Individual and Couple Therapy
in Tacoma and Seattle

Tacoma Office near Proctor District

35th & N. Cheyenne St

Ample Free Parking

Tacoma Detailed Directions

 

Seattle Office on Greenlake

Greenlake Wellness Group

7900 East Green Lake Drive North, Suite 202

Free Convenient Parking

Greenlake Office Detailed Directions

 

(253) 240-0625

parke@parkeburgess.com



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MUSINGS BLOG

Wednesday
Nov062013

Is Psychotherapy a Medical Procedure?

I think if you asked almost anyone on the street whether psychotherapy is a medical procedure, the great majority would think that a very strange idea. Frankly, the same is true among legions of psychotherapists and counselors. It’s a goofy notion.

But a whole branch of our field has dedicated itself unceasingly to promoting this very idea. Why? In part, these professionals worry that therapy doesn’t have the respect among the general public and, worst of all, other healthcare providers that it should. But mostly, it’s because this field wants to have access to health insurance coverage.

Health insurance carriers only cover medical procedures, so if therapy is not a medical procedure it is not covered. Simple as that. Therefore, therapy must be a medical procedure, right? Wrong.

I could go on at great length about how poorly therapy fits the medical model once you really think about it. Maybe another time. What matters here is that trying to pretend that therapy is a medical procedure involves twisting everything inside out and doesn’t serve anyone very well.

So, yes, I am saying it: psychotherapy should not be covered by conventional health insurance, as long as the insurer subscribes exclusively to a medical model.

But am I saying that psychotherapy should not be covered by some kind of insurance? Absolutely not. Indeed, the same case that argues for coverage of medical procedures applies equally well to therapeutic work; it’s just that these are two different kinds of thing. Auto insurance and flood insurance, for example, may both make a lot of sense, but it wouldn’t make sense to pretend that they are the same thing and should be covered under the same policy.

Psychotherapy should be covered because it’s a human right. We as a society know how to alleviate emotional pain and have trained and licensed professionals qualified to do it. Everyone should have access to that, just as we believe everyone should have access to healthcare for physical pain—it’s a basic right.

And psychotherapy should be covered because the social costs of excluding people from this benefit are much greater than the costs of including them. The social costs of crime and violence, substance abuse, lost productivity—not to mention the unfathomable human and social costs of passing depression or abuse down from generation to generation—can be measured in the billions of dollars per year.

What would make far more sense than no insurance for therapy or our current medical insurance for therapy is a separate psychotherapy insurance. Medications would still be covered under health insurance, but this insurance would cover therapeutic office visits and residential (in-patient) programs.

As long as we’re dreaming, let’s throw out a few numbers. The standard policy would provide 24 hours of individual psychotherapy per year at 100% and an additional 24 hours at 80%; it would cover couple therapy for ten 75-minute sessions per year at 100% and another ten at 80%; and for families with children, it would cover ten 90-minute family therapy sessions per year at 100% and another ten at 80%. The plan would have, say, a $400 deductible.

Although I made these numbers out of whole cloth, they represent what I would consider adequate coverage for those in need of out-patient therapeutic support. The relatively scanty coverage of current plans reflects “parity” with medical coverage but not the well documented realities of actual psychotherapeutic work. With support such as I have proposed, people in need might actually be able to get the help that would dramatically improve their own lives, the lives of those who depend on them, and the society that they help comprise.

Thursday
Oct172013

"What Is Our Deepest Desire?"

A fellow EFT practitioner shared this gorgeous poem with me, a poem by Miriam Pederson. It is the most deep and wise piece of writing I have seen in a long time!

To be held this way in our mother’s arms,
to be nestled deep in the warmth
of her body, her gaze,
to be adored, to overwhelm her
with our sweetness.
This is what we seek in chocolate,
in the food and drink and drugs
that stun the senses, that fill the veins
with the rich cream of well being.
What we take for lust—can it be, perhaps,
a heavy pang of longing to be swaddled,
close, close to the heartbeat of our mother?
No bucket seats, Jaccuzi, or even a lover’s embrace
can duplicate this luxuriance,
this centered place on the roiling planet.

