In the Middle of the Night

I woke up in the middle of the night lonely. It was an odd feeling. I don’t feel lonely so often, and never before after waking up from a sound sleep at the magical point in the night when the traffic on the freeway has slowed, it’s quiet, and you can hear even with your eyes closed that it is really night out there.

One of the strangest things about being me is that anything to do with family is beyond me. I was raised by people who fed me (sort of), clothed me (most of the time), put a roof over my head and abused me. And not much else. There was no sense of grief for me when I cut ties to them. I don’t recall missing them. I was afraid of them. That’s all. My feelings were unmixed.

I know the struggles most people have with parents over their lifetimes: becoming independent, building adult relationships, dealing with difficult parents, addressing age-related issues, coping with a dependent parent, and finally accepting their loss. But I can’t relate to it personally. I can’t say I’ve been there, or that I ever will be there.

But in the middle of the night I began to understand that other people have things I don’t. Not everyone, of course, but many of them. They have these things called families, and they consist of a somewhat stable group of people in your life that are in some ongoing way there.

Now, this isn’t to say that I don’t have great friends. But I do know that it isn’t the same. There is no one who has known me since elementary school. There is no one around who held me as a baby or watched me grow up.

In a real way, I am the only continuity I have. I am the only one who remembers anything about my life or my past, or who I was.

It’s a strange thing.

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The Pull towards Certainty

uncertaintyWhen I was in graduate school, a mentor teacher of mine told me, “Everyone wants to know what to expect.” He was right. Even as adults, uncertainty is uncomfortable. We prefer to know what will happen next, even to the extent of paying good money to psychics to find out the future.

But it isn’t exactly the same between cultures. Hofstede posits that there are more and less uncertainty tolerant avoidant cultures. Really everyone is uncomfortable with uncertainty, but uncertainty intolerant cultures use external means to cope: rules and beliefs.

Cults are microcultures that are uncertainty avoidant to the extreme. In fact, the point of a cult is usually to provide absolute certainty about life. A cult will tell you what to think, what to do, what to wear, what to say, what the meaning of life is, what your purpose is, and pretty much anything you want to know. It will tell even you your own future. If you follow the rules of the cult, you’ll prosper. If you don’t, you’ll be damned in this life and beyond.

As someone who has exited a religious cult, what I’ve noticed about other exes is that most of us continue to find uncertainty very difficult. Anxiety over uncertainty is both unexpected and unaccustomed. Although we recognize the cult we were in was mistaken and in many cases spiritually and emotionally abusive, we don’t necessarily realize that the certainty it offered altered our expectations of life in unreasonable ways and diminished our ability to cope with day-to-day living.

In a cult, uncertainty and doubt are the enemy. Usually, they indicate your faith is weak or that Satan is tempting you. After a cult, uncertainty can continue to feel the same way: an indication, perhaps, that we’ve chosen the wrong road.

It isn’t. Uncertainty is a part of what it means to be an adult making the best choices we can given our current information while never knowing exactly how our choices will pan out over the long term. And part of life is learning to manage our anxiety over our uncertainty.

What I’ve noticed is former cult members often continue to expect certainty from other situations. We may leave the abusive cult only to find ourselves in another controlling group, or in a controlling intimate relationship. Or we look to science and want absolute proof of everything we believe.

But for the most important things in life, we really don’t know exactly what is true or what is correct. We don’t know ahead of time if our intimate relationships will stay strong over a lifetime. We don’t know if there truly is a God or not, and if so how we should worship. We don’t know what financial decisions will let us retire before we are 90 and what will cost us our savings. All we can do is look at the facts as we know them and make the best guess we can.

Further Reading:

The Hofstede Center

Uncertainty Avoidance

The Cult of the Unconscious

Psychodynamic therapy looks no different than any other kind of psychotherapy.
Psychodynamic therapy looks no different than any other kind of psychotherapy.

Psychodynamic therapy consists of “talk therapy” that relies on theories of Sigmund Freud, his followers, and those who broke away from him. What ties together what can be rather diverse therapies is a belief in the importance of locating repressed, primitive drives and needs and bringing them into conscious awareness.

