August 22, 2016 · 6:10 am

You must not run away

 

“No one is after you! No one, I say! You all ran away–and now I know why. I sat by the lake, and there came a fly. The fly ran away in fear of the frog, who ran from the cat, who ran from the dog. The dog ran away in fear of the pig, who ran from the cow, she was so big! The cow ran away from the fox, who ran as fast as he could in fear of the man. That man heard a thump, and away he. It was just a sheep, with an old tin can.

I looked at them all, and then I could tell they all had no fear, and now all was well. They all went away. They all waved goodbye. SO…I sat by the lake and looked at the sky.”

–from A Fly Went By, by Mike McClintock

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August 14, 2016 · 8:56 pm

As dark as it gets

 

“Around ten o’clock, Andrew revealed a surprise: he’d been in therapy before, as in before he’d ever called me. And not even therapy, but analysis: for two years. He left because he didn’t like what he started to feel, a parallel between his drug addiction and emerging sexual compulsion. Though tired, I perked up, sensing something coming. Andrew spoke theoretically, about chasing highs, going back to an original experience. It felt like a prefacing explanation, his talk of addiction, its bedrock principles. Then he told me about his first time, the predictable, clandestine grope with an older girl, when he was eleven, she fourteen. The dreams of that girl, and his lust for teenage girls in general had never gone away, but he wouldn’t tell me more, not while there were legal issues pending, files not yet written. With that stuff looming, I wondered why he’d tell me anything, but then, I am ever struck by the desire to be known, by someone. Andrew’s loneliness gripped my heart, even as he retreated from memory, back to theory. He had an idea about pedophilia, he said, lowering his voice. It related to that original experience, that primal desire to be a child, experience pleasure as a child—natural, he argued. Shortly thereafter, his face broke, as if the pain in his soul had just hit him: that unsolvable clash between ancient fantasy versus the demands of growth.”

— a passage from Venus Looks Down On A Prairie Vole

Several points here, will touch on just a couple for starters. In this chapter, Daniel Pierce, my troubled protagonist and therapist, has serendipitously reunited with a patient he’d A.) thought he’d lost after a bad intake session, and B.) is the man whose privacy he is being pressured to violate by a rogue former prostitute and later, lawyers. Check out my novel and you’ll find out why.

The above conversation happens in the “privacy” of a shared room in a sober living environment–both men’s retreat. What Andrew (alias Derek) reveals here he would likely not have in the structured, orthodox forum of the therapist’s office. The thoughts Andrew shares are of a kind that few, in my opinion, share unless a near-profound alliance has been established. The reference to analysis, as distinguished from therapy, implies the depth divide between models of care, and further suggests what Daniel and Andrew tacitly have in common: they both tend to leave before the going gets tough.

 

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August 2, 2016 · 11:07 pm

Politics and psychotherapy

 

“Hi all, been thinking about political content on this list-serve recently, especially after a member was recently rebuked for posting a link in support of Bernie Sanders. I asked administrators for the policy pertaining to such posts and saw in the supplied policy an item that asks members to refrain from making political endorsements.

Endorsements of what? I wondered, as the policy didn’t specify endorsement of individual candidates or campaigns, which appears to have been inferred. What about endorsement of political opinions, or of political realities (via presumed consensus), as they are implicitly described sometimes in this forum. For example, when members post articles about single payer/payor systems, or police brutality, or white privilege, the articles don’t so much endorse candidates or specific referendums, but they tend to presume consensus as to what our world is like. So, when clinicians speak of “bringing awareness” about a social condition, they are not inviting debate so much as asserting authority, more or less dispensing what they think are facts about a world situation.

This sets up a tricky situation for mental health professionals and for this list-serve. If we have clients who proclaim a mental health condition that is dominantly attributable to an external reality, such as a social condition or political situation, versus a greater weight of attention to an internal disorder, then the onus is upon us to become educated as to that external reality, (perhaps eschew focus upon internal pathology) to educate colleagues about that external reality, which in effect means we will be endorsing a social/political view, and instructing those who don’t appear to perceive the political reality, such as others on a list-serve.

In light of this, it seems arbitrary to censor endorsements of individuals or their campaigns–merely a rebuke of the unsubtle–when the infiltration of politics into our profession is another kind of reality.”

—
That’s from a message I posted last week on an EBCAMFT list-serve. About the same time I fielded a compelling suggestion from a client who hadn’t read my post, to the effect that politics were a part of people’s lives and are therefore a valid topic for psychotherapy. Didn’t I agree? she more or less challenged. Sort of, I more or less replied, intrigued by her argument, but not wanting to study up on each political topic she seemed to want my interest in.
What’s most compelling is the idea that a person’s external reality, the community (or polis) in which people live, is inextricable from a person’s psychology, no less so than a person’s intimate relationships, or their unconscious functioning. I am reminded of a discussion some years back with a Mastersonian consultant, to whom I asked about the cultural lens within the Masterson model. It’s not there, she said, though I’m paraphrasing her. Indeed, it’s not explicit or otherwise clear, unless you comb through libraries worth of material, that the discipline of psychoanalysis has ever been influenced by cultural relativism, though it surely has by politics (think influence of two world wars on notions of death instinct and repetition compulsion).
However, I think the reverse is true. Take the concept of internalized oppression, for example. This idea, derived firstly from Sigmund Freud’s writings, latterly from object relations theory, holds that individuals formulate representations of self based upon what is introjected from caregivers. Thus, if a child is demeaned, he or she will formulate a negative experience of self and act accordingly. Cultural relativists simply take this principle and apply it to peoples, especially those marginalized. And so this is part of the individual’s experience, this attachment to a community, a system. Well, that’s a lot to fit in the room, at least.

