Tuesday, September 26, 2006

Please Understand

[posted by dinah]

If you read Richard Friedman's article Empathy and Understanding Aren't Enough in today's New York Times, you said to yourself, "Shrink Rap's gonna be all over this one."

Dr. Friedman writes:

I could already sense trouble. After six years of insight-oriented therapy, this patient had little sense of his own role in his unhappiness or what to do to turn his life around.

Next, I tried something a little more challenging: “I don’t get a sense from what you’ve told me that you feel responsible yourself to do anything to improve your life.”

With this, he sat bolt upright in the chair, crossed his arms and replied icily: “I’ve been working very hard all these years in therapy. You have no right to say that. You hardly know me.”

He had been working very hard all right — to maintain his status as a victim of a troubled history. And this was something he was loath to surrender. He clung to the notion that he was unhappy because he had been mistreated by various figures in his life: his parents, his teachers and disloyal friends, among others.

Dr. Friedman goes on to tell us that he helped this patient by telling him to grow up and get a job.

So I treat this patient as well as a few of his clones. The problem of being a victim and using this status to justify dysfunction is not uncommon, though I would argue with Dr. Friedman that it's hard not to sympathize with someone who has had a miserable childhood. Why some people move on and others stay stuck is as perplexing as why some folks have one reaction to a medication and others don't.

In past posts, I've made the comment that psychotherapy is a safe place for a patient to hear difficult things. So, I like the premise of Dr. Friedman's article though it's never been my experience that psychotherapy is simply about validating suffering and colluding with dysfunction; only a lousy therapist would do this. The role of empathy and understanding, however, is in itself often comforting and healing, and at the minimum, it supports the therapeutic alliance. The part I find hard to buy is that so soon (?the first session), Dr. Friedman took a patient who didn't particularly like him and yet was so quickly able to fix him without the backdrop of empathy.

No one listens to me like this.


ClinkShrink said...

Somehow I doubt this patient was truly 'fixed', except for maybe in his willingness to trust another therapist again. But I agree about the difficulty getting someone to break out of the idea of continuous victimhood---in my practice it gets used to justify a lot of criminal behavior.

Sarebear said...

I don't think "grow up and get a job" is very constructive. I think there are ways of being gently challenging, with some occasional possibly a bit jarring, in a good way in that it jars one out of a rut or something, without being so vague and, well, unpleasant.

Now, sometimes being challenged isn't pleasant, I can attest to that, but I generally see before the therapy session is over the point of what my therapist did; it's not some vague, critical thing.

My therapist's understanding and empathy IS a large part of the safety I feel in therapy, and helps me be more courageous in the difficulty of issues I confront . . . I suspect it can be sort of a tightrope of balancing for a good therapist to juggle understanding and empathy, with sometimes pointing out or questioning the patient on a subject that could use some movement . . .

jw said...

Well, I have a few thoughts (hardly surprising).

First, to some therapy is clearly not at all a safe place. As I've said repeatedly, for me it was not at all a safe place due to the politics of gender having twisted the Drs' thinking.

Of the 43 men I've talked to with a history similar to mine, only one found therapy a place of even minor safety: All because of the politics of gender having twisted the therapist's thinking. So, to me, safety in therapy must be weighed against how the politics of the day twist the thinking of the therapist (with regard to what the politics of the day are: The misogyny of Freud's day versus the misandry of today or the whatever of tommorrow ... substitute rascism ... blah blah blah).


It seems highly likely that the personality preference / odds based view of gender will be proven the correct view.

To the 50% to 66% of males who use the classic male meme, a wake up call of "stop complaining, get up off your butt and get a job" IS the correct and sensible path to follow: The same applies to the 25% to 33% of females who use the classic male meme.

That said, using the "wake up call" in a case wherein the patient is using the classic female meme or the non-gendered meme is probably abusive and certainly ineffective.


I am not at all sure of this empathy thing. Too often, what is called empathy is only an extension of the politics of the day having little or nothing to do with really empathizing with the other.

To empathize means be willing to overthrow one's internal diaglog and see what the other sees, that is a very hard thing to do.

Thus, I prefer the "I do not know how you feel: I am willing to listen and learn." view in place of empathy. While this is a hard thing to learn it does not have the drawback of requiring one to throw aside one's preconceived notions and politics.

foofoo5 said...