It has been criticized as being fundamentally unscientific: there are a number of assumptions common to psychodynamic theories that are untestable. Is there an ego? An id? Are conflicts between conscious and unconscious material really the source of all our problems? There is really no way to know. It hasn’t been scientifically validated, and it can’t be.

The therapy itself has shown some success. There are studies that do indicate it is more effective than no therapy and a small number of other studies indicate that it is more effective than other forms of therapy. But not many. In general, empirical researchers haven’t shied away from looking at it too closely. And it may be no more effective than other forms of psychosocial support—or than joining a club or getting a dog.

But psychodynamic therapy is usually assumed to take many sessions show results—more than the cognitive behavioral therapies, which means it costs more. And that creates a niggling sense about it that it’s nothing more than a long con.

And that may be exactly what it is. This isn’t to say that the therapists doing it are con artists. They are usually well-meaning, well-intentioned people who genuinely believe that their brand of therapy works. But I wonder if they’ve been had. I wonder if we’ve all been had.

It interests me because psychodynamic therapy shares a crucial element of its foundations with religious cults: namely, the circularity of it. In therapy, the patient typically free associates—talks about whatever comes to mind—and the therapist analyzes it for unconscious drives and needs. The idea is for the therapist, or the patient and therapist together, to bring these drives and needs—and the conflicts they are creating into conscious awareness.

The assumption is that the patient, at least at some points, will be resistant to having these drives and needs, and the conflicts around them, brought to the surface. The more the patient disagrees with the analysis, the more resistance is assumed to be at work. The psychological patient, unlike a patient sitting down with his medical doctor, is assumed to have deeply mixed feelings about getting better.  Working with resistance is assumed to be part of the process.

We had a different name for this in the 2×2 cult. We called it “lacking the right spirit” or “taking our own way.” A Pentecostal friend of mine said they called it “being unwilling.” But the point is the same. Being a good person and a good patient involves deferring to authority, even if it has no scientific basis and is costing you a great deal of hard-earned money to tell you things that don’t seem to be helping and that you don’t believe to be true.

I don’t bring this up to bash psychotherapists, or to express my lack of gratitude to well-meaning, well-intentioned therapists who tried to help me for many years. I bring it up because when we offer fraudulent, untestable, and ineffective medicine to sick people and swear up and down it will help and that if it doesn’t help it’s their fault, we deny them the opportunity to find more effective treatments. And they stay sick. The cost of our love affair with an ineffective therapy is an unnecessary perpetuation of suffering.

Further reading:

Anestis, M. (2012, Januardy 25). Long-Term Psychodynamic Psychotherapy; Discussing the Evidence. Retrieved from: http://www.psychotherapybrownbag.com/psychotherapy_brown_bag_a/psychodynamic-therapy/

Treating Complex Trauma: Trauma-Focused Cognitive Behavior Therapy

In an earlier post, War and Torture: Treating Survivors of Ongoing and Repeated Traumas, I mentioned rather briefly that Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has shown good results in treating survivors of repeated and complex traumas such as war, torture, and childhood sexual abuse. As survivor of complex trauma myself (torture and childhood sexual abuse, as well as ritual and severe physical abuse), I can attest to the veracity of those findings.

Psychodynamic therapies encompass a wide range of theories and practices derived from Freud, his followers, and those who broke away from him. It is focused on expanding the range of the ego. An entity I continue to fail to understand.
Psychodynamic therapies encompass a wide range of theories and practices derived from Freud, his followers, and those who broke away from him. It is focused on expanding the range of the ego. An entity I continue to fail to understand.

For more than 20 years, I have been a psychotherapy services–on and off, but mostly on. Most of it has been unhelpful. I kept going back because I needed help and, darn it, something had to work. But it really didn’t help. Not very much.

And then about 8 years ago, I quit therapy, focused on my job and friendships, found myself an appropriate and supportive intimate partner, began to research some of the mental illness I grew up with, joined online support groups, and started up some do-it-yourself dialectical behavior therapy.

