April 27, 2014 · 4:11 pm

Fill My Holes, Please

You’ll have to get past, way past, the innuendo in order to read this one. But it is about sex, not drug rehab.

This is a story about the birds and the bees…and insects. I’m referring to Nymphomaniac, avant cinema provocateur Lars Von Trier’s last installment of what’s dubbed the “depression trilogy” (the other films are Antichrist and Melancholia). If you’ve heard anything about this controversial 4-hour, Volume I & II epic (apparently 5 hours in its uncut version), then you’re likely aware of the explicit sex scenes, the use of digital compositing to superimpose the genitals of porn actors over those of the film’s actors. You may be less aware of its dense symbolism, thematic complexity, and stridently taboo outlook.

Charlotte Gainsbourg plays Joe, the self-loathing title character, discovered beaten and bruised in the film’s opening scene by a diffident, scholarly recluse, Seligman, played by Stellen Skarsgard. Refusing either medical attention or help from police, Joe accepts Seligman’s hospitality, returning to his humble home, a sparse, shabby room, wherein she can rest, recuperate and, as it turns out, tell the long confessional story of her self-proclaimed nymphomania. From the outset, Joe makes it clear that she is ashamed of her sexuality, saying she has callously used people throughout her life, and that she therefore deserves the brutality she has endured. Seligman listens intently with a combination of sympathy and detachment—less a confessor than an analyst. No solution-focus in his repertoire. Still, he confronts Joe’s self-loathing, challenging with intellectual arguments that compare Joe’s behavior to that of an immature insect (the definition of a nymph, for viewers who don’t know). He also weaves in references to mathematics and religion, and in so doing, becomes a comic counterpoint to Joe’s compulsive hedonism, and also an unlikely listener. He is a forgotten kind of neutral: not only “non-judgmental”, he is a virgin, perhaps a eunuch.

Anyway, Joe seems to trust him, though she is irritated by his tangential curiosity in academic versus taboo or sensual matters. She attempts an argument that she is evil. His rebuttal is a proclamation of what is merely natural. Thus, Seligman is undisturbed by the story of Joe’s once teenage competition with a rival to see how many anonymous sexual conquests can be made on a train. As she recounts one presumably disturbing sexual episode after another, he maintains his cool, non-judgmental stance, ever keeping the horror at bay, ever blocking an imagined audience’s shock. The character of Seligman seems like a stand-in for Von Trier: fascinated, but rebutting society’s finger-wagging, defending sex. However, Joe is a tough, complicated patient/penitent. Her shame is powerful, but so too are her defenses. In Volume I, we learn of her “pact” with peers that entails the rejection of love. The compulsion to act out sexually is integrated into a philosophy that normalizes exploitation and quietly justifies an ongoing and progressive habit. In her confessional, Joe disdains sentiment, and alternates her self-loathing with fiercely defensive diatribes.

Volume I ends with a crisis of sorts: Joe’s sexual tolerance (in addiction terms) has peaked; she can no longer “feel anything”. In Volume II, after experiments with sado-masochism, among other things, the specter of “treatment” for Joe’s nymphomania is finally raised. But she rebels against the pedestrian and “bourgeois” therapist who prefers the term “sex addict” and who glibly counsels Joe to methodically abstain from her sexuality. After three weeks of abstinence, Joe stands up in a support group, subverts the implicitly rote exercise, proudly declares that she “loves her cunt”, and triumphantly walks out of the session. Shame? It comes and goes in this story framed largely around flashbacks. Only as she ages and the present-day telling begins does she contemplate the emptiness within her double entendres: “Fill my holes, please”.

And it is ambiguous when the shame began for her. As Joe tells the backstory of her nymphomania, a younger Joe is characterized as a somewhat blank, almost doltish (though not innocent) figure, played by novice actress Stacy Martin. As a teen and early twenty-something, Joe seems dissociative, not exactly there, whether seducing a future husband, Jerome, or scheduling-in a series of lovers into her daily routine. Even when confronted by a lover’s humiliated wife and pre-teen sons (a dark but comic scene featuring Uma Thurman), she seems unmoved and distracted. Meanwhile, Joe neither seems seductive or even flirtatious with men, mostly because it simply isn’t necessary for her to be so. It’s as if Von Trier is making an adjunctive statement about male sexuality, one that—from the POV of a man—makes for uncomfortable viewing: namely, that seducing men doesn’t require much effort, much less qualities like charm. To side-bar into something self-serving, she reminds me of my character Chris Leavitt from Crystal From The Hills, who I think is difficult to like or become interested in, largely because of his dissociated, secretive, not there qualities. Yet having readers like him is the task, wrapping backstory and more energetic characters around my wayward protagonist because the traumatized have an important story, whether they tell it well or not.

