Why We Hate...and How to Stop

The worst side-effect of our polarizingly partisan politics is how it makes us feel about each other. Or, more precisely, how it makes us feel about the Other - those from social groups to which we do not belong. The further we are divided from one another, the easier it becomes to hate the Others.

We've seen it throughout history, all the way back to Cain and Abel. People have hated each other on the basis of race, gender, age, religion, nationality, sexuality, and innumerable other aspects of social location we think we can judge based on appearance or behavior (clothing, car, weight, education, profession, etc, etc). This kind of hatred has led humans to commit all kinds of atrocities in the name of their own "tribe" - think about the Crusades, the Inquisition, the Holocaust, and multiple more recent Genocides...to say nothing of all the smaller-scale ways we damage each other's bodies, minds, and spirits. 

While there have been...interesting...studies done on how people can be convinced to take part in torturing others (e.g., Milgram's famous study), I am more interested in  how we end up hating and harming each other in our daily lives, and by extension, through our politics (or is it the other way around?). 

The biggest reason for hatred seems to be that we feel threatened by the Other. This dynamic is visible whenever a group of people declares that their whole way of life would be threatened by letting the Other group vote, or marry, or attend the same schools, or whatever the issue happens to be. Most recently, for example, conservative groups have declared same-sex marriage to be a threat to the integrity of heterosexual marriage. I am baffled, myself: how does recognition of one sort of relationship negate the value of another sort of relationship?

Perhaps it has something to do with the dynamic captured by Jewel's song, Pieces of You:

She's an ugly girl, does it make you want to kill her?

She's an ugly girl, do you want to kick in her face?

She's an ugly girl, she doesn't pose a threat

She's an ugly girl, does that make you feel safe?

Ugly girl, ugly girl, do you hate her cause she's pieces of you?

She's a pretty girl, does she make you think nasty thoughts?

She's a pretty girl, do you want to tie her down?

She's a pretty girl, do you call her a bitch?

She's a pretty girl, did she sleep with your whole town?

Pretty girl, pretty girl, do you hate her cause she's pieces of you?

It seems like our group memberships/identities are so important to us that the recognition of similarity with the Other - even a small glimmer of commonality - threatens our whole understanding of who we are and how we fit into the world. We get the sense that, if the Them/Us dichotomy is false, then much of how we understand the world might also be false, and the whole thing might just topple like a house of cards. We get anxious and fearful, and almost instinctively try to distance the Other from us in some way - often a way that is cruel.

The solution to this kind of hatred is both simple and difficult, because it involves no more or less than approaching (rather than distancing from) the Other. By getting to know one another, recognizing the similarities born of our common humanity, and the differences that enrich rather than threaten our society, we gain mutual respect, and lose our willingness to tolerate cruelty. 

Whom will you choose to approach? What hatred will you challenge?

Marking Milestones

It seems to be practically instinctive, the marking of milestones. From birth, our parents note our first step, first tooth, first word, first day of school. We learn to do the same, remembering our first kiss, first car, first day of a new job...etc. It's not just "firsts," though. Sometimes milestones are best (or worst) performances, such as athletes' "personal bests." Milestones can also be momentous occasions or achievements, such as graduations, weddings, baptisms and bar mitzvahs, among other events. Finally, milestones can be "lasts" - for example, the last day of school, the last time/place we saw someone, or the last time we did something we've now given up (like one's last drink in AA).

We mark milestones in all sorts of ways. This topic came to me as I followed news coverage of a milestone in my native Red Sox Nation: today is the 100th anniversary of the very first game ever played in Fenway Park. Now, that may or may not be of any interest to you whatsoever. However, it is interesting to note how that milestone has been celebrated. The two teams who played 100 years ago are playing again today...dressed in reproduction 1912 uniforms no less. Everyone alive who's ever been part of the Red Sox organization has been invited back to the park to participate in festivities, and some of the favorites are throwing out ceremonial first pitches. A special fanfare was commissioned to be composed, and is being performed by the Boston Pops. And of course, everyone is telling all of their most memorable Fenway stories.

