Book Review Prescriptions Without Pills by Susan Heitler

When I first started to develop my integrative psychotherapy paradigm, unified therapy, a central problem I focused on was how patients could fruitfully discuss sensitive family dynamics with their parents without the conversation turning into just another variation on the same exact dysfunctional theme. How could someone confront highly invalidating and/or abusive parents about their interactions, with a goal to stopping them, without the conversation devolving into mutual rage, defensiveness, attacks, and/or emotional cutoffs?

I was amazed at how family members could be such experts at re-framing something meant to be constructive back into something highly destructive. Readers of the comments to my blog posts on Psychology Today know that even today many people think I am the insane one for even thinking it is possible to interrupt this admittedly highly malignant process.

After I first developed and wrote about some good strategies for keeping things constructive, I came across a helpful book by Susan Heitler, Ph.D., called From Conflict to Resolution (W.W. Norton, 1990), which described several strategies for detoxifying toxic interchanges between intimates as well as between patients and therapists. The book helped me to refine and expand upon my repertoire of strategies. Since every family and family member responds differently, the more strategies I have in my bag of tricks, the more different patients I can help.

I later briefly met Dr. Heitler at a meeting of the Society for the Exploration of Psychotherapy Integration, an organization to which we both belong. Its purpose is to look into ways to integrate various ideas from the different "schools" in psychotherapy— primarily the psychoanalytic/psychodynamic therapies and cognitive behavior schools.

(As an aside, I have since become less involved with the organization for two reasons. First, the leaders of the group were afraid that if they succeeded in devising an overarching theory, then they would just become yet another therapy school. I, on the other hand, was tired of exploring and was interested in actually doing. Second, family systems and social psychology were woefully underrepresented in the group. Since humans are among the most social of organisms, that just seemed crazy).

Dr. Heitler has now written a self-help book for lay readers which goes over a lot of the same territory as the Conflict book, Prescriptions Without Pills: For Relief of depression, anger, anxiety and more. The title stems from an opinion we both share: today there has been an explosion of excessive prescribing of anti-depressant and anti-anxiety medication to clients who just have problems in living. While she is not against the use of medication, it is often just plain ineffective for many problems with which people come to mental health professionals. Antidepressants for example, as I have written about many times, are completely useless for chronic unhappiness as opposed to Major Depressive Disorder.

The book is chock filled with very useful suggestions for people who are locked into what were once termed neurotic styles. (See the bookof the same title by David Shapiro from way back in 1965). The term neurosis has unfortunately now been practically banned from psychological discourse and psychiatric diagnosis because its role as a "cause" for any psychological problem has not been "proven." 

It refers to problems created for people because of internal conflicts between what they would like to do based on their own preferences and what they think they are supposedto do based on the "rules" they have learned from their ethnic group, religion, and most importantly their families of origin. "Style" refers to such things as ways of thinking and perceiving, modes of subjectively experiencing other people, and repetitive, unthinking types of stereotypical behavioral transactions in various circumstances within one's interpersonal relationships.

People who will benefit most from this book are those who learned these styles growing up and who have gotten into some bad habits which create sadness (the author uses the word depression but seems, at least in this book, to have conflated major depression and dysthymia, the differences between which are elucidated in this post), anxiety, anger, and/or addictive behavior—but who are generally functioning fairly well in some areas of their lives, have minimally cordial relationships with their parents and siblings, and are highly motivated to change. They will find the suggestions in the book quite helpful in getting problematic behaviors and feelings under control. This in turn will help them with their love life and their work life as they interact with others.

I do not believe that people with more severe personality pathology and highly dysfunctional families will be able to successfully avail themselves of these strategies for reasons I will also mention in a bit. So this book will not be as helpful for folks like that.

Dr. Heitler describes the typical habitual ways neurotic people respond to problems, particularly interpersonal ones. The one healthy one is to define and boldly face the problems and to work on solutions to them. The unhealthy ones include folding (leading to discouragement and low moods; fighting (leading to anger and aggression); freezing (leading to chronic anxiety); and fleeing (obsessively burying oneself in a substance or behavior and becoming addicted to it).

A big part of the techniques for changing the bad behavior when it starts to occur is stopping and thinking about what the real nature of the problem is, as well as the reasons behind one's own seemingly overly-strong, over-the-top emotional reactions. The reasons for those are often past experiences with important attachment figures (emphasis on the word past. If those experiences are ongoing, that's a 'hole 'nother level) which bring up strong feelings.

For instance, if when you were growing up your divorced father frequently did not show up for his visitation days when he was supposed to, and in response you started to think that you are basically unlovable, then any time another person disappoints you, you might over-react even if the other person had a very valid reason for not doing what you had expected. 

