Category Archives: Psychotherapy

picture of therapy couch

Psychotherapy: Does Therapy Work?

Many people who are considering therapy for their psychological difficulties, may wonder how effective talking about their problems is really going to be… So let’s examine the question: Does therapy work?

What’s Wrong with Talk Therapy?

The concern about whether or not therapy works, might not be assuaged by reading a recent Time Magazine opinion piece, that questions the legitimacy of longer term talk therapy. In the piece, entitled “The Trouble with Talk Therapy”,  neuroscience journalist and author, Maia Szalvitz, argues that most therapists have no clue about the latest and most effective treatments for common psychological problems. Instead they want to “go deep” to uncover unconscious feelings and motivations, which she says, has not been found to be effective in treating problems like Obsessive Compulsive Disorder, Depression, Anxiety, and Post Traumatic Stress.

The problem, she says, is not that effective treatments don’t exist for these problems, but that therapists either don’t know of them, or choose not to make use of them.  She cites Alan Kazdin, who is the former president of the American Psychological Association, for saying that “Most of the treatments used in clinical practice have not been evaluated in research.  Also, many of the treatments that have been well established are not being used.”

As a result, Szalavitz claims, she has a hard time knowing where to refer herself or her friends for effective treatment, for as she concludes, talk therapy has an “evidence” problem…

What’s Wrong with Szalavitz’s and Kazdin’s Argument? 

Psychological distress cannot be separated from who you are as a person:

Szalavitz and Kazdin are asking the right questions, but on the basis of a wrong understanding. Their assumption is that psychological problems are “disorders”, and that “disorders” can be treated like one treats a medical illness. Hence there should be one best treatment for depression, one best treatment for OCD, one best treatment for anxiety, and so forth.

The problem with that understanding is that it is based on ignoring the subjective meaning and function of our psychological distress. What makes a problem psychological is precisely that it involves the life of the person. This means that I can be depressed for different reasons than you and that your obsessions and compulsions can serve a different function in your life than they do in mine. OCD and depression are therefore not phenomena that exist in some objective reality where they can be treated using some standard method that gets applied the same way to each person. Instead they are surface manifestations of underlying psychological conflicts and issues that are highly particular to each individual. If we want to get to the root of the problem, we must therefore make these particular conflicts and issues the real focus of the therapy.

Psychological issues are intertwined, not separate from each other:

Szalavitz and Kazdin also make another mistaken assumption. They believe that problems like anxiety, depression, obsessions, and compulsions exist independently from each other, making it the case that one can focus treatment on a single problem and select the best treatment technique for each problem.

In actuality, however, most people who come to therapy have a variety of psychological issues that cut across identifiable “disorders”. They bring their life to the therapy, not an illness. Any therapist is likely to agree that the longer one works with a client in therapy, the harder it becomes to provide a diagnosis. As the complexity of our understanding of our clients increase, so does the inadequacy of any particular label or diagnosis. People are first and foremost people and as they expand their own understanding of the interconnections between their symptoms and themselves, the need to localize and separate their problems from who they are as people tends to disappear. As the now deceased Dutch psychologist, J.H. Van den Berg, has pointed out, people come as wholes, not as fragments, and one cannot focus on a single area of a person’s life without implicating all the others. One cannot lift the corner of a carpet, without lifting the whole carpet…  

Psychotherapy focuses on subjective truth, not objective knowledge: 

A third mistake Szalavitz and Kazdin make is that they fail to appreciate that there are two different truths and realities in life. Science deals with objective truth and objective reality. It deals with “facts” based on unbiased observations and treats these facts as universal truths rather than contextual truths.

Psychotherapy, however, deals with subjective truth and subjective reality. Subjective truth and subjective reality are not a lesser truth or lesser reality. In fact, our subjective experience is often what is most instrumental in motivating our behaviors.

To illustrate the difference, let me provide an example: If a male client can’t grieve the death of a close friend, this is not because he is objectively incapable of grieving or crying, but may be because he subjectively believes that “real men don’t cry”. This subjective reality, which he may or may not be aware of at the start of the therapy, can explain his lack of ability to grieve. It also provides “evidence” for why he may objectively present as depressed. Natural grief that is being suppressed may turn into a heaviness that cannot be released and may lead to a lack of contact with vital emotions that manifests  as symptoms of depression.

In therapy, however, the client may not initially be aware of this subjective belief, nor would the therapist know of it simply by looking at the client’s objective symptoms. The secret to understanding the client’s depression thus lies in a subjective truth that must be discovered, not in an objective knowledge that can be said to be universally applicable each time somebody shows up as depressed.

Why Psychotherapy Cannot be Standardized… 

What Szalavitz and Kazdin don’t understand is that therapy is not factory work and is not about providing prefabricated treatments of objective problems. It is about understanding the unique subjective causes that motivate and explain surface level symptoms that may look the same, but have widely discrepant reasons for being. This means treating the “person”, not the “disorder”, for the person explains the disorder and not the other way around.

So Back to Our Original Question: Does Therapy Work?

I believe the answer is yes, but it works in a very different way than a coffee maker works to make coffee or an oven toaster works to make toast. It helps people discover their own subjective truths, and not simply to change a behavior. Following Szalavitz’s and Kazdin’s advise is to apply a logic that may very well work in the realm of machines and objective cause and effect, but is very ill suited for the likes of us

About me: I am Rune Moelbak, Ph.D.,  a psychodynamic therapist in Houston, Texas. If you are interested in learning more about how a psychodynamic approach can help you get to the root of your problems, click here.

