Wednesday, April 25, 2012

The problem of evil in psychotherapy

Recently, one of the clinicians I supervise asked me which direction to take with a client struggling with the question, "Why do bad things happen to good people." This is a question that comes up often in the psychotherapeutic session. It can be raised in a multitude of ways--"Why did I get sick," or "Why did my loved one die," or "Why did I have to get laid off?" These kinds of questions are posed frequently in therapy.  Often, there is an aspect of "What did I do to deserve this?" to these questions.

(Side note: I call this issue "the problem of evil" because it  is a philosophical question of how evil can exist in a just world. For those who believe that there exists a God who is omnibenevolent, omnipotent, and omniscient, the problem is often phrased as "How could God allow evil in the world?". However, the problem of evil is not limited to theists--many people believe that "what goes around comes around," or in some other kind of force that rewards goodness and punishes transgressions. The success of the book The Secret shows how much traction there is in a belief that the universe reciprocates our thoughts and actions.)

If we are working in a existential framework, we admit that there are no reasons for the good things or bad things that happen, and it is our own storytelling processes that create such meanings. I encouraged the clinician with whom I was working to examine the client's belief underlying the idea that there are reasons why bad things happen, with the idea that this exploration may assist the client in coming to some kind of acceptance of the things that have happened.

The truth is that the things that happen to us are not a referendum for how we are living our life--our outcomes are not evidence of how good or bad we are. In the specific case brought to me, this client is religious, so I suggested that this clinician would examine this belief in the framework of the client's religion. And, as with any cognitive distortion, I recommended that the client gather evidence to support or refute the idea that only good things should happen to good people.

I'm playing a winning game here and I know it. No religion in the world has failed to address this problem. In fact, a strong case can be made that one of the functions of religion is to address the problem of evil. And many people will find the classical explanations of why there is evil in the world satisfactory--explanations that do not blame the person for the things that have happened. For example, it is often comforting to believe that "God is testing me," or "I'm supposed to learn something from this," or "God never gives us more than we can handle."

But what about those for whom these beliefs are not comforting?

The alternative explanation to the question, "Why do bad things happen to good people?" is that bad things happen to everyone, and selection bias produces our belief otherwise. The world is not just, and misery comes to us all. So in the process of therapy, we could then look at our selection bias, which can be helpful, but it does not address the larger and more frightening reality that we live in a world that is not just.

Frequently, there is no answer to the question "What did I do to deserve this?" Somethings things just happen to us for no good reason. And while this can be comforting in one way, as it relieves us of responsibility for actions which are truly beyond our control, it can also be deeply terrifying because it may lead to the conclusion that the world is chaotic, painful and unpredictable.

For example, think of a child that assumes control for the condition of her family, her parents' relationship, or even abuse or neglect. Of course a child has no control of any of this, but it may be easier to assume that one has control than to face a world which can be painful for no good reason.

And so it can be difficult to face a world in which bad things happen to good people--or even simpler, in which bad things happen--and mitigating that difficulty is sometimes the object of existential psychotherapy.

While it may be terrifying to face a reality that the world can be a dangerous, threatening place, it is also redemptive. Facing this difficulty reality allows for a person to take responsibility for the things that she or he can actually have responsibility over. I can take responsibility for the ways that I act, or whether/how I accept my life circumstances. I can stop tilting at windmills and I can take responsibility for the things that I can control. Instead of believing, "If I do good things then only good things will happen to me," I can instead consider how I can best exist and thrive in a world in which things both good and bad happen to us.

Thursday, April 12, 2012

Who are your people?

It is a cliché in a session when the therapist asks, "Tell me about your parents." In educating new therapists (which I have the privilege to do for the University of Michigan and Wayne State University) I encourage them to avoid this kind of a statement. I encourage them not to say anything that sounds too much like it might come from a New Yorker cartoon. So the phrases, "How does that make you feel?" is out. And so is "tell me about your mother."

That said, the reason for avoiding the cliché is so that the therapist doesn't come off looking too much like a stereotype to the client, not because it isn't a good question. In fact, it is an excellent question—one of the most important parts of a good psychotherapy is coming to terms with one's family of origin. ("Family of origin" being the clinical way of saying "your folks.")

These days, many clinicians are trained in behavioral methods that minimize the relevance that the client's family has on the the client herself. I was in these methods, and practice them often. "We don't look at the past," I was instructed by well-meaning professors and others. "We stay in the here-and-now. We look at what is going on for the client in the now, and then we work with them to make the changes they want to make."

That sounds wonderful. And frequently, it works—in that it reduces some symptoms that often cause people to feel unhappy. And for people who are seeking symptomatic relief, this is a perfect fit, and where they stop psychotherapy. Success.

