drive the therapy forward. Here’s how it works.

When patients come to therapy, there are really two patients. There is the adult patient who listens dutifully while the therapist drones on on about how understanding will help you make changes and it is hard work and it is really up to the patient to want to change. Meanwhile there is a little kid who knows how things really work. The child in us all knows what he or she needs and is not interested in dull substitutes. She (or he) came in with a list of unfinished business from long ago, all the issues that she was not able to solve at the time. When they couldn’t be solved, what did she do? She saved them up for a time when conditions would be different and now it looks like conditions may just be right.

Why couldn’t she solve the problems back then? Children know that when there are problems, the ones who have the real power to solve them are the parents (or other caregivers). The child’s job is to influence the parent so the parent will take care of the problem. Let’s say a parent is depressed and totally self-preoccupied. The child needs love and attention and can’t get it. The child will invent a whole list of strategies:  Give the parent love, be unworthy so the parent will feel less bad, perform brilliantly so the parent will wake up and take notice. What they all have in common is the goal of changing the parent.

You guessed it, the child going into the psychotherapy consulting room is planning to use some of those very same strategies to get the therapist to change because that is how things get better.

Of course the therapist has another idea. The therapist thinks that the solution is for the patient (both child and adult) to accept the fact that there wasn’t enough love from the parent and to go through all the painful feelings of rage, hurt and sadness that the child knows are best avoided.

Let me digress for a moment. The power of this situation is hard to underestimate, and with so much power there are opportunities for bad outcomes. Fortunately our reader’s therapist has good boundaries and his patient is talking about what she is feeling. The key question about boundaries is whether the therapist has made or implied promises that he or she won’t be able to keep. This one rule covers essentially all the bad things that therapists can do. When that does happen, whether blatant or subtle, it is an indication that the therapist’s needs are taking precedence over the patient’s, and that is not therapeutic.

So the two go through their dance. The therapist’s humanness and real presence give the child hope and bring out young wishes and needs. On the other hand when they do come out, it is painful because they are not fulfilled. Hopefully the therapist understands this pain and, by being an empathic witness, helps it to heal. On the other hand, as the process goes on, the wishes are more and more obviously young ones. It is characteristic of childhood wishes that they don’t have limits. As they intensify, they become less realistic, less adult and more insistent. This may be embarrassing, even cause for feelings of shame, but it is exactly what has to happen. As the wishes become more intense, the frustration of the therapist responding only with understanding becomes more sharply painful. The anger, hurt and sadness are very real.

By putting off fulfillment to the future, the child was able to maintain hope and avoid the painful feelings. That is not so bad, since there was no way the feelings could be attended to back then. What the therapy has done is to force those long-avoided feelings out of hiding. Finally the situation from long ago has been recreated in the present and the feelings are palpably real. It is when feelings are actually present in the room that they can heal (see more on catharsis in the regular part of my website).

This part of the therapy process doesn’t feel like therapy at all. There is nothing as-if about it. It feels like anger and pain and sadness about life. For better or worse, that is when the most important therapeutic work gets done. Eventually the feelings heal and a more grown-up, philosophical view takes over (not the pseudo-adult one we started with, but a real acceptance). As this happens, it becomes more clear that some of the wishes actually can be fulfilled, but not by the therapist. In time, others in the patient’s outside world become more interesting than the therapist and now we are in the termination phase.

Of course, what all therapies seek is change, but change what? Most of the popular traditions focus the one way people change, but, by my count, there are seven. For both patient and therapist, knowing how each is distinct can sharpen our focus and help us see our own change processes unfold.

Neurophysiologists believe that change really occurs in the connections between neurons. They are also beginning to map out how different functions of the mind have different locations and work somewhat differently. Just as computers store information in different places such as your hard drive, a memory stick, or the volatile memory that was holding your essay when the power went out, your brain does, too.  So it is not a surprise that change processes are not all the same.

1.  The first is the transformation that happens when we tell someone about our painful feelings. It is so common that we may take this near-miraculous process for granted. People who have suffered major trauma don’t. They know that it can be the most challenging kind of change to undergo because you have to face the painful feeling and experience it’s full depth before the transformation can happen. Freud called this change catharsis, and I personally don’t think there is a better term, even though most of the time it is far from dramatic. This kind of change happens in every therapy session, not to mention every day of our lives.

2.  Stop running from your feelings. Avoidance becomes automatic. Most of the time we are barely aware that we do it. Humans are very good at avoiding the very thing we need most:  To go through feelings.  We need a therapist to hold up a mirror revealing how we have been avoiding. For example staying too busy can be one way. Rationalizing our misery is another. Even feelings like anger can cover up sadness we dread even more. The mind has any number of tricks but once we know about them, we can begin to choose to face our feelings and heal.