Picture of 5 post-it notes

5 Common Things People Say to Avoid Seeing a Therapist

The vast majority of people who are contemplating seeing a therapist will be marred by doubts and reservations that may ultimately get in the way of following through. Some of these concerns may be quite rational and practical, but others are typically roadblocks we put in our own way because we are afraid…

Resistances to Therapy:

Therapists have long referred to these rationalizations in defense of our fears as “resistances”. Resistance is an expected part of every therapeutic journey. What Freud determined quite early on is that people want change from a distressing situation, but are also deeply afraid of change and of the process that is going to get them there. A part of each person therefore actively – albeit often unknowingly -resists the process of therapy. These resistances often start before the person has even walked in the door and may prevent them from ever picking up the phone and scheduling that first appointment…

Here are five of the most common resistances people have to seeing a therapist and some reasons why they might be rationalizations that cover up underlying fears: 

1. I Should Be Able to Solve My Own Problems…

This resistance to seeing a therapist is quite common. Many people have learned that the hallmark of skillful and confident people is that they are able to manage life without relying on anybody else. They think they must be weak or inadequate if they have to see a therapist; that this means that they are not competent or skillful like everybody else, or that they can’t cope with life.

Fact is that underneath an overly self-reliant attitude are often deep-seated fears about depending on others. Many people develop the attitude that they must manage life on their own, because they are afraid that others would ultimately not be there for them in their hour of need. Reaching out to others and admitting that you need them can sometimes activate the feeling of becoming a child again who cannot fend for him or herself and who is utterly at other people’s mercy. Although we all have deep seated wishes to return to a state of being taken care of again, such wishes have often had to be squelched as part of growing up, and we may now judge ourselves as “childish” or “immature” for having them. And yet when we fall in love and develop strong relationships with others, we are confronted with the fact that these needs never went away. The ability to endure the vulnerability of depending on others is thus a necessary skill to have in order to form strong bonds and feel intimate with others.

It is now easy to see why some people may not allow themselves to even contemplate therapy. They don’t feel comfortable getting in touch with the child within and enduring the risk of rejection and let-down that comes with having to depend on others.

 2. Therapy is Too Expensive – I Can’t Afford It…

Finances are often used as a prime reason why therapy is not an option for a person. Sometimes embarking on therapy would truly be a bad financial decision, especially if you are struggling to meet your many financial obligations. At other times, however, concerns about finances may serve as a convenient way to appease certain underlying fears about the therapeutic endeavor itself. It is for example not uncommon to find that people will go on expensive vacations or remodel their kitchen, but not feel they can spare the expense to see a therapist.

Many times a concerns with financial means to pay for therapy conceals a variety of underlying concerns. These can include: guilt feelings about making yourself a priority, minimizing and deprioritizing your mental health, or resentments about the idea of having to pay for someone to listen. Many people are okay spending money on others, but feel uncomfortable with making themselves a priority. Therapy for them is the ultimate self-indulgence and may feel like a selfish need. Others, who feel quite okay spending money on material possessions like a new car, a new kitchen, or expensive jewelry, may not feel that spiritual things like their own mental health is of equal value. Finally, whether people admit to it or not, there is often some anger or resentments that people experience for having to depart with a treasured belonging (money) in order to get somebody to care or to listen. Rather than examine the variety of these concerns, it is often easier to chalk them up to the statement that therapy is simply too expensive.

 3. Seeing a Therapist Means I’m Crazy…

Many people find it difficult to square the idea of going to therapy with their need to feel normal. We have a very powerful social instinct that wants nothing more than to blend in with everybody else. We are afraid to stand out from the crowd in any negative way and we convince ourselves that therapy means that something about us is wrong or defective; that we have stepped outside of the acceptable limits of our society.

This resistance to the idea of therapy and what it must mean about ME or my self-concept is based on the illusion that “normal” people don’t need therapy. Fact is that every human being develops certain bruises to their self-esteem, experiences certain personal limitations in their interactions with others, and don’t know how to cope at various points in their life. Psychoanalyst, Nancy McWilliams, quips in her famous textbook to therapists, that the question to ask oneself is not: Am I nuts? But: How nuts am I? And nuts in what way?

People who go through life adhering to an illusion of normalcy can only do so by pushing their struggles to the side and pretending that everything is fine. Over the long term this actually produces more psychological distress than dealing with your issues head-on. Ironically, trying hard to be normal can be crazy-making, and allowing yourself to confront your irrationalities and “craziness” can make you feel normal again. Dismissing therapy as something that is only for “crazy” people is thus a way to express discomfort with who you are, and not acknowledging that it is human to suffer.

 4. It is Weird to Air My Dirty Laundry to a Stranger…

It is not uncommon for people to convince themselves that talking to a therapist will feel too awkward or uncomfortable. They might say to themselves that it is unnatural to talk to a professional about your problems, and that a therapist really offers nothing that a friend or family member couldn’t offer. In addition, they say, it is not comfortable to share their deepest darkest secrets with someone they hardly know and who doesn’t reciprocate by sharing something about their own personal life.

These resistances to embarking on a therapeutic journey serve as  deterrents to having to face one’s fears of opening up and becoming fully known to someone. One naturally feels quite “naked” and exposed when one is asked to divulge thoughts and feelings to someone who is not responding in kind. However, discomfort about opening up to a therapist is often about confronting one’s own shame about admitting to the full scope of one’s human emotions, thoughts, needs, and wishes.

The same qualities about the therapist that are often cited as deterrents to opening up, are also the qualities that ultimately allow people to go deeper into their issues and be more honest than they can be with a friend:

  • Because the therapist does not divulge much about their own personal problems, the client is free to focus exclusively on their own issues without having to be concerned about taking care of someone else.
  • Because the therapist is not part of the client’s life, a client can feel safe to genuinely express themselves without fear of repercussion for their everyday relationships.
  • Because the therapist is not a friend or family member, and has no self-interest in the client choosing particular actions over others, a client can discuss concerns without feeling an implicit pull to make particular decisions.

At the end of the day, the therapeutic set-up, while initially a foreign concept, actually ends up making it easier rather than harder for a person to share their thoughts and feelings freely.

 5. It Will Be Awkward if I Don’t Like My Therapist

Some people may hold themselves back from scheduling an appointment because they don’t want to get themselves into a situation they can’t get out of. They may be concerned that a therapist won’t be right for them and that it’s going to be uncomfortable to tell their therapist that they would prefer not to come back.

