Reflections on the Summer Series

We ended the summer teaching series on last week.  There were six sessions, and each of them was somewhat unique.

Due to a glitch in communication, the first invitations from the Ontario Medical Association went out across the province.  And, well ... no surprise, we received interest from all across Ontario as a result.  It’s no surprise that physicians including psychotherapy in their practice, whatever stage they are at, are searching for opportunities to discuss difficult and challenging cases.  They also, of course, are often seeking to connect with other like-minded colleagues.

Under the kind and expert guidance of my colleague and fellow education committee member, Dr Harold Pupko, small groups of physicians brought many varied cases to these peer consultation groups.  They ranged from the practical: a case where a patient from East Africa presented to a community health clinic requesting, on his first visit, that disability forms were completed (ODSP forms).  He did not want any other care.  We explored how to best go about creating a dialogue in this situation, in a situation where there was general distrust in the medical system.  Other themes covered were more complex, such as how to deal with poorly regulated and highly reactive patients in a full-time psychotherapy practice.

In our last session, the final case presented was of a woman with no friends.  She just seemed to be one of those people that don’t really come off as too unusual or bizarre, but somehow, just don’t attract people.  Her psychotherapist, a highly experienced colleague, had attempted the usual behavioural interventions - go to Meetup groups, seek out social situations, sign up for programs and courses and the like - but her patient continued to be politely brushed off by the people she attempted to befriend.

This led to a poignant discussion on the growing phenomenon of isolation in our Canadian society.  The cost is high and affects patients and caregivers alike.  Ultimately, it may be the biggest causative factor involved in rapidly increasing rates of depression.

The impact of this kind of social isolation is high.  I know it’s possible, with the right skills and training, to help most patients.  Usually, if one is able to work at the level of character structure, or at a more psychodynamic or somatic level, there’s the possibility of creating real change in therapy.  Here, we’re talking at the implicit level, or the dimension of the mind/body.  And that’s a beautiful process, because the patient may never know what they were doing wrong, with their body language or with subtle cues they transmitted to others.  But they change in therapy, and they stop doing whatever is was that they were doing before those attachment- and trauma-based procedural tendencies got in the way of their lives and their happiness.

We agreed that loneliness and isolation were creating the need to go a lot further in therapy, and that this is affecting the length of time we need to see patients and the stress of the work involved.  If it was easy to find community and belonging in the world, we would not have to work so hard, and – for a lot of patients – a little hand-holding and the sense of feeling held and cared for over a period of time, might be enough.  But one needs to leave therapy with a fairly complex skill-set these days to penetrate the social and work barriers that seem to grow by the day.  Sometimes, it does feel daunting.

So, here we are, in this time of shifting social forces.  Participants agreed for the most part that the old cognitive re-frames and interventions just aren’t cutting it any more.  

This is stuff you just won’t hear much in formal teaching any more.  There’s too much politics involved and too much for medical school faculties to lose by telling the full truth about how poorly some of their cherished modalities of mental health care actually work.  But in the real world, these techniques that look and sound so good in our lectures and in our journals are no longer adequate for the needs of our patients and our own lives.

So, we ended a good night on a good theme, I think.  Dr Pupko envisioned this series to create a forum for colleagues to come together and to talk and share.  Ultimately, he saw this as serving physician well-being and as building community in our profession.  And we came to the conclusion, at the last session, that what really matters, and what we most deeply require are these opportunities for sharing and belongings.

In this way, the summer series echoed the two series that will be starting on October 1^st – the Wednesday Night Main Speaker’s Series and the Caring for Self While Caring for Others Series.  We are all about creating community and opportunities to find a place where our personal truths and dreams are welcome.

 

I feel moved to end this post with the words of the famous psychiatrist and writer M. Scott Peck, who – towards the end of his life – thought deeply about community and truth:

“How strange that we should ordinarily feel compelled to hide our wounds when we are all wounded! Community requires the ability to expose our wounds and weaknesses to our fellow creatures. It also requires the ability to be affected by the wounds of others... But even more important is the love that arises among us when we share, both ways, our woundedness.” 

 

What are your feelings about  more opportunities to  access peer supervision and other forums for discussing clinical cases, personal issues in your practice and new ideas in neuroscience and psychotherapy?  Would you like to see more of this?  These kind of endeavours can be created- the summer series proved this.  They can happen, but only with considerable interest and support.

Sanctuary

The butterflies keep coming.

I was at Anastasia State Park this morning, braving the heat, and several times, I was fortunate to see giant swallowtails alight close by me, before flying off into the distance.

