Wednesday, October 17, 2018

Talking Politics in Therapy

Mirabile dictu, it is wondrous to hear, a therapist has wisely explained that he does well to help his patients to deal with reality. With the reality of their lives, with the reality of the market, with the reality of politics.

Therapist Richard Brouillette explains the problem in a New York Times column. He has discovered that real life dilemmas cannot and should not be reduced to an intrapsychic dysfunction. He sees that he must overcome his tendency to prescribe introspection in order to help his patients to deal with life as lived.

He opens with an anecdote:

“I’m meeting my boss later,” my patient said. “I’m worried she’s going to tell me I’m not pulling my weight, and that I should volunteer to work more hours to show my commitment.”

This tension had been building at her job for months, and she feared that there would be a tacit threat in this meeting: work longer hours, uncompensated, or we will push you out. She was already finding it hard to spend so much time away from home. But she couldn’t afford to risk unemployment.

“What am I supposed to tell my children?” she asked, breaking down.

My stomach knotted. Such worries among my patients are becoming so common, so persistent, that I find myself focusing less and less on problems and neuroses that are specific to individual patients, and more and more on what is happening to the fabric of daily life.

We do not know what to tell her. We cannot speculate about a situation we know so little about. Besides, we read about such stories in the Ask Polly advice column and have offered many, many commentaries in the past.

The point is, the patient’s problem is not a state of mind. It is not about feeling her feelings of finding out what she really, really wants. Her problem concerns her ability to do her job, to compete against others who put in more time and to bring up her children. It isn’t easy. It isn’t self-evident. But, it isn’t so much the market that’s at fault. Apparently, she chose a field where presence matters. Again, we do not know much more.

One problem therapists see is: how to cope with the job market, or with certain segments of the job market, especially when reality defies their post-adolescent expectations:

As a psychotherapist with a private practice in Manhattan, I see a lot of early- and mid-career professionals coping with relentless email and social media obligations, the erasing of work/life boundaries, starting salaries that remain unchanged since the late 1990s. I see “aging” employees (30 and up) anxiously trying to adjust to a job market in which people have to change jobs repeatedly and cultivate their “personal brand.” No one uses all her vacation days. Everyone works longer hours than he would have a generation ago.

It is, dare we say, a competitive marketplace. More than a few women with children choose less demanding careers, the better to have more time at home. They might choose to compete with the big boys, with the big boys who have wives at home, but that is a choice, not the fault of the job market.

Be that as it may, Brouillette points out that therapists often steer discussions away from the realities in play and toward a psychic something. I suspect that the real reason for this is that they do not know enough about how the marketplace functions. Thus they point things toward an arena where they feel comfortable: emotions, fantasies, wishes and the like.

Typically, therapists avoid discussing social and political issues in sessions. If the patient raises them, the therapist will direct the conversation toward a discussion of symptoms, coping skills, the relevant issues in a patient’s childhood and family life. But I am growing more and more convinced that this is inadequate. Psychotherapy, as a field, is not prepared to respond to the major social issues affecting our patients’ lives.

Needless to say, the therapeutic attitude makes patients feel that they are at fault for not being able to manage their lives. Yet, as Brouillette remarks, therapists are at fault for not knowing how to help their patients do so:

When people can’t live up to the increasingly taxing demands of the economy, they often blame themselves and then struggle to live with the guilt.

So far, so good. And then, Brouillette’s column takes a darker turn. We discover that his own knowledge of the economy derives from his experience as a community organizer, thus, that he sees reality in terms of social justice wars. He shows his patients how to deal with the market, but he sees the marketplace through radically leftist lenses:

When an economic system or government is responsible for personal harm, those affected can feel profoundly helpless, and cover that helplessness with self-criticism. Today, if you can’t become what the market wants, it can feel as if you are flawed and have no recourse except to be depressed.

Life and the marketplace are far more complicated than this piece of leftist boilerplate. Brouillette continues to echo a famous movie, Network, and the raging, rebellious declaration of character Howard Beale. If your knowledge of the marketplace derives from the movies, it’s time to learn more about it:

There comes a time when people can’t take it anymore, when too much is being demanded of them. How much blame can people tolerate directing at themselves? When do they turn it outward?

My sense is that psychotherapists are playing a significant role in directing this blame inward. Unfortunately, many therapists, because they have been trained not to discuss political issues in the consulting room, are part of the problem, implicitly reinforcing false assumptions about personal responsibility, isolation and the social status quo.

As it happens, Brouillette is correct to see that therapists are the problem, not the solution. It’s an occupational hazard:

If the patient describes a nearly unbearable work situation, the therapist will tend to focus on the nature of the patient’s response to the situation, implicitly treating the situation itself as unchangeable, a fact of life. But an untenable or unjust environment is not always just a fact of life, and therapists need to consider how to talk about that explicitly.