3. The third task is gaining knowledge of ourselves and how we manage to keep our misery intact. Changing our mind happens instantly when we are exposed to new facts, so changing our understanding and awareness should be the easiest to achieve. Unfortunately our tricks for avoidance may get in the way. As we let go of avoidance and heal painful feelings, new knowledge will begin to come into view.

4.  Changing dysfunctional values and beliefs is one of the hardest tasks. We all have values, attitudes, ideals and prohibitions. We are proud of our values, and defend them to the death. To a large extent, they form our unique identity. They also serve to help us resist temptation, which is why they are partially independent from the self and particularly hard to change. Unfortunately, we can also have values that are contradictory and even downright dysfunctional. For example, you might feel that you have to do everything perfectly. If so, there is another part of your mind that feels you should enjoy the fruits of life as much as others with lower standards. But you never arrive at perfection so you are not allowed to enjoy anything. The two values, perfection and enjoyment, are incompatible and no matter which way you go, there is a loud complaint. People who have suffered early trauma know that the experience causes internalization of negative attitudes about the self.  You have to fight to accept that you are as good as anyone else. These are two of many situations where values need to change. This kind of change requires energy, focus, hard work and time. Cognitive-behavioral therapy (CBT) specializes in bringing these “core values” to light and changing them.

5. The fifth task is to restart arrested development. In a way, humans are like plant spores. When conditions are not good, our development can be put “on hold.” More often than generally realized, we may carry some very “young” characteristics and reactions. For example caretakers sometimes give to others what they are still wishing for themselves. Fortunately, all that may be required for development to resume is a feeling of safety and connection. When this happens, as it often does in therapy, the path of psychological development can be picked up where it was left off regardless of chronological age. Just as in childhood, growth and development happen when we try out new behaviors and go through the feelings of anxiety, vulnerability and strangeness that accompany them.

6. Changing behavior patterns: As behaviors are repeated, they become habits and take on a life of their own. Even though their bad consequences are clear, it becomes automatic or nearly so to follow them again and again. These behavior patterns may be the primary impediments to change. For example, moving directly from impulse to action will consistently avoid the step of feeling. Similarly, acting habitually like a second class citizen can make a negative attitude toward the self appear to be an established fact. Behavior patterns can also include not doing something. A person who never says “thank you,” may be avoiding acknowledgement of the need for others. Lives that have been damaged by addictions and other compulsive behaviors can only begin to be repaired when the behavior is stopped.

7. Reevaluate secret wishes and dreams. This change process is the core of psychoanalysis. By age five, as I see it, we have enough grasp of time to solve the problems of the present by dreaming of a better future. Sometimes these dreams are experienced as shameful and unacceptable. They are not given up but buried, waiting for eventual fulfillment. Blocked by fear and guilt, out of conscious awareness, they wait and search for opportunity. Intensive therapy is calculated to call out these wishes and plans, which usually involve the therapist. Their coming to light is often stormy and difficult, but the end result is a chance to reevaluate goals that date back to a much earlier age, a chance to seek fulfillment of those aspects that are consistent with adult life and to let go of those that are not. This is classic “neurosis.” How do you know if you have neurosis? See my post “OMG Do I Have Neurosis?” below.

At any time in therapy, the work will be focused on one or two, maybe three of these processes or tasks. As you become more aware of just which ones you are addressing, you will be more attuned to the best tools to use and how your efforts should be directed. Furthermore, you will be able to monitor your progress by observing moments of change as they happen.

In order to help with your observation, we have developed the Scarsdale Psychotherapy Self-Test (SPST). Click the link at the right and rate the sixteen items that reflect how well your therapy is working. It is a tool for thinking about and evaluating therapies of all kinds. In addition you will be able to enter your ratings and receive a confidential report of how your therapy compares with others from our database. These seven tasks are the basis of the book I am working on, so I will value your feedback and ideas. Please use the comment link below.

Why are feelings sometimes oversized? Do you remember how big your house looked when your were a small child? Many years later when you go back to visit, you are surprised to see how modest it really was. Of course you remembered it the way it seemed at the time. Feelings are similar. The younger we are, the bigger feelings feel. When two-year-olds have a meltdown, it is real. At the time, it feels as if the world is coming apart.

Small children don’t have perspective on emotions. Now is forever and big is gigantic. When seemingly minor adult situations trigger giant feelings it is usually because they take us back to a much earlier age, perhaps when we were struggling with problems too big to master. Those feelings and problems were buried and stored away to heal some day.  When you go through the experience with someone you trust, you begin to see through the eyes of the other. Feelings get right-sized as you see from a more adult perspective. (See the main website, Psytx.com for a more extensive explanation of how emotions heal)