Monthly Archives: November 2015

The dog did it

 

A funny, perhaps illustrative story. During a worryingly lengthy gap between sessions, two therapists, myself one of them, walk along a strip mall, drinking coffee, fretting over a pre-holidays downturn in business. I turn to my right to see a car roll away from its parking spot—nothing unusual in that, I’d think if I were to give this event the headspace to generate such words. My eyes turn upwards to the driver, in this case a dog—a Doberman, I think—staring back at me, undisturbed. I scroll my gaze about the animal, in search of a human being. What? The dog appears to be saying with its stolid expression. Is there a problem?

“Holy shit!” I say usefully. I point to the car, now rolling silently into traffic, its emergency brake having been released by the dog, it seems. My friend does more than exclaim, he responds. Launching himself into the lot, he wades into the area behind the vacated spot, a space of about fifteen yards, and begins waving his arms to alert drivers, pedestrians crossing the stretch to enter the mall. Thankfully, there is no one moving behind the car as it pulls out. As I follow my friend, a woman behind me, shepherding two children, shrieks in horror at the disaster in progress, only it isn’t that exactly. Moving about one mile per hour, the car rolls backwards onto a curb and rather anticlimactically comes to a halt, bumping up against a vehicle fronting another row of cars.

Despite the absence of crashing sounds, the spectacle of a driverless car rolling a curb has drawn a crowd. A handful of voices stand behind me making plaintive sounds, nothing constructive. “What kind of car is that?” I ask aloud, collecting my wits. I’ll need to poke my head into shop doorways, call out for the owner. “A Mini Cooper,” someone responds. Moments later, this woman and I are making brief rounds of the local stores, making announcements, being confronted with more stolid expressions, though not those of dogs. Soon I give up this endeavor and return to the car, now perched atop a curbed island, its driver, the dog, still looking out at me, wondering what the fuss is all about.

By this time, my friend has ventured farther afield, towards the supermarket across the way, where the search for the Mini’s owner may yield better results. I take out my cell phone and call local police, and within moments, as a store manager approaches looking inconvenienced, I am talking to a dispatcher, describing the event. Meanwhile, I ask the manager a stupid question: “Are you the owner?” He frowns. “Of course not,” he replies irritably. Away from the store, the customers are not always right. He gets out a pad, takes down a license plate and heads back to his store, resolved to find the car’s owner should he or she be in the market. Thereabouts, the owner of the struck vehicle, a genteel, elderly woman, appears behind me, scrutinizing her car. The front of the offending vehicle is fused to her right anterior headlight, leaving at least one visible scratch, but the elderly woman seems quite grounded, her priorities more humanely focused.

“Is anyone hurt?” she asks, apparently not seeing the dog in the driver’s seat. “I don’t think so,” I say, after which I explain about the dog, the rolling; my slow response to the unfolding of this, uh, accident.

A minute later the bad-tempered manager, flanked by an anxious looking woman, returns. I feel poised to ask if she’s the owner, as if I’m in charge of the situation, but I hold my tongue, as if not wanting to risk being wrong again, thus eliciting more ridicule from the manager guy. “Oh my God,” says the anxious woman, though more in common surprise than shock or horror. She looks inside the compartment of her car, sees that her dog is unharmed, and still unperturbed. By this point the crowd has dwindled. The spectacle, absent its comic, supporting narrative, is suddenly unremarkable. It just looks like a car parked really badly, with a few onlookers studying the problem. For the next few moments I go quiet, having intuited the brittle defenses of the rolling car’s owner. They begin with the elder woman’s innocent query: “Are you the driver?” The other woman flicks her head about, as if fielding a cat-calling. “I’m not the driver, I’m the owner,” she retorts. I suppress a smirk and flippant rejoinder. Technically, she right. The dog is the driver, the culprit, I want to say. My friend, determined to intervene, affects a sober voice and tells the story from the witness point of view. His explanation of averted consequences befits his style as a therapist: “Someone could have been badly hurt,” he says.