So it is with Joe, though because we meet her elder version as an articulate and wounded storyteller, we perhaps feel more hope for her character, and more understanding from her POV. Nonetheless, her sexuality is an enigma: there seems to be little joy or even creativity in Joe’s past or present scheming, such as we might expect of a womanizer. For example, when seemingly traumatized by the delirium tremens of her hospitalized and dying father, she ventures down into the belly of the ward and is soon naked, bucking rhythmically atop an anonymous orderly. For Joe, getting laid is about as difficult as finding a break room with a vending machine. I make this point because amid the controversies that Nymphomania will likely spark, few will draw attention to how men are depicted. That’s because this is a film about a female protagonist as directed by a man, and is dominantly about women’s sexuality, so no matter how unflattering this film may be of men, it’s still far more likely that Von Trier will be accused of misogyny.

Regardless, of all the provocative tidbits in Nymphomaniac (there are soapbox moments about pedophilia and race for example) I think the most important issue concerns the filmmaker’s apparent attitude towards the genesis of Joe’s nymphomania. Using Seligman as a mouthpiece, Von Trier essays that Joe’s affliction, if it is even to be called that, is a natural condition, versus, say, a proclivity borne of childhood sexual abuse, as might be supposed by many viewers. I will admit to supposing this, partly because trauma is the etiology of Chris Leavitt’s affliction in CFTH, but mostly because Joe’s father, played by Christian Slater, is an alcoholic to whom Joe betrays an element of Electra complex—I made a guess during Volume I that Joe’s attraction to the mechanically inadequate and even mathematically precise lover, Jerome (8 thrusts: 3 missionary, 5 from behind) is a reenactment. Alas, there’s nothing in the film to substantiate my interpretation. Von Trier’s position seems to be more or less a Freudian/Kleinien statement: an assertion that human beings are sexual as infants. Without apology, Trier eschews latter day speculations of traumatologists, not to mention polite society, which remains horrified, not only by pedophilia, but also by the notion that children can have anything like sexual feelings. Seligman’s mini-speech towards the end—an unfortunately trite statement declaring that, if anything, Joe has been oppressed by a patriarchal society—suggests a feminist sympathy and a rebuke of mainstream prurience. Maybe Von Trier remembered some things as he was writing this story. Maybe he felt ashamed.

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April 14, 2014 · 12:50 am

What To Look For In Drug Rehab

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If you go to a 12-step meeting one of the slogans you’re likely to hear is “keep coming back”. It’s meant to welcome you, and be encouraging. And it is. But with respect to rehab, you don’t want to “keep coming back”. As a therapist of 20 years, I can’t tell you how many times I’ve heard something like the phrase “I’ve been going to rehabs for years,” from weary drug addicts who are still suffering, wanting to get clean. They are not so much unmotivated as stuck with something that is more than an attitude, and something closer to an embedded way of being: I want to feel better, not get better.

            Find a program that does not collude with this misguided goal. Here are a few tips and explanations:

1.)    First of all, size matters: the size (as in number of beds, # of patients participating in activities); the size of a case manager/therapist caseload. If a program has more than six beds, or offers groups with more than 8 participants, the tendency is for treatment to become unwieldy, possibly unsafe. If a therapist has more than half dozen patients on their caseload, it is unlikely they will have sufficient time to devote to one individual or family. I’ve observed these phenomena over many years, and depict numerous examples in Working Through Rehab.

2.)    Secondly, ask questions about the influence of patients’ rights groups, community licensing bodies. Some programs are more answerable to external regulators than others, which isn’t necessarily a good thing. In my book, I chronicle several instances wherein outside agencies influenced program procedures, often based upon societal norms, and not for the better. Often, accommodations served to enable problem-behaviors of substance abusers, not protect individual’s rights. This is a similar view to that offered in Dr. Drew Pinsky’s 2004 book, Cracked: Life on the Edge in a Rehab Clinic.

3.)    Thirdly, observe the proscription of depth therapy in rehab settings. Note the tendency of programs to sell short-term models that address behavior and cognition, but not underlying feeling states, maladaptive patterns of relating to others—attachment difficulties, and trauma. For example, anger management skills and mindfulness training are well and good, but they don’t address pervasive distortions of self and others. Furthermore, dovetailing with item #1, if a therapist is too preoccupied with multiple staff meetings, producing rote documentation, communicating with collaborators on largely pragmatic matters, in-depth focus with any one individual or family is more or less squeezed out.

