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Archive for February, 2010

My patient sounded bewildered.

“It was like I was watching myself going through the motions – repeating the same old pattern.”

He’d just broken up for the umpteenth time with a woman he’d been dating for over a year.

“It’s always the same thing.  I do something nice for her.  Then she tries to do something for me, but I freak out, and insist she doesn’t like me.  Then I do something mean, like flirt with someone else in front of her, just to prove she doesn’t like me,  and she gives up and we break up again.  So we’re back where we started, and I do something nice again, and off we go.  Eventually, even the women who hang on give up.  Then I find someone else and start over.”

He was caught in an endless loop – around and around and around.  The same thing had played out with every women before this one.

Freud might have called this a “repetition compulsion.”  I’ve heard other therapists refer to it as a “learned behavior.”

Whatever it is – it’s very common.  Left to your own devices – in other words, acting unconsciously – you will keep doing the same thing over and over again.

What you’re doing is replaying a pattern you learned as a child – clinging to it because no one has woken you up and made you ask yourself what on earth you’re doing.

My patient’s father was a frustrated scientist, trapped in a humiliating job, deeply insecure, very unstable.  My patient tried to please him by doing well in school, winning science prizes, trying to be the son he wanted.

Initially, the father would seem pleased and proud.

Then, once my patient allowed himself to relax in his father’s acceptance, disaster would strike.

The father would swing back into a frustrated rage – and take it out on his son.

It probably had nothing to do with the boy – it was the father’s own anger at his work situation – but the effect was devastating.

The pattern played out over and over again.  The son would over-achieve, and believe he’d won his father’s approval – then, as he relaxed into acceptance, the old man would turn on him with vicious criticism.

My patient learned it was okay to give his father – or any person – what they wanted.  But he could never relax and let down his guard.  That’s when the inevitable turn-around came.  He expected it – and braced himself for it – so he’d never again get caught by surprise.

You’ve probably heard of “Pavlov’s dogs.”

Ivan Pavlov was a Russian psychologist who performed a series of experiments on dogs at the end of the 19th century.  One of his chief discoveries was the “conditioned response.”  When a dog – or a person – is trained through repetition to expect an outcome from a certain set of variables, it is difficult to un-train that expectation.  It becomes a reflex.

Pavlov trained his dogs to expect to be fed when he rang a bell.  Eventually, just ringing the bell would make the dogs salivate, as they came to predict food was coming when they heard it.  The bell and the food were firmly linked in their brains.

That’s what happens with people when they get stuck in a loop, like my patient.

He learned he could please his father briefly, but his father’s acceptance would soon be followed by a mood reversal and attacks.

Now, with his girlfriends, he once again sought to please, but then shut down.  He was certain the old pattern would play out, so he refused to let them get close.

The problem was obvious: my patient was not a dog – and his girlfriends were not his father.

The instinct that once protected him from the pain of his father’s rages now sabotaged his chances at a healthy relationship.  To shed this old conditioned response, he needed to become aware of it.

A psychotherapist doesn’t change you.  He creates awareness.  If I show you a pattern of behavior that’s not working for you, you’ll figure out how to change it on your own.

If I tell you that you’re standing in a pot of water over a fire, you’ll jump out of the pot.

I show you the situation – you handle the fix.

There’s something psychotherapists call “the observing ego” – it’s like a little guy who sits on your shoulder and watches you from the outside.  He represents self-awareness.

My patient was developing an observing ego.  He kept having “deja vu” moments.  He’d been down this path before, and he knew it.

Now he wanted to change the old pattern – and try going someplace new.

I’ve worked with enough patients over the years to recognize that human beings are flexible – they change.  When I meet someone I haven’t seen in a long time, I suspend expectations, because I know people are moving targets.

You can change, too.  You don’t have to walk in circles forever.

If you spot a pattern that feels like a loop, take a turn and head someplace new.  At least you’ll know it’s really you at the controls – not one of Pavlov’s dogs.

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Sarah Palin’s nickname in high school was “Sarah Barracuda.”

Supposedly, this reflected “her competitive streak.”

Charming.

How did this happen?  How does a child grow up with a grasping nature so extreme that she becomes nicknamed after a vicious carnivorous fish?

There aren’t many clues in Palin’s early biography, which reads like a carefully pruned and polished star cheerleader’s resume…which, of course, it is.

Sarah was born the third of four children.  That’s our one clue.  Perhaps she had to compete for attention with older and younger siblings.

At some point in Sarah’s life – I’d guess the first five minutes – she decided there wasn’t enough out there for her.  At least, not enough out there for her if she was going to share any of it with anyone else.

Maybe it was a sense of poverty.  Maybe the Palins were poorer than their neighbors.  Or maybe competing with those siblings was enough.  But somewhere during that childhood, profound feelings of deprivation developed in Sarah’s psyche, and a famine mentality set in.

After that, all we can do is sit back and watch a mighty appetite gobble everything in its path.

When people are subjected to a severe deprivation, like a famine, they hoard and deny others and generally act in ways they aren’t proud of.  During the famine in China that occurred as a result of Mao’s Great Leap Forward campaign in the late 1950’s, widespread starvation led to cannibalism among the rural peasantry.  Hunger can drive people to do terrible things.  They can turn vicious.

A bit like a barracuda, tearing off hunks of flesh to gulp down its maw.

A bit like Sarah Palin.

Here’s a charming quote from the Barracuda herself:  “I love meat. I eat pork chops, thick bacon-burgers, and the seared fatty edges of a medium-well-done steak. But I especially love moose and caribou.”

The mental image is of a gaping mouth, with sharp teeth.

How about her politics?  Could they even be considered politics?  Mostly, it boils down to Sarah, Sarah, Sarah – and making money for Sarah.

She quit her job as governor to give speeches to the highest bidder, write a book and work on tv – all for enormous sums of cash.

She was willing to speak (and no doubt thrill and inspire) the Tea Party wackos – for many, many thousands of dollars.

Even when she was working for John McCain, it was clearly all about Sarah – her expensive clothes, her big family (she has five children), her gigantic super-church, her enormous state – even the humongous “big box” stores she enticed to the little town of Wasilla to replace its now-moribund downtown.

Something in Sarah’s background left her feeling hungry – deeply hungry – and she is still grabbing up everything at the table.  Her “politics” are a philosophy of greed.  She can get married – but gay people can’t.  She doesn’t want to pay taxes – even to help other Americans survive.  She’s got her healthcare – if you don’t have yours, well, tough luck.  She’ll drill for every drop of oil in a nature sanctuary until her giant SUV is purring like a kitten, slurping it all down, belching, and demanding more. Immigrants can stay out – this country is Sarah’s, securely stolen from indigenous peoples and guarded with guns guns guns and more guns, wonderful guns.  Sarah doesn’t like government – she wants to go it alone, because she’s got hers, and you can worry about yourself, thank you very much.

Sarah wants to get a gun and go out in nature and kill something beautiful and devour it.

A couple more charming quotes:

“If God had not intended for us to eat animals, how come He made them out of meat?”

“I always remind people from outside our state that there’s plenty of room for all Alaska’s animals – right next to the mashed potatoes.”

Sarah is a predator.  She’s earning a lot of money chomping her way through a frightened minority of mostly older, white Americans who are terrified of the future and will buy all the double-cheeseburgers, super-size fries and giant cokes they need to maintain a secure perimeter of human fat cells.  Hunkered down in their gated retirement communities, clinging to their beloved guns, they crouch by the glow of their wall-size flat-screen plasma tv’s and defend what’s rightfully theirs – which is to say, everything.

Sarah represents insecurity in love.  Somewhere along the way, early on, she decided there wasn’t any love out there for her.  So she had no love to spare for anyone else.

Kill or be killed.  Eat or be eaten.

There’s room for you next to the mashed potatoes.

That’s the barracuda’s creed.

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My patient, a senior associate doing IP litigation at a downtown firm, brought me the bad news.

“I got a terrible review last week.”

She seemed calm about it, considering. That’s because she knows how law firms work.

“I’m expensive, and they’re preparing for lay-offs. So they told me I’m terrible. It was ridiculous. They made stuff up off the top of their heads.”

I had to hand it to her. I wish I could have been so cool when the same thing happened to me.

My first year review at Sullivan & Cromwell went fine. Mostly, they didn’t seem to notice me. I wasn’t important enough to review.

Then, in the second year, it was suddenly a horror show. Nothing I did was right. The partners didn’t fool around at S&C – they give it to you with a sledgehammer.

