I rarely go to movies, maybe once a year. Inception (2010) was an exception largely in part of the fantastic reviews and I'm a DiCaprio fan. However, I was also curious as a psychologist. The movie was about levels of consciousness and memories. Memory formation has been a controversial area of research for decades with implications from the law to abuse to your own memory (check out the TED Talk "The  fiction of memory").

As I reflected on the movie, my mind kept returning to the therapy process. There were many themes in the movie that I experience in the therapy room. Initially I thought my narcissism was kicking in. Is it a bit much to compare working with a patient to a blockbuster mind bender? Set aside the process of inception or extraction. Reflect more on the underlying process of entering someone's mind, circumnavigating their and your own defenses, and uncovering raw, genuine experiences. Read below and you be the judge.

A major theme of therapy is the patient protecting the unconscious. Dom Cobb (DiCaprio) offers a service to Saito (Ken Watanabe) of training his mind to protect its secrets from extractors when in a vulnerable mental state. In Saito's case, the vulnerable state of dreaming.  People protect their emotional world by gaining distance from real feelings by utilizing defense mechanisms such as repression, rationalization, and humor. These mechanisms offer protection from the power of our emotional world. 

Therapy is the process of extracting. Extracting that memory or experience that lies deep within the psyche. An emotional experience that's difficult to reach. In the real world, we present differently than we do in the privacy of our home or a therapy room. We work to maintain our composure in public, counting down the minutes until you can finally be yourself. Our public and private experiences are different levels of consciousness. Therapy is the plot of Inception, gaining the combination to a personal safe.

Enter the character of Robert Fischer (Cillian Murphy). Saito has asked Cobb and his associates to enter Fischer's subconscious. This is mantra the role of psychoanalytically informed therapy; bringing the unconscious to conscious. Freud posited that people have developed simple and complex mechanisms to keep unconscious thoughts, feelings, and experiences from entering consciousness. Freud utilized a number of strategies to bring the unconscious to the conscious including hypnosis, free association...and dreams. 

The process of entering deeper into the mind has a sinister feel in the movie. For therapy, the belief is the opposite: if emotions are brought from the unconscious to consciousness, experiences can finally be resolved, leading to psychological relief and growth. During the process of exploring the unconscious, the therapist will regularly encounter resistance in the form of the patient's defense mechanisms. 

The projections in the movie are the defense mechanisms that are present in therapy. The role of projections were to block Cobb's team from completing their extraction mission, much like a defense mechanism blocks a therapist or even you from accessing experiences and feelings in the unconscious. 

To illustrate, let's use a therapy example. A patient conveys a story where a family member forgets the patient's birthday. The patient dismisses the forgetfulness as a non-issue because the family member has a busy life. The patient may then state birthdays are blown out or proportion, and actually express relief that their birthday was forgotten. 

However, at a deeper level the patient may actually feel hurt and disappointed. At an even deeper level, the patient may feel dismissed and unloved by family. The deep, core issue here is feeling dismissed and unloved. However, the rationalization (e.g., busy family member) and intellectualization (e.g., debate of birthday value) of the situation  serves as a defense against the realization of deeper, more profound emotions. 

Each "kick" represented a different level in the dream state, with its own world and sense of time. The same applies to the different levels of consciousness for each person. In the birthday example, each level of consciousness came equipped with it's own defense mechanism as well as a unique sense of time. Just as in the movie, as you move to deeper levels, the laws of time are compromised, and more signals or markings are needed to keep perspective. 

Yusuf kept a sense of time by playing music in the van. In therapy, a sense of time may occur by recognizing the context of the memory (e.g. the physical location of the experience, who you were with, etc.). Just like the kicks, moving from one conscious state to another with a patient can be smooth or violently jarring. Just like a kick, therapy is finite, each session is limited to 50 minutes. 