These kinds of fears of getting stuck in a bad situation often hide over discomfort with assertiveness and ultimately with anger and aggression. Some people feel that they would hurt their therapist’s feelings if they truly expressed their mind and feel like their only choice is to go along with whatever their therapist is telling them so as to not incur their therapist’s wrath. This of course leads to fears of being swallowed up in the relationship and losing one’s autonomy and independence.

It may be of great comfort to such people to know that therapists receive training in how to manage a client’s negative reactions, and that working through negative reactions is part and parcel of good therapy. Therapy is about creating space for clients to be themselves fully, which means creating space for negative as well as positive emotions. No therapy can ever be completely successful if a person has not been able to express and work through their anger, disappointment, fears, and frustrations as they pertain to their therapist as well as significant others. It is quite liberating to have the experience that one’s therapist can withstand one’s fury without retaliating or rescinding their support.

About me: I am Rune Moelbak, Ph.D., a psychologist in Houston Texas. I help people confront their fears and live more genuine lives. If you have fears and concerns about therapy that I have not addressed in this article, please feel free to send me an e-mail with your questions. For more information about the process of individual therapy click here.  

What's your story?

The Power of Story-Telling

On my recent trip to Nicaragua, I learned at least two things: 1. That when looked at from a Venezuelan/ Nicaraguan socialist perspective, the US is a country of police brutality and moral decay, and that, 2. Spirit Airlines are not stingy with their amenities, they are just engaging in “frill control”. Funny how reality changes when you tell a story differently…

A Cultural Lesson on the Power of Story-Telling:

Nicaragua is currently a country that receives a lot of financial aid from the Venezuelan government, due to their mutual sympathies toward a kind of socialism practiced by the now deceased political leader, Hugo Chavez. For that reason, you can find posters that pay homage to the former Venezuelan in places all over Nicaragua. You can also, I discovered, watch unadulterated TV transmitted straight from Venezuela.

When I would settle in at night after a long day of sightseeing in the tropical heat, I would turn on the TV in my air-conditioned hotel room, and would find myself fascinated by one particular Venezuelan station and the entirely different world-view presented there.

The US was on this channel depicted as quite morally depraved. The evening’s news included a segment on police brutality against civilians in various places in the US, presented as if it were breaking news.

The news was followed by a theme show featuring all the wonderful socialist initiatives of the Venezuelan government: First you saw how many modernized apartments were being built through the decree of the government, and then coverage followed of other government initiatives: workers would now be able to pay fair prices on everyday goods due to government intervention, the environment was now being saved through nation-wide programs to plant trees…. The initiatives were seemingly never-ending…

Every segment introduced one hopeful initiative after another, and the clips were always of people doing things together – collectively – making political decisions about what kind of society and destiny they wanted. This was a society that valued people and community over and above raw capitalism, and it reminded me a little bit of the Obama campaign’s “Yes, we can!”, which had that same kind of optimist spirit, before it lost its fizzle.

After watching this Venezuelan station for just 30 minutes I was left with an indelible impression of optimism, although a part of me of course knew that this was quite a different spin on reality than the one I had typically been presented with. From a North American perspective, Chavez was always depicted as somewhat of a selfish dictator, and socialism, of course, always depicted as bad.

However, crossing cultural boundaries, not just geographically, but mentally, is quite eye-opening. It made me think of the power of stories as a mediator of the reality we experience, the emotions we feel, and the actions that become conceivable. It also made me think of the tendency of stories to hide their story-like nature behind a presentation of facts.

The Venezuelan news station was not consciously telling stories, but merely reporting facts, and many of the stories we tell in the US media, to ourselves, and to others, have that same pretension to transcend their story like nature.

The Story of Psychological Disorders

The idea of the unadulterated fact is, however, itself the product of a story: the story of the enlightenment or of science. According to this story, we can access reality purely as it is in itself outside of the logic of a certain story line and pre-understanding. And yet, as hermeneutic philosopher Hans Georg Gadamer has pointed out, even science takes place within a prior understanding of the world. There is never such a thing as approaching the world without making certain pre-judgments or assumptions about it.

A research study about the effectiveness of a certain therapy for Bipolar Disorder for example, may seem like it is only reporting facts (looking at quantifiable variables and measurements of probability), but it is assuming an illness model of psychological distress which is not itself part of what is studied. An illness model, of course, is a story about why people suffer that attributes the suffering to a disease process or cause underneath the actual life of the person, and is by no means the only possible story.

The medical or biological view of psychological distress has a particular strong-hold in our current North American and European zeitgeist. People are always wondering: Do I have ADHD? Am I Borderline? Do I have a psychological disorder? …As if assigning a label and naming one’s suffering as a generic underlying “thing”, solves the problem, and alleviates the discomfort of figuring out why I suffer in some more human or existential sense.

And yet, these “entities” which we like to label ourselves with are themselves largely the product of stories. What appears to be science and is presented in an officially sanctioned diagnostic manual (DSM) as if it were, is really the product of a political process of debating different research studies, naming conventions, and inclusion criteria. Psychological Disorders are voted into existence. The other side of a disorder is all the contentious opinions that had to be tabled in order for the construct to appear as an independently existing noun.

Therapy as Story-Telling

Rather than try to fit people into categories of a medical story, therapy offers a space where alternative stories can be told. Therapy as a “talking cure” is really about telling your own unique story. A person is helped to unearth memories, feelings, and experiences that sometimes pose challenges to existing stories, and require the reorganization of one’s understanding of oneself and of the world. The medical narrative is here often a hindrance that disallows people from pondering the idea that symptoms exist for a reason, that feelings contain useful messages, and that our bodies express that which we cannot yet say.

* * *

And so it is that a trip to Nicaragua made me wiser about the power of the stories we tell and about the need to examine the stories we live as our own personal and cultural truths.

The Venezuelan government has their story…

Spirit Airlines has theirs…

What’s your story?

About me: I am a psychologist in Houston, Texas who likes to think outside the box and is committed to helping people find their unique personal truths. Read more by visiting my website.

Reaching the goal

Psychotherapy: What is the Goal of Therapy?