I think we mark our own milestones in ways that are less sensational, but none-the-less similar. We remember the stories on anniversaries. We use objects as tangible reminders or symbols. Maybe we even try to recreate the experience. All of these acts serve the psychological purpose of meaning making - they help us make sense of our lives, and life in general. They help us see how far we've come, to keep us motivated to keep going. They connect us with one another through time and space.

Similarly, marking milestones can be useful in therapy. Celebrations of important achievements, symbols of where clients have been or where they're going, and markers of baby steps along the way - like chips in AA to mark 24 hours, 30 days, 90 days, 1 year sober - create a trajectory of growth and development that clients can look back on. In doing so, they can better recognize progress that may otherwise be hidden by the tumult of the path, and they continue to "re-author preferred narratives" of their lives.

How do you mark milestones in your own life? How do you incorporate awareness of milestones into therapy?

End Game

Higher levels of care (i.e., any form of treatment other than outpatient therapy) are meant to be brief - they offer intensive intervention to stabilize acute distress, and get clients to the point where they can continue with standard outpatient treatment. Sometimes a client is so impaired that they do not stabilize quickly, even at the highest levels of care, resulting in long-term hospitalization. Most, however, show some improvement within a few days to a few weeks of treatment.

Because of the nature of higher levels of care, clinicians have to be thinking about discharge from the very beginning of treatment. Given that treatment is meant to stabilize acute symptoms, rather than restore someone to full functioning, what are reasonable treatment goals? What will tell us that the client is ready for discharge to a lower level of care? When should we conclude that the client has gotten as much as they can from this level of care, and lengthening their stay will not be therapeutic?

The answers to these questions are rarely clear. Client self-determination is a factor - what are their goals? Do they want to stay? When do they think they should discharge? It's not the only factor, though: sometimes clients want to discharge when they're still in crisis, and sometimes clients want to stay when they've already stabilized. Another litmus test is needed. Sometimes it's clear - the client is no longer suicidal or self-injuring; psychotic symptoms have resolved; weight is restored; target behaviors have been in remission for a period of time.

There are other times, however, when it is much less clear. Often, there is only partial remission of symptoms and behaviors, so the question becomes: how much improvement is necessary to warrant discharge? There are a few rules of thumb:

• Safety is paramount - if the client poses a threat to self or others at a lower level of care, they obviously aren't ready for discharge. Safety is also a consideration from the perspective of self-care, for psychosis, as well as indirect forms of self-harm, such as eating disorders.
• A decline in functioning may indicate that a higher level of care is necessary, while a plateau can be a sign that the client has gotten all they can from the current treatment and is ready for discharge. That said, some regression is possible prior to a planned discharge, and plateaus may not last.
• Disengagement may indicate a higher level of care (when there are safety issues) or discharge (when there are not safety issues) 

Especially the latter two considerations are very ambiguous to define in practice, and require judgment calls. When discharge is considered for clients whose symptoms have not fully resolved, it's important to ensure that there is some vehicle for continued care (e.g., outpatient providers who will continue to work with the client), as well as sources of support (family, friends) who can monitor the client's safety and help him/her decide if a return to a higher level of care is necessary in the future.

How do you decide when to discharge or terminate with a client? What factors go into that decision?

Sometimes the Bear Gets You (and What to Do Next)

A thoughtful supervisor once sagely shared with me a piece of practice wisdom: "Sometimes you get the bear. Sometimes the bear gets you."

Now, I don't know the source for this quotation, or to what it originally referred. It was first told to me in the context of work with preschoolers. However, I have found it most relevant to the practice of group work - no matter the population.

If you've led groups, you've most likely had the experience of things...not going as planned. After all, there are many variables in group leadership that are out of the leader's control - for example, who attends on any given day, what mood they're in and what else is going on in their lives when they get to group, and how they will interact with each other. Because group composition and dynamics change over time, it's very likely that you will walk into a group that's changed in subtle ways since the last time it met - whether that's the next week, the next day, or the next hour!

I've spent a lot of time working in partial hospitalization programs - day programs that offer short-term treatment for acute psychiatric conditions, as a way to reduce or avoid hospitalization. Treatment happens primarily in groups, and the population changes on a daily basis as people are admitted and discharged. Combining acute psychiatric symptoms with constantly-changing group composition, and people at various stages of treatment, makes it hard to plan a group that's appropriate for everyone. It can feel risky to challenge the group too much, or to introduce a new intervention when you can never be sure how it will go over.

