Monthly Archives: May 2014

The Accident

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I wasn’t even running late. At a quarter to five, I had about a half hour to get to an office that was just over a mile away. The thing is that I had multiple things on my mind, such as the limited number of checks at my disposal that week. I’d just ordered more, but in all likelihood they wouldn’t arrive before several bills were due. Then there was the form I was to fax off to the hospital: my wife’s healthcare plan. Would I have time for a quick trip to Kinko’s? I wondered.
Driving alongside the high school, I glanced to my left, then to my right. As my eyes passed over the digital clock next to the steering wheel, I noted an SUV about thirty yards ahead of me, but thought nothing of it. It was a twenty five mile per hour zone, or thereabouts, not that everyone adheres strictly to that limit. I was going around thirty, possibly a bit faster, and the SUV? Okay, maybe it was slowing down, obeying the speed limit, being more attentive to the distractible teens ambling along the sidewalkless road. Meanwhile, as my thoughts converged on a narrowing lane of consciousness, one more managed to squeeze in: wait, is that car even moving? I was still traveling at thirty plus miles per hour. The SUV, my disbelieving eyes notwithstanding, had ground to a halt with its indicator light clearly on, signifying a turn it was patiently waiting to make.
There was no way, I thought—no way I’d avoid a collision. I was about ten yards away, and at the speed I was going, contact was imminent. Still, I slammed on the brakes, thinking I’d turn my car to its side and crash into the back of the SUV with my driver’s side door leading the plunge. Less damage, I figured–to the car? me? It didn’t happen like that. Moments later, after a split second wherein I’d resigned myself not only to a crash but also personal injury, the front of my car hit the bumper of the SUV, the impact jolting the vehicle forward as I came to a shuddering halt. There was little if any time to feel anything: no pain, no relief for not having pain; no time, even, to process the sound of metal crunching. Immediately, the driver of the SUV, an middle-aged man wearing glasses who resembled the haunted leading man of Breaking Bad, exited and marched—no, he strode—towards me. As he reached my door he stopped and looked down through my window, staring at my face. He flinched like he was tempted to reach out, grab the door handle, and then pull me from my car. Instead, he waited, chomping on the bit to say something unpleasant.
“I’m sorry, are you okay?” I managed miraculously as I rose from my car.
“I’m pissed off and feel like kicking your ass,” shouted the man, his glasses shaking. I was shaking too. Had I looked down I might have seen his fists clenched, held in check by his side, but poised to strike at the slightest provocation. I didn’t look down. There was none of that looking up or down, so to speak—none of those provocative right brain gestures. Instead my eyes glanced off his face and into the distance with fleeting connection. It was a reptilian act, this look of mine: aversive, escapist; seeking the still territory. Peace.
“Please don’t,” I simply replied. Other words came to mind, don’t get me wrong. Talking to others since this incident, I speculate that some combination of intuition and training, my attachment gifts or pathology, depending on one’s point of view, clicked in and took over. You see, there were rules afoot in the above described moment: rules that may apply to men and women, but especially to men. Rule one says that if you want to not escalate a dispute following a threat, you must not counterthreat. This isn’t difficult to understand. It’s somewhat harder to execute, of course, again depending on your point of view. Rule two, however, is more obscure, much less talked about, and in my opinion, almost exquisitely difficult to execute. Rule two says that if you want to diffuse a threat, you must not state or even imply that the aggressor cannot do what he or she threatens. In order to proceed safely, as my loved ones (especially the women) would demand, I had to bite down—as in bite down hard—on the following type of answer: oh yeah, why don’t you give it your best shot?
Call it fear. Call it training. Call it empathy. Call it self preservation. Something moved me, quite consciously I might add, to be short, reasoned, yet uninflammatory in my response. Over the next minute or so, the other driver and I exchanged information while my body decompressed, my nerves rattled, and my shame—my shame at being a bad driver, that is—percolated. My adversary was soon quieted, possibly disoriented, and five minutes later he was on his way, muttering that he or his insurance company would “be in touch”. Another kind of threat. On the one hand, he too may have seen the wisdom of not escalating: why risk trouble for an assault if a judgment of my fault regarding the accident was impending? Secondly, upon noting his own lack of injury plus the relative lack of damage to his vehicle (his got scratches; I got the worst of it), he may have been decompressing also, not to mention feeling relieved that he hadn’t lost control and struck me. As I proffered my license and policy, he may have felt my defeat, my two-fold humiliation: my implied acknowledgement of fault; my swallowing of his threat without reprisal or counter-provocation.
Within the confines of a subculture that places value, real value, upon the undefended experience of fear, I can feel unjudged, held, perhaps even admired. It’s one of the perks of being a therapist, the immersion into this kind of sensibility. Some will comment that by appealing for no harm, for myself at least and possibly for the other driver, I had demonstrated real strength. I had presented myself with dignity, acted like the bigger man.
Who knows if my now absented adversary will think of these things, process notions of masculinity alongside the experience of trauma, mine or his? I hope he will. From within my fantasy, I hope that he will recall the rage with which he initially approached me; the transformation in him that seemed to take place as he observed my shaken, non-threatening demeanor; my disarming yet unprideful statement to him. In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I write about kids who might not even conceive of the lessons I draw from this accident. I write about kids with severe attachment pathology, long histories of violence, substance abuse to medicate feelings like fear and shame; a habit of psychic equivalence wherein feeling equals fact; a baseline bias towards survival in which time and perspective is shortened, split seconds become nanoseconds, and empathy—that capacity to feel into another and step outside of oneself—is forsaken. Observe the following passage from WTR:
“On the surface, it seemed to me that kids got into fights not so much because of gang rivalries or social marginalization, but instead because of more plainly interpersonal conflicts, such as that incident with Eddie and his hapless rival. Someone gets looked at the wrong way, and feels disrespected; someone’s shoulder gets bumped, and feels threatened, at risk of being a punk. For those feeling a surfeit of frustrations or humiliations in their lives, and without a place, the aptitude, or even the permission to speak openly of these stressors, “stupid stuff” becomes inflated in meaning. Seemingly trivial stressors are the proverbial straws on camels’ backs. As a result, thousands of clients have struggled their way through Therapeutic Communities walking a knife edge.”