Good therapy is not about offering solutions to people’s problems. It is about helping people understand what their problem really is… 

Meet Joe…

Joe is depressed. His wife just declared that she is going through with her divorce. Having built his past 20 years around the idea of being her husband, Joe now feels as if he is left with nothing. His entire psychological existence feels empty, and it is hard to face this brave new world of bachelorhood without a sense of hopelessness and despair. Can he ever re-find the sense of comfort and acceptance he had with his wife? Will he forever be alone? Can he ever reestablish himself in a life with meaning and purpose? Joe finds himself in the midst of an existential crisis, so he does what most people would, he decides to go to therapy…

To Joe the goal is clear: He wants to not feel depressed, to regain passion for life, to want to live another day… In short, he wants to feel better.

With this goal, most therapists would probably agree. Where they won’t agree, however, is how to get him there…

Therapy Goal A: Fixing What is Broken

If Joe were simply broken, there would be a way to fix him. Maybe his thoughts have gotten a little out-of-whack, maybe he has stopped taking good care of his physical health, maybe he is keeping himself from dating because of his unwillingness to mentally let go of his wife. These in fact are all practical problems that could be solved.

And many therapists would be happy to help Joe battle his own insufficiencies by helping him find rational and practical ways to solve these problems…

However, the efficacy of a person’s problem-solving ability always rests on the accurate definition of their problems. If you are trying to solve the wrong problem, no solution will ever really do the trick!

The reason why Joe is not dating is a logical consequence of a problem, which Joe himself has not quite adequately understood. Sure there are good arguments why he should be dating: It will maximize his chances of meeting another partner, and if he meets another partner maybe he will have someone new to fill the void in his life. But if his therapist had not been so busy helping him solve this problem, Joe might have discovered something else beneath it that might be even more valuable…

Therapy Goal B: Getting to the Root of the Problem

What Joe might have discovered is that he is afraid to let go of his wife for a number of reasons that may not seem logical to someone who is not in Joe’s particular shoes. He might have been helped to realize that he is afraid that once he lets go of loving his wife, he will never be able to feel that sense of love again.

This realization is not a problem to be solved, but a problem to be curious about.

Instead of jumping in to solve Joe’s problem, Joe’s new therapist instead helps Joe reflect on why that is.

Well, before he got married, Joe spent most of his life feeling rejected by other people. As a way of coping with the rejection, he became astute at shutting down his own need for affection. He developed a lifestyle where all his emotional connections were rather shallow and where he never truly allowed himself to depend on anyone.

His wife changed all that, but now that she is soon to be gone, Joe is faced with becoming his old lonely self again. His wife leaving him is thus only really the problem in some superficial sense.

Her departure is merely the occasion that reveals a series of others problems, which Joe had not had to face until now: Maybe he was not as emotionally available in the marriage as he could have been? Maybe he is still a hurt and rejected adolescent at his core, and the divorce is re-inflicting an old wound? Maybe his strategy of shutting down his emotions as a means of survival is now exposed as the devil’s bargain?

And this is where Joe’s real therapy begins…

A Better Therapy Solution…

The problem, it turns out, is not really his wife wanting a divorce, or Joe wanting to hold on, but rather Joe needing to come to terms with unresolved issues related to rejection, dependence, fear, and loss.

Had Joe continued with his old therapist, he would never have arrived at this more intimate understanding of the real issues involved. Instead of delving deeper into his problem, Joe would then instead have been implementing solutions to a problem he had not fully understood.

Finding a solution to a problem is easy, finding the right problem to solve is hard…

To discover the real problems is the goal of therapy…

About me: I am Rune Moelbak, a psychologist in Houston, Texas. I aim to provide a more thoughtful kind of therapy that will help people get to the root of their problems…

Existential Choice

The Existential Choice: Choosing Your Therapy Wisely

If you are suffering from depression, anxiety, or some other psychological struggle, there is almost always two directions you can go.  Whichever path you choose will have profound implications for the general direction your life will take…

The Symptom Path:

One direction is to stay at the surface and treat the symptoms as if they were problems in themselves.

If you suffer from insomnia, for example, what are some strategies you can use to trick yourself into falling asleep? This technical and managerial approach to life fits well with a modern zeitgeist of efficiency and productivity.

If you have a problem, all you need to do is to be smarter about it, and manage your life better.  If you are depressed, then go to the gym, change your diet, force yourself to be social, or recite positive messages to yourself before you go to bed. And if that doesn’t work: take a pill. Statistics show that every 10th person in Iceland lives an existence on anti-depressants, and in the United States the numbers are comparable.

The problem with this first direction is that it alienates us from our symptoms. When we take a pill to “rid ourselves” of a bad mood, we simultaneously tell ourselves that our mood has no inherent meaning or function. When we treat our insomnia as a simple problem to be solved, we simultaneously turn it into a purely behavioral symptom devoid of any personal meaning.

As Darian Leader argues, in his book The New Black, symptoms in this approach are seen as mistakes to be avoided rather than the bearers of truth.

Most of us are relieved by this fact, because most of us prefer a quick fix to our problems over the more labor intensive work  of exploring our inner lives. As Darian writes, “We prefer to see symptoms as signs of some local disturbance rather than difficulties which concern our whole existence”.

The Meaning Path:

And yet the other direction we can go as suffering individuals, is precisely back into the meaning and psychic function of our symptoms. Although the labor of finding out why I might be depressed or unable to sleep can be arduous, avoiding it, is to live my existence in some form of denial.

There really is no substitute for getting to know myself well enough to understand what my symptoms mean and why they are there. If I don’t, then the underlying issues remain and the symptoms will simply return in some other form at a later date.

The kind of depth oriented therapy I advocate,  cannot be reduced to simple formulas or strategies, and cannot be delivered as some form of education. It requires entering into therapy as an experience, where questions rather than answers guide the work. It also requires a suspension of that managerial mindset that wants to plan out time and view everything in terms of productivity and output.

Good therapy is not about simply changing your behaviors, your routines, or your way of thinking. It is about exploring the meaning of your symptoms. It is about honoring the underlying reason why you have become depressed, why you have started to feel anxious, or why you have begun to suffer anguish in one or the other way.