This is actually a way of conceptualizing what the psychoanalysts call transference. Many cognitive behaviorists claim they don't believe in it, even though they actually do but just call it by another name: mental schemas.

Dr. Heitler recommends visualization techniques one can use to let one's mind recall the important precipitating events from one's past. The techniques can be thought of as another way of employing what the analysts call free association.

She also suggests many useful questions to ask oneself and ways of thinking that one can use to explore one's own psyche, to change perceptions about what other people might really be doing and thinking, and clarifying dilemmas in life. She describes how one can use their own strong feelings as a vehicle for constructive engagement with other people in order to solve mutual problems.

When discussing mutual problems that occur in intimate relationships, certain words and phrases often lead to more conflict than light. The author provides a useful list of words to use and words to avoid in what she calls the Word Patrol.

The reasons these otherwise wise and productive suggestions are likely to fail in people from more disturbed families with ongoing repetitive dysfunction relationship patterns is because they are quickly and easily overcome by powerful family reactions to the patient's new behavior. If your new behavior causes your mother to suddenly stick her head in an oven, metaphorically or literally speaking, or if everybody you know and care about comes down on you like a pack of hungry wolves with the strong message, "You're wrong, change back," most people will wilt and go back to the way they were. This process is particularly vicious in families that produce people with borderline personality disorders, as described in this post.

Instead of responding with less defensiveness and anger, dysfunctional family members can twist around what anyone says no matter what words are used or avoided. They can employ ambiguity and double messages to such a degree that the person who is trying to engage them in problem solving does not know what was actually meant or whether or not any issue was really resolved.

This does not mean that family members in families like these cannot be reached. They most definitely can be. But the process is way more difficult and intricate than the solutions described in this book might seem to imply.

Book Review Unhinged by Anna Berry

I breathe you in again just to feel you
Underneath my skin, holding on to
The sweet escape is always laced with a

familiar taste of poison

~ Halestorm

In female patients with borderline personality disorder (BPD), a behavior pattern is sometimes seen in which the woman quickly gets involved with a seemingly charismatic but at base highly narcissistic male. At the beginning of the relationship, it's love at first sight. There is a whirlwind romance in which both partners seemingly have found their soul mates, and love is professed - occasionally with even a hasty marriage proposal, sometimes within just a couple of weeks. The couple spends all their free time together and can not seem to get enough of each other either physically or mentally.

Before too long, however, the man reveals his true nature. He usually becomes extremely controlling, hyper-jealous and possessive. He wants to know where the woman is every second, and tries to isolate her from her friends and family. All the while, he may lie about his own whereabouts and compulsively cheat on the woman. Not infrequently, he becomes physically abusive to her.

Alternatively, the seemingly exact opposite may happen. Without warning, the man seems to lose interest in her entirely, but nonetheless continues to string the relationship along for a considerable period of time.

In many such cases, after the couple finally breaks up, the woman repeats a nearly identical pattern with another man. She never seems to learn from her mistakes, and denies that she has ever seen any red flags that indicate that things might go awry.

What on earth is going on in the mind of such a woman?  In her new book, author Anna Berry  (a pseudonym) does a marvelously detailed, brilliantly written, and entertaining job of describing her experiences with instances of her involvement with three such men. The memoir is an excellent introduction to the inside of the head of someone like her.

In another part of the book, she describes an experience in which she sort of toys with a psychiatry resident serving as her therapist, demanding that he help her to get back a guy who has treated her like crap and then dumped her. The therapist persists in gamely confronting her about how obviously ill-advised and self-destructive such a course of action would be, if it were even possible.  

As described by the author, the resident seems to be following the suggestions of James Masterson, one of the early psychoanalytic pioneers in the treatment of BPD, to confront, confront, and confront some more. Such confrontations are supposed to be done empathically, however, and in this the therapist falls short, at least in the descriptions of the author.

At some point he even tells her she is a hopeless case - something a therapist should never say to a patient even for effect. She is often snide and sarcastic to him in therapy, yet she continues to see him and even feels abandoned when he has to move away.

The author eventually got herself out of her self-destructive lifestyle and then does pretty well for herself. So what is her explanation for her earlier, crazy-sounding behavior?  

Well, she says it was because she was (and still is) both mentally ill herself, and comes from a crazy family. She at times uses the word delusional to describe herself, and also states categorically that she had brief psychotic episodes - although as I will discuss, from what she describes in her writing, she never once says anything that would clearly illustrate a delusion, hallucination, or any other evidence of psychosis. What she describes so well is something else entirely. So why, even though she does things that seem crazy, does she insist on labeling herself psychotic?

Having never evaluated the author myself, I can only guess, although I certainly can speculate and offer a possible hypothesis. More on that later.

The confusion about whether the author is mentally ill or just self-destructive arose when I was approached by the publisher to write this review.  Initially, it sounded like the book was about the difficulty in growing up in a family with a parent who was chronically and persistently mentally ill, possibly schizophrenic. 

