Monthly Archives: December 2014

Good Enough

It’s a holiday giveaway, these free books (almost, but not quite free if you click on the link). A year after it’s initial publication (actually, closer to a year and a half), I’m looking to stir interest in my non-fiction and memoirish work, Working Through Rehab: An Insider’s Look at Adolescent Drug Treatment. This latest giveaway comes upon the heels of a workshop I recently taught–an overview of the disorder of self model created by James Masterson, that I provided for interns at a community mental health setting. Masterson’s work, referenced minimally in most training programs these days, is referenced centrally in WTR, as a guiding set of principles for what might happen in community or residential treatment settings, especially those straining to incorporate psychodynamic perspectives.

The difficulty is outlined in one of Masterson’s final works, The Personality Disorders: A New Look (published in  2000), in which he reviews the various methods used to treat Borderline Personality Disorder, as well as concomitant conditions such as Bipolar d/o or PTSD, and bemoans the dilution of intrapsychic focus in favor of pragmatic and utilitarian approaches. Like many, Masterson points out that modern neurobiological research has determined that a child’s brain increases 2 and 1/2 times in size during the first year of life, suggesting an “experience-dependent” growth pattern tied to a dynamic between caregiver and child–that the role of a caregiver is that of regulation; regulating the immature psychological systems which influence biochemical growth.

Masterson’s contemporaries, Otto Kernberg and Heinz Kohut, suggested more or less competing models for the treatment of individuals who suffer from development dysfunctions such as BPD. Kernberg drew from ideas put forth by Melanie Klein by indicating a constitutional excess of aggression on the part of such patients, with maternal or caregiver interaction playing a less influential role in his model. Like Masterson, Kernberg recommended an expressive psychoanalytic psychotherapy in treatment, but one that favored a focus upon transference interpretations, with insight into such interactions promoting integration, and thus growth. Masterson disagreed, thinking that confrontation of ego defenses, particularly regressions designed to ward off what he termed “abandonment depression” (as in an abandonment by a primary object) was the central task of psychotherapy. In Masterson’s view, interpretations prior to containment of defenses, or the establishment of therapeutic alliances, were ineffective. Meanwhile, Heinz Kohut, in whose model I was initially trained in the nineties, recommended an approach that drew attention to patients’ so-called unmet needs. Focusing more upon Narcissism than Borderline pathology (once deemed interchangeable conditions, incidentally), Kohut taught a model which focused upon mirroring responses, with less emphasis upon transferential interaction (Kernberg), or defense analysis (Masterson). The differences are crucial, parallel to what are termed “enabling” versus “recovery-oriented” approaches in the lexicon of CD treatment. As Masterson would say, what we call defense they call the patient’s “efforts to repair”.

In  WTR, I describe the influence of Masterson in my growth as a therapist in a residential setting, as well as my movement away from the Kohut model I’d originally been taught. My rationale was as follows: the patients whom I saw repeatedly in treatment were mired in patterns of lying, self-destructive behavior, suicidal and violent tendencies, alongside a variety of other defensive habits, yet few of these patients were sociopathic. They were admitted for a treatment episode that was daily, intense,  would last over months, if not longer, and engender transferential bonds that were complex. The stage was set for a psychoanalytic treatment, yet over time, the prominence of such models diminished, in favor of derivative approaches, Dialectical Behavior Therapy, so-called Strength-based models, that focus upon symptomology versus intrapsychic, or internal change.

Change. Meaningful, lasting: everyone in the field claims to want it, and even resistant patients give it lip service.  Notions of it inform but also confound treatment plans. In dispute with Kohut, WTR mischievously contends that mirroring defenses tends to reinforce defenses. In dispute with Kernberg, I offer that a focus upon constitutional aggression ignores underlying pathology. In dispute with Masterson, I’d say that mandated referrals engender “compliance” defenses, which contaminates therapeutic alliance, enabling defenses. Such bonds, as well as defenses, are nonetheless fluid, predictable and not. But to work through rehab, as either a patient or a professional, you have to make a choice at some point as to what approach is right. Hopefully, your choice is good enough.

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The Conversation, part two

Sophia quickens her step, chasing after Lefty, who did what his name suggests–he left–just as things were heating up with Harmon.

“Hey,” she calls out in a curt, half-friendly voice, like there was just one quick thing to discuss. Lefty slows but doesn’t turn, like he’s been caught by an officious school mistress. Maybe she doesn’t want much. Maybe she just wants to understand the few jibes he’d directed at her; the oblique remarks about her name, that of Harmon–his curious take on things. “I’m the community analyst,” he’d said in parting. Sophia catches up with him, is slightly breathless as she takes a pause, thinks about her name and wants to change it.

“I wanna know what’s up with you,” she asks.

“Oh, right. Acknowledgement”

“What?

“Nothing. Just something that was said.” Sophia blinks, taking in the data. It doesn’t compute. “Look, can’t you just be straight. We’re trying to have a serious conversation.”

“So am I,” Lefty replies with aplomb.