With each "kick" into a deeper dream state, stability and predictability were compromised. Cobb's team experienced a loss of control as they descended into deeper levels of the dream state. In therapy, as you venture deeper into a patient's psyche, there is the risk of destabilizing the patient. It's one thing to process a family member missing your birthday, it's an entirely different thing to process feeling unloved and forgotten by family. 

It's a very delicate process to venture deeper into someone's mind. Now add the time constraint of 50 minutes. It's not often talked about but there is a psychic pressure similar to the experience of deep sea diving or climbing a mountain. If you ascend from a sea depth or ascent a mountain too quickly, the body and mind sometimes have difficulty transitioning which can result in a sickness, shock, or even death. If you move quickly in and out of the unconscious, the patient can suffer a similar experience of sickness, shock, or even psychosis. It's imperative to bring a patient out of a deeper psychological state, and help them recover toward the end of the session. When the session is finished, that's the "kick" back to reality, the return to the world outside the therapy room. 

The underlying subplot of Inception is Cobb's unresolved trauma of his wife's, Mal, psychosis and subsequent suicide. Cobb feels responsible for her death, and his own psyche proves to be a complex web for the inception team. Ariadne, the dream architect, repeatedly questions whether Cobb can keep his own projections contained during the dream extraction and inception. 

This subplot is quintessential countertransference. Countertransference is the therapist's feelings that are stirred and brought to consciousness by the patient's experience. Entering Fischer's dream state stirs Cobb's own dream experience with his wife. A patient talking about abuse, loss, or fear can stir the same emotions in a therapist. Like Cobb, the therapist has to be vigilant and set aside their own experiences to work with the patient and their psyche. Countertransference is a powerful experience and should be addressed whether in a therapist's own therapy or in peer consultation. 

Inception concludes with Cobb returning home to his children. He spins his totem, his reality check mechanism, and the screen goes black leaving the viewer wondering if this last image is in fact reality, a dream state, limbo, or all of the above. 

Memory and the patient's reality (whether accurate or not) is the foundation of therapy. I often encourage patients to journal or talk to their parents, if possible, about early childhood experiences that we process in therapy (I encourage you as well). Sometimes we are sure of a memory, then are surprised by how we are our own inception team. Each person decides how they are going to encode an experience into a memory, without the guarantee of accuracy.

For example, I was sure of a decades old memory until a year ago. I remember riding my bike home as a kid and seeing my mom pull out of the driveway with a child in the passenger seat writhing in pain. I remember feeling confused and wondering what happened. According to my memory bank, I found out the injury details hours later when everyone returned from the hospital. 

I revisited this memory with my mom last year and her recollection floored me. She recalled sending me out to find this child as she feared something bad had happened. I found him injured in the woods, carried him from there into the house, and my mother took him to the hospital. 

Two incredibly different stories for the same experience. Only one of us can be right. So if my mom and I both spin are totems, which spinner will continue to spin?

Take a moment and ask someone about one of your memories. Ask them their experience and compare notes. You might learn something about yourself.


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Salmaan Toor is a licensed clinical psychologist practicing in Knoxville, TN. If you are interested in being notified of future posts, you can “like” The Family Center of Knoxville on facebook here or can follow me on Twitter here. Thanks for your support! 

By now you've all heard or read about the tragedy. A 16-year-old, Ethan Couch, killed 4 citizens (including 3 good Samaritans) and injured others, all while intoxicated on drugs and alcohol. He was sentenced to 10 years probation with probably 1-2 years in a rehabilitation facility.

As a human being, I am saddened and angered by this case. As a psychologist, I am terrified. The saddest part is there were many instances where Ethan wanted help and even showed he needed it. Passed out drunk in a truck at age 15 with a naked 14 year-old girl. Police find him, no consequences. Documented history of passive and criminal parenting. No documentation of parenting classes. Who knows what happened in that home, it certainly wasn't healthy.