4.)    Finally, hear with some distrust the phrase “fun in recovery”. This language is pitched to teens in order to get a buy-in, but while teen programs should include recreational activities, make no mistake: recovery, or meaningful change, is not fun. If you are a parent looking to place your child in rehab, I suggest the requirement of “fun” has not worked, and reinforcing this idea may have you or your child coming back, again and again.

 

 

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March 28, 2014 · 7:00 am

Effectiveness of Therapeutic Communities in Drug Treatment

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In a January 2014 issue of the Journal of Child and Adolescent Substance Abuse, within an article entitled “Therapeutic Engagement as a Predictor of Retention in Adolescent Therapeutic Community treatment,” authors offer that Therapeutic Communities (TCs) are effective in so far as they lead to reduced substance use along with reductions of other types of delinquent behavior. This isn’t a new assertion, nor is the apologist follow-up that much is still unknown in terms of what factors increase the likelihood that an adolescent will remain, much less thrive in treatment. Strange, since the Therapeutic Community model has been around for just over fifty years, ever since Synanon was founded in the late fifties to address problems of addiction. One might think that fifty years was enough time to give the Therapeutic Community model some scrutiny, some thought, and to determine what aspects of this somewhat controversial model work, and what aspects don’t. Well, it isn’t strange to me. Actually, when I consider all the elements of such a model (drawn from my fifteen years working within such programs), I try to imagine how a truly comprehensive research study might control for all factors. Therefore, it’s not surprising to me that the consumer of services is left reading research platitudes that beg a plethora of further questions.

            The efficacy of the Therapeutic Community model is one of several subjects I tackle in my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment. For those unfamiliar with the TC model, it is described by one notable researcher as the following: a total milieu treatment (as in residential) that promotes positive peer culture and socialization, with confrontation as a staple technique of the TC approach. How does that sound? If it sounds good so far, then okay. But if you’re reading from the point of view of somehow who might soon be living in a TC, or from the POV of a parent wondering whether to place your son or daughter in a TC, you’ll likely want to know more. You might take a look at literature on TCs that came out of Australia in 2010, though researchers Foster, Nathan, Ferry are similarly cautious about what is truly effective in therapeutic communities. Alternatively, you might want to tour such a place, take a moment to sit in one of its dorm-style bedrooms, and take in the atmosphere, the buzz. I remember the first time I toured a TC as a would-be employee. It was Thunder Road near downtown Oakland, and it was the mid-nineties. I took in the harsh noise of the unit that first day, as well as its tense silences. The atmosphere was one of anxiety, the restlessness of kids addicted to drugs, risk taking in general; the barely suppressed rage borne of thwarted freedoms and deeply-rooted yet thinly acknowledged pain. Through my book, I give readers a first-hand feel of how a typical TC operates. I’ll sit you upon its time-out devices, the bench, and have you gaze into its affirmation mirrors. I’ll give you a pair of hospital scrubs and strip you of your clothes and other belongings. Before long you’ll be sitting in confrontation group, or in something called contract breaking. Later, you’ll be doing some chores to keep you and your living environment both literally and figuratively clean. Then you’ll go to a 12-step meeting, and after that, maybe a family therapy session. You’ll learn that these norms, methods, and that the principles that underlie them follow a rigorous structure, and have a long pedigree.

            If you read studies about treatment models, you’ll likely come across terms like “completion rates” or “retention”. Within the literature pertaining to efficacy of programs, concepts like completion or retention are deemed tantamount to successful engagement of patients. If you complete a treatment of, say, 4-6 weeks (or longer), versus dropping out of treatment, then the treatment episode is implicitly effective, and a program looking to promote its services might refer to completion rates as indicators of success. Alternatively, programs might refer to studies (across programs) that demonstrate the efficacy of TCs in reducing substance use, though you might wonder about the methods of research. For example, if a person is said to be clean from substances post-treatment, how exactly is this determined? Is it through mandated submission to urinalysis testing? Or, are questionnaires being used: self-report essentially, from adolescents or their parental co-participants? Also, how long after treatment are the determinations being made? Are questionnaires being administered within 72 hours of discharge? Ninety days? Six months? I recall conducting post-discharge surveys for three different programs over the course of my fifteen years. The average length of time passed before conducting the surveys was about six weeks.