This is, in ways, an old quandary in psychotherapy. Should therapy strive to help a patient adjust, or to help prepare him to change the world around him? Is the patient’s internal world skewed? Or is it the so-called real world that has gone awry? Usually, it’s some combination of the two, and a good psychotherapist, I think, will help the patient navigate between those two extremes.

Between adjust and change, there’s a middle ground: to manage the problem. Brouillette, however, sees the market in terms of a need to fight against injustice.

Too often, when the world is messed up for political reasons, therapists are silent. Instead, the therapist should acknowledge that fact, be supportive of the patient, and discuss the problem. It is inherently therapeutic to help a person understand the injustice of his predicament, reflect on the question of his own agency, and take whatever action he sees fit.

And he ends up giving a patient some not-so-good counsel about dealing with a situation:

I once had a patient who had reached a breaking point with the situation in the startup where she was employed. In her therapy, she had been struggling for two years with the idea that it was possible to have authentic communication in relationships. Our therapy helped her hone her anger into a courageous, well-considered and pointed group email that resulted in nearly half of her co-workers supporting her and prompting direct labor negotiations with the chief executive.

Note that we do not know what the problem was. He describes the situation in such abstract terms that we do not know whether the patient was right or wrong about the point she wanted to communicate. The notion of “authentic communication in relationships” is too banal to tell us anything at all.

So, her therapist advised her to act out a role in yet another movie, Norma Rae, where a young woman provoked the unionization of a factory. Depending on the nature of the business, it might just be that Brouillette’s patient got herself labelled a troublemaker, not a team player. She might have damaged her career prospects. Anyone who joins a company with the express or implied intention of bringing social justice to the factory floor is not going to have a very good career. Labor negotiations can be constructive or they can be destructive. Without knowing more, we cannot tell.

Most importantly, it’s not an employee’s job to change the world or to radicalize the workers. Yet, Brouillette thinks that it is:

Patients become motivated to change the world around them as a solution to what had become internal stressors. This is an experience of not just of external but internal change, bringing new confidence and a sense of engagement that becomes a part of the patient’s character.

Surely, he does not want to show his patients how to sabotage their careers and then to feel completely self-righteous about it. 


Dan Patterson said...

And don't call me Shirley.
The post brings to the surface a topic that sprouted in the 70s then grew legs and ran around making (mostly) women crazy through to the present day. "I want moooore from life than a house with a white picket fence, husband, a dog, and 1.5 kids" they would proclaim. And later would de-MAN-d. OK, fair enough, let it be so. But with that horse comes a saddle and good luck cinching it, breaking the mount, and staying on it without busting a leg. Because we are human and are of two distinct sexes there are traits built in to "Our Bodies Ourselves" that defy our wishes to rule against. Oh there are exceptions and some of those have taken root in archetype; the masculine young woman in "Rooster Cogburn" comes to mind as an example, but those are exceptions maybe best left to entertainment.
The male and female human have destinies that both strive to fulfill, to deny lies difficulty and pain, pain that can be shunted by our ability to self-deceive, the presence of medications, and the comfort of a therapist helping off-load responsibility onto unsuspecting and often innocent targets. Like spouses, children, co-workers, and the social and economic constructions of our nation.
Life is hard and there is no way out. Making the most of it seems the only solution, so working with what God gave us makes sense.

Ares Olympus said...
This comment has been removed by a blog administrator.
Dr. Irredeemable Dreg said...

"Too often, when the world is messed up for political reasons, therapists are silent. Instead, the therapist should acknowledge that fact, be supportive of the patient, and discuss the problem."

I suppose it's ok to talk about politics, or even restaurants (and I've experienced significant acute distress as a result of poor service), when a third party is paying for it. Is political kvetching protected by HIPAA?

Ares Olympus said...

Perhaps this distinction helps clarify the need for both psychotherapy (that looks mostly inwards and backwards) and life coaches (who look mostly outward and forward) to helping people.

It also reminds me of George Bernard Shaw, never change yourself to match the world if you can find a way to make the world adapt to you.
"The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man."

David Foster said...

"I once had a patient who had reached a breaking point with the situation in the startup where she was employed." Working in startups is inherently a high-stress proposition. If this therapists advice to "hone her anger into a courageous, well-considered and pointed group email that resulted in nearly half of her co-workers supporting her and prompting direct labor negotiations with the chief executive" resulted in a toxic us-vs-them climate and eventually to the crippling or failure of the company, that wouldn't have been a favor to anybody (except competitors).