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July 23, 2016 · 2:36 pm

The problem of listening

 

“Thanks,” said the man in the bad shirt to his group. He kept a peripheral eye upon me, picking up my distaste in the air, my discrepant air. The process moved on, with my journeyman skills keeping things in order, neutral—not taking sides, not standing up for anything yet; not saying much of anything, even though talking’s easier than listening. Talking’s way easier, believe me. Storytelling: now that’s a cinch. Neutral is how I am, professionally and, now that I’m alone, also personally. Wanna know what listening looks like? It’s a stifled yawn pinching oxygen; a blank stare held together with tautened facial muscles, and a soft, metronomic nod providing faint reinforcement, possibly a tease, because maybe it’s a nothing, this service I give. Some really want it, and I’ve been like this for years: a cipher into which people deposit their brokenness, and then leave. Not much of a story here, you might think. If you’re a film producer, you’d say, “I’m not touching this, it can’t be done”, thinking this dull: unwatchable, or unreadable. Pornified eyes wouldn’t like it. But in the unlikely event that it hits big, is binge-read and wins awards I’ll gladly take the stage, drunk, saying “For twenty years people tried to write this script but everyone said it couldn’t be done. So and so tried it and failed. So did whatsisname, that other really famous guy.” That’s when I’d punch stuffy air; thank doting mom and rival dad, the wife and kid for their support, God for doing whatever he does, and say goodnight.

In group I became restless, started saying some things I shouldn’t have said, slipping from the listening stance: fighting with men as well as women. It’s what happens when people stop listening.

— a passage from Venus Looks Down On A Prairie Vole

Part of a polemic that runs through the novel: I set up a binary between notions of listening versus doing. Therapists don’t do anything. That’s the sometimes comic refrain that Daniel Pierce expresses, at times to punctuate a dramatic event. It’s not a popular image, this one of therapist neutrality, this sense that we sit back in our cozy offices, smugly observing pathology, remarking on it but not acting as agents of change. Not really. See, the task is to render it invisible…the change…so you won’t notice.

Not good enough, of course. For the general public, I mean: this traditional stance of not doing is not good enough.”I’M A DOER”. Isn’t someone scoring political points with this currently? When parents bring oppositional teens into therapy (as in Working Through Rehab), when wives call up and make appointments for their depressed husbands, when a couple presents for therapy needing help with a ‘crisis of communication’, and when people get out of line with respect to drugs, violence, and especially sex, people from officialdom call, asking for therapists to do something.

And so I chat the other day with an amiable lawyer, a good guy looking to represent his client and mine, someone who did something he shouldn’t have done, with a girl who was younger than she should be if doing what she was doing. But it was his fault. No argument there.It’s just that this lawyer wanted to know…what I was going to do. He knows what therapists do. He knows that we listen; that we don’t judge. But could I give him something, anything, live or in a letter, that he could share with a court and sound, ya know, convincing. He even voiced his suppositions, as if he’d hacked my association’s list-serve and scrolled through the typical ways therapists market themselves. Would I offer coping skills, he asked tentatively?  Teach ‘tools’ for affect regulation (actually, he didn’t ask that).

Empathy. Victim empathy.That’s what I offered. That plus the hope that what my client did he would not do again.

 

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July 22, 2016 · 7:39 am

The bourgeois hypocrisy

Lira hissed through her teeth—a disappointing, face-contorting habit, I wanted to say but didn’t.  “That’s irrelevant. Men are the ones that buy porn. The consumer is the oppressor.”

I paused, studied her face for a credulous moment, and thought politics, the global order. “Do you own a cell phone?” I asked. I knew she did having watched her scroll through it several times, but she didn’t answer, instead giving me an I’m-thinking-of-your-next-move look. “Ever think about who assembles those things and what wages they make?”

She rolled her eyes, said, “Here we go,” as if knowing my path.

“What would you say if I said that all your electronics purchases are made on the back of unfair labor practices in the developing world; that your cosmetics are made possible because of animal cruelty?”

She gave me a lazy-eyed stare. “Apples and oranges,” she replied.

I paused. “Really? That’s your rebuttal, a tired fruit metaphor?”

“You’re changing the subject.”

“It’s not a subject. It’s called context.”