            Imagine your information is used for such a study (not that your name would be revealed). Think what it would be like for you if your treatment program was deemed successful because people like you completed the required number of days, or because you volunteered that you were still clean after eighty nine days. And even if that’s true, what if you relapsed on day ninety two? A program might benefit from the statistics, but what consolation would this be to those who slip back into old habits, and perhaps worsen from a previous baseline of addictive behavior? Many who go through drug treatment do so on multiple occasions, at great personal as well as societal cost. In future articles, I will address the problem of repeat customers in treatment, and argue for practices that aim for long-term change versus band-aid solutions and a low-bar, common denominator of treatment success. Long term, as in sustained change is what the consumer of drug treatment wants, after all. And it will take hard work, not to mention patience if treatment programs are to meet these standards. Studies of treatment efficacy that track change over time are few and—of course—far between. Exhibiting a quality that is perceived in most addicts, consumers of drug treatment research follow an ironic yet understandably urgent pursuit. They want the immediate gratification of fresh information, the latest studies. They cannot wait.

 

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March 23, 2014 · 6:18 am

Exiting The Schizoid Program

Charlie Z., Candace Orcutt’s next case study from Trauma In Personality Disorder, seems at first to be living the life that schizoid personalities might envy: he lives alone, works with technology, and does not appear to have authority figures hovering over him. Then one day an intruder breaks into his apartment, pistol-whips him, and locks him in a closet, which later triggers associations with a childhood memory of being locked in a closet by his father as a punishment. The latter day incident immobilizes Mr. Z. His apartment, previously a haven, becomes as much a source of danger as the outside world. Sleep disturbance and panic symptoms follow; Mr. Z seeks medication, tries to use his intellect to reason through his fears. One foot in, one foot out, Mr. Z metaphorically and literally lives the schizoid dilemma in his apartment.

            In therapy it seems more or less the same: he reports feelings, says he’s in pain, but superficially describes the break-in event, and moves away from his feelings with plaintive questions, acting out in the form of lateness and canceled sessions. Candace delivers now familiar interventions: she assures him that memories fade, educates that his dizziness constitutes “remembering in the now”. Therapy eases his symptoms somewhat, but Mr. Z calls a halt to the sessions. Candace agrees, meaning she works with the disorder rather than resolving it. Nicely put, I thought, though I am once again struck by the way her cases stop and start.  

            Some time later Mr. Z. returns for therapy, ostensibly because his anxiety symptoms have returned, and Candace speculates that a new relationship with a female friend is the cause. This time Candace learns more about Mr. Z’s life, about his freelance work, his hobbies (science fiction—big surprise), and somewhat fastidious personal routine. She inquires after his new relationship, which is introduced first as a correspondence, but later graduates to a physical meeting, with all the attendant threats of closeness and sex. I like the way Candace uses Mr. Z’s comfort with computers as a bridge to negotiating a safe relationship. Actions can be taken but then undone; one can hit “escape” or exit a program, she reframes. This leads to further process about closeness, and Candace continues with interpretations of schizoid dilemmas. Eventually we learn more about Mr. Z’s childhood, about his being bullied into self-sufficiency by a rigid, perfectionist father and a passively cooperative mother. He resolves to think of them as cruel, and Candace offers speculations as to their own abuse history. I’m not sure what to write of these interventions, but was disappointed to learn that Mr. Z chose again to stop treatment. He reminds me of a Kafkaesque character transformed by his closeted life into some manner of human/rodent hybrid that’s ever hiding in the dark.

    

 

 

 

 

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March 8, 2014 · 11:14 pm

The Careless Passage of Time

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In the next section of Candace Orcutt’s book, Trauma in Personality Disorder, we read of Mr. H. and Mrs. M. Mr. H., she describes, presents a case with “traumatic overtones”, though the trauma isn’t obvious at first. Is it the rejection from his wife? The business failure, coupled with the partner’s nefarious financial actions? The problems with his adult children? He is depressed, Narcissistic, manifestly so (exhibitionistic?), and according to Orcutt, needful of mirroring, and not always with an accompanying interpretation. The Narcissist has an antipathy towards interpretation, she writes (p. 100), but she points out that the Masterson model bypasses this antipathy by wrapping such interventions with empathy for the patient’s vulnerability. With that seeming understanding in mind, one wonders why her transcripts appear to wander so often from the technique: instances of reassurance (p. 97: “it will get better in the end”, p. 91: “you have your kids and your pride. You’re managing”); so-called reasoning (p. 88: “Wouldn’t it be easier to stop fighting and accept the offer?”); a warning (p. 86: “Maybe it’s important to remember that reaction plays into others’ hands”); a confrontation (p. 85: “are you really defending yourself by turning this into WWIII”). The mirroring aims at maintaining idealized unity with the therapist; the confrontation a containment of acting out; the reassurance perhaps girds Mr. H. for his subsequent disclosures about an incestuous relationship with his mother. He ends therapy having broken a secret, and seems happy enough, with a new woman in his life and a better relationship with his kids. 