Before saying more about Ethan, let's address a couple of things about the consulting psychologist and “affluenza.” Affluenza is a fabricated psychological disorder (does not exist now nor ever in the diagnostic manual) that was allowed to be used as part of the defense. This is bizarre to me, I don't know how a judge would allow a pseudo-clinical term to impact a decision. I'm embarrassed that a psychologist, Gary D. Miller, used psychobabble in his explanation. However, a part of me gives Dr. Miller the benefit of the doubt and hope it was taken out of context.

In a recent interview, Dr. Miller said people are focusing too much on the “affluenza” diagnosis (I feel dirty typing that). The focus should be on the clinical terminology. I've worked a few court cases, and in almost every case, lawyers and judges only focus on the last page of the assessment which often includes the diagnosis and clinical recommendations. So clinical terms matter. Dr. Miller also suggested Ethan behaved more like a 12-year-old. Problem is 12-year-olds know right from wrong. My kids have a sense of right and wrong and they aren't even in elementary school. Again, I hope some of this information was taken out of context.

So why am I terrified?

There were a number of warning signs that were ignored. The parents had years, the police had chances, and now this judge had a chance. All of them failed. In a previous post (here), I laid out how it's natural for kids to have sociopathic tendencies. It is part of the developmental process. The other part of the process is helping kids cultivate care, empathy, and awareness. His sociopathic tendencies weren't extinguished, they were validated. Each time an adult passively allowed Ethan to commit illegal acts without consequence, Ethan received the message that not only was his behavior not wrong, it was right. He was essentially praised for bad decisions.

Now, he has ended 4 lives and destroyed families. The judge, Jean Hudson Boyd, had a chance. Judge Boyd could have set a limit, she could have said what you did was unacceptable in our civilized society. Instead, she validated murder. She validated a code that money and power are more important than humanity and life. She has confirmed Ethan's belief that he is more important, more valuable than other people. She has given her seal of approval of Ethan becoming a full-blown sociopath. The icing on his sociopathic cake is experts in their fields (i.e., psychologists, lawyers, police, and now a judge) have put all the blame on the parents. To really send home the message that Ethan isn't to blame, they ordered him to a beach town in California (see picture) so he can get away from his parents and their influence.

Yes, we are taking about a teenager. He certainly has an opportunity to fundamentally change who he is as a person. I truly hope that he does. I won't ever give up on a kid, it's not who I am.

However, facts are facts. The fact is he had friends in the bed of his truck, and increased his speed to 70 mph when they pleaded with him to slow down. The fact is his blood alcohol content (.24) was 3 times over the legal limit (.08) and he had THC and Valium in his system. The fact is he hit 4 people with his truck, and said to his passenger, “I'm Ethan Couch, I'll get you out of this.” To be that calm and calculated in that moment (and under the influence) is the definition of terrifying. It also suggests Ethan's case of “affluenza” was actually a fancy way of saying he's a budding sociopath, possibly psychopath. I hope I'm wrong.


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There is a really interesting video that has gone viral. The video shows a 10-month old girl who is sitting happily and then becomes sad and eventually cries as her mother sings a sad song (mom can sing, by the way). The mom finishes her song and her daughter visibly shifts from a state of sadness to content to happiness (with mom's comfort). 

The video comments range from amazement at the baby's emotional development to criticism of the mother for eliciting a crying response from a baby. When I watched it, I was in awe by how easily this infant girl accessed her emotions, so much so that she became tearful. I also thought the mom did well in helping her daughter return to a content emotional state with her words, tone, and most likely her body language. 

The topic I want to focus on is can you be too sensitive or access your emotions too readily. I regularly tell patients there is nothing wrong with a feeling, the problem arises when poor decisions and actions happen because of the feeling. So how do we find that balance?

A behavior or thought becomes a problem (clinically) when it impacts your daily life in an intrusive way. If you double-check the alarm system, that's not intrusive. If you double-check the system and then come back to check it again, causing you to be late for work, then it's intrusive. The same concept of intrusion applies to emotions. You still want to experience and acknowledge emotions, the problem arises when the emotion can't be contained. If you find yourself overwhelmed by emotions to the extent that it negatively impacts your thinking, productivity, and/or relationships, then you might be experiencing your emotions too strongly. 