“Context my ass. It’s a specious argument, Dr. Pierce, You’re saying the average consumer has as much culpability as a sex offender. That’s bullshit. No one would buy that argument.”

“Not in this society, maybe, but only because people here are hypocrites. The consumer is the oppressor, you said.”

It’s a shame that talk moves quickly sometimes, because I wanted to patronize her saying ‘specious’, which sounded impressive, like something a law professor would say—maybe that guy from the bar, I considered. Actually, I didn’t want to patronize Lira. I just wanted to argue some more.

–passage from  Venus Looks Down On A Prairie Vole

Maybe it’s the rhetoric of certain politicians currently reminding me of the polity’s gullibility, but I can’t let this go: one of the reasons AB1775 passed so easily through the California legislature was the notion that users of child porn enable child pornographers. Assuming you haven’t read my twenty or so other blog essays on that subject, let me remind that AB1775 is a 2015 law that re-writes the California civil code relating to child abuse reporting, apparently for the first time in 35 years, after the original Child Abuse and Neglect Reporting Act overlooked the issue of child porn, I guess. The new law allows–no, compels–mental health professionals to report to police clients/patients who view child pornography. Specifically, it mandates reporting with respect to that which depicts the sexual conduct of a minor (as in anyone under the age 18) over an electronic or digital medium. Genius. Now we have to violate confidentiality when teens sext one another.

The other pretext for this law was/is the unsubstantiated claim that such a measure will “crack down on child porn”. In other words, it will crack down on child porn to report to police individuals who, in the context of a psychotherapy session, talk about their child porn use, or e-mail pictures of their junk to their partners. For some this law will lead to humiliating discussions with unctuous adults who will educate about how to respect self and others. Boys will be schooled on how to respect girls’ bodies. Girls will be schooled on how to respect girls’ bodies. Some might criticize the circular nature of decision-makers’ interventions. Decision-makers will blink in confusion because they won’t know what circular reasoning is.

For others (men, basically), the law will lead to their arrests, their job losses, their ostracism from society, the sudden loss of custodial rights with respect to their children; the convenient awarding of full custody to another likely informant, the other parent. In case you think these are good things (and you probably do), one other likely outcome is that such individuals, following the adjudication of their cases, will be mandated into mental health treatment (this is hilarious!) wherein–it is presumed–they will honestly disclose further their history of child porn affinity and commit themselves to healing, trusting fully the confidentiality of the psychotherapeutic space.

This law will have no effect on the sociopaths who produce and distribute child pornography, any more than a generation of arresting pot smokers has won the drug war. People like me won’t be reporting such people to police because…how should I say this…THEY DON’T GO INTO THERAPY, IDIOTS!

For all the politicians who voted for this bill; for the lawyers who wrote it having consulted with maybe two therapists in San Diego County who also believe in things like conversion therapy for gay people; for the right wing politician who fronted (“authored”) the bill, declaring it would “crack down on porn”, scoring cheap points with an illiterate constituency determined to scapegoat society’s sexual miscreants because it doesn’t understand real social issues; and for all of you who enable poverty and economic exploitation in developing economies everyday of your lives with your electronics hoarding, drooling consumerist habits, I have the following message:

YOU ARE ALL…

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July 16, 2016 · 9:42 pm

Sexual Schizoid

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“They say in SAA that you get to define your own bottom line,” offered another man. He licked his chops, tilling the ground of groupspeak as he had an equally dubious claim involving a late teenager (so he said). A hyper-masculine, balding figure, he personified a certain faction of my group: conventionally unattractive, sired in conjugal visits, wired towards the visual; overflowing with discharge, living just this side of incontinence. These guys tend to not open up much: they speak in code, use phrases like “I crossed the line” to briefly reference why they’re in treatment. Then it’s back to the persecution litany: about their hearings, upcoming or past; about the unfairness of courts, probation officers, the unforgiving nature of wives. I think of women and what they think. What do they expect from these men if not porn addiction? Come to think of it, do those women even look at porn? Have they watched the films, studied scores of images? You see, in some respects they have it backwards. Objectification—that’s the right word, isn’t it? That’s what’s happening to women. But hold on. Do they realize how many porn clips don’t even show men’s faces? Often, all you see are these girthy, circumcised peters sticking out between splayed pairs of legs. Talk about objects. In porn, the penis is the star, make no mistake about it. It is center stage, in the camera’s face, and literally in women’s. But at least their participation makes use of eyes.