Orcutt writes that mirroring alone may be necessary when the patient is feeling especially vulnerable. This feels very permitting somehow, as though the interpretive piece were an extra chore for both patient and therapist; both are spared the task of dealing with the question of criticism that ambiguously lies within mirroring interpretations. Mrs. M is stoical, likes to “fix” problems. She seeks to control feelings, often by dismissing them, and thinks that having feelings and acting upon them are conflated concepts. She also discovers a family secret, through the experience of an accident in which no was injured, though Mrs. M. begins to suffer symptoms of PTSD. She wants medication, and hypnosis; she doesn’t want to dwell. She resists the psychologizing of her reaction from doctors, but soon integrates the therapeutic suggestion that her symptoms derive from stress, and more importantly, she acknowledges helplessness with respect to her fears. This appears to open up memories, including an incident in her teens wherein she felt responsible for a friend’s accident. Symptoms persist, and the therapist gives homework for Mrs. M. to interview family members about recurrent dreams of a little girl being killed. The investigation unearths a horrific family secret: a tragic incident in which Mrs. M’s four year old twin sister is accidentally killed by her mother’s first husband. Mrs. M. had witnessed the scene, but was thereafter amnestic, and the mother resolved to not talk about it. This is a painful story, one that had me reflecting sympathetically upon the father of the deceased girl as much as the horror of Mrs. M. She is distraught by the discovery, and blames the therapist for not preparing her for the burdens of memory. The therapist reassures that life will be put back “into one piece”, and adds that perhaps time will bring a change. Cliches aside, attributing change to the passage of time seems incomplete, even careless.

 

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February 16, 2014 · 11:22 pm

Gloria’s on the run now

Director Sebastian Lello’s Gloria is receiving well-deserved applause for being a tender, courageous look at the much maligned sexuality of aging women, but commentary is still missing the mark of this lovely film as far as I’m concerned. It may take a therapist to fill in the gaps.

Pauline Garcia plays a fifty something woman a few pounds above her best, but still possessing an abundance of charm, not to mention a quietly seductive streak. As the film opens, she appears alone at a bar of the kind of disco that doesn’t seem to exist in the youth-centered world in which I live. Meaning, she’s not exactly out of her element, as nearly everyone seems over fifty, soft around the middle and looking for love. Her character, Gloria, is not really a cougar, as some critics have suggested. There’s no evidence in the film that she is drawn to younger men, as that term implies. She lives alone, works in a sterile office in Santiago, Chile, and leads a lonely and, most importantly, a somewhat unrealized life. Among other things, she drinks too much, smokes marijuana, and seems to lack insight. She meets Rodolfo, a seemingly warm, gentlemanly fellow who diffidently courts Gloria on the dance floor. She gives him winsome looks that tread a line between demur and eager posturing, but in the bedroom, the truth of her hungry desire is unleashed amid carelessly dropped clothes; hers and Rodolfo’s fleshy groping.

All is good for a spell, though it isn’t long before Rodolfo’s feckless nature creates problems. Evasive about an ex-wife, a pair of dependent-adult daugthers, he unnerves Gloria with his reluctance to unveil her to his family. She appears to press the issue by instead introducing him to her family, so within a gathering that dovetails a birthday celebration with a family reunion, subtle points are made about her character. Firstly, the party also introduces Rodolfo to her daughter, who we learn is pregnant, and Gloria’s ex-husband, who was hitherto unaware of his daughter’s condition. The daughter’s truculence towards her father, as depicted in these scenes, is compelling, as it suggest two things: that the daughter, not Gloria, carries the ongoing protest against the once neglectful father, and by extension, absent men in general; secondly, given what we’re soon to learn about Rodolfo, it seems that Gloria is pathologically drawn to unavailable partners, and it is telling that no one appears to notice this. A moment of drama occurs as Rodolfo inexplicably abandons the party, which humiliates Gloria in front of her kids and the ex-husband. Rodolfo appears days later, complaining that he felt mistreated at the party, ignored by Gloria when feeling unwell, and more generally by the intoxicated, family-centered event. His account is thinly credible, but just about good enough for Gloria, who grants him a second chance.    

