Author Archives: Paula Zuckerman, LCSW

The Prevalence of Social Anxiety

Scratch the surface and there it is.  Social anxiety is much more prevalent than people realize.  I hesitate to use the word ‘disorder’ because many people who suffer from it don’t meet the DSM criteria.  In more lay man’s terms they would be considered painfully shy.  Saying one is very shy seems more acceptable than saying they have ‘social anxiety disorder’.  Severe shyness is often something that’s been there since childhood.

In my practice over the years, I would say that more than a third of those I see have social anxiety in varying degrees, even if never diagnosed.  Many are able to hide it so well, no one would ever know.  They are good actors & often that helps.  But more often they are avoiders, afraid to deal with the world. Then there are those with more overt symptomatology who suffer from panic attacks, are almost are unable to speak, shake visibly, and will actually faint if the stress is enough.  Medication has been very helpful for some as well as psychotherapy along with the use of CBT.  In my practice I have noticed it gets significantly better but it rarely goes away completely.

Most people have a certain amount of anxiety in obvious situations like making a speech or meeting new people or confronting a difficult situation.  But for people who have social anxiety, the triggers are not necessarily visible.  They can be afraid to make phone calls, get on a bus or walk down the street for fear they may meet someone, talk with shop clerks, have difficulty going out in general, and without a drink or two, barely function in social situations.  It may not always be apparent, but inside they are struggling.   They are severely self-conscious.  I believe that many alcoholics suffer from social anxiety and that that may be a contributing factor to their disease.  Intimacy and social anxiety is another difficult combination.  Meeting people is hard enough for those who suffer from it, but add the pressure of relationship, and the situation can become impossible.  Loneliness and social anxiety are not strangers.

Over the years I have noticed that not only is the anxiety itself dehabilitating, but the shame and judgments that accompany it make it much more painful and problematic.  Often those who suffer from it consider themselves, wimps, cowards and just plain stupid for not being able to do things that seem to come so easily for others.  Self-hatred & self-criticism are very common.  They are aware that most of the fear is irrational and hate themselves for not being able to overcome it.  It constricts their lives and they feel they are at fault.  Consequently the self-hatred is continually reinforced, and that makes the anxiety even worse.  It’s bad enough to have it to begin with, but with the added  constant erosion of self-image, the pain is that much greater.

Unfortunately, like most things, intellectual knowledge does not always help with how one feels.  Most social phobics have been chipping away at their self- esteem for a long time.  These judgments about themselves can feel like a religion.  In their core they know how bad they are. It’s a long standing belief system that has offered a certain amount of protection & explanation for their plight.  That makes it harder to help alleviate the anxiety.   Acceptance is the friend of someone with social anxiety.  It takes away the added burden of self-hatred which in turn makes life easier.  Getting to a place of acceptance is very difficult for most.  There are usually some very unrealistic fantasies about what they would be like if they weren’t so shy. But it is the first step in the healing process.  Liking oneself better usually is.

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The Changing Face of Psychotherapy

Many years ago when I first started out in the field it was not uncommon for people to be in psychoanalysis or psychotherapy 3 – 4 times per week.  These days someone coming even 2 times per week is rare.  This change is partly because of the intrusion of insurance into medical treatment of all kinds.  Insurance controls what services are reimbursed and the frequency of visits, tests, etc.  This is especially true for mental health services, often considered by many as the stepchild of medicine.  Few can afford to see a psychotherapist more than weekly.

We can blame insurance companies & say “they’re the culprits”.  Insurance companies are offering less and reimbursing less for services they do approve, making it harder to get needed mental health services.  But this change is also because of the availability of different forms of psychological treatment, including medication, the difficulty in providing studies which can ‘prove’ the efficacy of psychotherapy, and the evolving nature of our culture at large.