As the following video illustrates it in the case of depression, this reason is often not just some external cause, but is often an inner difficulty or struggle that first needs to be brought to light. Therapy is the process that allows this to happen…

About me: I am a psychotherapist offering meaning-based therapy in Houston, Texas. Visit my website for more videos and information…

 

Social Anxiety

A Fresh Look at Social Anxiety

Social Anxiety, like so many other “anxiety disorders”, is not really about anxiety. If we look a little deeper there is almost always something else at stake…

Anxiety as Substitute Emotion

Quite frequently, anxiety acts as a substitute emotion that takes the place of the real issue that therapy needs to focus on. Anxiety is to our internal dilemmas, as loss of consciousness is to alcohol consumption. Both serve to shut down something in order to keep us safe.

In the case of alcohol consumption, loss of consciousness prevents us from drinking more and thus from dying of alcohol poisoning. It is our body’s inbuilt safety mechanism.

Similarly in the case of anxiety: I become anxious because I cannot contain some truth, some emotion, or some problem in my conscious awareness. The danger is here the danger of my own awareness, which has the power to destroy me psychologically, just like alcohol can destroy me physiologically. My anxiety indicates that I am not at peace with myself or that some admission of a banished truth or feeling would have dire consequences for my current self-understanding.

Social Anxiety as a “Disorder” of Shame

In the case of my social anxiety, the danger to my self-understanding is activated in relation to others. Others are perceived as passing judgments on aspects of my natural, spontaneous self.

However, the judgment I expect from others is already a judgment that I have passed on myself. Only if I have come to dislike or devalue some aspect of myself, can others now be in a position where they can expose this most shameful part.

What is at stake in social anxiety is thus the public shaming of an aspect of myself, which I am unable to love. This is why labeling social anxiety an anxiety disorder, is really to get lost in the symptoms, rather than to understand the cause. Social anxiety is not really about anxiety, but is about shame and self-worth.

A Cure through Love

Shame, of course, develops in and through my interactions with others. As French existentialist, Jean-Paul Sartre has stated, “For me the Other is the first being for whom I am an object; that is, the being through whom I gain my objectness”.

Who we feel ourselves to be is thus always tied to the many ways in which others have reacted to our internal experiences and natural self-expressions. When these reactions have been kind and affirming, we have internalized a sense of love and acceptance, and when they have been critical or invalidating, we have internalized a sense of shame or wrongness.

To truly rid myself of social anxiety is thus not simply to conquer a fear, but to develop compassion for myself. One must often revisit moments in one’s memories where other people’s reactions to me, hurt me or made me feel dangerously exposed.

These wounds to our sense of self must now be attended to, rather than hidden away for no one to see. In my opinion, this is how good therapy can help you get to the bottom of what social anxiety is really about. Therapy provides a new kind of validating relationship in which all parts of you can be seen, and in which you can now see yourself through the eyes of an “other” who no longer judges you for being yourself.

About me: I am Rune Moelbak, Ph.D., a psychologist in Houston, Texas with a different approach to psychological issues. Learn more about my insight-oriented approach to treating social anxiety.

Insight

Psychotherapy: Does Insight Cure?

Over the past 100 years, therapists have asked themselves the question: what really produces change in people? In this connection, the role “insight” plays in helping us resolve our issues has often been a point of contention… So does insight really cure?

Insight in Psychoanalysis

In the heyday of psychoanalysis, a prevalent belief was that change resulted from understanding our unconscious conflicts, or making the unconscious conscious. The main tool of the psychoanalyst was believed to be the offering of an interpretation of the unconscious truth of which the client was unaware. Unfortunately to get to this point, people often needed to be in “analysis” for years, and the outcomes weren’t necessarily that consistent nor impressive.

The Cognitive-Behavioral Critique of Insight

This led to a wave of criticism against the psychoanalytic idea that insight is a sufficient condition for change.

Cognitive Therapy:

The dissatisfaction with the slowness of change led a psychoanalyst like Aaron Beck to focus instead on making the client aware of the more immediate automatic thoughts that exist just beneath our conscious awareness. He invented what has now become known as cognitive therapy, an approach where the therapist uses logic to help the client refute their “irrational” emotion-driven beliefs. Instead of spending years probing the unconscious in search for “truth”, Aaron Beck and his followers instead engage directly with the client’s thoughts and help them realize the absurdity or contradictions of some of the things they tell themselves.

Unfortunately this kind of rational approach to change often does not really address the logic contained in a person’s emotional responses and it ends up reinforcing an untenable division between the emotional and logical dimensions of existence. Clients end up at war with themselves, and the unaccepted emotional impulses eventually tend to return with a vengeance.

Behavioral Therapy:

Other therapists have responded to the dissatisfaction with lack of change through insight by emphasizing “practice” over “understanding”. They advocate that you take concrete steps to change something about your life and help nudge you in that direction by addressing all the obstacles that get in your way. Unfortunately this kind of behavior therapy often leaves you feeling that you are acting against your own will or against your own emotions. Although you may succeed in changing your habit for a while, most people end up back in their comfort zone once therapy is over and they have no “coach” yelling in their ear.

Both the cognitive and the behavioral approaches to therapy are essentially ways to speed up the process of change by tackling problems directly, and circumventing the slow process of insight. However, ironically, they often do so by not having sufficient insight into the problems they set out to change. They frequently offer premature solutions to inadequately understood problems and they often don’t really have a complex enough understanding of the forces at work within the person.

Insight as Experiential Truth

In my opinion, a lot of the backlash against insight-oriented approaches to change, has to do with a premature definition of what insight really entails. If we define insight as intellectual understanding, then the critics are probably right: Nobody was ever really changed by simply knowing about their problems or having an explanation for why they do things the way they do them.

However, insight is not the process of passing information from one mind to another. That would be teaching, not therapy. The insight that good therapy produces is both intellectual and emotional, or rather, it is existential. It addresses the person as a whole, at a level where no division exists between mind and emotion. The quality of such an insight is that it is irrefutable.