“I don’t need to be counseled,” the woman replies tersely. My friend denies trying to counsel—a lie, albeit a well-advised one at this stage. He turns away, not wanting to deal with her further. Shortly, the Mini owner woman turns to the elder woman, who visibly recedes, not wanting a fight, it seems to me. The other woman inspects the back of her Mini Cooper, gives a cursory look at the elder woman’s vehicle. “That’s not so bad,” she comments presumptively. She gives me a glance as I am positioned centrally—appearing significant, if quiet. I turn to the elder woman, feeling protective, and deciding to make implicit my importance. “I may have to leave soon, but I can give you my name and number if you want a witness.” The elder woman thanks me. At that point the Mini owner asks what’s happening and I explain that police are expected soon. “What did you tell them?” she asks suspiciously. I give a brief, just-the-facts description, which she rewards with the words, “of course it rolled. I didn’t drive it”. Duh, she exudes.

Later I reflect upon a few meanings, about denial, projection, even codependency (the owners of the two cars hugged as my friend and I moved away—conflict avoidance, we thought). I thought further about my own denial: the seconds of disbelief, regarding the surreal time-suspended roll of the dog-driven vehicle. I thought of the Mini owner, that anxious, embarrassed woman, who acted punchy when feeling surrounded, her possible neglect evident to several witnesses. In retrospect, it’s not clear that she acted neglectfully. Accidents happen, or dogs are smarter than we think, and eager to drive. Who knows whether that event could’ve happened to anyone? But it’s the persecutory anxiety that really strikes me: the impulse to defend, deflect, even find fault with those observing problems. Minutes prior to this happening, my friend had been explaining that he’s powerless over his clients, whether they will let him help them. His exchange with the Mini owner mirrored his earlier commentary. Whether or not that woman felt lucky to have avoided disaster, we’ll never know. At the time she couldn’t deal with the feedback, let us help. She couldn’t acknowledge what might have happened.

 

 

 

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Working Through: the bad news about neuroplasticity

 

A young man stomps down the hallway to my office. He’s been told to come speak to me, is more or less cooperative, though he is fuming, or “triggered” as his peers would say by an as-yet unidentified stressor. Once inside, he sits on the edge of my couch, poised to lunge should anything else graze his volatile mood. “What’s happening?” I ask. What happened? That’s the subtext and layered backstory.

Turning out his pockets, emptying upon my table a previously hidden arsenal of knives and electronica, he raves incoherently about someone who hasn’t returned his call; about someone whom he feels threatened by–an invisible oppressor, spreading ‘lies’ about my client. Whatever’s happened has stirred old material, I surmise. The following conversation will process the present tense, assess risk for dangerous behaviors, and seek to redress a distortion or two, at least from my standpoint. Will it work? The factors in question are numerous, I figure. Much depends upon the nature of the trigger or triggers, the history of similar events in this young man’s life. The prospect of new learning, containing negative or destructive behaviors, plus installing a new and desirable response and sustaining that response will depend also upon the relationship to me, among other things. Does he trust me? Will my interventions be not only well-timed, but compassionate, insightful, true? Has he trusted people like me in his life: teachers, parents; authority figures of one sort or another?

And that’s just scratching the surface, and so it goes. The question of what contains danger, or causes meaningful change, ‘reconsolidating’ traumatic memories remains mysterious, yet to hear some speak you’d think that neuroscience of the last decade or so has at long last delivered the long awaited elixir to traumatic response. In the April issue of The Journal of the American Psychoanalytic Association, Richard Tuch challenges some of the claims made by neuroscientific researchers in recent years, especially as it pertains to the so-called reconsolidation of traumatic memory.

During a seminar, Tuch opined that emotional memories continue to exert an influence over an individual’s emotional life even after a transference (within treatment) has been ‘worked through’. Nuancing his message, Tuch stated that a more likely outcome was for a patient to learn the ability to stand apart from the experience and recognize it (an emotional memory) for what it was. In shorthand: to develop an observing ego. A student challenged this modest assertion, citing “breakthrough” research which proclaims the discovery of the brain’s ability to delete specific, emotional memories, as well as non-conscious beliefs and schemas, at the level of physical neuronal synapses. Indeed, some studies have demonstrated how retriggered memories can undergo a process of “reconsolidation” if, during a critical period, a subject is given a protein-blocking agent, or is presented with new data that contradicts the conditioned response. I even cited some of this research myself to support ideas proselytized in Working Through Rehab, my incendiary critique of adolescent drug treatment. Recent discoveries in research have been hailed as provided evidence of the mind’s flexibility, or “plasticity”, suggesting renewed hope for meaningfully curative responses to trauma.

