Foucault, and stuff (this is a piece I wrote for a newsletter on social justice informed practice)

When clients come into my office for psychotherapy, they are usually focused inward, potentially seeking a diagnosis, and often asking “what’s wrong with me?” Yes, the majority of my clients are working through gender dysphoria or pursuing recovery from an eating disorder, and while these are indeed conditions I can diagnose, much of the work I do with folks is about exploring the ways in which structural oppression related to their sexual orientation, gender expression or race is causing distress, both directly and in its internalized forms. In other words, we shift from asking “what’s wrong with me?” to “why do I think something’s wrong with me?”

From a social justice perspective, one of the most insidious ways oppression in the form of patriarchy, misogyny, class bias and racism (among others) does its work is through internalization. When people internalize these structures of power and disempowerment, the self hatred and self doubt that ensue wreak all kinds of havoc in terms of beliefs that impact behavior and emotional experience, which then often leads to the development of some form of psychopathology. I vividly recall a professor at the Smith College School for Social Work stating: “The greater the oppression, the greater the depression” and I have seen this to be true over and over again in the lives of the people who walk through my office doors.

There was a time (and in some cases, that time is now) when people in my chosen profession, social work, were largely tools of oppressive structures. In the words of Michel Foucault: “The judges of normality are present everywhere. We are in the society of the teacher-judge, the doctor-judge, the educator-judge, the social worker-judge.” For example, as the majority of my clients are transgender or gender non-conforming people, many require authorization from me for their insurance companies that they are “trans enough” to receive gender affirming hormone therapies or surgeries. Many of these folks also experience profound depression and/or anxiety: how would you feel if your fate, your ability to live a life as yourself, was in the hands of an ostensible expert, deemed more expert than you about your own self-hood by virtue of their social position and capital?

My work, as a social justice oriented feminist relational psychotherapist, is kaleidoscopic. I work to support my clients in identifying the ways in which they’ve internalized oppressive structures. We work together to identify the ways they’re policing themselves and warping their sense of self through these lenses, and then we work to dismantle the problematic internalized beliefs that are setting them up for emotional distress and behavioral dysregulation. In other words, I sincerely look forward to a day when I become obsolete.

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All or Nothing.

In case my clients hadn’t mentioned it enough this month, an excellent article about “All or Nothing” thinking showed up in my inbox a few days ago that sealed the deal on me writing about this topic.

For the uninitiated, All or Nothing thinking goes something like this: “I just ate x, which was not on my strict list of safe foods for my special and restrictive New Year’s resolution diet, and therefore I have ruined my day and I’m going to eat several more servings of x, as well as anything else I happen to encounter that is off-limits.” Other variants include the belief that an A minus is a bad grade, and since you just got one, you’re never going to do your homework again because what’s the point if you’re just going to fail, or that because you did not get this particular job, you are clearly unemployable and are never putting yourself through the humiliation of sending out a resume again.

There are a lot of problems with this kind of thinking. As my handy-dandy examples suggest, one of the most significant is that it tends to lead to quitting, inertia, anxiety, depressive thoughts and other totally fun experiences. The actions that flow from All or Nothing thinking are usually the opposite of effective. Otherwise known as ineffective.

Let’s take our poor sad friend on the All or Nothing diet who has “cheated” or “failed”: she’s really extra screwed because the rules of her diet were written by All or Nothing thinkers to start with, but beyond that, if the goal of the diet was to, for example, eat fewer treats, then responding to eating a treat by deciding she has failed and eating a whole bunch more treats is pretty counter-productive.

Here’s an alternative. (And for the sake of argument, let’s say it’s reasonable that the dieter has decided her health or self esteem or chronic headaches or whatever it is would be ameliorated if she ate fewer treats.) Rather than taking the All or Nothing path of deciding that all treats are off limits at all times forever (and therefore if she has one, she is a failure, and off the diet, and should “take advantage” of already having “ruined the day” and squash in as many treats as possible), she could think a more helpful, more effective thought. Something like “I’m going to pick one treat per day to really savor and enjoy to support myself in eating fewer treats overall. If I have a moment or day where I eat more treats, I’ll use that as a learning experience to see if there are any ways my plan needs to be adjusted.”

Now, if she eats an extra treat, she hasn’t failed, she has stumbled upon a piece of data that is a total gem because it’s going to help her figure out a more effective plan e.g. “Oh, I see that it’s not a good idea to eat my special treat when I’m distracted by paperwork because I won’t really savor it and I’ll be more likely to want more. Excellent! Good to know.” (Her therapist might have had to support her in re-framing things that way, but hey, it’s cool to ask for help.)