— A passage from <em>Venus Looks Down On A Prairie Vole

The above passage describes the population of sex offenders that Daniel Pierce treats in his weekly group therapy. They’re a motley (as opposed to diverse) crossection of underdogs, typically unsophisticated, unlike predators who don’t get caught. Initial contacts with these guys are not just haunting, they’re an all-around humiliation, plus descent into a dark cave. Gruff, terse like their fathers and grandfathers were, they answer questions from counselors like they’ve just come from their lawyers’ offices, and are therefore still following the dictum, say as little as possible, which echoes their characters. Besides their illegal behaviors, the non-violent or non-direct contact offenders are socially withdrawn figures more so than anti-social; diffident more so than brutal. They shy away from intimacy, though more so out of bewilderment than contempt. Their relationships are with machines, computers–that which seems less impinging. To the average observer, they might seem like they’re on the spectrum of autistic disorders, and they might seem as self-absorbed or un-empathetic as any Narcissist. But the accent of their fears is less upon rejection as it is upon safety, and to remain safe this need must remain invisible. Difficult patients, they do not crave understanding, but rather a calculated space between themselves and others. It might sound a bit like this:

Therapist: So, what happened? What’s led you to make an appointment?
Client: (staring at therapist with concealed hate, as if the question is stupid) Got arrested. Crossed the line. (shrugs, pauses. The statement is done)
Therapist: I see, what exactly did you do that led to the arrest? (no more open-ended questions for a while, looking to avoid stonewalling)
Client: (ever externalizing) The charge was lewd and lascivious…with a minor…while intoxicated…something like that
* To get an actual narrative one will need a police report. Imagine what the more blunt truisms might sound like…
Client: Got caught with my dick in a hole
Therapist: By hole, you mean a female?
Client: Yup, one of them…

Most of the men I’ve worked with don’t betray thoughts like these, not so much out of shame, rather because they have little incentive to be honest, or to understand their disordered selves. Their situations mirror their fears, resulting in a self fulfilling prophecy: they are under someone’s control. See, sex offender treatment isn’t looking for honesty in its subjects. It’s looking for compliance, and in no other area of mental health treatment is this misguided objective more pronounced. Therefore, if sex offender treatment doesn’t work (an ambiguous conclusion) it’s because the systems that govern the treatment are misinformed, under-educated, and catering to public opinion rather than the recommendations of research. I write as a former provider under the California Sex Offender Management Board (CASOMB), and now operating privately and sometimes working with men who seek treatment BEFORE they get caught…BEFORE they hurt someone.

Treatment with them is not about compliance. It is about understanding. Imagine that.

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July 10, 2016 · 6:02 am

Sexual Narcissism

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“I’m in porn.” He’d said it quickly, in a clipped voice, while looking away, like he’d wanted the words off him, shooed away. I gave him a stilled look at which he grinned teasingly, masking unease. “Well, alright. I’m getting into porn, I should say. I’ve been in one clip so far.”

“Uh-huh. What film? What’s its title?” Rick laughed again, and shook his head. I felt like an idiot, stalling with questions to conceal my blushes.

“What film? I don’t know, man. Who cares…what film? Big dicks. It’s called ‘Big dicks’. There. I just gave it a title.”

“I’m sorry. I don’t mean to—”

“Nah, it’s cool. I don’t know why I’m giving attitude, actually. I’ve got a name, if that means anything. Kane—Kane Able. How do you like it?”

“A play on…I suppose.”

“Sure.”

“That’s good,” I lied.

So I asked about plot. About the film with no name: I asked if his clip contained any plot, or acting, or even theme. Surprisingly, Rick, or Kane—was pretty sure I’d not make the shift on this one—said there was. Firefighting, he said, not surprisingly. His part, as in his role, was that of a firefighter who has entered a burning building to rescue a trapped woman, who is feebly crying out (I imagined the acting) until the hero arrives, ready to spare her. The room is very hot, about which the performers comment wittily, and then the room gets hotter, and soon they don’t care so much about the fire and…well, you get the picture.

“Any dialogue?” I asked. Rick looked at me as if I were reading from a book of stupid questions.

“I ad-libbed this one line as I came: ‘fire in the hole, baby’, I said.” This time I said nothing. “I know, don’t tell me,” Rick lamented. “Pretty dumb, huh?”

“Did she say anything, have any lines, ad lib or scripted?”

Rick shook his head, uttered a dismissive noise, like I’d asked whether the props spoke on set. I blew air through my teeth, and thought of Lira.

“That’s typical. It goes to show there just aren’t enough good roles for women these days.”

— a passage from Venus Looks Down On A Prairie Vole

An example of parody in my mischief novel: the name Kane Abel is a play on words, of course, common to porn actors. My favorite from the real world of porn? Peter North. Subtle, right? Anyway, Kane is otherwise Rick, a young man whom Daniel Pierce meets while living at a sober living house, wherein he’s in retreat from a fraught personal and professional life. Rick’s day job is in a seafood restaurant, as a chef. There he causes trouble, disturbing his boss and Daniel’s temp boss, Jimbo, by stirring unrest, harassing female staff, flirting with nubile customers, doing very little cooking, it seems, while strutting his sex like a farmyard stud. Rick likely thinks his place in the service industry has layered meaning. He’s the kind of man who feels entitled to promiscuity, who feels offended, let down by another man’s diffidence, thinking that humankind benefits from the indiscriminate sharing of seed. He’ll try to re-ignite something in Daniel, provoke a libidinal return in the grieving, wilted psychologist. That last line, Daniel’s teasing of a feminist complaint, glides over Rick’s head, not so much because of stupidity, but rather self-absorption.