We have these kinds of insights throughout our lives, and we can recognize them as such, because they do not allow us to go back to the way things were. Once they happen, they transform us. They are the insights that we get from watching a really thought-provoking movie that impacts both emotions and mind and let’s us see the world in new ways. They are the insights about ourselves that we gain from being in a romantic relationship, or breaking up a relationship. In short they are the insights from life’s many little significant moments that make us realize something about who we are or what the world is like.

Existential philosopher Martin Heidegger speaks of this kind of truth as Aletheia or unconcealment. It refers to the moment when something that was always already there, is shown to us. When this happens, I don’t experience it as some intellectual understanding, but as a homecoming or a return to something which had been forgotten or covered over.

Psychotherapy as an Experience of Truth

Psychotherapy is a process of unconcealing these irrefutable truths contained within our own experience. These kinds of insights return me to myself and give me no room for argument.

The best way to reach them is not to provide explanations to people, to engage in logical arguments with them, or to suggest ways for them to act differently. It is to provide an experience.

Insight is therefore not just about what is revealed, as the critics often assume. It is also about how it is revealed. Simply telling someone a truth is not effective and is easily refutable. Letting someone experience truth, on the other hand, is quite a different story. My experience can teach me something about myself that I can just as little refute as I can refute that I have a nose, or that I have two ears. If I had a good time at a party, for example, this truth is irrefutable. It does not matter if someone else tells me it was a bad party. My truth is irrefutable. I cannot undo the fact that the party was enjoyable for me.

Therapy is a process of giving a person an encounter with the truth of their own experience. This is what insight as aletheia is really about.

It can be as simple as giving a person the realization back that a word he seems to be using creates a tie between his history of being sexually abused and his current social anxiety. “I don’t speak much in social situations”, he says. “You don’t speak much, or you keep silent?”, I utter. Without me telling him, the client has now been given back an experience of the connection between his shyness and the fact that he has had to keep a secret about his abuse all his life. I did not provide a laborious explanation, but used my words to “unconceal” something; to show him rather than tell him. The result was a visceral reaction in the client who now experienced himself in accordance with a new truth. He had been given a new foundation for his thoughts and experiences, revealed to him by his own words and his own unmistakable reaction to my words. He had learned a truth which could not be undone.

Therapy proceeds through such little insights, and a person changes without ever really forcing a new behavior or battling a single thought. So to answer our question: Does insight cure? The only way to tell is to experience it for yourself…

Note: If you would like to read more about therapy as an experience of truth, read my article: “On Cultivating the Therapeutic Moment. From Planning to Receptivity in Therapeutic Practice.”

 

Marius: The Healthy Giraffe Killed at Copenhagen Zoo

The Zoo in Our Psyches: What Marius can Teach us About our Unconscious

The Copenhagen Zoo Debacle:

This week, the debacle about Copenhagen Zoo and the killing of the healthy giraffe Marius really got people’s passions riled. The bloodied image of a cute giraffe was hard to watch and I have to admit my own first reaction was to go and like the Facebook page for “Animal Activists against Copenhagen Zoo”…

The Other Side of the Story

A few days later, however, I watched a television interview with the Danish Zoo director who explained why the giraffe had been killed. He explained why killing the giraffe was necessary out of love for the species and how it was essentially no different than killing a cow or a chicken. Nature too is ruthless, he said, and the natural course in the wild would have been for the herd to fulfill the function of the zoo-keeper and for Marius to meet a similar faith. He went on to defend the dissection of the giraffe in front of children as an educational experience, for why shield children from reality? Feeding the giraffe to the lions was also spoken about in a matter of fact way, for how do you think lions survive in the wild?

Guilty as Charged!

The media, however, would hear nothing of it. In the most dramatic display of contrast to the zoo-director’s story, they displayed the gory details of the event as an act of unspeakable violence and moral depravity. They focused on Marius as a singular individual that we could all imagine keeping as a pet, and not as livestock or a member of a species. They also carefully picked out one child in the crowd who could not bear to watch the dissection and played the clip in slow-motion for dramatic effect. In subsequent interviews on Anderson Cooper 360, the zoo-keeper was invited to speak, but really only to ridicule his point of view after he went off the air. This was a trial where the Danish zoo-keeper was guilty and where the morally indignant needed no proof from the defense to arrive at a common sense conclusion.

A Confrontation with the Unconscious?

What struck me about this whole debacle was that the zoo-director’s truth could have no place in the American psyche. His viewpoints and actions spoke to a different kind of reality that was as real as it was raw. His was the reality that could not be considered without making us uncomfortable. And yet, when it came to talking about the need to feed lions animal meat, the natural ruthless herd behaviors in the wild, the educational value of not shielding children from experiencing reality, or the view of Marius as a member of a species rather than an individual with a name, did he not have a point?

In my opinion the drama of the Copenhagen Zoo and the strong reactions it elicited indicates that it tapped into an unconscious conflict and confronted us with something real that we would rather repress. Hence the strong moral reaction that could not even give room to consider the zoo-keeper’s perspective. The zoo-keeper reminded us of something we would rather not know, and our moral outrage shielded us from knowing that we would rather not know it.

Speaking an Unpopular Truth

And, yet at the end of the day, I could not but admire the courage of the Danish zookeeper to speak a truth in spite of death threats, moral outrage, and judgment without trial. In his insistence on confronting us with a different perspective, he forced us to confront something about life that has no room within our everyday self-understanding: The fact that we are killing animals every day to manage animal populations in the wild and to feed ourselves, the reality of seemingly unkind actions that are undertaken for the sake of a supposed greater good (such as going to war, executing people on death row, spying on other people and countries without permission, or even keeping animals in zoos in the first place). The Danish zoo-keeper forced us to look at ourselves a little deeper to confront a reality which we would rather have happen behind closed doors, and out of sight.

So What Does All this Have to Do with Therapy?

The Copenhagen Zoo debacle reenacted a psychological drama within every human being between Eros and Thanatos, or the forces that bind and bring together and the forces that separate and confront us with limits.