For the first time, I began to get noticeably better in terms of my overall mental health and general sense of well-being. It wasn’t roses by any means, but it wasn’t just running on a hamster wheel anymore. When I did return to therapy two years ago, I used it in a particular, self-directed way. I didn’t just go and see where the conversation took me. And I stopped looking to therapy to provide me some kind of magical insight into myself and focused on telling the story I needed to tell. And I kept getting better.

I’ve been wondering recently why this was. I think I have an answer.

We need a network of people who care about us, even if it's just a little. (Children 6 months after the Haitian earthquake.) Photo credit: IFRCT
We need a network of people who care about us, even if it’s just a little. (Children 6 months after the Haitian earthquake.) Photo credit: IFRCT

Most of the psychotherapy I’ve been engaged in has been psychodynamic in nature. And it is not especially effective with complex trauma. I’m not sure it’s especially effective at all–not more than having a good friend who cares about you and listens to you talk once a week. Or getting a dog. But I can’t really say one way or the other. I haven’t researched it, and I do think different problems have different solutions. So maybe psychodynamic therapy works with some problems. But it doesn’t help you deal with repeatedly being raped, for example, or having lived in a war zone. Not much anyway. And it might take 30 years to notice substantial improvement. And frankly most of us just don’t have that kind of time. Or money.

What works is relatively new on the scene, and that’s why it took so long for me to get help. The science wasn’t there, and I was so conditioned by psychotherapy to believe I needed to confront my difficult feelings that I couldn’t believe there was any other way of working.

I’ll tell you what I did in the end and why it worked. First, I provided myself with psychosocial support. I did not make friends, but I made better acquaintances. I gave myself meaningful work to do that gave my life a sense of meaning. Both the World Health Organization and The International Red Cross and Red Crescent Societies  say that psychosocial support helps communities marshall existing resources to manage difficult situations.

Cognitive Behavioral Therapy assumes that our thoughts, behaviors, and emotions all interact. If we can create change in one, we can often create change in another.
Cognitive Behavioral Therapy assumes that our thoughts, behaviors, and emotions all interact. If we can create change in one, we can often create change in another.

Victoria Follette in her book Cognitive Behavioral Therapies for Trauma mentions that beginning with an initial course of Dialectical Behavior Therapy prior to starting TF-CBT is helpful for some patients with especially intense or complex traumas. It was helpful for me, as I lacked the skills necessary for managing the extremely intense feelings involved in working with my memories of trauma.

This isn’t to say I lacked emotional skills in general. The extremely intense emotions of trauma requires specialized skills. And we don’t learn these just anywhere. They are learned through deliberate effort and practice.

In particular, I incorporated mindfulness and distress tolerance into my emotional management toolbox. Mindfulness helps works against dissociation, and it is the habit of dissociation that makes resolving trauma so difficult. Distress tolerance reduces impulsivity, and it allowed me to dredge up memories strongly associated with suicidal thoughts and urges without endangering my own safety. Those skills gave me a foundation for further work.

Only after that did I start working with memories. I used two strategies from TF-CBT, although there are other strategies with a track-record of effectiveness, and one other variety of CBT that is not specifically designed for treating trauma but was important for helping me address my faulty beliefs from having been raised in a religious cult.

The TF-CBT strategies I used are prolonged exposure therapy (PE) and Cognitive Processing Therapy (CPT). I repeatedly exposed myself to memories of trauma while making a conscious effort to manage the emotions effectively without dissociating (dissociation shuts down the ability to engage in a conscious or deliberate way with the world or with our minds) and I looked at what thoughts and beliefs I had formed during trauma in order to challenge them with more complete information.

The third form of CBT I used was schema therapy, which looks at important beliefs that interfere with functioning. Because I was raised in a cult, and because I was raised by parents who thought in deeply faulty ways, I have inherited a number of faulty beliefs about the world and what it means to be a good person. I don’t believe in these whole-heartedly–I did after all leave the cult world when I was 15–but they linger at the margins of my mind and are also closely tied with trauma memories so that the intensity of the trauma experiences sustains them.