Even then, I remember wondering about that one partner who seemed to like me. Of course, he wasn’t mentioned at the review.

Years later, after I’d given up on a legal career, I realized the truth. They’d probably given identical reviews to ten or fifteen percent of my class that year. We were the ones who left. It was a lay-off. Those terrible reviews were the partners’ way of creating a paper trail in preparation for letting us go – covering their tracks in case we sued.

My patient – an experienced senior associate at her second law firm job – knew how to handle this sort of thing. You don’t let them throw you.

(more…)

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When gay people come out of the closet, they usually run into some variation of the “but that’s unnatural” argument.  This is the apparently sensible claim that it doesn’t make sense to be gay.  Isn’t sex for procreation?  Why would two males or two females become romantically involved if they can’t have a child together?

It seems like a reasonable argument.  You can point out that some sort of gay behavior occurs in every species in the animal kingdom – which is true – or that gay sex is simply fun – also true.  But that only begs the question.  Why?  Why are there so many gay animals, and people, in the world when reproducing your own kind is the basis for a species’ success?  Having fun doesn’t seem to explain this apparent contradiction.

The answer is that gay people help nature hedge its bets.  A successful species typically keeps extra cards up its sleeve because the rules of the game can change without warning.  Gay people represent some important extra cards.  They are a natural, genetic variation that helps guarantee the successful raising of young.

Many species show wide genetic variation.  Dogs, for example.  You can breed a chihuahua that weighs 2 pounds.  Or you can breed an Old English Mastiff that weighs 300 pounds.

Why should canine genetic material be so mutable?  Because being tiny – or being huge – might come in handy.  You never know.

The ultimate disaster for a species – extinction – happens when its members fail to adapt to an altered environment.  That’s why you want to have as much flexibility as possible to respond and survive when something unexpected occurs.

It could be a meteor striking the Earth.  Or a volcano erupting.  Or a pandemic disease wiping out three-quarters of the population.  The game can change – and a species has to change too – sometimes a lot – in challenging new circumstances.

Having gay members of your species could make the difference between survival and extinction.  Gays are unique – and vitally important -because they do something no other members of that species will do.

I don’t mean have gay sex.

I mean raise other people’s children.

Gay animals are perfectly happy to pair-bond and mate with members of their own sex,  so their sexual relations are non-procreative.  They do not have children with their partner.  That means they are available to raise another animal’s children.

Say a heterosexual zebra, or otter, or muskrat or human is killed and leaves behind a helpless child.  Heterosexual animals, who can have  children of their own, will probably refuse to raise this other animal’s child, or at best do so grudgingly.  They have their own children, who are a higher priority because they will pass on their genetic material.  But a gay member of the species will happily step in and raise that helpless child.

He has no reason not to.  He is not caught up in the battle to mate and reproduce.  His preoccupation is caring and nurturing within a relationship.

If a male animal loses a female partner and is left with children who need care, he might have trouble locating another female willing to raise these children.  But a gay male would happily accept the job.

If a female animal loses her male partner and is left with young to raise, another male might reject the task of raising those children.  But a gay female would, similarly, be happy to help out.

Gays play a role in increasing the success rates for child-rearing in all species.  In the event of a large-scale disaster, resulting in many adult deaths, gays could fill an especially vital role in helping to raise the young.  They would not compete for sexual partners.  But they would help out with the kids.

It could make the difference to a species’ survival.

That’s what’s happening right now, with humans.

Many heterosexual human couples have children they are unable or unwilling to raise.  These children are put up for adoption – but there are too many of them to be cared for solely by heterosexual volunteers, who usually prefer to raise their own children.

That’s why, throughout the world, gays are the unofficial backbone of the adoption system.  Without them, many children would suffer terribly, never finding wiling, dedicated adoptive parents.

It is an open secret that in most states, the adoption system would collapse without the participation of gays and lesbians.  In 2007 it was estimated that there are 270,000 children living with same-sex couples in the USA.  Of these, one-quarter, or 65,000, have been adopted.  Gays are a small minority, perhaps as few as 4% of the general population.  But there is no question that gay people do a lot of adopting and provide loving homes for hundreds of thousands of children who desperately need them.

Unfortunately, in a few states, right-wing religious zealots have persuaded politicians to ban gay adoption.  It is not clear whether this misguided attack on children and the rights of gay people is constitutional.  A court battle is raging in Florida.

Meanwhile, these laws prevent gay people from playing a role nearly as ancient as life itself.  That is a tragedy, which could result in a calamity.

It’s also unnatural.

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Inevitably, a few times a year, a new patient refers to me as “doctor.”

I always flinch.

First of all, I’m not a doctor.  I don’t have an MD, which would make me a medical doctor – or even a PhD, which would make me a “Doctor of Philosophy” like a college professor.

Well, actually, I am sort of a doctor, kind of.  I have a JD, which makes me a Juris Doctor, or Doctor of Law – which means I’m a lawyer.  But I don’t think that’s what you mean when you call your psychotherapist “doctor.”

The fact is, people with a lot of different educations, backgrounds and degrees practice the art of psychotherapy.  Here’s the run-down of the most common professionals in my business, at least in the New York area:

1.  A psychiatrist. This is a medical doctor, who went to medical school and got an MD, and could, I suppose, probably remove your appendix.  In the mental health field, psychiatrists are the people who handle medication.  I occasionally refer one of my patients to a psychiatrist colleague when I think he might benefit from an anti-depressant or anti-anxietal or some other type of psychiatric medication.  Some of my patients get psychiatric drugs from their regular family doctor, but psychiatrists are the experts in this area.  They also work with patients who are very ill, such as those suffering from severe cases of schizophrenia, depression and bi-polar disorder.  Often these patients are seen in a hospital setting, due to the severity of their illness.

2. A Psychologist. A psychologist has a PhD, and many of them are affiliated with universities, where they may do research.  When you read an article in the newspaper on the results of a “study” – something like “people who have sex after 60 are more content with their marriages” or “teenagers who watch less television have higher reading scores” – that kind of social science study would be done by a psychologist.

Psychologists also work in Human Resources at corporations, advising on how best to manage employees, and they do psychological testing.  For example, if you want to give someone a test to see if they have Attention Deficit Disorder, you might send him to a psychologist for a set of tests.

3.  A Social Worker. This is the degree I hold.  Social workers are people who work with people in all kinds of settings.  “Clinical social workers” are social workers who, perhaps in addition to helping people navigate their way through social services, obtaining housing and so forth, also do psychotherapy with their patients.

It might seem like this is a list in order of quality.  After all, if you can get a “real” doctor – why settle for a mere PhD posing as a doctor or some measly social worker?

Freud was plagued by just such questions.  When his trusted protege, Theodor Reik, came to America and tried to practice psychoanalysis (which was more or less another word for psychotherapy), he was attacked by a group of medical doctors, who accused him of illegally practicing medicine.  Freud ended up, in 1926, writing an entire book in Reik’s defense, “The Question of Lay Analysis.”  In it, he said essentially that there’s no reason a psychotherapist needs to be a doctor, unless he’s doing something – like working with a severely mentally ill patient, or prescribing medication, which would draw on medical training.

I agree with Freud (which is convenient, I admit, since I’m a social worker.)

But there is a deeper issue here.

Anyone can do psychotherapy.  It is an art, and there are many different schools of thought regarding the details of how one works with a patient in a psychotherapeutic way.

The truth is I didn’t learn most of what I know about psychotherapy from Social Work School – I learned it from my own work with other therapists, both as a patient and as a student.  I worked with two excellent psychotherapists in psychotherapy institutes, which is where young therapists (psychiatrists, psychologists and social workers) sometimes go to train.  Both had doctorates, but (I found out later) one’s doctorate was in Theater and the other’s was in Education.

I guess my point is that it doesn’t matter all that much what education you have.  Psychotherapy is experiential – you don’t learn it in a classroom or from a book so much as from doing it yourself.

I also believe it is an innate skill, like playing the piano or being good at math.  At some level, you’re just born able to work as a therapist, or you’re not – and it doesn’t matter if you’re a dentist or a fireman – you might be a good therapist, or you might not.

Most of the degree and licensing stuff is pointless.  It would probably be better – as in the old days – to let anyone go to an institute, study with some therapists, and – if they feel the urge – hang a sign and practice psychotherapy.  If they’re good, they’ll flourish.  If they’re not, they won’t.

That might sound crazy, but that’s how Taoist fortune tellers get started.