Sometime things go pretty much as expected - with various group members behaving predictably (in both helpful and unhelpful ways), and grasping the material to whatever extend their symptoms and abilities allow. These are the days  when no (metaphorical) bear puts in an appearance.

Occasionally, things go better than you could ever have anticipated. The group has a breakthrough, connecting to each other and/or the material in new, deeper, more authentic ways. Their passion, compassion, and creativity outstrip yours and take whatever you've planned to levels you couldn't have come up with (after all, we all know that a group is, in many ways, more creative than an individual). On these rare but precious occasions, you get the bear.

However, things don't always go as well as you hope, or expect (even when your expectations are low). Sometimes a group will go to pieces (metaphorically and literally). Members squabble, form cliques, and are unkind to each other. They become oppositional, clown around, make a scene, or otherwise interrupt the group process. Perhaps members who were previously divided suddenly find common ground, uniting against you (as happened to an unfortunate colleague today). At best, you spend the time putting out fires and responding to inappropriate behavior, and don't get to convey whatever material you had planned (in other words, the behavior is effective in its goal of disrupting/derailing the group for the day). At worst, you have to invite (*insist*) one or more members leave, or even just end the session. These (you guessed it!) are the occasions when the bear gets you.

It doesn't matter how brilliant you are as a therapist, or how motivated and cooperative your clients usually are - sooner or later this bearish group dynamic will take over, and get the best of you. It's normal, and sometimes a necessary stage in the group's development. The trick is to respond in a way that moves the group dynamic toward a more productive resting point. Perhaps, to continue with my metaphor, the way to prevent that bear from getting you again is to tame the bear as a circus performer instead of locking it up in a zoo. (Of course, remember that other bears will inevitably come along eventually!)

Easier said than done, but here are my suggestions:

1) Interrupt the disruptive behavior as soon as possible, to keep a counterproductive dynamic from becoming a new norm. Redirect, or when necessary remove instigators or stop the group.
2) If there are a small number of instigators, address their behavior 1:1 to figure out what happened to trigger it, and discuss how they can be more productive when the group resumes.
3) When the group resumes, reiterate the group guidelines, however they have previously been decided/conveyed. Invite the group to discuss the last meeting in the context of these guidelines. Hopefully, more positive group members will confront the disruptive behavior, thereby reestablishing pro-social and productive group norms. (It's more powerful when the message comes from peers rather than the facilitator).
4) When appropriate, invite further processing of the underlying issues that contributed to the group dynamics that occurred at the last meeting.
5) Move on to the real "work" the group has gathered to do, and whatever material you have prepared.

When the bear gets you, it's also incredibly helpful to process it with colleagues and/or in supervision. Process your own reactions and frustrations, try to figure out what (if anything!) you might have done differently, and discuss a plan for the group's next meeting. This step is absolutely crucial when the group is meeting as part of a milieu (e.g., the partial program), where other staff are running groups with the same participants, and working with various clients individually. Without good communication and mutual trust, negative group dynamics can infect the treatment team and become "staff splitting" - which has negative results for clients' treatment, and staff morale.

So, in summary: Bears will come and go. Sometimes you will get the bear, but other times the bear will get you. It's inevitable...but not always negative in the long run, because it offers an opportunity for groups to address specific issues that might not otherwise come to light, and it offers you an opportunity to hone your skill at leadership, and conflict resolution.

What suggestions do you have for when the bear gets you?

"MSW?"

I heard a colleague quip that many students begin their MSW program under the assumption that MSW really means "Must Save World." Now, I know they don't really think it stands for that - but, many do think that is, in fact, what it means to do social work - saving people and/or society.

I can't remember if that's what I thought at the beginning - how much I was able to distinguish between "helping" and "saving." I do know that I started to become aware of this distinction quite early on in my MSW program, with the first semester focusing heavily on empowerment, strengths-based, and solution-focused approaches to social work, which privilege the client's agenda and wisdom about what should change and how. In contrast, trying to "save" someone tends to veer into benevolent paternalism - the sense that you, rather than they, know what's best for them. It can result in disempowerment, dependence, resentment, and continuation of patterns of oppression. The goal of helping professions is to help - to offer tools and support for clients' own processes of change - rather than to impose change.