As I walked, I was thinking about the concept of sanctuary, what this means, and if it can be cultivated and created.

I left Alachua, close to Gainesville, in north Florida, a few days ago, after completing a five day program run by the Florida Societyfor Bio-energetic Analysis. The theme, no surprise, was on opening up to love. After spending a profoundly intimate experience with twelve other participants and two trainers, I rented a car and drove to St. Augustine, to process, relax and spend time on the ocean.

The program in Alachua was dedicated to the memory of FrankHladky, MD. I admit that I never heard of Dr Hladky before receiving an invitation to the workshop. I know a little about him now, but not a great deal. He never wrote a book. There is a three part audio on YouTube featuring him being interviewed by Alexander Lowen’s son, Frederic. I know he was a psychiatrist, that he believed strongly in aliveness, and that he practiced for a long time, including some early years in the military. He died in 2012. And he’s going to bring me to the concept of sanctuary, and this short video makes a nice bridge.

After the intensely emotional and shared energies of a group process, it isn’t always easy to locate a way into an aspect of the event that invites a more public discussion. Some of the experiences do not translate easily into words. Perhaps that explains the gap between finishing the program and starting this entry.

Diane Gobrogge, one of the trainers, had studied with Frank Hladky for many years. She shared some of his mannerisms, and gestures, and teachings. Her love for his teachings shone through her own teachings. She remarked on how Frank would often pat his patient on the back at the end of the session and say: You’ll be okay.

What struck me was her observation that colleagues were always welcome at Frank’s big house in Oklahoma. It was a place to go to connect with other bio-energetic practitioners, to relax, and renew and to connect with nature.

This led to me thinking how important this kind of sanctuary is in the life of a therapist. We need silence and distance, and we also need the company of others with similar sensibilities. We need a safe refuge where we can do work with colleagues whose skills we can respect and honour, whose abilities and intuition can support our emotions and our own ceaselessly unfolding and emergent process.I wasn’t going to include this short poem by Dorothy Parker, but then I saw a picture of her, seated between Faulkner and Fitzgerald, on a mural at the Starbucks in the Barnes & Noble bookstore in St. Augustine. She has her drink and they have theirs, but otherwise, there is no contact.

“My land is bare of chattering folk;
The clouds are low along the ridges,
And sweet's the air with curly smoke
From all my burning bridges.”I understand that Dorothy Parker suffered from depression. I like the image of smoke rising from burning bridges – already these burning bridges are shifting images. But her sanctuary feels to be a lonely one, estranged, the self-imposed and painful sanctuary occupied by so many sad souls.

I felt moved even more deeply by this longer poem, also named Sanctuary, by Jean Valentine:

"You who I don’t know I don’t know how to talk to you
—What is it like for you there?
Here ... well, wanting solitude; and talk; friendship—
The uses of solitude. To imagine; to hear.
Learning braille. To imagine other solitudes.
But they will not be mine;
to wait, in the quiet; not to scatter the voices—
What are you afraid of?
What will happen. All this leaving. And meetings, yes. But death.
What happens when you die?
“... not scatter the voices,”
Drown out. Not make a house, out of my own words. To be quiet in
another throat; other eyes; listen for what it is like there. What
word. What silence. Allowing. Uncertain: to drift, in the
restlessness ... Repose. To run like water—
What is it like there, right now?
Listen: the crowding of the street; the room. Everyone hunches in
against the crowding; holding their breath: against dread.
What do you dread?
What happens when you die?
What do you dread, in this room, now?
Not listening. Now. Not watching. Safe inside my own skin.
To die, not having listened. Not having asked ... To have scattered life.
Yes I know: the thread you have to keep finding, over again, to
follow it back to life; I know. Impossible, sometimes."

In her memorial, Diane noted these qualities in Frank Hladky: As our Teacher he taught the importance of Contact, Trusting the Organism, Following the Impulse, Always looking for the Aliveness in the body and Finding One's True Nature.

She noted his love of D.H. Lawrence, and recalled Frank handing out this quote of his at a workshop:

"This is my creed: For man the vast marvel is to be alive. For man as for flower and beast and bird the supreme triumph is to be most vividly, most perfectly alive.
The magnificent here and now of life in the flesh is ours alone, and ours only for a time.
We ought to dance with rapture that we should be alive and in the flesh and part of the living incarnate cosmos."