When the old woman, small and light,
can be carried in the arms of her son,
he, at first, holds her tentatively,
a foreign doll,
but gradually, as the pool loses its ripples,
he sees his face in hers
and draws her to him,
rocking to the rhythm of her breathing.
This is the way to enter and leave the world.

"What Is Our Deepest Desire?" by Miriam Pederson, from New Poems from the Third Coast: Contemporary Michigan Poetry, edited by Conrad Hilberry, Josie Kearns, Michael Delp and Donald Hall. © Wayne State University Press, 2000.
Friday
Sep062013

Review: Broucek on Shame and the Self

Broucek, F. J. (1991). Shame and the self. New York: Guilford Press.

This is an extraordinary, broadly scoped, and passionately argued book. Broucek founds his conception of shame on the development of the self. Broucek locates the beginning of shame as a problem at the time when the child begins to recognize herself as an object in the field of the other. The key developmental moment, then, involves the acquisition of what Broucek calls "objective self-awareness:"

The acquisition of objective self-awareness requires that the child grasp that he is visible to others in the same way that others are visible to him, that is, that he has an exterior on which others can have a perspective that he can never share, except in a very limited fashion (pp. 37-38, emphasis original).

In general, this objective self-awareness is not a constant state of being, but one we move into and out of. We experience it more often than not suddenly, unexpectedly, and have a sharp feeling of uncomfortable exposure. Broucek importantly observes that we cannot simultaneously maintain both a sense of self from the inside (that is, self as subject) and the sense of self as seen by the other (as object), so this sudden experience of exposure is disorienting and disorganizing, requiring a dramatic shift in brain state. This kind of visibility suddenly and forcibly takes us out of ourselves, which Broucek takes to be an elemental feature of shame.

I think this is an enormously important contribution to our understanding of shame (and Broucek makes wonderful hay of it in his critique of modern society), but it seems to miss a crucial distinction. I want to say: being visible to the other is not necessarily like that, but only is like that under certain conditions. The gaze of the other does not necessarily compel us to regard ourselves as an object; there is something specific to the circumstances of the gaze and, more importantly, the quality of the other's regard of us that feels objectifying and therefore changes how we regard ourselves.

Many theories, like Broucek's, rest heavily on the idea that exposure brings shame. But these theories all seem to miss that it is only unwanted exposure that induces shame--namely, it is when we are visible to the other so that they might (or do) reject us. Exposure is not the main issue (though it is closely proximate to the main issue). Rejection is the main issue. Gershon Kaufman indicates this clearly when he speaks of the sundering of the "interpersonal bridge," and Silvan Tomkins points to the same dynamic, albeit indirectly, when he speaks of the sudden diminishment of excitement or interest.

This distinction, I think, is immensely important. Deep down we want nothing more than to be exposed--that is, to feel free to be open, transparent, and vulnerable: and loved all the more for it. This is the state of early infancy (at least for a securely attached child), and it is the state to which we all yearn to return. Moreover, it is this very state of innocence that we lose with the onset of shame, and that shame, when consistently over-utilized and under-repaired, banishes to the nether regions of implicit memory. We long for exposure, but shame renders it perilous, so we resist being exposed. Herein lies the real tragedy of shame.

Couple therapy, to give one highly significant example, aims to create a zone of safety for the partners to be exposed to one another and, at long last, to feel loved all the more for it. When this can occur, a seismic shift of the psyche usually follows, as though an enormous weight has suddenly been lifted.

Monday
Sep022013

One Post Everyone Should Read

If forced to say one and only one thing that would be most helpful to most people struggling with the vicissitudes of emotion and mood--in other words, to most people--this post is what I would choose to say.

Sometimes we feel bad. No one really likes this. In fact, our whole nervous system is set up to get out of bad feeling as quickly as possible and restore a sense of feeling good. But, as it turns out, feeling bad is part of what it is to be human. If we can orient ourselves to this crucial fact and its many implications, we can avoid a lot of unnecessary and fruitless suffering.