While having a psychotic parent can certainly create family dysfunction and personality problems in offspring, it also sounded like the author herself was struggling with psychosis, and psychotic illnesses per se are not the main focus of this blog. When I asked them for clarification on this, the answer I got did almost nothing to clearly answer my question.

In the book, the patient discusses her own diagnosis, and implies that BPD was the closest thing in the diagnostic manual, the DSM, to what she had. Nothing in the book would cause me to doubt that proposition. She also discusses how she was also diagnosed by different mental health practitioners with a different psychiatric disorder almost every time she saw a different clinician - clinical depression, bipolar disorder, bipolar II, multiple personality disorder, episodic depression, seasonal affective disorder, dysthymia, cyclothymia, anti-social personality disorder, histrionic personality disorder, schizotypal personality disorder, and post traumatic stress disorder.

Her conclusion from having had these different diagnoses was that people just don't fit neatly into the DSM diagnostic boxes. While that is somewhat true, and while it is also true that people can have more than one psychiatric condition (comorbidity), it seems that in her case these labels were applied to her when she in fact did not actually meet the diagnostic criteria at all. She cannot be bipolar if she never had anything resembling a manic episode, or be histrionic when she is primarily an introvert who usually hates to be the center of attention, or have seasonal affective disorder and be depressed at any time of year.

The diagnosis of the author's mother is rather obscure in the author's descriptions. Her brother clearly has severe schizophrenia, and in the beginning of the book it sounds as though the mother did too.  She clearly had psychotic episodes. At one point she throws a lot of the possessions in the house out because voices are telling her that the objects are dirty and if she doesn't throw them away, everyone in the family will get sick and die.

As the book progresses, it eventually becomes clear that the mother's psychotic episodes are episodic and accompanied by her talking non stop and staying up without any sleep for days at a time. Her psychotic episodes would be exacerbated by prescription drug abuse and alcohol - she would often get large quantities of benzodiazepines and other controlled substances from three different free clinics that never communicated with one another. Again, without examining her myself, true bipolar disorder would be the most likely diagnosis if these descriptions are accurate and complete.

Clearly growing up in a chaotic household had a bad effect on the author's mental stability, particularly as she was neglected quite a bit. There often was no food in the house. Dad was apparently too busy having sex with his mistresses openly in the house, with the kids there, to go to the grocery store.

But has the author ever been delusional? Well maybe, but not by her own descriptions in the book. What she describes as being delusional is really a description of her lying to herself while knowing the truth deep down. A real delusion is believed totally and without any doubt, and is certainly not shared by anyone else like a manipulative boyfriend. This is an essential distinction.

In describing her rush towards involvement with one of the problematic men, she says she "could have seen the warning signs a mile away" (p.29).  Although she does not explicitly say that she did not see them, it sounds like she made a concerted effort not to.  On page 74, she writes, " I still didn't have the insight to recognize my destructive relationship patterns, but I can feel the impending doom approaching deep in the pit of my stomach, the way a seasoned sailor can feel approaching storms in his very bones."

That clearly sounds like it was not insight into her relationship patterns that was lacking, but rather that she had decided not to think too much about them. Last time I checked, stomachs can't really think.

On page 87, she describes red flags going up in her brain, but then shrugging her concerns off.  Again, not a psychotic process. She also peppers the book with phrases such as "passive aggressive cry for help and state of denial." Not a psychosis.

She describes her "voices" as almost psychotic hallucinations, but they sound a lot more like the "tapes" we all have running in our heads left over from childhood that tell us what to do and not to do. They are not described as completely external voices like the ones we all hear every day coming from other real people. The hallucinations of psychosis are more like real external voices than inner thoughts.

The first clue that she had never been psychotic was actually a beautiful description of a person with BPD's inner experience - way back on page 5: "...the day-to-day torture of having to create inner and outer selves simultaneously, and maintaining both convincingly...perfect real world training for a professional actor."

So why does she keep telling herself how mentally ill she is? Well, one possibility is that, coming from a family where mental illness is sort of the norm, these thoughts provide her with a sense of belonging and familiarity. Those are powerful needs for most people. Again and again, she uses the same words to describe both herself and her mother, as if their psychiatric experiences were actually far more similar than they really were.

But of course she would be conflicted about thinking herself to be crazy, because, deep down, nobody really wants to be or thought of by others in that way. The author often lived in fear that someone would find out how crazy she was - before demonstrating it to them in spades.

On page 200, she indicates that one of the most important lessons she learned from her psychotherapy was "I am not my parents." More accurately, she probably learned she did not have to be like them. Her mother and brother would never have recovered the same way she did with just the treatment she eventually received that was helpful to her.