The affair continues towards disaster with grim inevitability. In the theater, I could hear the murmuring “uh-ohs” of fellow audience members, especially women, who saw where this was going. The pair visit Rodolfo’s place of business, a theme park centered around paintball which he either owns or manages. Among other things, the scene of Gloria playing with a paintball gun foreshadows the end of hers and Rodolfo’s affair, and the style of revenge she will likely seek. Meanwhile, a comic subplot about a stray, hairless cat that keeps infiltrating Gloria’s apartment takes shape for anyone looking for underlying themes. The cat belongs to an upstairs neighbor, a disturbed man who keeps Gloria awake at night with unexplained screaming fits. The cat escapes abuse and seeks bonding with Gloria, but at first she is uninterested, which is significant. She’s too attached to abuse to notice the clues that surround her.

Of course, Rodolfo abandons Gloria a second time. It happens during a romantic getaway to a stylish hotel resort. During dinner, after Gloria has playfully dropped his phone into a plate of soup, which prevents him from taking calls from his clinging daughters, he rises from his seat, kisses Gloria in a manner that seems eerily violent, and walks away, declaring he will be back soon. The audience knows better. He has disappeared, and soon we watch as Gloria pulls an all-nighter: she gambles in a casino, picks up a few friends, an oversexed date who leaves her blacked out on a beach (maybe she’s been assaulted–it’s not clear). Eventually, she wanders back to her hotel, where she learns that Rodolfo has stuck her with the bill. She is humiliated again, defeated.

Redemption occurs (partly) in the aforementioned revenge with paintball guns that Rodolfo has previously (and unwisely) gifted her. Otherwise, she later rejects his predictable appeal for a third chance, but concurrently accepts the cat’s presence, at least until her upstairs neighbor drops by to claim it. Finally, Gloria attends yet another social event, becomes as drunk if not drunker than she had ever been before, and once again makes her way onto a dance floor, which recalls the film’s opening. The difference is that she’s not looking for a partner this time. Dancing to the eighties party favorite, “Gloria”, a seemingly vapid tune whose lyrics are actually something of a cautionary tale, she dances with herself.

It will be tempting for some theater-goers to see the film as an anti-male statement, but I don’t think it is. Such interpretations are for those who tend to externalize problems; who think Gloria is simply a victim of bad men. It’ll take something else for audiences to learn something real from this work of art. It requires a mature sense to experience Gloria as a marvelous film about conflict avoidance, and the need to learn about oneself before committing to others.     

 

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February 11, 2014 · 8:14 pm

A Meeting of Trauma and Character

In a crude way, I think I have been caught within the divide that Candace Orcutt describes very well in Trauma In Personality Disorder.  For many years, while working in the field of substance abuse, I was assimilated into a clinical milieu that prioritized character work, more or less, while ignoring trauma work. Then, during the early part of the last decade, I was awkwardly moved to take the level I training for EMDR, the first third of which resembled a late-night infomercial. It was a heady atmosphere, with therapists and social workers enthusing over the prospect of diminishing symptoms in five sessions or less.

            Orcutt’s wonderful book is helping me melt the uneasy feeling that these two realms—character and trauma work—are mutually exclusive goals. No one ever said so directly, nor have I ever put that belief into words. But it’s been in the dialectics, somehow: the discussions between professionals working in teams, or voices heard at conferences, case presentations. Someone will speak of the need for boundaries, limit-setting with a patient, and on cue, someone else will counter with reminders about past traumas, the need for empathy and patience, as if these concepts were all at odds with one another.

I think it’s the same for readers of my novel, Crystal From The Hills. My protagonist, Chris Leavitt, doesn’t readily inspire empathy, largely because his characterlogical defenses (drug abuse, acting out, denial and regression) dovetail with dissociation, creating an aloof, if intriguing figure; a man who is difficult to reach, feel into.  

            I appreciate the breakdown of technique into the five steps: functioning, containment, strengthening, Cognitive and behavioral change, and insightful and dynamic change. There’s a common sense approach here, above all: the patient’s functioning, their surrounding circumstances, provides the “holding environment” for the work. An assessment of such circumstances is where the work starts. Secondly, containment: therapy draws attention to acting out, denying, blaming, substance abuse and other addictions, and the destructive consequences. In strengthening, a consciousness awakes, an afflicted individual starts to take responsibility; a therapist informs that setbacks may happen as a matter of the therapeutic process, or teaches relaxation techniques. The therapist doesn’t rush to provide insight ahead of the patient’s readiness. The patient realizes that the process of individuation occasions anxiety and sadness. Orcutt appears to paraphrase abandonment depression as part of trauma work.