The role of women. What indeed is the role of women?

**image by Philip Lawson

 

 

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July 3, 2016 · 6:04 am

Have you ever been with…?

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She rolled her head slightly, like she was lining me up in her crosshairs. “You are shitting me”, she began hotly. “I know what you’re saying, but it’s not even the same. Man, I’d like to see you walk in a prostitute’s shoes. Only then would you know how lonely and scary it can be. Tell me you know what it’s like to work knowing your life is at risk: that you could be killed, jumped at any time because you carry cash; jumped in your own home if that’s where you do business; that no one will protect you unless you pay them; that no one would even care what happens to you cuz they think you’re nothing. Tell me you know what it’s like to give up your body everyday, to men who barely think of you as human, knowing that you’re giving away that part of yourself, every night.”

I gazed upwards, studiously contemplating sky and stars, life on Venus and Mars, alien yet pure of love and hate. “Well, I don’t know about the getting killed part. But the rest I can compare with, roughly.”

“Uh-huh?” she scoffed. “So you think you relate to prostitutes. How many have you been with?”

“Wait, I never said I’d been with a prostitute. I mean—”

She laughed back. “Yeah, I bet you haven’t.”

“I haven’t,” I replied adamantly. She relented.

“Alright. I’ll believe that, I guess, but it shows you don’t know what you’re talking about.”

“Well I’ve listened to quite a few—had them as patients.”

“Uh-huh.” She sat quietly for another few moments, letting her amusement subside. Then her voice turned somber, almost reverent.

“You ever cheat on your wife?”

“No,” I said flatly. She nodded inertly. “You believe me?” I followed up.

“I guess.” I uttered a noise which she took as a rebuke. “What do you want, a medal?”

I paused upon feeling aggrieved. “Sort of,” I replied.

“What?” she asked laughing.

“I should get a medal, actually. Any man who manages to avoid temptation should get a medal.”

“Any man? How about women?”

“Okay, women too, but it’s not the same for them.”

It got better. Soon I was expounding upon all the disadvantages men feel in the realm of sex.

–a passage from Venus Looks Down On A Prairie Vole

So a character poses a question, “have you ever been with a prostitute?” In doing so, the female antagonist is half-shaming the everymale of my story, and half-challenging his social critic credentials. Because he claims to know something. Daniel Pierce, my jaded psychologist, alcoholic widower, has a few thoughts on the subject of prostitution: like the chestnut leftist argument that all occupations in the western world entail prostitution. Therefore he doesn’t wring his hands on behalf of women, especially not women like Lira, who hardly seem like victims. Objectified? As in treated as, or thought of as an object? Sure, he concedes. But so is everyone to one degree or another, he retorts. Has she been subjectified, as in abused, or discarded. Not really, she admits, though she’s had close calls, and felt a constant risk. But she’s also profited considerably from her illicit business, spared herself the financial uphill that many of her same-age peers, male and female, face in today’s world. Above all, like any natural survivor or leader, this alpha prostitute has been nobody’s waif, but rather a cool, even dominant figure in the quasi intimate transactions of her past. In those dark, clammy pairings who has been more vulnerable, more ashamed, more consistently?

Her? Daniel Pierce writes a different script

** rendering by Philip Lawson

 

 

 

 

 

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June 25, 2016 · 8:44 pm

The Trauma Currency, Part Two

(Continued from part one)

Cermak’s intent was to present codependency as a legitimate focus of clinical attention, applicable to a variety of contexts. And so we have the Co-Addict Model, which draws attention to problematic behavior as a function of an underlying, pervasive disorder. While RT adherents may agree with aspects the co-addict corollary, their clinical focus downplays the pathologizing accent. Coping strategies, such as keeping busy with tasks, are instead normalized, cast as affect regulating under exceptional circumstances. Certain behaviors such as indiscriminate sharing of a sex addict’s behavior with friends or family, including children, are discouraged; however, these behaviors are framed as products of social isolation and episodic trauma brought on by an addict’s behavior, not an underlying or even associated pathology. The notable literature that represents this position includes Your Sexually Addicted Spouse (Steffens, Means, 2009), and Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts (Carnes, et al., 2012): the latter, in keeping with recovery tradition, outlines a healing process in stages: a pre-discovery stage, followed by phases of crisis/decision, and repair. In the crisis/decision stage the partner asks, “how did I get here?”, and comes to realizations like, “nothing in this marriage has been real”. Note the emphasis upon present or recent past events, not family of origin, early developmental or even adult developmental material.

The framework of RT appears to contraindicate a neutral therapeutic stance, becoming partner-centric, especially upon discovery of sexual betrayals, because the proposed de-pathologizing shift only applies to partners. There’s nothing in the RT paradigm that contests the assessment of sexual addiction. Indeed, the scope of questions for the revised version of the Sex Addiction Screening Test (or SAST) has widened in recent years, to address not only changes in technology—the broader means of acting out available to sex addicts—but also the impact upon partners of sexual betrayals. Notice, for example, a question on the 1989 version of SAST, “Does your spouse ever worry or complain about your sexual behavior?” (Carnes, 1989), versus a question on the revised 2008 version: “Has your sexual behavior ever created problems for you and your family?” Notice the slant has shifted to query problems identified by the would-be addict, instead of that which is externally identified by a partner whose perspective might be denied by the would-be sex addict, or distorted by a co-addict disorder.