As a psychologist these kinds of uncomfortable truths are what my work is about. People do not come to therapy because they feel all the right feelings. If that were so, they would probably be quite at peace with themselves. No, they often come because they feel wrong for having their feelings or cannot accept certain impulses, thoughts, or wishes that are deemed morally depraved by themselves and by society at large.

A person who has just lost his father, may for example not feel grief, but may feel anger at his father or relief. However, because these feelings are not morally acceptable, he will develop guilt about them, and do his best to suppress them.

Hence, in her book about the psychoanalytic community in New York, Janet Malcolm talks with a psychoanalyst who says that he does not offer condolences to a client who has just lost an important person. Why? Because he does not want to assume that the client is sad, and does not want to suggest that there is one right response to a given event.

Psychology as a Pursuit of Truth

A good psychologist does not approach a client’s emotional life through the lens of commonly accepted truths or expectations, but seeks to provide an opportunity for the less acceptable truth to be spoken. A psychologist, in other words, wants to access rather than silence the metaphorical zoo-keeper from within. Similarly to the drama played out in the social media and in the news, this truth may initially be violently defended against, and might invoke the client’s discomfort or disgust.

My identification with the Danish zoo-keeper who speaks an unpopular version of the truth, is therefore not a justification for the killing of Marius, but an appeal to more closely examine every voice inside of us that is too distasteful to be heard, too violent to our preference for harmony, and too at odds with the prevalent moral consensus.

line

Psychotherapy: The Shortest Distance is Not Always a Straight Line

In psychotherapy the shortest distance between two points is not necessarily a straight line. The laws of math that apply to the physical world often seem to be suspended in the therapist’s consulting room.  And yet the geometry of straight lines has an orderliness to it that makes it appealing to clients and therapists alike…

The Therapist’s Fascination with Straight Lines

Were you to peek inside most “behavioral health” agencies today, you would see the logic of straight lines applied everywhere. The fascination with geometric rationality is here so dominant, that you would be excused for wondering if their psychotherapists had a background in engineering, rather than psychology…

Psychotherapy in these settings has become a very rational and well-planned endeavor that is usually centered around a geometrical road-map, also called “the treatment plan”.

Guided by the dictates of the treatment plan, therapists in these settings are asked to first identify the client’s problem, next help the client set some goals, and finally devise a plan to most quickly and efficiently achieve those goals. From then on therapy is supposed to follow the plan in a straight line from start to finish. Any deviation from the road map is considered disruptive and tangential. It threatens the geometric principles of treatment.

In line with this approach you can hear well-respected cognitive behavior therapists (the engineers of the field) speak of “potentially therapy-disrupting behaviors” that include “attempts [by the client] to overly control the pace of topics of conversation during the interview” (Wright, Basco, and Thase). You can also hear statements such as: “One of the challenges in this treatment is to avoid getting distracted by discussions of other problems the client may be facing” (Safren). In short, we must straight-jacket the process to make it fit with the plan. We must shape the territory to make it look like the map!

Two Different Views of Psychotherapy

So what is wrong with this picture? To the rational mind, planning psychotherapy ahead of time and directing treatment with an authoritative hand toward definite goals can seem very intuitive and appealing. And yet, I would argue that it misses the point altogether…

Psychotherapy is not about getting somewhere that is known in advance. In fact, therapy is itself a process by which we discover where we want to go and what we want. To determine the goals in advance of the therapy is thus much like putting the carriage before the horse…

If we use the metaphor of a road-trip to describe what psychotherapy is, then we can perhaps compare the two approaches in the following way:

In the first more “planned” approach, we are trying to get the fastest way possible from New York to Los Angeles. We therefore take the freeway in a straight line to the destination, missing all the sights along the way. We end up in Los Angeles in record time, but have learned very little along the way. We have reduced the journey to a simple means of transportation to get us from point A to point B.

In the approach I advocate, we might also begin our journey toward Los Angeles. Instead of zooming past all the sights, however, we allow time to get off the beaten path and leave ourselves open to new experiences along the way. What might then happen is that we discover that we would rather go to Cleveland, or that it isn’t really so important to get to Los Angeles right away. Maybe it is more interesting to make a detour to the Grand Canyon, or to follow our chance encounters.  We may even decide that our whole enterprise has been a mistake and return back home.

I am speaking metaphorically here, of course, about the nature of the human psyche: Contained within us there are many unexplored territories, and many memories and experiences that can teach us something new about what we really want in life. Going in a straight line may therefore not be the fastest way to get where we ultimately want to be…

Psychotherapy and the Dance of Life

The irony is that when we plan psychotherapy too much, we miss out on all the key therapeutic moments. The real “stuff” of psychotherapy is not about getting to the destination, but about all the little surprises that happen along the way. The goal of psychotherapy is not to get us from point A to point B in the most direct way possible, but to help us undergo a journey where the destination itself can change as we discover new things about ourselves. In fact, even if we ultimately end up in the same place, from a therapeutic perspective it matters how we got there. If we took the freeway, likelihood is we bypassed all the realizations and all the emotional twists and turns that would have given us the true conviction that Los Angeles is where we need to be. We would have exchanged one place with another without being none the wiser…

The intellectual insight a person can have in session 1 can also be the one they ultimately end up with in session 20. However, it took the twists and turns of therapy, to make the person know what they knew, in their gut. To the outsider it may look like nothing much has happened, since after all the person is back just where she started. And yet to the person who did the traveling, this place is completely changed now, and it feels like she has made a quantum leap in her understanding of herself.

Trying to bypass the journey to simply get to the result is to mistake intellectual insight for an emotional experience of truth. It is to cut out the “therapeutic middle” which is where all the action happens…

On this point, I am reminded of a very insightful video, based on the teachings of Buddhist philosopher Alan Watts. In the video we are shown how a linear pursuit of higher and better accomplishments ends up being a failed strategy in the end. Once we arrive at the promised destination, we realize that there is always another goal to be accomplished. Once we finally reach the top of the mountain in our final age, we discover to our dismay that all we are really left with is a sense of emptiness and hollowness; a bitter realization that it was all for naught…

Why? Alan Watts reminds us: Because life wasn’t about getting anywhere. It was about a dance. The point of a dance, as with a musical piece, is not to quickly get to the end. It is about the dance, and about the music. Therapy is also a dance, and if we get somewhere too fast, we might just end up missing the point…

To read more about the perils of a rational/planning approach to  psychotherapy, download my article: Cultivating the Therapeutic Moment: From Planning to Receptivity in Therapeutic Practice.