The popular culture has become one of ‘quick fixes’, a ‘just do it’ mentality, and one of instant gratification.  Medication has changed the way people deal with issues. They often look first to a pill to solve their problems.  I have said before that I believe in medication.   But it’s not the magic answer and it is not right for all.   Studies have shown that medication in combination with psychotherapy is most effective.  But just as important a factor is that people are less willing to ‘go deep’.  And I don’t know if that’s all negative.  Sometimes Cognitive Behavioral Therapy – CBT makes a dent and I use it.  But there is a vast difference between knowing something intellectually & have it filter down into emotional understanding.  There are many who know the right ways they should think but can’t make the switch even with workbooks and reminders.  Then there are those who don’t make the effort because of underlying issues that stand in the way.  Our quick fix society wants to believe that these things work, but in my experience they are an aid for some but definitely not for all.  Just like medication, there is no magic.  I often say that if there was a magic pill or if I had a magic wand I would use it & find another line of work.

My friend reminds me that readers today have very short attention spans – no more than a paragraph for a blog.  I don’t know if that’s true or not but, there is definitely a trend toward shortening all aspects of communication.  I don’t know if that is good or bad or just a fact of the modern world and our busy lives.  The jury is out.  But it has certainly affected the practice of psychotherapy from the time I began working.

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Psychotherapy has an Image Problem

I saw this article in todays New York Times Op Ed section and found it interesting and informative.  See what you think.

http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?hp&_r=0

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Observations on my work with Couples continued

Acceptance

We are all different and no one is perfect. You will never get exactly what you want, but hopefully you will get mostly what you need.  How you fold the laundry or whether you can make a perfect omelet should not be a major factor as to whether to be together.  Fairness is very important, but it’s also important to remember that what you each bring to the relationship matters in weighing both the good and the bad.

W. could not screw in a light bulb and was the most mechanically inept man R. had ever met.  He was not the macho guy she had always dreamed about.   He could never find anything in the refrigerator and would always say “where is the ….”  R. would scream “just move something and you will find it”.  This was not an uncommon occurrence but it mattered not one bit because the warmth, love, and caretaking that W. showed R. made up for it in spades.  But she could have thought “if he really cared he wouldn’t burden me so much. He would remember all of what I said/needed/wanted”.  It’s a matter of weighing the plusses & minuses and hoping that the scales balance more often than not in the positives or are mostly even.

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Observations on my work with Couples continued

Humor

Fighting & anger can be less intense if couples can laugh at themselves and see the humor in it all.  Predicaments in life have a funny side to them too.  That is not to say that we shouldn’t take things seriously, but having the ability to see humor in certain situations makes for an easier time.  Couples who have a sense of humor stand a better chance – at least in my experience.  And when I say ‘humor’ I don’t mean sarcasm & making fun of the other person.  Those things are usually not funny if you are the recipient and/or if the situation is not lighthearted.  Your partner’s sensitivities should always be taken into consideration.

The following story exemplifies how humor can be very helpful.

After a hard day working E. finally sat down to read & relax for a few minutes.  When A. came home a short time later, he looked at her & said “woman, get into the kitchen & start rattling those pots & pans”.  He was joking but it took several days for E. to get it.  It was only when she told the story to a friend who began to giggle, that she realized that it was very funny and that she over reacted.  She began laughing & laughing, and it became a seminal story in how a sense of humor can help ease conflict & misunderstanding.

More to follow.

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Observations on my work with Couples continued

Anger & the Art of Fighting

When you are together with another human being, anger, annoyance & irritation – whether expressed or unspoken, are only natural.  After all, we are not clones of each other no matter how well we mesh.  But how a couple fights is key.  Most of the couples I see don’t know how to fight in ways that resolve issues rather than exacerbate them.  Then there are others who don’t want to resolve issues but want to be ‘right’.  Some fight almost as a way of life.  They will argue about which side of the refrigerator a magnet belongs on.  Although some claim that fighting is positive because it adds spice and makes the sex better, I have not found that to be the case with those who come to me.  Rather they are hurt and exhausted, drained of the positive feelings that brought them together to begin with.  A major part of my work with couples is to help them learn how to fight better.  This and learning how to communicate are key factors in helping make a relationship work.

More to follow.