The RT model calls for sex addicts or acting out partners to be identified as perpetrators of trauma, and this term—“perpetrator”—seems close enough to the connotations of “offender” that observers may be surprised that APSATS hasn’t called for the inclusion of more sex addicts on public sex offender registries. In the RT model, partners are validated as victims of a relationship-specific betrayal, and thereafter supported to integrate this experience in a way facilitates a healthy re-emergence in life, comprised of self-care, fellowship with a strong support system, realistic observation of sex addict behavior, but also renewed trust in humankind. The approach suggests that observation of predisposing pathology and validation of traumatic experience are mutually exclusive goals, which may lead to facile, short-term interventions, tailor made for practitioners presenting brief, intensive programs of care. While this may be an appropriate shift in the paradigm with respect to many partners or with all partners of sex addicts in the immediate aftermath of discovery, I wonder about the pathology that will be overlooked in the service of trauma validation, especially amid follow-up treatment episodes wherein identified-patient premises collapse over time.

In cases of sexual betrayal, a therapist working with acting out and non-acting out partners functions as a container for memories and emotions that cry out for expression, or disavowal in the case of those struggling to cope with the past. This Winnicottian task dovetails with reparation efforts—a Kleinian concept before a sex addiction treatment strategy—which hinges upon individuals’ capacity for mourning. Klein (1975) wrote that grievances we harbor towards parents for the wrongs they have committed, and for having denied those wrongs, elicit feelings of hate and desire for revenge. Durham (2000) has argued that the capacity for making reparations in the internal world is the basis on which empathy for others is established. When individuals defensively split, they attach to a narrowly defined narrative: therefore (borrowing the RT Model identifiers) a victim’s anger and hatred is rigidified in the face of a perpetrator’s denial, which represents an evil system built upon a primitive intrapsychic structure. A working through of splitting, into mourning, requires the perpetrator to own his destructiveness so as to experience mourning; then, if the victim is sufficiently open to an awareness of “good enough” qualities in the perpetrator, a re-internalization of that individual as a good object might occur, which in turn enables the victim’s own work of mourning.

Whether or not labels of victim, perpetrator, addict, or codependent are necessary, harmful, or inhibitive of this process seems ambiguous. Assessment and diagnostic nomenclature informs psychiatric intervention; enables the placement of individuals in appropriate levels of care, including hospitals when necessary; generates short and long-term treatment planning goals. Informing patients of their diagnoses gives informed consent to treatment based upon an understanding of conditions that are the focus of clinical attention. At the same time therapists know the stigmatizing risk associated with assessment and diagnostic labels, particularly those whose prescriptive measures are not clearly defined, or subject to a range of treatment alternatives, despite the attempts of some who promote protocols in response to diagnoses. The advisability of informing a patient or client that he or she has a substance dependence, for example, seems predicated on particular factors well understood across professional disciplines, and by the general public: that the problem can be accurately assessed in a short time frame; that prescriptive measures can be readily understood by those potentially receiving services (such as recommendations of abstinence, or attendance at 12-step meetings); that a person may be at grave risk of illness, injury, or even death if immediate intervention does not occur.

Are these factors true with respect to sex addiction, or codependency, or personality disorders? Maybe in some cases, but of the forty five questions on the revised SAST, for example, only one pertains to behaviors that place afflicted individuals in dangerous situations. In my training I learned to refrain from using diagnostic or assessment labels when addressing clients about their problems, unless the applicable term or terms seem critical for intervention, or unless prescriptive measures based upon the nomenclature can be articulated succinctly and concretely. Otherwise, confusion and/or resistance typically follows, with clients left thinly understanding conditions, floundering to make sense of new identities imposed by expert opinion. I often experience this when clients meet with me for the first time, having been diagnosed by a previous practitioner with, say, Narcissist Personality Disorder. They’ve been given an article to read, or a DSM criteria sheet to examine. Afterwards, they exhibit disorientation, manifest with awkward attempts to describe their freshly assigned disorder. When devising a plan, they offer that they need to learn to empathize with others more. Woodenly, they report feeling instructed, and branded, but not understood.