The nervous system is designed by evolution to maintain homeostasis--that is, to keep the body in the range of conditions wherein it can continue to live. A simple homeostatic mechanism is the common household thermostat. Its function is to keep the interior temperature within a certain range. The thermostat will monitor room temperature and turn on the furnace if the temperature falls below a certain point, turn off the furnace when the temperature gets to a certain point; or turn on the cooling system when the temperature goes above a certain point, and turn off the cooling system when the tempterature falls to a certain point. All of this produces the following cycle:

At the top of the cycle, the temperature is in the ideal range. Gradually, the temperature moves one way or the other, in the direction of too hot or too cold, until, at the bottom of the cycle, the thermostat is triggered to activate the mechanism to restore the desired temperature (furnace or cooling system). Gradually, the temperature returns to the desired range, at which point the corrective mechanism is switched off. The cycle repeats.

The human central nervous system does the same thing on many different levels at the same time. It monitors our blood oxygen and C02 levels, our body temperature, our blood sugar levels, hormonal levels, and so on. At an aggregate level, all of these factors and many more contribute to our overall state. We experience well-being when all these systems are in their optimal ranges, and some kind of discontent when one or more of these systems are sufficiently out of whack. Because the total system is much more complex than the thermostat example given earlier, there is often a lag time between when we experience discontent and when we start to feel better. This is the time when our central nervous system (CNS) is re-organizing itself on various levels to coordinate a re-regulation of the total system. Thus:

 

This cycle operates continuously virtually from the moment of conception until some time after we exhale our last breath. It never stops. At any given moment we are somewhere, as a total system, in this cycle. This is true for every one of us, all the time. As sentient beings capable of self-consciousness, we experience this cycle profoundly. It first impresses itself upon us early in infancy, if not before, and never releases its grip. We are thus always involved in the following drama:

Because our CNS is oriented always to restoring a good feeling, most of this cycle can be experienced as a problem, even as it is a perfectly inevitable part of any homeostatic system. Tragically, we can become so concerned with not wanting to feel bad that we become stuck in the lower regions of the cycle. Various psychological mechanisms can develop that, in effect, block our ability to round the corner and move back toward feeling good. Shame, a topic of special interest to me and much discussed in this blog, is one of those mechanisms that keeps us locked into perpetual states of feeling bad.

Therapy is especially effective in helping us see how we get stuck in feeling bad, and how we can unblock ourselves and keep this cycle flowing in an optimal way. Part of it, an important part, is recognizing that feeling bad is not a problem so long as we have some confidence that feeling good is just around the next bend.

Of course, I don't mean to minimize how profoundly difficult it can be to work through the impediments to a smoothly flowing homeostatic cycle. There are many thorny issues that can be involved, including trauma, organic (genetic) predispositions, and attachment dynamics of all kinds. But, as I say, if I could impart but one idea that is potentially most helpful to the largest number of people, it would be the idea of this dynamic cycle as a basic rhythm of human life.

Monday
Aug122013

Review: Helen Block Lewis on Shame and Guilt

Lewis, H. B. (1971). Shame and guilt in neurosis. New York: International Universities Press.

This work seems to be regarded as Lewis' crowning achievement, and is best known for its emphasis on the power of unacknowledged shame in psychotherapy to impact the client in negative ways in the course of therapy. Lewis operates squarely within the psychoanalytic tradition as it had evolved by the middle of the last century. Both because of its age (more than 40 years) and its theoretical affiliation, the book has an exotic, antique feel to this reader. Three of its chapters (Chapters 3, 4, and 5) are of strictly historical interest, reporting a kind of proto-attachment research that the author fails to integrate into the much more compelling general approach to shame and guilt offered elsewhere in the book.

The early chapters (1 and 2), on the other hand, provide the best and most richly elaborated discussion of shame and guilt I have yet seen anywhere. In Chapter 2, Lewis makes a reasonably thorough study of all the terms in the dictionary associated with shame and guilt and attempts to map out their relations--a fascinating endeavor that bears abundant fruits, though I think she might have gone even further. I highly recommend that all students of the phenomena of shame and guilt acquaint themselves with these chapters.