A few years ago, visiting Hong Kong with a friend, we happened to wander into a Taoist temple, and he suggested we visit a fortune teller.  This is very common in Hong Kong – some people visit a fortune teller regularly, some just when there’s something troubling them that they want to work out.

First, you shake some bamboo sticks from a cup.  The ones that fall to the ground have numbers written on them.  Those numbers somehow guide the work of the fortune teller, who sits in the back of the temple in a special booth (there may be many fortune tellers working in a large temple.)

So, I shook my sticks, recorded my numbers and went with my friend for a consultation.  It was entirely in Cantonese, so my friend had to translate.  We paid a small fee (there’s always a small fee.)

The fortune teller turned to me first, eyed me curiously, and said “You are kind to your former lovers.”

I was staggered.  My first partner died young, many years ago.  I’ve always made it a point to reach out in affection and friendship to former partners, after having lost someone who was so precious to me.

Then he turned to my friend.  “You act confident at work, but you are not so confident inside.”  Of course, my friend had started a new job that month, with a major promotion.  He was demolished by this insight.  “How did he know?”  he kept asking for days afterward.  It was the first time he’d admitted to himself that he was feeling overwhelmed by his new responsibilities and needed support.

I had the clear sense that this “fortune teller” – an old man in a silk jacket at a Taoist temple – was a colleague.  Clearly a skillful psychotherapist, he was working in a different modality, but essentially doing what I do – observing, listening, and offering insights intended to create awareness.

He offered us longer, weekly sessions – for a slightly larger fee.  We had to decline.  I think we were both tempted, but we had to fly home the next day.

It doesn’t matter what degrees you have.  What I do – psychotherapy – is practiced in one form or another by fortune tellers, palm readers, priests, shamans and people holding every other crazy title you could imagine.

We’re all doing the same job, which is as old as humanity itself.

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Last October, a law school placement director friend of mine forwarded me an email with a juicy piece of big law gossip. A former associate at Sullivan & Cromwell had offed himself. He was 39.

The body was discovered beneath a highway bridge in Toronto. A few days earlier, it was revealed that since the mid-90’s, he and a co-conspirator made ten million dollars on an insider trading scheme. He’d stolen insider information from S&C, arriving early in the morning to dig through waste baskets, rifle partners’ desks and employ temporary word-processor codes to break into the computer system.

“You can’t make this shit up,” was my friend’s comment. “Wasn’t he from around your time?”

It took a minute to locate the face. Gil Cornblum. Jewish, a bit pudgy, with big round glasses. Gil, in that ridiculous little office two doors down from mine.

What was Gil like? Mild-mannered, pleasant, always smiling.

I should have known something was wrong.

The pieces fit together.

Gil kept weird hours. He used to chuckle that he liked to get in early so he didn’t have to stay late. It turned out he was in at 5 am, combing the firm for insider tips.

The lavish wedding, too. A mutual friend was invited up to Canada to watch Gil tie the knot, and was blown away.

As people do in these situations, I stopped for a moment to contemplate Gil’s death. His body was discovered at the bottom of a highway bridge. He was still breathing, according to the bits of news I found online.

So far as I could tell, that meant portly, lovable Gil Cornblum threw himself off a bridge on a Canadian highway in the middle of the night and lay on the bottom – of what? A rocky riverbed? – shattered and dying.

Suicide amounts to punishing whoever is supposed to take care of you because you feel their care is inadequate.

Certainly, the care we all received at S&C was inadequate, and we committed suicide a little each day just by staying there and putting ourselves through that abuse as our lives passed us by. Our slow suicide manifested in other ways as well. Most of us mistreated ourselves by neglecting our health, letting our friendships die off, ignoring our families, our hobbies, our lives.

Maybe insider trading was Gil’s grand suicidal gesture, his protest against the abuse he received. He put his entire life on the line, knowing he might well be caught, end up in jail and lose everything. He was playing Russian roulette, and maybe he knew he’d kill himself if he got caught.

And all for what? Money.

(more…)

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Gerald Lucas, a psychotherapist who runs an institute in New York City, used to tell his patients he regretted he couldn’t make the world a better place – he could only make them better able to handle it the way it is.

Sometimes the key to happiness is a little like the key to Weight Watchers – learning to stay away from things that are bad for you.

Luck certainly plays a role.  My relatives fled to the United States from Poland and Lithuania because the Czar and other nasties were oppressive, violent rulers.  Forty years later, Hitler rolled in and committed the worst crimes in human history.  It could have been my relatives in those Nazis death camps, but for dumb luck and the determination to leave the bad behind and seek something better.

The world can seem like an unpleasant place sometimes.  If you need evidence, open this morning’s paper and take a look.

As a psychotherapist, patients bring plenty more proof that evil exists.  It’s a good wake up to some harsh realities.  As with everything else in psychotherapy, awareness is all.

One of my patients was violently raped in her early twenties.  Working with a rape survivor taught me a lot about human dignity and the process of recovery from trauma.  It also taught me about rape.  Knowing someone who has been victimized by violence introduces you the fact that it really happens, to real people, all too often.

This woman gave me a book to read about rape, “Lucky,” by Alice Sebold, the author of “The Lovely Bones.”  It is a memoir of Sebold’s own experience of rape, and a book I shall never forget.  My patient taught me another important lesson:  if something like that happens to you, you will do everything in your power to avoid letting it happen again.  She took a self-defense class, carried a can of mace, and never again walked home alone late at night.  There are predators out there, and at very least, you can take all available precautions.

So this week, when a beautiful young female patient complained to me about what she’d been through recently, I wasn’t surprised.  In the past year she’d had a guy slip a drug into her drink, an older man – a professor, no less – approach her inappropriately for sex, countless construction workers whistle at her, and a best friend fall victim to domestic violence, then return to the boyfriend who beat her up.  It was quite a list, but I believed every word.  We talked about how she could be careful – and stay away from people who mean her no good.

Another patient I saw recently had a run in with a sociopath, a person who lacks a conscience.  A sociopath will tell you whatever you want to hear, take pleasure in lying to you and generally not give your feelings a thought as he pursues his own agenda.  “Sociopath,” or the technical term, “Anti-social Personality Disorder,” are arguably just mental health lingo for a criminal.  Many of the people who populate our prisons – the hard-core law-breakers – are socipaths.

The sort of run-in that happened to my patient could happen to anyone, and all too often it does.  It’s not a nice experience.  This guy was very charming, and appeared to have a successful career.  He moved in with her and said he wanted to marry her and have a child.  What he didn’t mention was that he already had a family – a wife and children – who knew nothing about this other relationship.  The “business trips” were spent with this family, 20 blocks away.

My patient asked what she could do now that she’d discovered the truth.  I gave her my blanket advice for dealing with sociopaths:  stay far away.  She moved somewhere else, and hasn’t seen him since.

Obviously, women aren’t the only people who are victimized by evil deeds – although they do seem to receive more than their fair share.  Children are victimized in terrible ways each and every day, and  I’ve worked with adult men who have survived domestic violence, sexual abuse and other ills.  Bad things can happen to anyone.

My point here isn’t that the world and everyone and everything in it are bad.  There is plenty of good out there, too.  It’s just that you need to keep what is bad far away – and, at the same time, pull the good nice and close.

In everyday life, that means more than just staying away from predators and sociopaths.

It also means:

Don’t date someone if he doesn’t treat you with kindness, consideration and respect.  He should be grateful and appreciative to have you in his life – or you can find someone who will be.

Don’t work in a setting that is hostile or toxic.  Your workplace should make you feel appreciated for the work you do.  You should look forward to coming in to work each day – or you should work someplace else.

Don’t consider someone a friend unless he’s got your back.  “Friend” is a powerful term – it means someone you can say anything to and who can say anything to you.  It implies loyalty, caring, trust and respect.  Anything less is an “acquaintance.”

Breathe in the good.  Breathe out the bad.

Sometimes it’s that simple.

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The orgasm has been compared to a sneeze – they’re both involuntary muscle spasms.

I think I can draw a more useful parallel:  a laugh.

Laughing is certainly more fun than sneezing, and there’s another useful similarity – they’re both about relaxing, and letting yourself have fun.

Most of my patients who have trouble attaining an orgasm are able to climax when they’re alone, but not with another person – especially not with someone they know.

It’s hard to relax enough to have an orgasm in someone else’s presence.  It’s also hard to laugh with a stranger.  That’s why the number one thing my patients say they are looking for in a partner is “someone who can make me laugh.”  It’s a sign that you’ve achieved a connection – you can let go and relax and laugh.  You feel safe enough to be yourself.