            I appreciated Orcutt’s examples of confrontation of particular defenses. Most are readily understandable. It is even helpful to have each defense assigned a distinctive look and sound. The art of writing is to make ideas seem simple; the technique effortless. I know it isn’t. In the technique that is outlined here, the palette of interventions is widened. Therapeutic neutrality is flexed, and supportive comments and confrontations seem to live together in a therapeutic style. The case of Mrs. X called for many skillful interventions: confronting avoidance (p. 53, 55) and sustaining the thought as she defended against insight. Excellent. Integration is followed by a supportive comment from the therapist, a reminder that trauma distorts time, but that threats are no longer in the moment. Nicely illustrated. The case gets more vivid as Mrs. X becomes more anxious, starts calling the therapist in off hours, with panic about paralysis in her wrists, the fear that she is being held down. She abreacts. The therapist does some reality testing, followed by reassurance, encouragement. Reading this made me nervous, I have to say: this sounds draining.

            Yet the acting out isn’t done. Upon calling for hypnosis, Mrs. X “learns” of her father’s sexual molestation of her, and considers legal action, which would be undermined by the hypnosis, actually. In anger, she turns upon the therapist, who becomes a stand-in for a negligent mother. Like Chris Leavitt, perhaps, she is fascinating and disturbing all at once.

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Aside

Fictions from memory

At the outset of a psychotherapy episode, a man referred to me by a trusted colleague outlines goals drawn from a course of group therapy: “I’d like to get to the root of my anger,” he says. I nod, affirming that this seems a worthy goal, though in truth I’m not sure what he means. I mean, I know what a root is, and I know roughly what is meant by the phrase he uses. But I feel uneasy, because I don’t know how to get to the roots of this man’s problem. I don’t think we’ll decide upon something; at least, not in the tidy, package way that treatment plans and opening discourses on therapeutic goals suggest. I don’t think that anyone would find roots to a problem in the sense of finding a definitive answer.

In the first five chapters of Paul Renn’s Silent Past and Invisible Present, the reader gets a review of neuroscientific thought relating to trauma, the formulation of memory; the history of psychoanalysis and its treatment of trauma; how it conceives of childhood memories as either the product of fantasy or else real life events. I am reminded that Sigmund Freud once attributed fantasy wish-fulfillment to patient who reported seduction by a friend of her father. While acknowledging the real-life event, the focus turns to the intrapsychic as far as treatment is concerned, and the case study appears to predict the later disputes between the likes of Klein, Fairbairn, and researcher John Bowlby.

We have declarative memory, autobiographical information that speaks to who we are, or who we think we are. Emotional memory, including thoughts and feelings operating in a relational context, shapes memory and fosters experience of reality. Trauma, the readings propose, distorts or inhibits play, wounds consciousness, and generates false equations, the psychic equivalence between internal reality and external reality. “I know for a fact that she hates me,” said a teenage client once to me. I could not have convinced him otherwise—not that I tried. This problem likely stemmed from the aggregate of events that could not be remembered in detail, or symbolized by verbal description. They were rooted in affect dysregulations, the creation of a false self as trained through misattunements. The amygdala of the limbic system will have been developed to interpret cues coming from early caregivers, process the fight/flight emotional response and provide emotional meaning, and activate memories such that they are experienced thereafter in the moment, as if time stands still. The Hippocampus, that evaluative organizer of information, is inhibited in times of trauma, suggesting a triage of tasks that strikes us as—what?—short-sighted? I suppose I could reflect on experiences of cold feet and sudden holes in my stomach to relate instances of my enteric nervous system influencing my own reactions—memories in my body.

In reading chapters four and five, which seem to recapitulate post Freudian psychoanalytic theory and the debates of its adherents, I note the familiar divides between the likes of Fairbairn and Bowlby, versus Freud and Klein. I continue to wonder if the disagreements were overstated, and that a difference in accent, as in the weight of focus, was most apparent. For example, could not an emotional attachment to a caregiver (Fairbairn, Bowlby) be thought of as a subset of drive theory, in so far as a libidinal gratification is derived from an attachment to a caregiver? After three years of intermittent exposure to this chapter of psychoanalytic history, my philistine curiosity laments, what was the fuss all about? I appreciate the author’s reminder about Winnicott’s notion of the “capacity to be alone”. It seems to me an eloquent statement of the value of silence, as experienced by two people sitting in a room together, experiencing a feeling. It’s not a shared experience per se, because the autobiographies are different, and because each person’s experience of emotion is different. But there are therapeutic values present: empathy, attunement, a witnessing. I think I have these experiences. Finally, I am introduced to the term hermeneutic: the understanding of subjective inner reality, with a distinction drawn between historical truth and narrative truth, between real events that might not have occurred, but are nonetheless “true”. This notion is a tantalizing one. It lets me off the hook from knowing, and I’ve always liked that aspect of my chosen business. The problem is: it lets me off the hook from knowing.