I once saw a couple for therapy; the husband alcoholic, constantly cheating on his wife, spending all the money intended for bills, etc. Week after week it was the opera of "help- rejecting complaining": "Yes, but..." He blamed her, she blamed him, and after months, I wanted to bang their heads together like the 3 Stooges.

They appeared for their appointment, and he had spent the rent money and was spotted by his wife with another woman. She waited up for him and they'd had a hellacious fight. But they presented the details in a flat monotone, first the one side, then the other. I finnaly said to him, "You have crossed the line and now can be called a "professional alcoholic," and to her, "You are a professional doormat." "Let's just get you food stamps and general relief because you are both benefitting from this 'helplessness' and it doesn't appear that you are motivated to change it." They both stared at the floor, saying nothing.

After a long pause, he looked up at me and said, "You can get us food stamps?"

DrivingMissMolly said...

Someone help me. . .there is a saying that; "When the student is ready a teacher will appear."

Perhaps the PT was ready?

When you go to someone new it's like your pores are open. It is another fresh perspective to absorb and to germinate fresh ideas into your mind.

It is difficult for me to believe this anecdote, however, and it's oversimplification, but epiphanies can and do occur as we all know.

I have often thought of this as I ruminate over past failed therapeutic relationships with therapists and psychiatrists. Was I not ready, or were they just less than competent.

I suspect it was probably a bit of both. . .

DrivingMissMolly said...

I had to add one more thing...the borderline tendency to see things in black and white is represented in the last sentence of my prior post.

Just because I didn't have a good therapeutic relationship with several therapists and psychiatrists does not mean that they are/were all incompetent.

Some of them were, but not all. Many just were not right for me and a few told me straight up they did not want me as a PT for whatever reason.

One more thing--

Getting better is hard. having a new state of mind that may be clearer and more optimistic is foreign and scary. Victimhood enables you to hide from that fear.

I want to get better, but if/when I do, that means I have to be fully responsible for everything in my life. Suddenly everything opens up and I put alot of expectations on myself. I get overwhelmed.

Maybe the PT in the anecdote went through this?


Sarebear said...

Molly, I SO have felt/do feel what you are saying, there.

EXACTLY what you are saying, in your last comment.

DrivingMissMolly said...


Thanks. I thought of deleting both of my comments because I feel like I am not making a whole lotta sense today.

I have recently been ill with a respiratory tract infection.

Yesterday I felt much better. I forced myself to do 4 loads of laundry, clean the kitchen, give the dog an extra walk, put on a facial masque and fix my fingernails, all because I knew that the window for "feeling better" depression and health wise, was gonna be a short one.

I wore myself out and as a result guess what? I am sicker today.

I do the same when the depressive fog lifts. I think of my future, world peace, housework I've neglected, projects I want to undertake--I literally freak myself out!

MT said...

Why is "a job" better than a life of leisure and ongoing regular therapy? Isn't that how the heirs and heiresses live? We owe the cornerstones of modern science to unemployed aristocrats. Is it unhealthy to be an artist without a "day job?"

Sarebear said...

I hope you get better soon, dmm.

I've been sick myself, was rather miserable with a fever and horrid other stuff, chest cough, other crud last week. So I sort of feel your pain.

You sure put me to shame. All I did today was sleep. And, surf, and watch tv. I did do two productive things last week, tho, so that's something. My sense of efficacy is rather poor, anyway.

It's not a contest, tho, I keep telling myself that.

jw said...

murky thoughts: There's nothing murky about your thought!

Society should run with about 6% of its middle class males "dropped out." That is, we should have about 3 in 50 of our middle class males effectively doing nothing: These men are the creative drive which spurs the new; they refresh society with new and untried ways of seeing things.

Sadly, we're running with far far too many of these men at about 13% and growing. That means we're starting to fail, the numbers mean we're starting to fall apart.

The same men who drive innovation also drive social failure through substance abuse, chronic laziness, etc.. It is a case of too much of a good thing for the society's best interests.

So, is there anything wrong with being an unemployed artist? NOPE! As long as there aren't too many unemployed artists. Same with the bachelor "farmers" and such.

BTW: There are female anthropological drivers as well, but that is a whole other discussion!

Anonymous said...

Maybe the approach taken with this patient more nearly coincided with what he wanted or needed at that point in time. That doesn't mean his previous therapy was useless. But he was ready to move on, otherwise why see a new therapist?