Sex is a barometer for communication in a relationship.  If a couple stops having sex, their communication has usually shut down.  There’s something they aren’t talking about, and it shows.  They’ve tensed up and stopped talking – the trust in their relationship is compromised.  That breakdown of trust is reflected in their discomfort opening up sufficiently to do something as awkward and private as get naked and have sex.

For some of my patients, having sex with strangers is easier than sex with someone they know because they can hide with a stranger.  In some sense, they are alone, since there’s no real connection, so they can let go.

It’s interesting that a good comedian’s job is to relax us enough that we laugh in the presence of others.  The best comedians can make you laugh even if you’re trying not to – it really is involuntary.  They do this by surprising us with forbidden communication.  Ironically, one of the easiest way for a comedian to get a cheap laugh is by “working blue” – talking about sex in an open way that surprises the audience into admitting truths about themselves.

In order to relax enough to have an orgasm, you need to own the forbidden feelings around this act of supreme openness. Instead of beating yourself up for having a “problem,” you can treat your feelings with respect, own them, and explore them.

Why is it scary to open up and relax around another person?

Probably because when you did it before, in the past, you got hurt.

Simple enough.  A trained response, just like Pavlov’s dogs.

So you’re going to have to respect that trained response, and address it by reassuring yourself that this time you’re safe.

Maybe, as a child, it wasn’t safe to open up and be yourself, relaxed and present.  You learned to close down and assume a defensive posture.

But as an adult, there’s nothing you can’t handle – because you always have yourself nearby.

Someone’s got your back.

So go ahead.  Laugh.  Or sneeze.  Or whatever.

It’s going to be okay this time.

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The People’s Therapist now has fans.  Literally.

I’ve created a “fan page” on Facebook.

To become a “fan” please go to my Facebook “fan page” and click “become a fan.”

Voila!

You will subsequently become eligible for all the rights and privileges that befit a loyal fan of The People’s Therapist.

Mostly, that means I can send you updates about the site and perhaps the publication of a book or an event I’ll be featured in – that sort of thing.

It will also make me feel good.

Thanks.

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Most of the Western world seems to have had a good laugh this week at an unidentified Arab ambassador to Dubai.

This gentleman rushed to annul his marriage contract and cancel his wedding after he finally got a look at his bride-to-be’s face and realized she was cross-eyed and had a beard.  She’d worn a niqab, a heavy veil, during their courtship, so he’d never actually laid eyes on her until moments before they tied the knot.

It’s a great story, and it does seem pretty silly to marry a woman when you haven’t even seen her face.

But before we laugh too hard at another culture’s ridiculous, sentimental notions, maybe we should take a look at some of our own.

Like marriage.

The People’s Therapist is well aware that he sounds like a grinch when he writes about this subject, but here goes.

Marriage makes no sense.  It is a lot of sentimental clap-trap.

And I’m sorry, gay folks, but you’re out of your minds if you think this tired old convention is going to make you any happier than it’s made the heteros.

A couple is happy because it’s happy.  Getting married, if it has any effect at all, usually only helps to break you up.

Before you start drafting that angry comment, consider the reality of a wedding.  You stand with your partner, your best friend, someone with whom you share a very personal, private relationship – in front of a roomful of family, friends and near-strangers. What do you do in front of all those people?  Promise you will stay together forever.

No one can promise that.

A relationship takes place in the moment.  You probably have a shared dream – someplace you want to go together, and that’s great.  But no one knows if that dream will last, or if you’ll get there.  That’s why it’s a dream.

Relationships are like movie film – lots of tiny boxes with a little piece of shared experience captured in each one.  When you take all those little moments of shared experience and line them up, it tells a story that seems inevitable.  But it never was inevitable, and there’s no way to know what’s coming next.

The worst part is that couples often become hyper-focused on the wedding itself.  These affairs can be enormous undertakings nowadays, which grow into monsters that gobble your life.  The wedding -essentially a big party for your relatives – can become the shared dream.

That means, when the wedding’s over…there’s nothing left to chase.  Some couples find themselves staring at one another, blinking in the sunlight, wondering what to do next.  And that thing to do next might not be something they want to do together.

Maybe the ultimate reason I’m so down on marriage is that I’m a therapist, and I’ve seen divorce, up close and personal. And yes – gay divorce, too.

It’s awful.

I don’t know if it’s the rotten state of divorce laws – they date back to the Victorian era, when a woman was essentially a piece of property – or just the broken dream itself, but people can lose their minds during divorces.  I’ve seen couples sue one another until they’re both bankrupt, and then keep suing.  The lawyers are happy to take their money until there’s none left, at which point they walk away and leave the unhappy partners to battle it out on their own.

It’s ugly.

But most marriages end that way.  In divorce.  In the US, 50% percent of first marriages, 67% of second and 74% of third marriages end in divorce.

Wow.

I’m sorry. I might be the Grinch. But I didn’t invent that reality.  It just is.

Instead of bemoaning the death of family – or whatever you want to call it – how about we face the fact that you can’t judge the quality of a relationship based upon its longevity.  You might spend a marvelous three years with someone and decide that it’s time to move on. Or you might stay together for sixty years and be totally miserable.

It’s not about staying together with the same person forever.  It’s about finding something that works in the moment – the here and now – and enjoying it.  Wake up each and every day as though it were the first day all over again, and decide then and there if it’s  where you still want to be.  If it is – great.  It is isn’t – also great.

Why does that seem so awful?

Because there’s a child inside you who longs for stability.  All children crave stability – it’s what they thrive upon.  And marriage regresses us into that child.

An adult doesn’t need a relationship or a ceremony to provide him stability.  He carries it within himself.  He can leave one relationship, be by himself, or enter another relationship.  It doesn’t matter that much.  He’ll do just fine.

An adult doesn’t need a parent – he contains his own parent.  His partner can be his friend, his ally, his playmate, his companion – his equal.

An adult is a whole person, not a half person.  And if the other whole person leaves to try something different, he remains a whole person.

I suspect there ought to be some sort of legal protection for couples who have children.  Perhaps civil union is the answer for those legal issues.

But traditional marriage is a silly, out-dated custom.

When you pull up the veil, and see what’s really there, you might be in for an unpleasant surprise.

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The other day, I was listening to a patient explain to me why he was ugly and no one could possibly find him attractive.

This was news to me, because so far as I could tell he was a very handsome guy – film star handsome.  It was a puzzling case.

Let’s talk about beauty – plain old physical appearance.

The first steadfast rule is summed up by the old cliche – beauty is in the eye of the beholder.

If you’ve never thought about what that really means, let’s do it here.

The fact is there is no standard for beauty.  That’s a myth.  The gossip mags and entertainment shows on television hold up one star after another as the ideal, but it’s not true.  Only you decide to whom you are attracted, and your taste doesn’t have to match anyone else’s.

Different eras have held widely varying ideas about what is beautiful.  Even now, Americans are only beginning to open their eyes to the beauty of different ethnicities whose images were almost entirely absent from the popular media for centuries.

Just as you have a right to decide whom you think is beautiful – other people have that right, too. And it is quite possible someone might decide his ideal of beauty is…you.

My patient had been told by various people that he was handsome, and some had even attempted to pursue him, but he’d always dismissed their interest.  He couldn’t accept that other people didn’t see what he saw when he looked in the mirror:  he was too short, had bad skin, bad teeth, a bump on his nose.  Even as he enumerated these terrible flaws, I strained to see what he was talking about.  I looked – and saw a handsome guy.

The problem wasn’t with how this guy looked.  It was with the messages he was given as a child.

His parents had him when they were very young, and their marriage soon broke up.  The father, caught up in a nasty divorce battle, fought for custody of my patient and won it, only to dump the boy on resentful relatives.  My patient grew up receiving the message that his presence was a nuisance – that people wished he wasn’t there.  He learned that he was nothing special – certainly no one whom anyone would notice or be attracted to.

My patient went on to succeed in his career, against the odds.  Despite his parents’ disinterest, he worked hard in school and rose to an impressive position in the business world.  But he still felt ugly – nothing special.  His physical appearance became a container for all the feelings his parents put in him about himself.

In our session, I reminded him that his parents were old now, and far away – he hardly saw them anymore.  Nowadays he was the one in charge of parenting the little boy inside him.  And he was doing a lousy job of it.

I asked him when he first became ugly.

He shrugged.

I asked him whether he was ugly back when he was a little boy.   Was he ugly at 6?  At 10?  At 12?  When did the ugliness first arrive?