This is often true with individuals who are told they have a sex addiction, or a codependency problem, and while many can wrap their minds around the concept of sex addiction, the assessment still bears much explanation and holding of emotion. As for codependency: from an object relations point of view, that umbrella term represents a whole multitude of dynamic relational configurations, replete with intersecting projections and introjections. So no wonder partners of sex addicts are flummoxed and invalidated by the term, regardless of what betrayals they have felt. Aren’t many or even most shocked to hear that they may have enabled another’s addiction? Won’t many be confused to hear they may have contributed to another’s disorder by an overly close, or conversely, a distant involvement? Doesn’t it jolt the senses, the unconscious, one’s entire being, to hear that one might have a sex addiction, and that an important aspect of that concept is its impact upon intimate partners? Ultimately, what seems important is to hold the idea of a complex problem, brought to light by acting out behaviors, but not reducible to those habits, necessarily. Might it not render the divide between rival models of treatment moot to consider that our clients deserve to not be hamstrung by labels, or denied what is useful in our nomenclature? Rather, they should feel held by our open minds and fuller understanding.

 

 REFERENCES

 American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA. American Psychiatric Publishing.

 Bergner, R. & Bridges, A. (2002). The significance of heavy pornography involvement for romantic partners: research and clinical implications. Journal of Sex & Marital Therapy, 28, 193-206.

Black, Claudia (2009). Deceived. Hazelden. Center City, Minnesota.

Carnes, P. (1989) Contrary to Love. Hazelden.

Carnes, S., Lee, M. A., Rodriguez, A. D. (2012) Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts. Gentle Path Press.

Cermak, T. (1986). Diagnosing and treating codependence. Minneapolis, MN: Johnson institute

David J Ley (2012, September) “Abusing the Term Trauma”. Retrieved from https://www.psychologytoday.com/abusing-the-term-trauma/

Durham, M.S. (2000) The Therapist’s Encounters with Revenge and Forgiveness. In “Psychological Repair: the intersubjective dialogue of remorse and forgiveness in the aftermath of gross human rights violations”. Journal of the American Psychoanalytic Association. Volume 63. Number 6. December 2015

Glass, S. (2003) Not just friends: Protect you relationship from infidelity and heal the trauma of betrayal. New York, NY. The Free Press.

Klein, M. (1975) Love, Guilt and Reparation and Other Works, 1921-1945. London: The Free Press, 2002.

Steffens, B. A., & Rennie, R. L. (2006) The traumatic nature of disclosure for the wives of sexual addicts. Sexual Addiction & Compulsivity, 13, 247-267.

Steffens, B. A., & Means, M. (2009) Your Sexually Addicted Spouse: How Partners Can Cope and Heal. New Horizon Press.

 

 

 

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June 19, 2016 · 3:34 am

The Trauma Currency, Part One

 

“You didn’t get here overnight,” writes Claudia Black in her 2009 book, Deceived. It’s a solemn lesson, aimed at co-addicts, partners of sex and porn addicts—women, mostly—who are raised in households impacted by addictions of various kinds. Their childhood histories are “training grounds” for adult dysfunctional relationships, wherein such individuals engage in so-called co-addict behaviors: tolerating hurtful behavior, avoiding conflict, taking care of others, accommodating. Black describes a woman named Katy, a “perfect candidate for partnering with an addict”, who becomes compulsive in busy behaviors, attending to her children, her job, avoiding seeing and feeling, the anticipated rejection and abandonment by her sex-addicted husband (Black, 2009, P.85-86).

Profiles like the one above seem conducive to interventions that draw attention to patterns of dysfunctional behavior; patterns that implicitly predate the discovery of addictive behaviors by sexually addicted partners—this is according to adherents of the co-addict model, which is based upon the Al-anon 12-step recovery program. Treatment based upon this model prescribes self-examination for partners of sex addicts: examination of and responsibility-taking for repetitively destructive or self-defeating behaviors; examination of trauma repetitions, reenactments of familial scripts with the unconscious hope of creating new drafts in later life. The idea recalls certain 12-step slogans, such as the supposedly Einsteinian definition of insanity: doing the same thing over and over again, expecting a different result. This too is a derivative notion, echoing Freud’s concept of repetition compulsion, first published in 1914 at the outset of the First World War. The concept of trauma has gradually merged into the lexicon of psychology since then, reaching into or underlying our understanding of several mental health disorders, including addictions.

However, some practitioners and researchers might disagree upon the premises of partners of sex addiction treatment, and therefore differ significantly in therapeutic approach. In “From Victimhood to Victorhood” (published in the March/April issue of The Therapist), Alex Katehakis writes that a “major shift has occurred in treating partners of sex addicts”. The shift she describes is towards the Relational Trauma (RT) Model, in which practitioners emphasize that partners’ relational bonds are destroyed by betrayal, as precipitated by the discovery of sexual acting out—not a historical and ongoing pattern of destructive or self-defeating behavior by non-acting out partners. In the RT approach, practitioners eschew the implication that partners contribute significantly to an addiction by an elaborate, conscious or unconscious pattern of enabling. Such suggestions are misplaced and hurtful, if sometimes accurate, assert the proponents of the RT Model, while their interventions are by contrast comforting and affirming, emphasizing the depth of betrayal by a perpetrating partner. The champions of this position are The Association for Partners of Sex Addicts Trauma Specialists (or APSATS). Their members, as well as those of the hegemonic Certified Sex Addiction Therapist (CSAT) network refer to “sex addiction induced trauma” as a specified subset of a PTSD-like condition.