When I returned to work with a therapist, I used my therapist to help me with the PE by telling her about specific, difficult memories. Her role as a sympathetic witness to my experiences has been invaluable, and helps me to re-interpret the world as a place in which I can be cared about and supported. It provides me with direct evidence that my sense of being utterly alone with the trauma is no longer true.

I don’t really recommend a do-it-yourself approach to trauma. It’s much easier and more likely to get you good results if you can undertake it with a trained therapist. But I do recommend that you look for a therapist who can provide you with the appropriate form of therapy.

Just as you would see an oncologist to treat your cancer, you probably want to see a therapist competent in providing effective, trauma-focused therapy to treat your complex trauma. You would not see a family doctor to treat your cancer, or a witch doctor, or a priest, and it won’t help very much to see a psychoanalyst, a generalist, or your local religious leader for your complex trauma. Difficult problems require highly expert solutions.

Further Reading:

Follette, V. and J. Ruzek. (2006). Cognitive Behavioral Therapies for Trauma. New York: Guilford Press. (Available from Google books.)

Resick, P., P. Nishith, P. and M. Griffin. (2003, May). How Well Does Cognitive-Behavioral Therapy Treat Symptoms of  Complex PTSD? An Examination of Child Sexual Abuse Survivors Within A Clinical Trial. CNS Spectrums. Retrieved from: http://www.nctsnet.org/nctsn_assets/Articles/40.pdf

Living with Uncertainty

The people you could ask if God was busy. They knew "the truth." Which meant they knew everything. Photo courtesy VotisAlive.
The people you could ask if God was busy. They knew “the truth.” Which meant they knew everything. Photo courtesy VotisAlive.

Yesterday, on my way to work, as I was contemplating my own thoughts about myself and the world (which is what I do on the way to work), it occurred to me that I felt anxious about life, about what might happen, about not knowing exactly what I should do or what would give me the results I wanted in a particular situation.

And it occurred to me also that no one really does. We don’t know exactly what might get us what we want in life, what course of action would be best to choose, or how things will all turn out in the end. We sometimes feel anxious about this.

Uncertainty and anxiety about uncertainty are a part of life.

If you were raised by good parents and have always been a member of a supportive religious group or no group, then you will be wondering at this point why I’m pointing out the obvious. But if you have ever been part of a controlling group–religious or otherwise–or had controlling parents, then you can probably understand my epiphany.

Controlling people do not like uncertainty. They like to be right and to know they are right. And if you spend enough time with them, you will also start to think that uncertainty should be avoided at all costs.

I grew up in a religious cult that refers to itself humbly as “the truth.” (I understand Jehovah’s Witnesses also refer to their church as “the truth,” but I didn’t grow up reading The Watchtower. This was different.)

What we had in spades was certainty. Certainty in all aspects of life: what to do, what to wear, what to say, what to feel. And if you didn’t know, you could pray. God could be expected to tell you. All we really needed to worry about was what to eat–there were no rules about diet.

What has been different about life after being out of that group is that God rarely tells me what to do with the mundane aspects of my life. He seems to have no interest in how I spend my day, what career choices I make, or even what relationships I choose to deepen. And the difference for me is that I am left in a state of uncertainty and anxiety.

Which is fine, really. It’s part of being a member of the human species.

What’s difficult about uncertainty for a former cult-member is that it is so unexpected. We don’t see it as a normal part of life anymore. It is an alien intrusion, proof we have made the wrong decision and should go back.

But it is proof we are alive.

War and Torture: Treating Survivors of Ongoing and Repeated Traumas

Participants of the Treatment and Rehabilitation Center for Torture Victims, Palestine
Participants of the Treatment and Rehabilitation Center for Torture Victims, Palestine

The Upsala Armed Conflict database lists 33 countries with ongoing armed conflicts in 2011. Some countries, such as Afghanistan, have been in the midst of low-intensity warfare for most of the last several decades. Individuals living in these areas are subjected to intense, and unpredictable violence and unexpected losses: massacres with ethnic overtones and terrorist bombings in addition to all-out firefights between insurgent groups. Those who flee do not always find themselves arriving into safe hands, but instead imprisoned in crime-ridden refugee camps where those charged with their protection further abuse them.