Sophia recoils. “It seems more like it’s a game to you–a game of hide and seek. I mean, do you even have an opinion about what happened. Do you think an injustice occurred, is happening, like all the time?”

“I don’t know,” Lefty shrugs. Sophia’s eyes narrow: a blur of contempt and hurt.

“How can you not know? Do you honesty think that if that kid had looked like you or me, the same thing would have happened? Don’t you see the inequality that’s all around you, or do you just not care because to look at it would mean you’d have to give up your privilege?”

Symbolically, unconsciously, Lefty looks askance, past Sophia’s shoulder, her hot, burning eyes. He sighs.

“Actually, I do think those inequities exist, and I do think them unjust. I just don’t know if the incident yesterday was an example of that.”

“Are you kidding?”

Lefty straightens, gulps. “No I’m not. That incident needs to be looked at on an individual basis, not as something representing a trend. Those people, all of them, deserve a fair hearing, not to be treated as scapegoats.”

Sophia protrudes her face into his. “Really?” she retorts, portending sarcasm. “You think all of them are scapegoats, as in equally?”

“Maybe,” Lefty musters.

“You need to wake up, friend, and by the way, I’m not sure you are a friend. You need to get off the fence, open your eyes. I can’t believe this. It’s so frustrating to know people who just refuse to see things. I could tell you about countless stories of people getting abused, persecuted. I bet that none of that has ever happened to you. I mean, I’m not saying this never happens to us, but…whatever.” She stops, takes a breath just as her volume reaches some predetermined threshold. She looks away, heaves a deep breath.

Disgust.

Lefty searches for her gaze, his own breath trapped. He has nothing left to say, and neither does she, but her job is done. Satisfied, she sees it in him, finally–what she’ll settle for. Lefty is uncomfortable.

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The Conversation

Harmon, a man concerned with togetherness, saw it in Sophia: the fear. He saw it in her name: so much fear. But that was beside the point. The point was to speak openly, to matters that were front and center, not these fanciful tidbits, undercurrents.

“We need to have a conversation about justice,” Sophia brightly declared.

Harmon was hesitant. “Well, yes, of course. Though I think it’s really about social cooperation, plus economics, philanthropy, about having the conversation that brings different sides to the table.”

Sophia scratched her head and furrowed her brow. Consternation–twitchy, nervous consternation.

“Why do you do that with your hands?” This was Lefty, on the periphery of friendship, niggling at Harmon. Lefty was so-named because he came at things sideways, liked to observe that which happens in silence, detached from intellect.

“It enhances my point,” replied Harmon curtly. His hands, aloft and frozen, had been rotating vertically, moving the air.

“I…I don’t really know what you mean. I mean, sure–it’s about cooperation, and economics–but I think certain things need to be acknowledged. I think some things speak for themselves, and it’s not about whether people give things. It’s about how things are divided, about poverty and inequality.”

“Yes, all these contexts are important, but I think you have to be careful on these subjects. You can’t just come at people bluntly–the way you want to. It makes people defensive.” Harmon, on precise cue, delivered a sweet smile. Sophia, diffident yet brave, soldiered on, shaking her head.

“I don’t know…I just think we need to be honest, not have some kind of dance–this ‘cooperation’ as you call it. It’s important. People are getting hurt, being traumatized. People are dying.”

Harmon stretched out his arm and held his palm upwards. “Sure. But see, it’s not a zero sum game, social justice versus cooperation. It can be both if you take an even-handed approach.”

“What does that one mean?” asked Lefty, eyeing hands studiously. Harmon cut him a sideways look; ignored him and continued. “Words like justice are…” he paused “…inflammatory. You have to build slowly, assert an agenda but one that seems inclusive, doesn’t alienate with tendentious language.”

Sophia’s reply was brittle. “I think this is disingenuous. If we bring people to the table, have this conversation, it needs to start with some understandings. We need to say to one side, ‘look, you’re in the one-up position. The onus is upon you to acknowledge that, at least–”

“They’ll know you want more than acknowledgement. That word is disingenuous also.” This wasn’t like Harmon to interrupt. His face and tone hardened. Lefty noticed, smiled.

“Well, sure. That’s right: I–we–would want more than acknowledgement. That’s just where it would start: agreeing that things aren’t equal.”

“They won’t necessarily agree with you.”

“They should.”

Harmon winced, and his hands came together, though only at the fingertips. They barely touched.

“And that one?” Lefty asked.

“Look, shut up,” spat Harmon. Lefty burst into laughter while Harmon turned on him bitterly. “If you don’t have anything meaningful to say, then why are you here?” An awkward silence followed: Harmon sat back, embarrassed. His reasonable front had been broken. Sophia leaned forward and sulked.

“You’re missing it,” said Lefty finally. He’d become serious all of a sudden. “The conversation won’t happen talking about justice, or cooperation in the way you’re talking about it. The problem is with the people–all of them. They don’t really listen to each other. They don’t know how.”

Harmon shook his head. Sophia’s face clouded over. She turned to Harmon: “Whatever. We need to continue this conversation.”

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