Sources:

Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD. A cognitive-behavioral treatment program (Therapist guide). New York, NY: Oxford University Press.

Wright, J. H., Basco, M. R., & Thase, M. E. (2005). Learning cognitive-behavior therapy. An illustrated guide. Washington, DC: American Psychiatric Publishing.

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corridor with word "help" written in middle

Why Psychotherapy is not about Solving People’s Problems…

The Uncommon Wisdom of Psychotherapy…

Psychotherapy is not about solving people’s problems, at least not in the same way as a math teacher helps you solve a math equation, or an auto mechanic helps you fix a broken car. As a person, your problems cannot be separated from you, and you can therefore not simply treat the problem without in some fundamental way becoming changed yourself.  In fact, as I will explain, sometimes the very desire to solve your problems, may itself be part of the problem…

This is a difficult idea to understand in a society that values self-improvement and shows us every day how we can use the latest technological advances to improve how we look, how we feel, and how we perform. Self-help gurus, experts in the media, and the latest “solution-focused” psychotherapies, seem to offer us the knowledge and techniques to “fix” ourselves and become who we want to be.

Why our Symptoms are not Problems to be Solved…

The idea that we can solve our psychological issues by finding some technique or rational solution, is often the product of an unstated dualism. The symptom that bothers us, be it a perceived character flaw or some other deficit or deficiency, has often become split off from ourselves. It has become a part of ourselves that we do not accept. We experience it as incongruent with who we want to be. Our disliked symptom seems to serve no role and have no contribution to make. It is considered “irrational” and unwanted. And the best thing therefore is to find a way to be rid of it.

And yet this separation of our irrational and problematic parts from our cherished and rational self is a flawed starting point for change. It assumes that we are like a four-legged lizard that can simply lose its tail when it is no longer needed. We might as well be trying to spit out our own tongue or eat our own mouth, because the task we have set ourselves is just as contradictory.

Discovering the Logic of our Symptoms

The problem is that our annoying little habits and traits only appear senseless and tasteless when we have defined our problem in too narrow of a way. Only when we cut our symptom off from  a wider interest in understanding ourselves, does the symptom appear like a bad tooth that can simply be plucked without any repercussions for the rest of us.

Once we begin to understand what really keeps the symptom in place, however, we realize that the symptom is often a sign of an internal conflict with which we are struggling as a human being. The symptom, therefore, far from being a problem we can simply solve, is thus in fact a solution to a problem which we have not been able to solve. It points us toward a larger issue of which we are not aware. The symptom indicates that something is awry, but does not indicate what exactly. This however is what psychotherapy is for… 

Hence, a person who desperately wants advice about how to stop having panic attacks, discovers through psychotherapy that the panic attacks are really a result of the person’s battle against his own impulses. The person has not allowed himself to admit to feeling angry with his parents and has in fact waged an ongoing battle against himself to not feel certain feelings that produce anxiety and discomfort. His need for tight control of his emotional life and the impossible bind that he not be who he is, is nevertheless a failing strategy. His anxiety attacks indicate precisely this.  

The person’s pursuit of a solution to get rid of his anxiety attacks, as if they were simply irrational and alien intrusions into his existence, keeps the real issue at bay. Instead of heeding the message of the symptom, the person now instead enters into a battle with a part of him which he cannot understand. He may try anti-anxiety medication, relaxation techniques, and whatever other desperate solutions people can offer him. But because his attempt at a solution is an attempt at covering up the real problem, whatever he tries to do is destined to fail. He is like a person attempting to become a lizard, or attempting to divide himself in two. He wants to rid himself of the symptom, but does not realize that the symptom is connected to him, just like his nose is connected to his face.

How Psychotherapy Can Help Us

Many of our psychological symptoms and issues are the result of such impossible battles with ourselves. The more we try to fight against what we don’t like, the more the disliked parts of ourselves are forced to return with a vengeance or to appear at the most inopportune times.

When we instead stop trying to solve our problems, and start to be curious about what sustains them in the first place, we may discover to our surprise that our symptoms all of a sudden disappear.

If I am feeling angry but cannot accept anger as part of my life, this is not really a problem to be solved, but is rather a problem that begs a whole new series of questions. Why am I for example uncomfortable with anger?  Might it be that I fear that it can be destructive and make me lose the love from others on which I desperately depend? If so, how did my sense of love and worth in relation to others become so tenuous? And what repercussions does this have for my ability to assert my own needs without feeling guilty or bad? Might it force me to act out my resentment in passive aggressive ways that interfere with my ability to both endure and maintain intimate relationships?

These series of questions are all contained within one single symptom. What started out as a panic attack has now given way to an exploration of inhibited anger, problems with intimacy, and questions about tenuous self-esteem. These questions have not simply displaced me from the real issue, but have problematized my initial problem, and made it about something more than the simple removal of a symptom. As the problem has shifted, so has the nature of my symptom and the solutions that now seem relevant. Rather than being solved, the symptom has now dis-solved.

Instead of battling my symptom, which had initially been a blemish on my self image and a nuisance to get rid of, the symptom now instead shows itself as a gift in disguise. Unwrapping its message leads to ever greater riches in my understanding of who I am and why I am the way I am. Instead of running around like a lizard wanting to lose my own tail, I now begin to integrate all aspects of myself into one unified congruent existence… Instead of solving my problems, I begin to understand what they are really about in the first place… This is what psychotherapy can help you do. 

About me: Rune Moelbak, Ph.D.  is a psychologist and psychodynamic therapist in Houston, Texas. To read more about the theoretical principles that guide me in my work, visit my website, or listen to this recent podcast where I explain more about my approach to psychotherapy