But the trouble is that some people want more out of therapy. Some people want inquiry and insight. They don't just want to have a specific symptom reduced; they want to get better. And, contrary to what the behavioralists may tell us, our families are a part of our here-and-now. The parts of my parents that I carry around in me won't be silent just because a therapist wants to focus on some new intervention or technique. Those voices and those memories are loud and clear in my head, even if I am no longer encouraged to share them.

Our culture has prepared a fertile ground for this kind of forgetting of our past. We are reminded of Miss America that we can be anything we want. We are encouraged to get the latest and greatest technological gadget every time a new one comes out. We view adults who live at home as having "failed to launch." Everywhere we look for the quick fix, and for the easy way out. Teach me to be a millionaire in a year, or how to work a "4-hour-week." Quick fixes are in; long processes of hard work are out. It is not hard to see why psychotherapists are encouraged to provide a 12-week cure.

Let me digress for a minute, and in doing so I am going to say something cliché: As I get older, I begin to appreciate the wisdom of my grandmother. And while I appreciate both of my grandmothers, I'm thinking here of my father's mother. She was a quiet, humble, and devoutly Christian woman who lived in a very small rural town in the northern part of Michigan's lower peninsula. One of the things that I remember her talking about is the families of the folks who lived in and around her town. "Blood will out," she would say, as well as "The apple doesn't fall far from the tree."

It's interesting to me that the sciences of mental health are beginning to come back to some of these old-fashioned ways of thinking. If you want to be happier, they tell us, make a list of everything you are grateful for. If you want to feel good about yourself, tend to your close relationships. If you want to have a positive emotional experience, focus on forgiving yourself and others. How fascinating that, as we go forward in psychology, we seem to go backwards in values: Count your blessings. Be kind to other people. Forgive. Don't be a stranger. These days, a convention of mental health professionals can sound a lot like a small-town quilting bee-—and for a good reason: These particular techniques are the tried and true strategies that kept people sane, kept them close together, and helped our ancestors survive.

And so I wonder how long will it be before we come around to "who are your people?" I suspect that this will be presented as a revelation in mental health science--that your family matters in who you are in the world. I cannot help but believe that there is value in knowing where we come from. And so I think there is a place in good psychotherapy for understanding one's family, because by knowing who our people are, we know who we are.

Our legacy, our inheritance, is not a punishment or a curse. It is nothing less than the sum total of the forces that brought us into existence, and that shaped us into who and what we are. The stories of triumph and anguish, the world-view of our families, the attitudes and beliefs about the world that we learned from our parents... As humans, we are a combination of all of this added to our own authentic selves. There is tremendous power in looking that legacy in the eye, and consciously choosing to engage it. And I think that is valuable work worth doing.

Wednesday, April 4, 2012

The Closet as a Given

I've noticed something in my work with GLBT people that I wanted to mention.

Over the years, I've begun to recognize that people conceptualize "being in the closet" as a default state. Queer people are thought to be "in the closet" unless they tell someone about their sexual/gender/romantic orientation. And so, it can seem that the normal state is for queer folks to be closeted.

But really, the opposite is true: The dishonesty that queer people engage in to be in the closet is an action, not the lack of action. It is not accurate to say, "I'll just do nothing and stay in the closet." One cannot stay in the closet by doing nothing; one must make an effort at being perceived as heterosexual or cisgender.

The heterosexism and cisgenderism that our society maintains--that consciousness that presumes heterosexuality and cisgender status for everyone--is a web of actions, not the lack of an action. Heterosexism and cisgenderism are not default states, either: They require work to maintain.

So "being in the closet" requires work--but so does "coming out." And one reason that coming out also requires work is that so many of us queer folk have internalized the avoidance, the dissembling, and the general dishonesty as part of our lives. But make no mistake: Presenting a false-front to the world is an active process.

There are implications for therapy, and for social justice, in the recognition that being closeted is the created structure. Maybe I will go into detail about how that has played out in my practice in later blog posts.

For today, I just want to make this point: The process of being in the closet requires action. Of course, the process of coming out, of living authentically, also requires action--but not because being closeted is a default state, but because queer folks who come out are in resistance to a society that is also acting--the active process of assuming all individuals are heterosexual and cisgender.

(PS: This makes me wonder what the "default" state for queer people is, in regards to our identities. Perhaps it is that our society has eliminated any possible default state for queer identities--and perhaps this is just another reason why the word "queer" is so appropriate: There is no default for that which is queer.)

Image credit: "MCCALL'S MAGAZINE, KIDS IN LINEN CLOSET," from the George Eastman House Collection. The commentary below the image is mine.