He shrugged, and said he’d always felt that way.

I asked him if there was such a thing as an ugly little boy.

He said, no, probably not.

So were you ugly when you were 7?

He said he didn’t know – probably.

I said of course not.  There is no such thing as an ugly 7 year old.  In fact there is no such thing as an ugly child.  No child is ugly because every child is unique and beautiful.

So why are you treating this child with such cruelty – telling him such terrible things about who he is?

The messages my patient was addressing to his child were the same ones his parents sent him.  A psychotherapist calls these messages “negative introjects” – voices that were put inside you as a child, messages that keep playing years later, like:

You are a nuisance.  You are nothing special.  You are always in the way.  We wish you weren’t here.

I asked him to create some healthier messages for his child self.

He looked at me blankly.   Like what?

Well, let’s pretend your mother wasn’t absent from your life when you were little.  Let’s pretend she took you up in her lap when you were a boy and said something like:

You are my little one, my precious little fellow.  You are handsome and good and you make me proud.  You are my boy, my special boy.  You are beautiful.  You are my treasure.

Tears started to run down my patient’s face.

She never said anything like that.

I know.  But you can say it.  You don’t have to feel ugly.  There’s nothing ugly in you and nothing ugly about you.  You deserve love because you are beautiful.  Inside and out.

Please don’t tell your child he is ugly.  He isn’t.  He’s you, and he deserves your love, so he can learn to accept love from the world outside.  It’s critical to his happiness.  Please be a better parent to that little child.

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The People’s Therapist displayed his legendary tact and discretion during a recent interview with the lovely and talented Kashmir Hill, Associate Editor of the esteemed yet tasty legal blog, AboveTheLaw.com.

Despite my best efforts, tongues appear to be wagging regarding certain shocking revelations about The People’s Therapist’s previous incarnation as a high-powered Wall Street lawyer at Sullivan & Cromwell, a top white-shoe firm.  To put it bluntly – though I am loathe to – I told the truth about the toxic environments at big law firms, and the psychological toll they take on the people who work there.

Twitter is a-buzz and Buzz is a-twitter with these shocking revelations.  Facebook is…uh…blue in the face.

Curious?

Here’s the link for the interview.

For more juicy brilliance from the lovely and talented Kashmir Hill, you can also check this out this site (highly recommended by The People’s Therapist.)

Those of you with heart conditions or delicate sensibilities – please exercise caution.

This material may be inappropriate for young children or those recently graduated from law school.

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Children need a lot of attention.  When they don’t get it, they’ll often act out – misbehave – in a desperate attempt to be paid attention to, even if the result is negative attention.

I had a patient who used to vomit frequently as a child.  It became an unpleasant regular event during family meals – but he managed to distract his mother for a few minutes.  Even if she was cross and impatient with him, at least she was paying attention.

Scott Brown, the newly-elected US Senator from Massachusetts, grew up in a family where there wasn’t much time available to devote to raising children.  His parents divorced when he was an infant, and both the mother and the father have since remarried three times each.

Scott’s mother was living on welfare at various periods during his youth, and Scott sometimes ended up getting shipped off to live with his grandparents or his aunt.  He had siblings, too.  My guess is there were enough other children around to consume whatever time was available for Scott.

How did the young Scott Brown respond to this situation?  He acted out – badly.  By the time he was 12 years old, Scott was arrested for shop-lifting from a record store and brought before a judge.

This is where things get interesting.  Brown’s story is that the judge, Samuel Zoll, shamed him by sentencing him to write a 1500-word essay on how his siblings would feel watching Brown play basketball in jail.

The People’s Therapist suspects something else happened, too.  Scott had finally forced a father figure – Judge Zoll – to pay attention to him.

That’s why he stole from the record store in the first place.  He didn’t need records.  He needed a parent-figure’s attention.  And he got it – even if it was negative attention.

From that point on, we see a string of events suggesting that grabbing attention – even negative attention – became an unconscious impulse in Brown’s life.  Here are a few examples that jump out at you:

1.  Posing nude for Cosmopolitan Magazine as a law student;

2.  Using the “F-word” as a State Senator during a debate on gay marriage at a high school; and

3.  Presenting his daughters, Ayla and Arianna Brown, as “available” (whatever that was supposed to mean) during his acceptance speech for the US Senate.

The biggest attention-getter of all was politics itself.  Brown seemed to run compulsively for everything there was to run for, from Property Assessor to Selectman to State Representative to State Senator.

This latest campaign, for the US Senate, was an even bigger attention-getter, and once again, it was negative attention. Brown’s role was the spoiler.

Teddy Kennedy, a legend in the Senate, devoted much of his life to fighting to guarantee decent healthcare for all Americans. On the cusp of achieving this goal, Kennedy died after a courageous battle with brain cancer.  Brown’s job?  To get elected on a wave of Tea-Party cash, so he could shatter Kennedy’s dream.  Brown had to get elected so he could be the 41st vote that would allow the small Republican minority from mostly under-populated states, representing an even tinier minority of Americans, to abuse the filibuster rule and destroy years of hard work by blocking healthcare reform.

We can only hope a father figure – perhaps President Obama could fill in for Judge Zoll? – will arrive to give Brown the attention he needs.  Maybe he should be forced to write a 1500-word essay on how his siblings would feel watching him destroy a chance at decent, affordable healthcare for millions of Americans.

This country has had enough of angry little children in positions of authority.

We need leaders who can behave like adults – who win our admiration for what they achieve.  We do not need another attention-grabbing miscreant who will stop everyone in their tracks by throwing up at dinner.

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Here’s further evidence that Sigmund Freud didn’t invent the concept of psychotherapy out of thin air:

There was a precursor, and his name was Charles Dickens.

Way back in 1843, thirteen years before Freud was born, Dickens wrote a book summing up the process of psychotherapy.

The title of this scholarly tome?  You’ve probably read it – or perhaps you are familiar with one of the film versions.  My personal favorite stars the legendary Scrooge McDuck.

I’m only half-kidding.  So let’s review the storyline of A Christmas Carol, and see how it relates to the process of psychotherapy.

The plot should be familiar to most of us:

It’s Christmas Eve, and the old miser, Ebenezer Scrooge, is at his office, being unpleasant to everyone around him.  Scrooge scoffs at his nephew’s invitation to a Christmas party, refuses to donate to charity and scolds his employees, letting everyone know his top priority is money, not relationships with other people.

The diagnosis is pretty clear.  Scrooge is unconsciously clinging to money as a surrogate for love.  He doesn’t feel cared for by anyone, and perhaps he believes he is undeserving or incapable of attracting the love he needs.  Scrooge discharges anger indiscriminately at whomever is nearby, chasing away anyone who attempts to offer him care.

Eventually Scrooge leaves his office and heads home, where he is confronted by the ghost of Marley, his old business partner, who has organized an intervention. Marley informs Scrooge in no uncertain terms that he has to do some work on himself or he’ll end up just like Marley did – dragging metaphorical chains around, miserable and unloved.  Marley recommends psychotherapy.

Plenty of my patients come to me on the advice of friends.  There’s something about hearing from a good old comrade for the one hundredth time that you “really should think about seeing a therapist” that eventually brings someone around.  That’s especially true when – like Scrooge – it’s clear that you’re miserable.  It also helps when the friend, like Marley, admits he’s had some of the same issues himself.

Marley goes so far as to recommend his own therapists – and to make the appointments.  He lets Scrooge know that three ghosts will be dropping by that night for some serious counseling work, and that it will be very experientially-oriented, probably with a Gestalt focus and incorporating some aspects of psychodrama.  Marley has even paid the fee in advance.  There’s friendship for you.

Scrooge is skeptical – after all, he’s never done psychotherapy before, so he figures he’ll play along, but doesn’t expect much.

The first ghost arrives – the ghost of Christmas past.  He’s an old school psychoanalyst and wants to start right off with deep psychodynamic exploration – digging deep into Scrooge’s past, examining the environment in which little Ebenezer grew up and how it shaped his patterns of behavior and the assumptions he makes about the world around him.

Scrooge learns that his fear of risking authentic contact – opening himself up in a way that would permit meaningful contact with others – resulted in his fleeing to money as a replacement for the love he needed.  Instead of being generous and open-hearted like old Fezziwig, his first employer, and containing his anxiety, Scrooge acts out on his unexamined feeling and flees from Belle, the girl he loves.  Scrooge ends up surrounding himself with money – a compensation for feeling that he is unloved and unlovable.