**photo by Helnwein

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Adolescents and brain development: “Naming an emotion can calm it”

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Putting aside for now questions confidentiality and containment, matters of how to confront or otherwise engage kids about addictive use of substances, let’s turn to some research about human development which helps us understand child development and the implications for drug treatment. Last year, Daniel Siegel, renowned psychiatrist and neurobiologist at UCLA, published Brainstorm: The Power and Purpose of the Teenage Brain, a book seemingly aimed at an adolescent readership.
Siegel’s book touches on many subjects which affirm assertions I make in my own book, entitled Working Through Rehab: An Inside Look at Adolescent Drug Treatment. Firstly, Siegel explains the adolescent’s susceptibility to such things as novelty seeking, risk taking, the seeming observance of positive outcomes of behavior, coupled with the seeming disregard of negative consequences—all of which are characteristics of an addictive personality. He points out that during adolescence there is an increase in the activity of the neural circuits utilizing dopamine, a neurotransmitter central in creating drive for reward. A drug, alcohol for example, can lead to release of dopamine, and users may later feel compelled to drink further so as to re-trigger a dopamine release (the addictive cycle). When alcohol wears off, dopamine levels decrease, and those who become addicted experience withdrawal symptoms, and are then driven to use more of the substance that spiked the dopamine circuits (tolerance). Through phenomena such as pruning and myelination, humans are able to integrate functions of various areas of the brain—the cortex, limbic system, and brainstem—render it more efficient, and in particular consolidate skills around that which is repeatedly experienced.
And therein exists the problem for many who become addicted or otherwise troubled. Alluding to problems of attachment in early childhood, as well as social conditions that exacerbate feelings of disillusionment and disconnection, Siegel observes that many seem to become arrested in survival modes of thought and behavior, and therefore strain to develop skills that serve collaboration: so-called pro-social behaviors, reflective thought, and above all, empathy. They become prone to what psychoanalysts call psychic equivalence—the inner sense of conviction as to what others are thinking, leading to impulsive action. For the individual lacking what Peter Fonagy calls mentalizing skills (the ability to reflect upon another’s mind), even another person’s neutral responses are filled with hostility. Therefore, not only must those individuals not be trusted, they must be defended against, at all costs.
These were among the qualities that I observed repeatedly over my fifteen years working in adolescent drug treatment, in kids and sometimes parents; especially at Thunder Road, the Oakland facility wherein I worked until 2011. There were distinctive patterns of thought, feeling expression, and behavior that I observed, and which I depict and chronicle in my book. Siegel writes about many of these phenomena from a largely theoretical point of view. He describes the tendency for troubled kids to avoid their feeling states, to feel anxious but “get rid of the feeling”, rather than being open to learning about those feelings. In the dynamic between parent and child, he reminds us of feedback loops: the cycle wherein kids act out in some manner, producing negative consequences; adults react severely, exacting consequences that further stifle adolescents, who in turn rebel against the restrictions with further, perhaps even more egregious behaviors (BTW: I see this playing out with adult couples, also). Implicitly, Siegel affirms the premises of both drug treatment and psychotherapy (sometimes compatible entities, believe it or not) by indicating that in the brain, naming an emotion can help calm it. Here the psychiatrist is encouraging something that many resist. Indeed, hardly a week goes by without someone in my practice asserting that the problem is not so much “not talking about it”, but rather “talking about it.” The solution, according to the addict not in recovery, is not a sustained emotional release, but rather the opposite: silence and isolation.
Dan Siegel’s book, Brainstorm, is a useful affirmation of several ideas promoted in Working Through Rehab, though don’t get me wrong. I’m hardly claiming originality. In keeping with my sense of being a droplet in huge reservoir of information, my book contains well over a hundred references and endnotes. In the fourth of these articles devoted to adolescent drug treatment, I shall explore the territorial battle between theories of psychotherapy, and in particular, upbraid the narrow-minded, cynical, and even corrupt disregard of long-term, psychodynamic models of psychotherapy. As a preview, I’ll return again Siegel’s thoughts. In Brainstorm, he challenges the adolescent reader to reflect upon his or her past—the early attachment experiences—which are a staple of long-term, psychodynamic (as in psychoanalytically-derived) practice: “It makes sense for you as an adolescent to make sense of your life history so you can be as fully present as possible in your relationships. What this means is reflecting on your relationships in the past in your own family life and asking yourself how those experiences influenced your development.”