The problem, as Tuch writes, is that such research involves a particular kind of memory that is readily subject to operant conditioning: the kind of memory that is short-term and responsive to a simple stimulus, such as an accident, or a stimulus that can be simulated in a controlled, experimental setting. Take the work of Daniella Schiller (et al), whose 2010 paper, “Preventing (blocking) the return of fear in humans using reconsolidation update mechanisms”, has been among the sources influencing the new enthusiasm about neuroplasticity. I detailed (though later edited down) the specifics of Schiller’s consolidation experiments in Working Through Rehab. In her study, human subjects took part in what may seem to have been an old-fashioned behavioral experiment: individuals were shown colored squares (CS) paired with electric shocks to the wrists, while physiological reactions were measured via skin conductance response technology (SCR). On the following day the group of subjects was to undergo an extinction exercise wherein the CS would be paired with no shock. The experiment called for a control group to be given a CS ‘reminder’—a CS paired with a shock—ten minutes prior to the extinction exercise, where the CS is paired with no shock. Follow me so far? The ten minute window between exercises was dubbed a reconsolidation window, as in an opportunity to contradict data, delete previous responses; demonstrate plasticity, and so on. Then, on the day after that, another trial experiment was conducted, with subjects exposed to the CS again, again without the accompanying shock. The control group subjects consistently exhibited no SCR, in contrast to their counterparts who had not received the CS reminder and extinction exercise.

This led to some interesting, and again—influential—interpretations. Gorman and Roose (2011) point to the study as an indicator that timing (just timing?) of interventions (from their standpoint, interpretations, not instruction per se) must exist in proximity to reactivation of trauma material in order to block consolidation of maladaptive response, and to allow for a re-writing of a traumatic narrative through a therapeutic discourse. In 2012, when I was writing my book, I thought this a worthwhile assertion, but today it seems overreaching, and in retrospect, I wish I’d waited upon the sober skepticism of Richard Tuch: “Whether these findings can be extended to include memories that are the product of the sort of ‘cumulative trauma’ typically responsible for the disturbances we see in our offices seems highly unlikely,” he writes. Furthermore, the so-called reconsolidation efforts described in the research follow soon after the memory-producing experience, reinforcing the heuristic belief that proximity of feedback to a stimulus is essential to learning.

Or, as I put it to a parent recently: “if Jonny speaks out of turn in class one day, you don’t wait several days, or ‘when the time is right’ to admonish the behavior. You address the behavior in the here and now.” That’s a tenet of teaching, not to mention operant conditioning: to address children quickly and succinctly about what’s happening, as defined in strictly behavioral terms, ignoring psychodynamics. Outside the academic or experimental realm, matters seem different: emotions count in so far as they exist, though they are avoided. Memory counts. Relationships matter, and time is somehow a fuzzier element between people. The emotional context of these moments is anxiety—the fear that accompanies complex memory, the interaction of projections and introjections, the unconscious. I can think of many words to describe the mind. Complex is one of them. The word plastic is not yet among my favorites.

 

Gorman, J.M., & Roose, S.P. (2011). The neurobiology of fear memory retention and psychoanalytic theory. Journal of the American Psychoanalytic Association. 59: 1201-1219.

Schiller, D., Monfils, M.H, Raio, C.M., Johnson, D.C., LeDoux, J.E., & Phelps, E.A. (2010). Blocking the return of fear in humans using reconsolidation update mechanisms. Nature. 463: 49-53

Tuch, Richard (2015). Brief Communication: problems applying neuroscientific research to the clinical setting. Journal of the American Psychoanalytic Association. 63: 311-316.

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To Write And Not Be Read

Walking by an antique store, looking at the old and discarded yet preserved, I happened upon faded signs with oblique aphorisms: sing though you are not heard; speak though no one listens. Were they antique notions, these calls to action? I was reminded of the Paul Simon song, “Sounds of Silence”, with its eloquent, melancholic reference to “people writing songs that voices never share and no one dared”. This appears to be a tragedy: a post-Kennedy death lament about brightness lost, squashed under oppression, the corruption of secrets. That was fifty years ago. Awakened, pop stars and their listeners found their freedom amid their friendly darkness soon enough, with words and ideas that were shared, because people dared.