With this learning under my belt, I left school (with my MSW) believing that it wasn't my place, and could harm my clients, to try to "save" them. However, it wasn't until my first job after graduate school that I fully understood that I couldn't save anyone. The old adage holds true: "You can lead a horse to water, but you can't make it drink." While I can use motivational techniques, suggest options available to a client, or even get them hospitalized to stop them from harming themselves or others, I cannot impose change on anyone through the force of my will. If they don't want to change, they aren't going to.

Many clinicians use the rule of thumb that you shouldn't work any harder at a client's recovery than they do. I'm not sure it's possible or desirable to follow this rule exactly. For example, I think sometimes the therapist or peer group can hold onto the possibility of and desire for change when a client has lost sight of the goal, or lost hope of achieving it...but only if the client starts with, and eventually regains, their own motivation. I also think there are times when it becomes necessary to work harder than the client - for example, when the stakes are high as a result of suicidality, homicidality, or other risk to physical safety.

Sometimes a suicidal client will ask why I don't just let them do it - what does it matter to me if they live or die? It's their life.... And yes, preventing suicide is imposing my values about life (and my professional mandate) over client self-determination. I believe that suicidality is a time-limited symptom that will pass, while death is permanent. If we can keep someone alive, by hospitalizing them or whatever, there is every chance that they will eventually feel better. But, these are my beliefs, and may not be shared by the client. However, I also know that people who are fully committed to suicide, or addiction, or any other life-threatening path, will not show up, or will take off, or will lie and say everything is fine...they have the autonomy to pursue their own agenda. As long as they're presenting for treatment, though, I'm going to assume they do want help. I have learned from this work that I can't save anyone - but I when people allow me, I can help them save themselves.

Ultimately, I'm glad that I don't have the power or the responsibility to save the world. It's a relief to know it's not possible, even if it's also sometimes frustrating or scary. How do you think about and feel about this issue? When and how did you discover that MSW does NOT stand for "Must Save World?"

Flexible Thinking...Let's Streeeetttch!

Therapists from diverse theoretical orientations seem to agree that a major goal in treatment is increasing flexibility of thought.

It's a weird concept, right? We can tell if someone's body is flexible if they can master gymnastics or yoga, but how do we know if their mind is flexible?

I find it easier to identify when someone's thinking is NOT flexible - in other words, when it's rigid. Rigid thinking is fixed - it doesn't adjust to accommodate new or conflicting information. It assumes universality - that there is only one accurate way to view things. Other perspectives are only considered in order to refute them.

Taking this as a reference point, then, flexible thinking actively considers alternative perspectives - not just to oppose them, but to really consider them as possibilities. Instead of insisting on one Right Answer, flexible thinking recognizes that there can be multiple truths, and they can change over time - that much of what we collectively identify as truth is simply our current best guess, and by nature provisional. As a result, new and sometimes contradictory information is welcomed.

So why is flexible thinking such an important goal of treatment? Well, for one thing, it tends to be more accurate simply because it considers contradictory information and alternate viewpoints. It also leads to innovation - new scientific discoveries and creative or technical inventions don't come from rigid thinking! On the other hand, rigid thinking tends to cause emotional pain - for example, most depression, anxiety, and self-harm are fueled by fixed beliefs about self, others, the world, and/or the future.

The good news is that flexible thinking can be learned (actually, per Piaget, it has to be learned, since it requires abstract reasoning skills). How therapists help clients develop more flexible thinking varies depending on the approach. Modeling, examining the evidence, noticing patterns, working through underlying conflicts.... How do you approach it?

All Therapists are Gamblers

I've never been to a casino, or bought a lottery ticket, but I still gamble. When I work with high-risk clients, I take a gamble every time they walk out the door. I like to think it's not much of a risk, because I'm experienced enough to sense a client's degree of risk/safety - but we all know we can be wrong, and situations can change rapidly.