As I reflect on five days of deep interpersonal, loving connection and support, I find myself wishing that kind of sanctuary was always available to me, in the way Dr Hladky made possible. The work of psychotherapy is, like the work of a writer, ultimately lonely. We give, and our giving is done invisibly, save for our patients, who bring their pain and their hopes to us.
In my previous career, as a full-time emergency physician, the hospital was – in many ways – a sanctuary of sorts. We witnessed for one another, we went out together; we played baseball together. Psychotherapy is different. My most fluid and successful resuscitations in the ER were always seen. My most powerful psychotherapy sessions can only be described, after the fact, in a forum like this one, which can never capture the myriad of non-verbal contact and emotional nuances that pass fleetingly by in a moment of deep transformation.

Maybe that’s why I’ve been seeing so many butterflies this summer. There’s something about the brevity and beauty of their lives, that speaks to the work I am doing in my own life.

Sessions, workshops, healing moments – they are all brief, all pass by in the seeming blink of an eye. And yet, something lasting and profound is left behind and we carry it inside ourselves, ready to bestow it on others, on the hurt places inside ourselves. In workshops, there can be such a deep sense of travelling a path together, that cords are forged for life, tender tendrils of commonly experienced pain and love. At the end of my level 1 training in Sensorimotor Psychotherapy, one of my trainers, Celia Grand, said to us that the connections we made would remain alive in the universe for all our lives, even if some of us did not meet in person again.

Cada paso que diste fue un peso que yo tambien di said one Chilean participant in the closing circle. “Every step you took felt like a step I took.” She was speaking to all of us. We walked together. Each individual session felt like a group embrace.
Medicine, psychiatry ... these once proud disciplines now seem beleaguered and exhausted and frightened. Research shows that one of the only effective interventions for the onslaught of rampant burnout (approximately fifty per cent of physicians in Canada and the United States now show significant signs of burnout) is group sharing and group process.

The main intention of our teaching series is to create community and to foster a setting for sharing in dialogue and mutual support. We are only at the beginning of this quest. My vision is to see a time when we will all have places to go where we might renew and re-inspire without running away from our challenges, or without the need to turn our back on them.
Without sanctuary, life – even at the best of times – is difficult. What might sanctuary look like for you? How can you see joining with other physicians and physician psychotherapist or mental health care practitioner colleagues and working on your own health, healing and sense of connection?
Can you envision a sanctuary for yourself that would, first and foremost, support your aliveness and connection with your soul?

Tiger Swallowtail, Snow Angels and the Perks of Being a Wallflower

I've been promising to write about the movie Perks of Being a Wallflower for some time now; it seems like I've been waiting for some way to easily transition into it.

The other day, I was sitting in a session with a weekly patient who was reporting on a bad week. For a moment, she picked up that I had broke attunement with her.  Unfortunately, by the time I could interject that there was a tiger swallowtail fluttering against my fourth floor office window, the butterfly was gone.  

This sighting arrived as quite an out of the ordinary event.  We do see some butterflies in Toronto, although not nearly as many as we once did.  I'd seen a black swallowtail in our vegetable garden (I do live in the suburbs) a few weeks before, but this was the first time this summer that I'd seen a tiger swallowtail.  I wondered what it was doing, remaining in my line of sight, for a long, lingering moment, in this uncharacteristic location.

My patient lost her Mom when she was young; on some level she lost her mother at an even earlier age, because the mother of her infancy already suffered from a serious, intermittently and progressive debilitating disease.  Her mother's symbol of hope, during her prolonged illnesses, the young woman sitting across from me shared, with considerable emotion, was the butterfly.

From butterfly sightings, I'm going to take you to snow angels.  I'm going to do that, because there's a scene in Perks of a Wallflower where the main character, Charlie, feeling alienated, leaves a party and starts making snow angels on the cold winter ground.

 A few days later, while I attended a talk on pivotal moments, Jim Duvall made mention of one of his clients, and about their story about making their own snow angels as a reparative and transformational act.

I'm not going to delve into synchronicity here, or into the symbolism of butterflies and snow angels.  I like Jung and I've done my own Jungian analysis, but I want to go somewhere else with this post.

For the same reason, I'm not going to say a great deal about the movie.  It's from a book, written in 1999, that has sold around a million copies, and the writer, Stephen Chbosky, had a major input into the movie.  It's about kids growing up in Pittsburgh just a little later than when I grew up, so I'm quite familiar with the ethos and the music and culture of the time.  The movie is engaging in its human dimensions and achingly believable at times.  I enjoyed the film, which didn't try to be more than it’s meant to be, and - in doing so - felt very true to the rites of adolescence.  I should also mention that this is a movie where we sense that Charlie may be suffering from more than the harshness of life's passages.  It becomes increasingly likely that he is suffering from a mental illness, an inherited burden from the past... 