Over the last year I’ve been writing a new novel, about a psychotherapist who wonders whether to speak out and be heard. The story parallels my own process, of course: my inner rumblings about my role within the mental health community; the role the therapist has within the community at large. It’s a unique, if ambiguous role, straddled between obligations: the duty to hold private or confidential the disclosures of individuals in a safe, therapeutic setting, unfettered by restriction, so that psychological healing can occur. This duty is offset by a sometimes explicit, sometimes vaguer obligation that therapists have towards the broader public: to protect children and the elderly from harm; to protect the imminently endangered from harm; to educate and/or soothe the countless selves that are depressed and suicidal, or paranoid and abusive, or even murderous. The public wants these selves medicated. Or, they want them locked up. Otherwise, they want them spoken to soon, by people who claim to know what’s wrong, not just what’s true.

And it’s not like it was two generations ago, when seeking a therapist meant finding a shrink who didn’t have a long waiting list, or else it meant settling for the pastor at the local church and asking for forgiveness, if not so much understanding. Nowadays, psychiatrists dispense pills and supervise hundreds of cases, but otherwise leave the detailed talking and listening to others: social workers, marriage and family therapists, psychologists, behavioral technicians; life coaches, certified alcohol and drug counselors, pastoral counselors with clinical education and training; specialists in everything from trauma, eating disorders, autism, to sex addiction—all these conditions that seem to have exploded in frequency. There’s a whole lotta sadness and crazy around, so business is booming, but there’s almost as many types of counselor as there are diagnoses, so not to worry: there are plenty of us ready, willing, and able to listen to the words, hold your secrets…most of them.

See, when I listen to Simon’s words—“people talking without speaking”, “people hearing without listening”, or “but my words like silent raindrops fell”—I consider different meanings, depending on my mood, or the pressure, internal or external, that I feel. Does the singer fear that his words will be punished? That his daring will lead to annihilation? Or does he fear neglect, a narcissistic wounding born of others’ misunderstanding, or indifference? For many who step into our offices, privacy is either a promise or a curse: the office is where the words spoken are kept. The office is where the words spoken are kept. When the session’s over, the frustrated speaker ventures away from the closet and witness, deciding whether to speak further, share in contexts of presumed lesser safety. Meanwhile, the professional has decisions to make: was there anything disclosed that must be shared, or should be shared, for the protection of society? Is there a victim to warn, or a hospital bed to make ready? Should police be contacted? If the issue is less critical, should family members, a partner, or a would-be collaborator be included? Should the individual’s thoughts and feelings be dealt with in isolation, held like a precious gift? Or is there a ‘system’ to attend to, with a village or team ethic invoked?

To varying degrees, people who enter therapy want the same things: to find space and acceptance for their distinctive selves—while reconciling these needs with a need for others’ proximity or acceptance. It’s the strategies that truly vary, depending on the conditions of being in relationship. In negotiating the psychic economy, some people hide in therapy while hoping to not hide in life—hoping that at some point someone will accept them and understand. Some are frustrated soap-boxers, profuse in their disclosures, treating the therapeutic space as a place for treasures to be taken out of the trove, gazed at and pored over, but taken no further. At the end of each hour, those thoughts and feelings, once delicately removed, are returned, ever to be kept safe. For some, words that are spoken mustn’t be retold. For the like-minded writer, the thought-provoking book, nurtured like a precious stone, must likewise be protected, and thus edited. Its original draft/self must be burned, actually, because its words cannot be read. They are raindrops.

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Deviancy Today

The latest issue of Psychology Today features an article entitled “Sympathy for the deviant”, fronted by a teaser, “Do we misunderstand sex offenders?” It’s a leading question, suggesting, as such questions tend to, that misunderstanding constitutes prejudice. The thesis of writer Jennifer Bleyer is that sexual abuse stigma may prevent people from getting help before they commit harm. She follows accounts of men who slide from attraction to early adolescents, to grooming behaviors, skinny dipping, sleeping nude with underage partners, from embracing to sexual intercourse. The passage from intrigue to abuse is insidious, laden with denial, compulsion and horror. Partners share their trauma as they watch their husbands being hauled away to jail. The husbands, like the wives, are shaken, apologizing desperately, seeking forgiveness before anything’s been understood.