 

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Servant of the Process: Team v. individual approaches in drug treatment

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What process? You mean the process of addiction? Do you mean the process of working with teens in a rehab setting? There are several elements of Working Through Rehab: An Inside Look at Adolescent Drug Treatment, that bear explanation. One of the more important features is this whole question of whether to treat the substance dependent individual (teen or otherwise) through a team approach or through the model of individual therapy. In a hospital-based drug treatment program, professionals assert that they work as part of a team which may include a variety of collateral contacts, each of whom may come from differing disciplines: therapists, teachers, doctors, psychiatrists—you get the point. If not characterizing a team approach, practitioners may use synonymous language, and describe their work as “systemic”. Among other things, it means that information drawn from patients, in individual, family, or group therapy formats, is shared with all members of a treatment team, in or outside of a program. The idea is to contain destructive behaviors, including but not exclusive to the addictive use of substances, and to uncover discrepancies in reporting by the patients. The premise is that addicts lie so the information they share with individual therapists is not reliable. As a result, traditional rules of confidentiality are loosened, especially with patients mandated through legal authority, such that the priority task—interrupting problem behavior—is more likely achieved. The argument goes something like this: since patient disclosures are unreliable, the traditional ethos of treating disclosures as sacrosanct is misplaced. Therefore, in a hospital or group home setting wherein therapists are operating from a “team approach”, individual counseling sessions aren’t really what they appear to be. There are invisible parties in the room.
For the most part, I have supported this therapeutic stance, especially on occasions (more numerous than not, actually) when it seemed obvious that patients were not truthfully reporting either cravings or continued using behavior. It has often seemed that if programs are to really intervene with a pattern of drug use, then it is necessary to maintain a skeptical position with a patient; to not get caught up in a patient’s denial system, and to consult with others—in short, to not get fooled. To work in a rehab setting and learn the ropes is to have the experience of being played by slippery drug addicts, over and over again, until this lesson is learned. Problem? To share information with colleagues and collateral contacts risks stalling or undoing the fragile trust-building that all therapists must achieve with their patients. So what, I hear the average drug counselor saying, especially those of the so-called old school variety. That trust-building isn’t happening anyway, they’d argue. After all, it is the addict, not those who live or work with them, who fail the exercise of trust. It is they who fail to trust others, family, friends, and helpers, by repeatedly not sharing the truth.
These are sound arguments that routinely bully therapists who otherwise hope to not waste their time with reticent, untrusting patients who will likely resist the spirit of help being offered. Despite my overall support of the “addiction model” ethos, I nonetheless think the arguments of individual therapists, particularly those working outside the addiction model, make compelling counterarguments regarding the loss of confidentiality. From this tradition, derived from a plethora of psychoanalytically oriented therapies, the patient in therapy must be assured that their disclosures will be treated confidentially. To do anything less would compromise trust and inhibit disclosures, rendering therapy an exercise in compliance—not meaningfully different from a relationship with a teacher, probation officer, or some other obvious figure of authority. Trust-building is a long-term task that can and should transfer to personal relationships, enabling meaningful dialogue about difficult subject matter over a lifetime. Trust-building isn’t simply a therapeutic nicety that will allow a therapist to have cordial exchanges with a reluctant patient. Secondly, and perhaps most interestingly, some argue that the containment bias of addiction model proponents sets up an artificial situation, one that is ultimately unhelpful to addicts and their loved ones.
To explain: one of the most difficult things for a loved one to say to the addict is something like “I don’t believe you. I think/feel you’re lying.” Fundamentally, it feels unempathetic and disrespectful to confront someone in this manner, and therapists usually feel a parallel dilemma: how to confront with tact while not rupturing the therapeutic bond. Paradoxically, many therapists have found that when they do confront lying behavior in patients, tactfully or not, it often improves the bond as opposed to disrupting it. Some of the best moments at Thunder Road occurred when committed staff, on the back of a solid bond with a difficult kid, pronounced its belief that the patient/addict was lying. This action, fraught as it is with anxiety and risk, enables the therapist to more fully empathize with the oft-gaslighted loved ones of addicts, those whose entire lives seem to revolve around similarly painful dilemmas: what can I say when my gut tells me something’s not right? What’s the easiest way to say I don’t trust you, don’t believe you?
No model of care is perfect or even close to being perfect. Addiction models and traditional psychotherapeutic models are not mutually exclusive, and don’t believe anyone who tells you they have evidence of what works and what doesn’t. They’re lying.

 

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