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Observations on my work with Couples continued

Deal Breakers

Some problems can be divided into what I call ‘deal breakers’ and then everything else.  And not every ‘deal breaker’ ends a relationship.  Issues regarding religion, money, children, location, and whether someone wants to be in a relationship at all, are potential ‘deal breakers’.  But often the obvious is not ever dealt with prior to getting together.  People hope that these problems will magically disappear.  They ignore the elephant in the room.   It is only human.  We are taught that “love conquers all”.  So we pretend and hope for the best.  Also, some ‘deal breakers’ are covers for other underlying feelings, and until you explore, you can never be sure.

More to follow.

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Observations on my work with Couples Continued

Infidelity

Infidelity is an issue for at least half the couples that I see. Cheating can shake the foundations of a relationship to its core. But although it is usually thought that infidelity will put an end to a relationship, I have not found that to be the case. I treat infidelity as a symptom of something amiss in the relationship itself. That is not to say that there are not those who can’t stop cheating or those with sex addictions and the need for constant validation. But for the most part, infidelity is a communication by acting out of inner anger, rage, dissatisfactions & disappointments. It is commonly thought that men express this by cheating more than women do. That is probably statistically true, although women cheat too. But women tend to express verbally what bothers them, whereas men may have more difficulty doing this. Women also tend to be more willing to try to get past infidelity. I think men have a harder time. If this means I am unfairly sexist in my view, so be it. But again, these are only my observations.

More to follow.

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Observations on my work with Couples

Couples therapy helps people make decisions about their relationship. They will either stay together better or decide to separate. Sometimes they decide to stay together even if things are no better. I can never predict because sometimes I have been really surprised. The only thing I can say is that if two people really want it to work, there is a better chance that it will. Love, commitment & connection count for a lot in helping couples resolve major issues. It helps if they come before things are at the breaking point, if they stay for more than a few sessions, and if both have the same agenda. I always try to remember that they didn’t start out this way. They wanted things to go well and to have a good life together. The following are some major issues that turn things awry.

Communication

The biggest problem in communication between couples is the illusion that it has taken place. It amazes me how often there are assumptions and reactions to those assumptions, & reactions to those reactions, without ever finding out what each other means or is trying to say. Resentments build. People accuse, get angry – either verbalizing the anger or holding it in. Holding it in can be with awareness or without. Often there are triggers that can make someone extremely reactive because of past issues and vulnerabilities. Almost no one comes into a relationship without ‘baggage’. In my opinion, the trick is to have baggage issues that don’t collide too much. This is rare for couple’s I see.
Communication is by far not the only problem I have encountered in my work with couples. And also there is no guarantee that if communication improves things will get better. But usually it does.

More to follow.

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Mixed Thoughts on Medication

Medication and its efficacy is a very hot topic and these are just my observations over a very  long time period in both private practice and a clinic setting.

My feelings about medication are mixed.  Neurology & chemistry effect how we all see things.  Over the years medication has dramatically helped the very severely disturbed, but for others, the feedback is more ambivalent.  And even for those that ‘really’ need it, the side effects can be daunting.

It is often said that medication changes the black to gray (if one is lucky), but the way people approach their problems and how they interpret themselves and their world, is not changed much by medication – in my opinion.  Pathways that are more adaptive need to be created by self understanding and hopefully by softening the effects of trauma.  This is not easy to do by any means. Tons of CBT work books & self help books attest to how hard it is. It helps to know, but it is no guarantee that it will filter into our beings.  What the brain knows intellectually is very different from what is experienced emotionally.

I often recommend medication in conjunction with psychotherapy and have worked with some excellent psychiatrists.  But I do not push it unless it seems critical.  People I see are often very reluctant if not down right opposed to medication.  Partly because of the side effects but mostly because it feels like that means they are ‘really sick’ and it signifies a loss of self-esteem.  Also, many would like to try more ‘natural’ products.  Often people improve without medication & others decide at a later time to try it.  I have never kept statistics because I never see individuals as numbers.  I have also noticed that for some people, medications that were helpful stop working after about 2 years..  And there are so many medications & cocktails out there that the choices are enough to make you dizzy as well as cautious.

All this being said, there is no question that psychotropic medication has been a godsend for many.  But it is no panacea and for those who think it is, there is often a let down.  There is no magic wand.  If I had one, I would use it.

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