The next therapist (er, ghost) to visit is representing Christmas present.  This guy is probably from the Albert Ellis Institute – his orientation is clearly cognitive-behavioral.  He has no time to waste digging into the past and finding precursors for Scrooge’s behavior.  This therapist wants to work horizontally, not vertically – in the here and now, examining Scrooge’s thinking as it affects his daily behavior.  He takes Scrooge to see the folks who populate his life – Tiny Tim and Bob Cratchit at their humble home, and Scrooge’s nephew at a Christmas party.

Scrooge realizes he’s been self-isolating.  This is depression – Scrooge has been acting in on unexamined anger he’s long harbored at not receiving the care he needs.  His cognition – “money is the only thing I can trust” – needs to be reality-tested, and counter-thoughts formulated, such as “maybe people are important, too” and “perhaps if I stop being such a grump people might give me a chance.”

The third and final therapist arrives looking like he means business.  This guy is hard-core, probably one of those French existential types who reads a lot of Lacan and takes no prisoners.  This guy isn’t messing around.  He puts death front and center – the eternal inevitability at the conclusion of every life ever lived.  Scrooge sees what death really means – that his life is nothing more than a brief opportunity for joy – and that human connection is crucial to attaining that goal.  He realizes that this isn’t a dress rehearsal – it’s his one chance at existence, and he doesn’t get another run-through.

That does it.  The session with the French guy cracks Scrooge’s resistance, and new awareness arrives fast and hard.  He wakes up a new man.  With consciousness comes the desire for change.  Now that Scrooge can see himself – the roots of his patterns of behavior, the distortions in his current cognition, and the pressing insistence of his mortality – he longs to express his authentic self, his best self – to become the man he truly is.

Voila!  Another happy customer.  Psychotherapy changes another life for the better…thirteen years before the birth of Freud.

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The People’s Therapist was working out at the gym on the elliptical trainer the other day when he realized he’d come to the end of an issue of The New York Review of Books – his customary cardiovascular/literary fare.  In desperation, I reached for whatever other reading material happened to be lying around, and discovered a deliciously tacky gossip mag.

Flipping open at random, I found myself confronted with a headline about Prince William, the future king of England.  Apparently, he’s got a new girlfriend – Kate Middleton – and the rumors are that she’s “just like his mother, Princess Diana.”

What caught my psychotherapeutically-inclined interest was how commonly this trope – marrying someone like your parent – emerges in popular culture.  It’s so unremarkable that we take it for granted.

But it raises an interesting question:  Why does it seem like people really do choose partners who are just like their parents?

The answer relates to how you adapt, as a child, to your early environment.

One of the patients I saw this week, for example, grew up with a father who was extremely narcissistic.

When I use this term, I don’t mean it in the sense of merely being egotistical, but in the Freudian sense of being unable – like Narcissus in the Greek myth – to see past his own reflection and realize that others have separate needs and concerns.

The whole world, for this woman’s father, was about him.  He sucked up all the attention and ignored everyone else’s needs.  His wife – my patient’s mother – fell into a caretaker role, appeasing and placating him.  When dad had one of his rages, mother and daughter ran around doing whatever it took to calm him down.  Their own needs were ignored.

My patient evolved behaviors to handle living in an environment with a narcissist – mostly running around doing everything for him and always letting him have his way.  When she grew up into an adult, she went out into the world expecting to find another narcissist for a partner.  That would feel familiar, and almost comfortable, since it was what she was used to – it matched the skills she’d adapted as a child.  She knew everything there was to know about handling a narcissist – dating anyone else would bring fresh challenges she wasn’t sure she could handle.

Sure enough, later in life, my patient found herself dating guys just like her dad – high-maintenance guys who demanded all her attention but never seemed to notice her needs.

It’s as though my client – and perhaps Prince William and everyone else – adapted to an environment the way an animal evolves.  If you live in a pond, you evolve web feet.  Once you have web feet, you expect to live in water, because you aren’t much good anywhere else.

But humans aren’t ducks, and the strategies you adopt to survive in your childhood environment don’t have to become permanent physical characteristics.

Children have little choice but to adapt to their environment.  They don’t control much of anything – they need to adapt to survive.

But adults can choose the environment in which they wish to live, and they can shed an old adaptation if it becomes self-sabotaging.

My client didn’t have web feet, and she didn’t have to live in a pond.  She could change, and choose a new environment that better suited her adult needs.

That meant she could stop dating men like her father, and ask herself who she really wanted in her life.  It also meant she could learn new adaptations to address this new sort of person.

For someone used to placating and pleasing a narcissistic tyrant, it was an adjustment to meet someone calm and relaxed and caring – someone who expected a balanced give and take in a relationship.  My patient had to remember not to do everything for her new boyfriend, and to enforce her own boundaries as well as respecting his.

It was all rather new, and a bit scary – like a duck acquiring new feet and learning to live on land.  But she caught on fast.

Prince William, for his part, might choose to marry someone like Princess Diana, or he might not.  His mother may well have been a lovely, giving person and the perfect model for a mate.

The key is that the prince be aware of his unconscious adaptations and ask himself what he, as an adult, truly desires in a partner. He’ll never find what he needs marching blindly into an old pattern simply because it feels familiar.

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The couple sitting in my office were clearly in no mood for social niceties.  It was strictly down to business with these two.

There seemed to be nothing they agreed on.

She insisted he marry her as a sign of his seriousness.  He wanted to wait until she stopped verbally attacking him.

He hated her family and had a special loathing for her brother.  She said it was unfair for him to split her from those closest to her, and that she hated being forced to be the go-between in these situations.

She attacked him for not taking his career seriously enough or earning enough money.  He said that was unfair, since he’d had to work part-time for the past year while he cared for his dying mother.

It seemed like this might be a long evening.

During initial appointments like this one, a couples counselor has a variety of options for how to proceed.

One general rule, especially when things look dire, is to remind the couple that my goal isn’t to keep them together – it’s to create a greater awareness of where they are.  So I did that – reminded them.  And they shrugged.  Staying together wasn’t looking likely.  These two weren’t expecting miracles.

Next, I tried to establish the parameters of their issues with one another, and prioritize those issues.  I did some sentence completion exercises, in which they finished the phrase “this relationship would be more successful if…”  But this couple wasn’t having much trouble with that.  They knew their issues backwards and forwards.

I worked to get them to hear one another.  I had them repeat back a paraphrase of what the other had just said.  But they were hearing one another – they just weren’t agreeing.

I instructed them to to lead with their feelings when they addressed one another, employing “I-statements” in which they described their own feelings in response to the behavior of their partner – e.g., “I feel sad and hurt when you…”  They had no trouble detailing their unhappiness with one another.

I investigated how they were relating outside of my office, specifically how they were experiencing the partnership.  I asked them both to estimate what percentage of the time they spent together was “fun” for each of them.  They agreed it was fun about 60% of the time.  Not inspiring, but not hopeless.

Finally – in desperation – I used my secret weapon.  I asked them how they first met.

“Well,” said the guy, who was suddenly wearing a shy smile – the first hint of a smile I’d seen all night, “we’re both Puerto Rican.  And we were at a Puerto Rican club in Queens – someone’s birthday party.  And there was this beautiful girl across the room….”

She giggled.  “You were staring at me for about an hour.  I had to say something.  There was no way to avoid it.”

The secret weapon had worked.  In an instant, the mood had shifted.  From two people who looked like they wanted to kill each other emerged two people back on their first date, remembering what it was that brought them together in the first place.

A partnership is not intended to feel like a chamber of horrors.  It’s supposed to be fun.  There’s really no other reason to bother attaching your life to someone else’s.  You do it because you want to.

The first time you met your partner, you probably got together because you wanted to.

Later, if you hit rocky times, one good trick is returning to that first date and trying to figure out what happened to make things go wrong.

Generally speaking, problems arise when a couple switches from alliance – working together towards a shared purpose – to opposition – battling over everything.

These two in my office were like the US Senate: nothing could progress because all they did was argue.

Now that I had them at least smiling, I asked what their shared purpose was, the mutual goal that – back in those early days – originally brought them together in alliance.

They both grew silent.  It seemed a struggle just to admit that things had once worked.

He finally began to speak.  “Well, we were both Puerto Rican,” he said.  “And that meant a lot to us both.  We wanted to raise a traditional family.  We wanted to get a house together, with enough space to have lots of people over and cook a mess of food and have fun, the way we grew up – the way our parents would bring the whole family together for good times.”