Last thing on the video. If I had a concern, it would be that this little one may be more emotionally developed than her peers and that trend may continue. Most may think that is a good thing, but it can lead to trouble. Imagine being 10 and having the ability to empathize with your peers, but your peers are still struggling with empathy (which is developmentally normal into the teen years). It would be heartbreaking at times to not understand why you are sensitive to others' needs but your peers aren't that way. I've worked with kids and adults like this. I find myself telling them that they will have an easier time as they get older, but for now we have to find a way to feel and contain the emotional impact of an experience.  

Containing emotions is actually a part of therapy. You may think therapy is a space to dump your emotions out like a psychological landfill. This happens and is appropriate, but another part is helping the patient regroup during and at the end of the session. This process includes learning how to express and contain emotions. If a patient is emotionally fragile, I'll spend the last part of the session helping the person return to a sound emotional state. This may happen by processing the experience, by shifting topics, or even by saying stop. You'd be surprised by the power of saying “stop” or “no”. In the end, you have to find what works for you. Whether that is going for a walk, changing the subject, listening to music, venting to a friend, or even smiling. 


As usual, feel free to share this post via facebook, twitter, etc. Comments are welcomed!

Salmaan Toor is a licensed clinical psychologist practicing in Knoxville, TN. If you are interested in being notified of future posts, you can “like” The Family Center of Knoxville on facebook here or can follow me on Twitter here. Thanks for your support!

According to Seligman, Steen & Peterman (2005), the secret to happiness isn’t money, adventure, or love; it’s expression of gratitude. If you want to read the study or view a creative summary and twist to the study, check out this Upworthy.com video by clicking here.

If you don’t want to read or watch, I’ll do a quick summary. Basically, it was found that people are happier when they express gratitude, and even happier if they are able to express gratitude directly to the person. The largest increases in happiness were found in those who initially reported the lowest levels of happiness.

This makes sense, right? Expressing gratitude means that you are polite, thoughtful, and respectful. Anyone would think these are characteristics of a well-adjusted, happy person. The catch is that there were people who initially expressed low levels of happiness, but their happiness increased significantly after expressing gratitude verbally and directly to another. Why?

Well, I think the answer lies in the process of expressing gratitude. One of my mentors always said, “It’s the process, not the content,” during our supervision sessions. It took me a while to understand what he meant, and I think it applies here (Thanks, Jeff). I’ll write about “the process” more in the coming weeks.

The process of expressing gratitude is powerful and intimate, more so than most people realize. It’s one thing to say “thanks”, it’s another thing to expound on that “thanks” and express how someone has really helped you as a person. Expressing gratitude opens your emotional world to another. That can make anyone feel vulnerable.

Why would someone feel vulnerable?

Two reasons why someone might feel vulnerable are: 1) the possibility of being hurt/exploited/criticized and 2) the possibility of actually emotionally connecting with another person in a healthy way. The latter is what happens with gratitude. When you express gratitude, you are saying, “I really appreciate you and the positive impact you have had on my life.” It may feel uncomfortable, but it feels good to make another person feel good, at least according to this study.

Why does any of this matter?

Well it matters quite a bit, certainly in therapy. My standard approach to working with a depressed individual is maintaining and increasing positive experiences (click here to read more about my approach). However, “positive experiences” are usually defined by actions that bring you joy: a hobby, lunch with a friend, something that makes you feel good. This study adds the twist of making someone else feel good by expressing gratitude. It will certainly add to my approach and hopefully yours.

If you are having a down day (or even a great day), express gratitude to someone. Test the idea out. See what it's like to send an email versus a phone call. If you're really brave, share your gratitude in person. You might be pleasantly surprised by how good it feels.

As usual, feel free to share this post via facebook, twitter, etc. Comments are welcomed!

If you are interested in being notified of future posts, you can “like” The Family Center of Knoxville facebook group by clicking here. Thanks for your support!