One of the thematic anthems of the movie is the song Asleep by the Smiths:

This could ostensibly be a song about suicide, and it would not be possible to listen to it without considering this as a theme of the song.  And yet, as I experienced the song with fresh ears during the movie, I recognized that it was also a song about hope, about dying deeply, in order to experience transport to a better place in the living world.

So that’s a particular thing about psychotherapy.  Some of the best therapists around have the ability to go to the edge with their patients, to ride the torrential waves of passionate transference and countertransference into powerful corrective experiences.  It takes a great deal of natural aptitude, and it can only happen with a very special therapist.  When it does, powerful shifts may ensue, and accelerate the healing process by months or years.

For your interest, here’s the official trailer for the film:

It’s worth watching the evolution of the storyline between Charlie and his English teacher.  Support and validation do not necessarily need to be direct; sometimes an oblique approach is best.  There’s a constant presence here in Charlie’s life, and a tacit belief in his future, which supports him through his passages of loss and loss of innocence.

One of the fascinating phenomena of our modern time is the ability to compare our reading experiences with those of other readers.  A growing venue for this endeavour is through the website Goodreads.

While on Goodreads, I discovered several reader conversations on the book version of Perks.  One long thread discussed whether Charlie suffered from autism, while another asked what kind of mental illness was at play in his life:

http://www.goodreads.com/topic/show/728045-what-kind-of-mental-issue-does-charlie-have

I was at first surprised to see how many readers mistakenly entertained the diagnosis of autism, even more surprised than I was at the idea that such debates could captivate the imagination of so many book readers.  I recognized the nature of diagnoses, and their rise and fall.  Where the diagnosis of schizoid character structure was once very central in understanding mental illness, autism and Asperger’s have very much now captured the popular imagination.  Who says that how we diagnose and conceive of mental illness is not subject to cultural and social and theoretical trends?

I was pleased that enough readers correctly identified Charlie as suffering from Complex-PTSD or Dissociative Identity Disorder.  It seems more difficult for us to accept those disorders which admit we are susceptible to abuse and trauma.  Somehow, it’s easier to think in terms of genes and neurological failings than it is to conceptualize mental illness in terms of responses to overwhelming pain and intolerable levels of affect.

The movie is clear about what’s going on here.  We are informed that Charlie was sexually abused as a child.  We know he frequently checks the clock, to see if he has lost time during dissociative episodes.

In a powerful scene, we see structural dissociation at play, where the normally gentle and soft-spoken Charlie comes to the defence of his best friend, who is being bullied by a homophobic classmate.  Charlie comes to with bruised and bleeding knuckles, once his fight EP (see ANPs and EPs from earlier in the blog) has receded and his ANP is present again.

Charlie is finally hospitalized, at the end of the movie, where his kind and attentive psychiatrist patiently encourages him to face his pain and his memories.  She emphasizes the necessity of this, through a soft expression of contact that conveys conviction and compassion. We know she will, like his English teacher and his friends, go the distance with him.  This hospital is quiet, and the environment feels nurturing and healing. 

As I watched the ending, I found myself wondering how Charlie would fare if this was Canada, in 2014.  Would he simply be over-medicated and mis-diagnosed?  Would the message from his physicians be to avoid his pain and acquiesce to a compromised life of numbness and under-achievement.

We talk a big talk here about anti-stigma.  Is that our way out of having to actually treat serious conditions like Complex-PTSD and Dissociative Identity Disorder?  Is anti-stigma really a way around abandoning the seriously wounded and betrayed members of our society, who refuse to present with simple “mood disorders” meant to respond to medications and short courses of manualized therapy?  Do you think that Charlie (or Stephen Chbosky, whose story it perhaps conveys) could have been treated successfully in Canada, even in a private setting?

As you finish reading this post, I wonder if any of you have ever found it difficult to refer a patient with a post-traumatic or stress-based condition, or a dissociative disorder, for definitive care? 

And how about butterfly sightings?  Have you ever had a similar moment of grace, or of finding nature in tune with an ongoing therapy. Has some magical moment left you with a sense of the greater harmony underlying all life.

Finally, are you practicing trauma-informed care yet?  Or considering it?  Or simply hoping to hear more about it?  We will be having a free workshop on trauma-informed care as part of our ongoing Wednesday Evening programming, this February, taught by Dr Catherine Classen, from Women’s College Hospital.  It’s our hope that our education series will continue to provide you with tools and knowledge to assist your self-care and your care of patients like Charlie, who so desperately and deservedly ask for your help.