Because we (as a profession and wider society) value self-determination and are loathe to infringe on anyone's free choice, the threshold is quite high for holding someone against their will on psychiatric grounds. Unless someone is immediately suicidal or homicidal (like, they have a plan and intend to enact it if we let them walk out the door), or behaving so bizarrely that they are at imminent risk of physical harm (wandering down the middle of the street; refusing all food and drink - things like that), they don't have to go to the hospital...and we, by extension, do have to let them walk out the door.

For most clients, most of the time, that's not much of a gamble. But there is a definite gray area where you know the client is at risk, but not enough so to override their self-determination. Sometimes, these clients can be persuaded to be hospitalized voluntarily - but often they refuse.

I find myself with several clients who are hanging out in the gray area, making me a little nervous as they walk out my door.

I have a psychotic client who has reportedly spent most of the week hiding out in her closet, eating only sporadically, and once going to the bathroom in a bucket..."but I only did that one time, Natalie!" She absolutely refused all efforts to convince her to go to the hospital, assuring me her family would be checking on her regularly, and promising to go to the hospital if they found her hiding in the closet again.

I have another psychotic client who missed his last appointment with me (though thankfully he did go to his med evaluation). He has to leave stores and other social settings sometimes because the voices tell him to hurt people.

Another client also keeps to herself because she has impulses to hurt people. She is able to choose not to act on these impulses by thinking about the consequences for herself and her children. But she hopes to someday main or kill the people who sexually assaulted her in the past (including a brother) and does not plan to continue with therapy to work on any of these issues.

Today I saw a woman who has habitual suicidal ideation which she does not intend to act on - but it has gotten markedly worse this week, after a loss and a break-up, and she decided on a method long-side (OD on IV heroin). Even though she assures me she has not intention of acting, I am not terribly comforted by that. She did agree to go to a partial hospital program...but can't start until Tuesday.

Finally, I have a client with OCD who has intrusive, obsessional violent thoughts toward himself and others. These include sexual aggression against children, homicidal ideation, urges to self-injure (because he considers the thoughts of violence toward others signs of his own badness), and thoughts/plans about harming his mother's cats. My worry is assuaged by the fact that he has never tried to harm any other people...but he has engaged in non-suicidal self-injury, and attacked (but not tried to kill) a cat.

So, with all of these clients, I let them walk out the door with some definite trepidation. I'm mostly sure they won't come to harm before I see them next...mostly. I'm wondering how other people would navigate these kinds of risks. How do you manage safety issues on an outpatient basis, and when do you decide that the risk is too high? When and how do you seek consultation on risk issues? In short, what's your gambling strategy?

Practicing Wisdom

If you're in the field, you've heard the term "Practice Wisdom." It's used to describe the intuition clinicians develop through experience - a sixth sense or "third ear" that can't be learned in books and is hard to put into words.

It's interesting to note the differences between how professional organizations and third party payors have tried to "manualize" (i.e., standardize) treatment, and what experienced clinicians know and do in practice.

Take the Diagnostic and Statistical Manual of Mental Disorders, for example, soon coming out in its 5th edition. The purpose of the DSM is to standardize diagnosis so that we can communicate about clients (in research/academic arenas, and treatment collaborations) with some confidence that we're speaking a common language. But, the "standardized" diagnoses really vary widely - an individual has to have a minimum number of symptoms to qualify, but many different combinations of symptoms may all qualify for the same diagnosis.

In contrast, experienced clinicians recognize the "feel" of various diagnoses, and sometimes subtypes of commonly-combined symptoms. For example, depression can be characterized by neurovegatative slowing (increased sleep, increased appetite, psychomotor retardation, avolition, anergia, and so on), or the less common "agitated depression" (decreased sleep, decreased appetite, psychomotor agitation).

Even more tricky, how does one differentiate between psychosis that is part of a mood disorder (e.g., depression with psychotic features) and a primary psychosis (schizophrenia or schizoaffective disorder)? For me, it's a "feel" I get from the person: how present they feel in the room, how distressed they are by the psychosis, how aware they are of other people...and a certain look around the eyes.

How do you find yourself relying on specific practice wisdom to clarify what the DSM doesn't?