Similarly, with the A minus, and the job that doesn’t pan out, if the goals are academic success and employment, and the disappointment is a perception that these outcomes might not work out, quitting all together is only going to take our All or Nothing thinkers farther away from their goals. (Also, an A minus is a really good grade, and perfectionism is very All or Nothing.)

All or Nothing thinking isn’t logical by it’s nature because it’s usually driven by a strong emotion (shame, fear, remorse, despair, euphoria), which is the primary way to identify that you might be in the throes of it. Any action that you’re drawn to while experiencing a strong emotion is suspect, and worth putting through the All or Nothing test. And wouldn’t you know it: Mindfulness helps here. Holding awareness of your emotional state provides the opportunity to catch yourself in those heightened moments when you’re vulnerable to distorted thinking, which provides you with the opportunity to review your thoughts and action plans before tumbling down the All or Nothing rabbit hole.

Like so much of what I recommend to folks, this is hard work, but it’s a way easier path than holding yourself hostage to a cycle of unrealistic standards and constant feelings of failure. At least, I think so.

Just a spoonful of sugar makes the medicine go down.

I’ve been thinking a lot about medication lately. (Also working overtime to buffer my family financially for my upcoming maternity leave, hence the sparse postings.) (Further parenthetically, I am not, to be clear, a prescriber of such, nor do I believe that psychotropic medications work for all people in all mental health situations.)

I’ve noticed that the people I see in treatment tend to fall into several camps. The first group believe that medication is the most important part of mental health treatment, and if they don’t feel “normal” yet, then they just haven’t found the right pill at the right dose. These folks tend to get frustrated the minute I mention the word “process” in relationship to their wellness, or suggest that the choices they’re making or the beliefs they have might be contributing to feelings of being less than well. Obviously, I’m biased towards thinking that my professional output leads to effective outcomes, but these folks and I don’t tend to do very well together.

The second group of people I see are highly medication resistant, either because being diagnosed and prescribed a medication feels stigmatizing, or out of fear that the medication will in some way fundamentally and/or irreparably alter their personality or state of being. While resistance to therapy is not a problem here, I have found that people in this camp hit impasses as well because their symptoms interfere with their ability to act on insight and new learning sufficiently to make serious headway.

Historically, I have not found myself to be particularly effective in convincing folks in either of these groups to budge towards the middle path, but, in an interesting twist of fate, my pregnancy has provided me with some rather powerful talking points.

The story goes like this: up until my late husband’s suicide, no one in my circle of wellness helper types had ever recommended medication to me, which is a mystery I’ll leave for another time, but that probably has its roots in my particular cultural location. Regardless, things got sufficiently squirrelly in the aftermath of his death that I ended up with a referral to a psychiatrist. We tried me on a few different medications over the course of a year or so, all of which I “felt” in various ways in terms of both their impact on my mood and various physical symptoms, until both the psychiatrist and I agreed that we’d landed on an antidepressant and a take-as-needed for supremely anxious moments combination that was the most helpful with the fewest annoying side effects.

And then I got pregnant, and had to drop it all so the baby didn’t get a cleft palette and a heart defect, which was a sacrifice I was (hopefully obviously) willing to make.

But now, I have my symptoms back, and it’s giving me a very useful perspective on what medication does, what it does not do, and why I probably would have been a lot easier to live with, both as myself and in relationship to others, if I had gone on medication about a decade and a half sooner.

When I went on the medication, I had a basic hunch as to what was different, but mostly I just knew that I felt better, and that better was good. Now that I’m off, I have been able to pinpoint exactly what has come back: there are a set of experiences, the most salient being this state I get into for about 24-72 hours at a time in which I’m tense, irritable, sad, afraid and just super negative, that immediately reemerged off the medication. It didn’t change who I am, or how I think, or my beliefs. It just eliminated that particular mood experience from my life.

What’s further interesting is that I can now look back on my life and identify when it was that this particular state started coming over me, either sporadically, or for months at a time, and say AH HA! That was a brain state, the kind that medication can shift. That wasn’t “me”, which is what I used to think. On medication, no cloud of icky. Off medication, clouds of icky are in the forecast every few weeks.

In defense of my non-pill-prescribing-profession, I’ve been using mindfulness, a variety of coping skills including talking with my partner about how this is a transient state, cleaning random things, and baking a lot of whole grain muffins (the most recent batch were banana chocolate chip), to get through since I don’t have the medication tool at my disposal these days, but I never thought I’d say that I was looking forward to getting back on medication (in, like, two years when daughter has been born and is finished breast-feeding).

And I am.