PTSD-like because while discovery of sex addiction has been deemed a life altering event and has even been demonstrated to be a traumatic event for partners, according to numerous researchers (Bergner & Bridges, 2002; Glass, 2003; Steffens, 2006), each stops short of applying the PTSD diagnosis, suggesting that many or most partners of sex addicts do not meet full criteria for the condition. A resulting controversy seems partly attributable to conflicting language in the DSM-V. Psychologist David J Ley argues that typical partners of sex addicts do not meet criteria of section C of PTSD code F43.10, “persistent avoidance of stimuli associated with the traumatic event(s)”, by pointing out that these partners often demonstrate “obsessive, ruminating fixation on the details of their partners’ betrayals and actions”. He states that the essential features of sex addiction—sexual betrayal, infidelity, lying—do not constitute trauma for partners, however repetitive these behaviors may be, and that describing them as such does disservice to those who need services relating to life threatening events. With respect to the diagnostic question, I observe that language in section E of code F43.10 indicates that “marked alterations in arousal and reactivity associated with the traumatic event(s)” do meet criteria for the diagnosis of PTSD. This includes hypervigilance, which would likely describe the partners Ley discusses in his writing. Perhaps at odds with the criteria of section C, this language of section E suggests that a more concrete understanding of “avoidance of distressing memories”, versus hypervigilance, is called for; or that alternating or interwoven patterns of avoidance and hypervigilance merit further discussion as features of partners’ clinical presentations.

Ley’s position is interesting in so far as it challenges the premise of the RT model, the sex addiction-induced trauma assertion. While the assignment of trauma to sex addiction may be debatable, it might lead us to consider what life altering events are brought on for partners by other addictions. Alcoholics and gambling addicts also engage in patterns of deception and blaming alongside their destructive behaviors, yet we do not hear of “alcoholism induced trauma” or “gambling addiction induced trauma” as it might pertain to partners or families of drinkers and gamblers. With respect to sex addiction, I’d suggest that it is not so much the presentation of PTSD-like symptoms that warrants a specialized assessment label, or the pervasiveness of deception, or even the ongoing denial of partners’ assertions that sex addicts often exhibit. Rather, I think it’s the nature of the behavior, the context of the lies and deflections—sex—that hurts so deeply. After all, what is harder for our clients to talk about than problems relating to sex? What elicits shame, triggers vulnerability, rage, more than this traditionally-cited root of psychoneurosis?

At least trauma has been codified into psychiatric nomenclature. The same can not be said of sex addiction and codependency, neither of which is delineated within the DSM-V, still. While proponents of RT and co-addict models appear to accept the existence and clinical relevance of sex addiction, or Hypersexual Disorder (as it was proposed to DSM-V committees), they differ with respect to codependency. Proposal for inclusion of a Codependent Personality Disorder was originally made by Timmen L. Cermak in 1986. The diagnostic criteria for the condition then included such statements as “continued investment of self-esteem in the ability to control oneself and others”, “assumption of responsibility for meeting others’ needs to the exclusion of one’s own”, “enmeshment in relationships with personality disordered, chemically dependent, or impulsive individuals”. Cermak’s proposal also included a category which outlined other symptoms, including “excessive reliance on denial’, and “hypervigilance”, which should sound familiar, as the language of the DSM-V criteria for PTSD appears to echo this juxtaposition of ideas/symptoms.

REFERENCES

 American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA. American Psychiatric Publishing.

Bergner, R. & Bridges, A. (2002). The significance of heavy pornography involvement for romantic partners: research and clinical implications. Journal of Sex & Marital Therapy, 28, 193-206.

Black, Claudia (2009). Deceived. Hazelden. Center City, Minnesota.

Carnes, P. (1989) Contrary to Love. Hazelden.

Carnes, S., Lee, M. A., Rodriguez, A. D. (2012) Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts. Gentle Path Press.

Cermak, T. (1986). Diagnosing and treating codependence. Minneapolis, MN: Johnson institute

David J Ley (2012, September) “Abusing the Term Trauma”. Retrieved from https://www.psychologytoday.com/abusing-the-term-trauma/

Durham, M.S. (2000) The Therapist’s Encounters with Revenge and Forgiveness. In “Psychological Repair: the intersubjective dialogue of remorse and forgiveness in the aftermath of gross human rights violations”. Journal of the American Psychoanalytic Association. Volume 63. Number 6. December 2015

Glass, S. (2003) Not just friends: Protect you relationship from infidelity and heal the trauma of betrayal. New York, NY. The Free Press.

Klein, M. (1975) Love, Guilt and Reparation and Other Works, 1921-1945. London: The Free Press, 2002.

Steffens, B. A., & Rennie, R. L. (2006) The traumatic nature of disclosure for the wives of sexual addicts. Sexual Addiction & Compulsivity, 13, 247-267.

Steffens, B. A., & Means, M. (2009) Your Sexually Addicted Spouse: How Partners Can Cope and Heal. New Horizon Press.

 

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