How can it be understood? the article asks. Given the legacy of silence and collusion, it won’t be easy, writes Bleyer. She points out that discussion of sexual abuse emerged from the cultural shadows in the 1980s, when a confessional culture lead survivors to speak out. “For the first time, its prevalence and its adverse effects became apparent. The pendulum of public concern swung hard in the direction of indignation, as sexual abuse went from being largely ignored to intensely condemned.” In psychoanalysis this is called reaction formation. In short: guilt. The guilt feelings are appropriate, but as many within our profession argue, guilt also gets in the way, by stirring its derivative, rage. It gets in the way by disregarding some facts: that recidivism rates for sex offenders, for example, are lower than for other major types of crime and much lower than is commonly believed. Take radio show host Bill Carroll, for instance. In July, he and politician Melissa Melendez clucked righteously that sex offenders can’t really be treated. “You can’t change a pedophile’, he said. The next day I went on his show and told him what’s what. In September, a board member for the California association of marriage and family therapists (CAMFT) opined that sex offender treatment was ineffective, offering in a public forum that over half of offenders continue to offend despite treatment. After the forum, I stepped up and with a polite smile told her she was wrong also.

No surprise that this side of the information divide makes it to public ears, coloring opinion. Given the hysteria that such opinions generate, few learn the truth as Jennifer Bleyer reports: that only 40% of convicted sex offenders meet criteria for pedophilia, or that pedophilia refers to an attraction, not necessarily a behavior or set of behaviors. It chills the skin of progressives to consider that pedophilia is likely an orientation, and likely because they don’t wish that sympathetic term co-opted by an unpopular segment of society. They may be assuaged to learn that pedophiles have been shown to be shorter on average and more likely to be left handed, as well as having lower IQs. One study has shown they are more likely to have suffered childhood head injuries. My own clinical experience (not based upon a large sample, I should note) bears out the impression that pedophiles are prone to childlike personas, presenting as sexually diffident, living on the margins.

In Germany, a prevention project begun in 2005 aims to prevent abuse by offering anonymous treatment to people who are sexually attracted to minors. In on TV ad, a masked man recites a script of self-loathing, followed by a pronouncement of what he had learned in therapy. In the ad’s climactic moment, the man removes his mask, exposing his shame, but also expressing his hope. “I don’t want to be an offender,” he says. According the Bleyer, over 5000 people have come forward seeking treatment as a result of the ad campaign, leading to the establishment of 11 clinics across Germany, with a specific sexual abuse prevention at the core of program mission statements. CBT and testosterone-reducing pharmaceuticals are the preferred interventions, not so much psychoanalysis. Oh well, progress not perfection, I say. With this article in hand, I approached my colleague at work, a man exhorting me to renew my credential for treating sex offenders with the state. We should be bypassing the state, I said. Long term, we should be trying a version of what they’re trying in Germany: reaching out, through our website, through social media, through CAMFT board meetings, meetings with the California Coalition on Sex Offending (CCOSO). We should be aiming at those individuals who are out there, seeking help, looking for therapists, programs, who will speak to their particular problem.

So far, no one in this neck of the woods is doing this. No one’s aiming a marketing strategy at sex offenders, or sex addicts who might transform into offenders. No one’s funding a public service announcement on a bus or billboard, outreaching with a message like the one suggested in Bleyer’s article: “If you’re concerned about your attraction to children, call this number.” My colleague claims–rightly, I think–that new reporting laws such as AB 1775 will make preventions efforts such as what’s happening in Germany virtually impossible. Maybe that’s true. Maybe someone with a problem can’t really talk to me. If they tell me they look at underage porn, I’d have to report that to authorities, who may choose to let therapy do its thing, or they may not. They may choose to break down my client’s door, confiscate electronica, make an arrest that will trigger a catastrophe in that person’s life. I guess they’d call that prevention too. But they couldn’t call it understanding.

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