And war is only one type of traumatic event. Repressive regimes routinely use torture to subjugate and terrorize their citizens, including rape and other forms of sexualized violence. The International Council on the Rehabilitation of Torture Victims claims that as much as 35 percent of refugees have experienced torture.

In 1999, WHO estimated that there were approximately 50 million displaced person and refugees around the world. About 50 percent “present mental health problems ranging from chronic mental disorders to trauma, distress and great deal of suffering.”  Of these, about 5 million have ongoing mental illness or have been highly traumatized and require professional treatment. An additional 5 million experience significant impairments to their social or psychological functioning.

We now know with some degree of certainty that the sooner traumatic events are addressed and attended to, the less likely they are to lead to pathological symptoms in those who experienced them. We also know that individuals who have had multiple traumas over their lifetimes are more at risk, especially if those traumas remain unresolved. Addressing the needs of repeatedly traumatized individuals quickly is important to their overall recovery and for the recovery of their communities.

The Red Cross/Red Crescent recommends a tiered approach to mental health interventions: community-based psychosocial support that strengthens social and emotional supports and enhances resilience for a wide span of the community, psychotherapy for those with pre-existing mental illnesses or who have been highly traumatized, and psychological first aid. WHO recommends a similar approach.

Professionals providing psychotherapy within these populations usually adopt whatever methods of working they have been trained in and a wide variety of strategies have been used in the field. Given time and economic limitations, most interventions are short-term–the priority is to restore the client to normal and effective functioning. But some organizations provide therapy for as much as a year or more.

According to Mary Fabri’s review of the literature, Trauma-Focused Cognitive Behavioral Treatment (TF-CBT) has been identified as an effective intervention for highly traumatized individuals and CBT-guided treatments constitute a “best practice” approach. Group therapy has a mixed record of effectiveness, but family interventions and psychosocial support seem to enhance the work of individual psychotherapy. Of the greatest priority is adapting the therapy to the culture and needs of the client.

Further reading:

Dwary, M. (2006). Counseling and Psychotherapy with Arabs and Muslims: A Culturally Sensitive Approach (Book Review). Retrieved from: http://www.arabpsynet.com/Books/Dwairy.B1.pdf

Fabri, M. (2011). Torture. Best, Promising, and Emerging Practices in the Treatment of Trauma.

Hardi, L. and Adrienn Kroo. (2011). Torture. Psychotherapy and Psychosocial Care of Torture Survivors in Hungary: A Never-ending Journey.

Human Rights Watch. (2002). Hidden in Plain View: Refugees Living without Protection in Nairobi and Kampala. Retrieved from: http://www.unhcr.org/refworld/docid/3e314172e.html

International Federation of Red Cross and Red Crescent Societies. (2009). Community-Based Psycho-social Support: Trainer’s Book. Retrieved from: http://reliefweb.int/sites/reliefweb.int/files/resources/130F79651B1E9A68C12575C90043CC48-IFRC_june09.pdf

International Rehabilitation Council for Torture Victims. (2011, 20 June). Up to 35% of Refugees are Torture Victims. Retrieved from: http://www.irct.org/Default.aspx?ID=3843&PID=13717&M=NewsV2&Action=1&NewsId=3221

Kakuma Refugee Reflector: A Kakuma Free Press. http://kanere.org/about-kakuma-refugee-camp/

Levine, P. “Trauma is Treated in the Body, Not the Mind.” Somatic Experiencing. Retrieved from http://traumahealing.com/somatic-experiencing/

Levine, P. (1996). Trauma Healing Articles. Retrieved from: http://www.traumahealing.com/somatic-experiencing/reference-healing-trauma-lessons-from-nature.pdf

Upsala Conflict Data Program. (2012, 17 February). CDP Conflict Encyclopedia: http://www.ucdp.uu.se/database, Uppsala University. Department of Peace and Conflict Research. Retrieved from: http://www.ucdp.uu.se/gpdatabase/search.php

World Health Organization. (2013) Mental Health of Refugees, Internally Displaced Persons, and Other Populations Affected by Conflict. Retrieved from: http://www.who.int/hac/techguidance/pht/mental_health_refugees/en/