“And we were both serious people,” She added.  “I take my job seriously as a nurse, and he was in law school, and he knew from day one that he wanted his own law firm.  We were both ambitious, but we shared the same values around work and family.”

So what happened?

The more we talked, the more reflective, and the less combative, they grew.  There had been a plan – a project – a sort of shining city on a hill in the distance, and they were walking towards it together hand in hand…until they lost their way.

That’s when the focus on where they were going disappeared, and they turned to battling one another.

A couple is drawn together for a reason.  They want to chase a dream.  If you lose that dream, you can end up enemies instead of friends.

Reject opposition.  Embrace alliance.

That person you’re living with is not your enemy – he’s your ally.  If he isn’t – you shouldn’t be living with him.

Maybe it’s time to renew your purpose, and make sure you’re both in it together.  It’s a lot more fun that way.

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Christine Daniels was a transsexual sportswriter.  For many years, she was known to thousands of sports fans as a columnist for the Los Angeles Times, writing under the byline “Mike Penner.”

Christine transitioned into a woman in April 2007 and began using her female name on her column.  In late October 2008, she returned to appearing, and writing, as Mike.  On November 27, 2009, she chose to take her own life.

This is a tragic story.  It’s also an opportunity to talk about gender – an important and often misunderstood topic.

We’ll begin by differentiating, and then examining, three gender-related variables that define all of humanity.  They are:

(1) gender assignment at birth;

(2) sexual orientation; and

(3) personal gender identity.

You can think of these variables as three separate sliding scales – everyone falls somewhere on a continuity within each one. You – like everyone else – had a gender assigned to you at birth, awakened in childhood or adolescence to some sort of sexual orientation and discovered within yourself some type of personal gender identity.

1. Gender assignment at birth: I’ll take this one first because it seems simple.  What could be more obvious that the gender you’re born with?  We’re all born either a boy or a girl, right?

Actually, that’s not the case.  Perhaps as much as 1.7% of the human race is born with a degree of sexual ambiguity, and between 0.1% and 0.2% of people are ambiguous enough to attract specialist medical attention, including, in some cases, surgery to disguise or correct sexual ambiguity.  These people used to be called “hermaphrodites” but the modern term for them is “intersex.”

Intersex people exist and always have.  They are a normal part of the range of human difference.  Unfortunately, they live in a world that mostly ignores their existence or treats them like freaks.  And they can have a tough time of it, dealing not only with the medical issues involved in their difference, but also the accompanying stigma of not looking, or feeling, like everyone else.

2. Sexual orientation: This variable should be familiar enough to most people.  Orientation refers to which gender you choose for a sexual partner – essentially, with which gender you choose to fall in love.

You’re probably used to hearing about lesbian and gay people and their lives, but even sexual orientation can get a bit tricky to parse.  Bisexual people exist, and sexual attraction can be fluid and change over time.  Sometimes people are surprised by an attraction they weren’t expecting to feel.

It should be common knowledge that gay, lesbian and bi people face discrimination and even violence in their lives, as they fight a campaign for greater understanding and acceptance of their difference.

3. Personal gender identity: This is where things get really interesting.  There are countless ways to experience one’s own gender, and perhaps even more ways to express it outwardly.

The transvestite – or “cross-dresser” is a person who enjoys dressing like someone of the opposite sex.  There are male cross-dressers and female cross-dressers.  A “drag queen” or “drag king” is a man or woman who is a performer, and cross-dresses as part of his or her work as an entertainer.

A transsexual is a person who feels that his or her gender assignment at birth incorrectly represents who he or she really is.  For example, a person with the outward appearance of a male at birth, but who is transsexual, will come to understand (usually during his early childhood) that he is actually female.  It is as though a female brain were placed in a male body.  Transsexuals often take hormones supplements or seek gender confirmation surgery to confirm their personal gender identity by matching it with the outward appearance of their bodies.

If this is beginning to sound complicated, that’s because it is.  There are countless terms used to describe people who express their gender in ways that don’t conform to societal norms.  My favorite, for its sheer simplicity, is “trans” – a sort of catch-all word for people who experiment with gender appearance and identity.  But there are many people who would argue with that definition and that usage.  That’s the nature of gender – it’s complicated, everyone is different, and the topic triggers fervent debate.  Mix in the additional complications of gender assignment at birth and sexual orientation and – well, you’ve got nearly endless diversity and plenty of room for misunderstanding.

Christine Daniels was a transsexual woman.  She decided to return to her male identity and live as Mike for the final year of her life, but I have chosen to honor the women whom I suspect she really was by referring to her as a female.

I have had the privilege and honor over the years to know and work with many trans people, including transsexuals and cross-dressers, as patients and as friends, neighbors and co-workers.  I have also known and worked with a number of transsexual psychotherapists, who remain valued and respected colleagues.

If it’s tough negotiating society as an intersex person or a gay man or lesbian, it is even tougher to live each day as a trans person.  I don’t know what it is about gender in particular, among the vast array of human differences, that ignites such misunderstanding and hatred.  Perhaps it is simply sexism.  The widespread oppression of women across the globe is an example of humanity at its very worst.  However you account for it, trans people face horrendous discrimination and persecution.

I have no doubt that Christine Daniel’s life was made more difficult by the misunderstanding of her trans identity.  Her death was a terrible waste.  We lost a talented, valuable, unique person.

You might think you don’t know any trans people.  Perhaps you do not.  It is far more likely that you do, but don’t realize it. Many transsexuals are “stealth” – they do their best to disappear into the background.  Their only desire is to live in a way true to themselves, and they are well aware of the persecution and violence that could greet them if they were found out by the wrong elements.

If you do have the good fortune to welcome a trans person into your life, I implore you to be gentle, and supportive, and sensitive. These are some of the best people you could ever meet and know – and, if you win their trust, they might introduce you to a world of  folks who do things their own way, in their own inimitable style.  They are a group of human beings whose path in life has taught them profound lessons in compassion, understanding and personal strength.

I’ll close with a link to a site that I wish didn’t have to exist.

Remembering our Dead, and the International Transgender Day of Remembrance, were created to honor trans people who have been victimized by violence.  It is a sad statement on the condition of humanity that these innocent people were murdered simply for being true to who they were.

In honor of Christine Daniels, please vow that you will become one more voice on the side of acceptance, and celebration, of trans people and transgender identity.

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The news has been full of reports of Heidi Montag-Pratt and her claim to have undergone 10 separate plastic surgery procedures in one day.  That includes rhinoplasty (a nose job), breast augmentation, lip collagen injections, chin reduction, and god only knows what else.

“I’m beyond obsessed,” is the frequently cited quote.

It certainly sounds like it.

The death of Michael Jackson also put plastic surgery into the news this winter.  Fans – and others – pored over photographs documenting the strange transformation that rendered him unrecognizable from his early days as a child star.

The question, amid all this hullaballoo, is whether there’s anything really wrong with plastic surgery.

A person clearly has a right to alter his appearance, and if he thinks the results are beautiful, that’s his business.  Plenty of people choose to cover themselves with tattoos, or get a multitude of piercings.  There isn’t much difference between that and having your nose straightened or your chin or breasts made larger or smaller – is there?

Not really.

We all have the right to look however we want to look, and I’m fine with plastic surgery – unless it becomes an addiction.  That’s when it stops being about controlling your appearance and making yourself happy, and starts to become a compulsion that can make you miserable.

The definition of an addiction is simple:

1) you no longer receive the same pleasure from the activity; and

2) you lose control over it.

That’s where the trouble starts.

It can feel very good to have plastic surgery.  If there’s some funny little quirk of your appearance that bothers you, and you finally get it addressed, it can be immensely liberating.  Several of my patients have had “boob jobs” and they might laugh about it, but say in all seriousness that it made them feel more confident and that they’re happy with the results.  One of my patients had a face lift, and was similarly pleased with how it made her feel – more youthful, less wrinkly, more confident.

The problem is that something that feels very good can become addictive if you become fascinated with that good feeling and try to recreate it again and again.

Along the way, you can ignore underlying problems.

There is a tendency, when you don’t feel good about yourself, to locate what bothers you in one particular physical feature.  That bump on your nose, or smallish bosom, which others hardly notice, might be inflated to enormous significance to you – until you become convinced that you would feel entirely better if you could just correct that one problem.

Initially, it might work.  At last – bigger breasts.  Or a smaller chin.  Or fewer wrinkles.  Or whatever.  Other people might not notice, or vaguely think you look better.  But to you – it’s a vast relief.