Chapters 6-10 provide a much more detailed and technical discussion of shame and guilt as they arise in psychotherapy. These chapters may be of interest only to therapists and theorists, but offer a plentitude of examples of shame and guilt as described by real world clients, both directly and indirectly. These chapters prove somewhat problematic, too, because Lewis' analytic interpretive approach requires one to have drunk the Freudian Kool-Aid in a way that few readers these days will have done--certainly, I have not. (For example, it seems that a disprorportionate amount of shame relates to masturbation in these anecdotes, whether the client knows it or not. Can't we be ashamed of anything else?)

My main issue with Lewis' presentation of shame and guilt concerns her strong theoretical commitment to distinguishing between them as if they are two entirely distinct phenomena. I both agree and disagree with this: it's true we can make a distinction between shame and guilt (and Lewis helps enormously to clarify this distinction); but fundamentally they represent a single movement of the psyche. Shame and guilt, in my view, are two facets of the same phenomenon. Lewis too strongly compartmentalizes the two, missing their underlying psychological unity.

Lewis distinguishes between shame and guilt as follows (p. 81):

Shame is an affective state; guilt may or may not be affective.

Shame is about the self; guilt is about something objective that may or may not involve the experiencing self.

Shame may be evoked by a moral or non-moral stimulus; guilt...is evoked...by the acceptance or acknowledgment of moral transgression.

Shame and guilt, in my view, represent different phases of a single psychic gesture. Shame is the affective core of that gesture. Accordingly, it makes no sense to speak of guilt as lacking an affective component. Shame is what it's like to perceive (real or imagined) rejection from an attachment figure. It's a terrible feeling. (It is also a neurobiological process involving basic emotion circuits, and an action tendency, and so forth.) In adaptive cases, guilt sometimes flows out of this feeling and ultimately motivates the making of amends. By this understanding, shame is the feeling that underlies guilt and motivates guilt-based thoughts and action tendencies. Lewis tacitly, and presumably unintentionally, illustrates this point over and over again in the later chapters as she identifies unacknowledged shame beneath many instances of guilt responses.

Lewis' second point refers to the by-now-venerable idea that shame is about the self and guilt is about actions performed by the self. This suggests that when we feel that we are fundamentally flawed we feel shame, but when we feel that we have done something wrong we merely feel guilt. This distinction has merit, but it overlooks a basic existential problem. How can we possibly separate our actions from our being? Parents are taught to discipline children for what they do, not who they are (so as not to shame them). But how can a child make sense of the idea that "I am a good girl who does bad things"? This is, at best, an adult concept; at worst, it's a pure fiction.

A better distinction might be: I can be a good person who sometimes makes mistakes which require correction. But this still doesn't avoid the trap of shame because we are left to ask: Why do I make such mistakes? What's wrong with me? And the next question: Other people don't seem to make the same mistakes, or as many of them, as I do, so how come I don't measure up? Moreover, the reliance on mistakes leaves aside the whole domain of human motivation that is not mistaken but anxious, selfish, hostile, and so on--all legitimate and unavoidable parts of the human psyche.

All this illustrates a fundamental principle of human psychology, I believe, that one can rarely feel guilt without feeling shame. Guilt is rooted in shame. Not all shame will eventuate in a guilt process, but the great majority (if not all) of guilt processes proceed from a basic shame experience.

Once this is accepted, Lewis' third distinction fades into irrelevance. Any perception of (real or imagined) rejection, whether it be connected to ideas that are defined as moral or not moral by the prevailing culture, evokes shame and may result in a guilt process. It's probably true that the guilt process involves cognitions that we may define as moral: "What I did was wrong, so I should make amends." But these are just cognitions that accompany the real drama of shame and guilt: the drama of feeling, of needing to belong, and trying or failing to recover from the painful experience of rejection.