Then you go back to do it again.

One of my patients had her nose done, and was happy with it – even if other people didn’t much notice.  That’s when she decided to have her chin done, too.  And then get it re-done, to get it just right.  And then a piece of bone came loose, and she had to repeat that surgery.

That’s when she realized the chin surgery was probably a mistake all along.  Instead of getting the same good feeling after each surgery, she only felt worse.

She realized it was becoming an addiction, and that she needed to stop using plastic surgery to escape doubts about herself, and her ability to find love.  There was nothing more that a scalpel could do for her.  She needed to find out why she didn’t like who she was – and address it in therapy.

It is impossible to say whether Heidi and Michael are examples of addiction, or just people who enjoyed altering their appearance to suit their own tastes.  But the signs – chiefly the sheer number of surgeries – are there.

Plastic surgery tends to have diminishing returns.  You can only operate on your body so many times before features scar up or grow distorted.  There’s also the issue of losing what makes your appearance special in the process.  The “ideal” features produced by plastic surgery tend to have a certain blandness.  The goal of plastic surgery, in most instances, seems to be making someone look more like everyone else, instead of making him look more himself.

If you’re considering plastic surgery, ask yourself whether you are really addressing a simple matter of a physical quirk, or whether there’s more going on that you need to stop and examine.  If the insecurity seems to involve more than just a bump or a wrinkle, it might be time to look deeper, and ask yourself what’s wrong with accepting yourself just as you are.

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I can’t complain.

Really, I shouldn’t.

But I will.

Because it feels good.

We all need to ventilate anger.  That means containing it, taking it to an appropriate place (like a therapist), and putting it into words.

A patient told me last week about his elderly mother, who, after a long, healthy life, was struck down unexpectedly in her mid-eighties with a severe illness, and hospitalized for two months.

Now, recently released and confined to her bed, she is miserable – and making everyone around her miserable, too.

She has plenty of reason to be angry.  This illness was plain bad luck, and it seems unfair that it should strike a woman who has always exercised and taken care of herself and never before been sick a day in her life.

It’s a lot to adjust to.  She will require kidney dialysis every other day for the rest of her life.  Her limbs are swollen and painful. Her attention span is short, and she has painful headaches.  She was once an avid tennis player, but is now reduced to using a walker to get around.

The problem, my patient told me, is that his mother is taking her anger out on the people around her, specifically her long-suffering husband.  She barks at him, criticizes everything he does – essentially makes his life miserable.

I proposed psychotherapy, but my patient only shook his head.  His mother’s rule has always been self-sufficiency.  Asking for help is out of the question.  She survived the Holocaust, and she’s tough as nails.  It is a point of pride for her never to complain, and never to ask for any assistance whatsoever.

That’s a shame.  Admitting weakness can be a sign of strength.

The problem with my patient’s mother is that she’s filled with anger, but has no healthy way to express it.  Putting it into words – complaining – is forbidden to her.  Instead it leaks out as misdirected anger, which usually ends up aimed at those who happen to be closest to her but least deserve it, like her husband.

Since his mother absolutely refuses to speak with a therapist, I told my patient he’d have to fill that role – to try to be the therapist his mother refuses to see.  I gave him a few pointers.

First of all, he has to get her talking – and keep her talking.  That means staying syntonic – going her way, not offering any resistance to any of her thoughts and feelings, but encouraging them.  Active listening, or “mirroring” would help, too.  That’s a technique in which you repeat back snatches or paraphrases of what the other person is saying, so she knows you’re there, and that you’re paying attention.

Like this:

His mom – “I hate this damned walker!  It’s humiliating to be disabled like this!”

Him – “It must be tough for you to have to use a walker after always being so active.”

A couple more pointers:

He will have to monitor and contain his own responses to her.  It wouldn’t be very productive if he lost his temper in the middle of their time together and started yelling back at her.  I recommended he wear “emotional insulation” while listening to her.  He could have his reactions – anger at the outrageous things she might say, or fear at the terrible experiences she’d endured – but he would contain them so they didn’t distract from his mission.  He couldn’t lose track of the goal:  to let her vent her upset in a way that would provide her relief.

One final thing:  I told him not to try to problem solve.  His mother – and most people – don’t want advice.  They want to be listened to and heard.  Real problems don’t have easy solutions, and the person with the problem is best-positioned to find one if it exists.  The goal is to parallel process.  While he listens, she explains the problem – and in doing so, works out an answer on her own.

I warned him that it might take a while – maybe an hour, the length of a psychotherapy session – maybe several hours divided over multiple sessions.  But eventually, if he stuck with it and got her to vent some upset and unhappiness, he’d detect a change.  I would expect to see a lightening of mood, with a return of interest in other people.  She might suddenly snap out of her gloom and say, “wow – it’s good to get that off my chest. So how have you been?”

There are a lot of ways a psychotherapy session can play out.  One of them is simply a release of pent-up feelings.  It might not sound as inspiring as a breakthrough session in which the therapist produces a startling intellectual insight.  But sometimes just listening – good, focused, active listening – can make all the difference.  An hour of bitching and moaning to someone, who’s job is to listen, can feel good – and stop all that anger from leaking out or being discharged on some poor, unfortunate by-stander.

One of my patients said therapy sometimes feels to him like a psychic massage.  You walk out feeling relaxed, looser and ready to face the world.

That’s what my patient’s mother needs.  I hope he’s able to provide it.

We all need a good kvetch once in a while.  If you’re in a therapist’s office – or with someone who’s willing to listen and tolerate your feelings – I don’t see how it does any harm.

It might even help.

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Studies have been done of resilient children – kids who have faced down tough times and survived intact.  They share one key finding:  These kids locate surrogates – replacements – for what is otherwise missing in their lives.

Whether it’s a teacher or a neighbor or an uncle or a grandparent – somehow, these scrappy little children overcome difficult circumstances to find someone to take care of them, to love them, so they can find a way to love themselves.

The challenges these kids face can be pretty severe – physical, verbal and sexual abuse, neglect, parents who are missing or mentally ill or addicted to alcohol or drugs.  By some miracle, they find what they need to survive and make their way forward to happy, healthy lives.

One year ago today, an old friend of mine from high school, Shin, died of breast cancer.  She couldn’t have been much over forty, and left behind a husband and two young children.

Shin and I reconnected in the days and weeks before she died. She was in Singapore and I’m in New York, but thanks to the internet, we were able to video chat regularly.  Towards the end she was having trouble breathing, so I spoke and she typed her replies.

When I realized Shin was dying, I expected that my role, as her old friend the therapist, would entail simply listening and being there for her.  Knowing Shin, I should have realized how much she had to teach me about what it means to be alive, to love, and to care for others.

Again and again, Shin repeated to me that her children were the most important thing to her.  Josie and Toby were very young, and she knew it would be devastating for them to lose their mother.

She created a sort of ritual as a way to prepare them – taking the children aside each day and asking them the same question:

“Where’s Momma?”

They answered as she’d taught them, by pointing to their hearts.

“That’s where I’ll always be,” she said.  And she held them tight.

Shin knew what she was doing.  She understood that her kids had a terrific dad – but they were going to lose their mother soon, and they’d need somewhere to go to process that loss.  They would need to look within themselves.

Studies of resilient children overlook another place where tough little kids find the love they need to survive.  They don’t just locate it in neighbors and uncles and teachers – they also find it within their own hearts.

You have a little kid inside you – the same kid you used to be.  And that kid needs love.  You’ll never receive everything you need from the outside.  Even the best parent or parent-substitute can provide only some of what a child needs.

The rest has to come from you.

When Shin taught Josie and Toby that Momma would always live in their hearts, she placed her own strength within them, setting them on a path towards self-sufficiency.  The unconditional love of their dying mother will remain within them forever – a well to draw on when times get tough.  They will never forget that there was a young woman named Shin, who was their mother, and that she loved them absolutely.

Shin’s goal was to place a love in her children that would evolve into a love for themselves – to make them secure in the conviction that they deserved care.

You need to find a way to love yourself, or you cannot survive.  You need to hear that message from within your own breast – that someone cares for you, and always will, no matter what.

Maybe you’re not always at your best.  Maybe you have regrets, and remorse.  Maybe it feels like there isn’t much love out there for you sometimes.

But there is a child within you.  He means no one any harm.  Offer him your love – carry it within you.

You can be a resilient kid.  You can stay conscious, and be your best self, and love the best, most authentic you.

You can be deserving of love – love from within your own heart.

Just like Josie and Toby.

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