In my novel, Crystal From The Hills, Chris Leavitt copes with his traumas, recent and past, with distortions, and through play: it is play gone wrong for an adult male with responsibilities and a supposed bright future ahead of him. What he really wants is to go back in time, pretend nothing happened, both on an intellectual and emotional level, and start life over again. The problem, solution, and the hope, lies in the witnesses: the impromptu, reluctant therapists that are the people around him. He believes what has happened to him, whether it has or not, because it fits his narrative truth, and his courage–his happy, yet unsentimental ending–is in facing his distortions.

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February 2, 2014 · 8:39 am
January 7, 2014 · 9:54 pm

Working Through Rehab: opening salvo

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So, you’re thinking of placing your kid in rehab? Or, maybe you’re thinking of getting a job in such a place, as a counselor, social worker, therapist, or whatever they’re being called these days. Do you know what it’s like being in rehab, or working in one? Have you visited a drug treatment facility, or heard stories from your neighbor who sent their kid to an out-of-state boarding school the previous summer, and later discharged just in time to begin senior year in high school. Are boarding schools the same thing as rehab? You wonder. A doctor outlines options: suggests therapy for a troubled teen, or an assessment at a nearby hospital, which boasts detox facilities and an intensive outpatient program, committing kids and their families to eight weeks of group and family therapy, ten hours a week, not counting the 12-step meetings that counselors will ask participants to attend on the weekends. A residential admission is the next level of care. It is the last resort as far as professional intervention is concerned—the last stop on the treatment ladder.

            Do you want this? Need this? Does a kid getting referred to rehab even have a choice: Meaning, is a court presenting rehab as an alternative to incarceration? Or are the parents the mandating authority? Perhaps your kid’s best friend has called you up, or texted you anonymously, warning that he or she is drinking or smoking much more than you realize, or “experimenting” with some other, supposedly more hardcore drug—one that will really scare you. You notice the kid’s grades are going down, and that more time is being spent with sedentary, seemingly anti-social activities: marathon spells of video-gaming; the vague notion of “hanging out”. What happened to that kid that seemed vibrant a year or so before: polite, energetic, and gregarious. Is this normal adolescence? You worry. How long do you wait to see what happens?

Maybe this isn’t your story. Maybe you’re a parent who has struggled with your own substance use. Maybe you’re an addict, and it seems like your kid is following suit. You don’t know what to do, or even if, given your own history, you have the aptitude or even the right to speak your concerns. After all, did you listen to adults when you were a teen? So, your kid is staying out all hours, has joined a gang, become a dealer as well as a user. Involvement in the juvenile justice system seems imminent, if it hasn’t happened already. You’ve already had several phone calls from Child Protective Services; one or two home visits. You and a couple of county social workers are on a first name basis.

Maybe you’re a fledgling member of the mental health profession, and working with troubled kids seems like a good idea: a stepping stone to a career as a social worker, a teacher, or, if you’re really stupid, a psychotherapist.  You’re a tweenie that’s looking for a job while in school. Or you’re a journeyman counselor that’s just completed requirements for certification as a drug and alcohol abuse counselor. An adolescent drug treatment program, attached, say, to a larger hospital, will offer steady employment, some modest benefits, if not a particularly competitive wage. You’re okay with that, maybe…for the time being. You want to reach young minds, work with those who may be more flexible in their ways, feel more hope than the adult addicts you’ve known. It will be less depressing, you think, working with kids.

Now that you’ve read the brochures and the websites of various programs, or taken tours of their sterile, hospital corridors and dorm-like accommodations, settle in for a first hand look at what happens in adolescent drug rehab programs, from the ground up, because that’s where I started. To do this properly, I have to go back in time to give some history, some context for what is happening today, especially in residential programs, for while some things have changed, others have not. Along the way, there are markers of change, nodal moments in my working life that in my opinion reflect trends in the business as a whole. If by the end of this text, the reader still wants to enter this field, or admit his or her child to a rehab like the ones I worked at, I’ll have no complaints. Just consider this the longest informed consent form in rehab history.

** opening of Working Through Rehab: An Inside Look at Adolescent Drug Treatment

 

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December 22, 2013 · 9:05 am

Getting Sucked Up

–A review of This Is The End

 

            The only problem I had was in not taking this film seriously, because I wasn’t supposed to, I guess. This Is The End, starring the latter day rat-pack of Seth Rogen, James Franco, Jonah Hill, Jay Baruchel, Danny McBride, and Craig Robinson, is a delicious comedy that moves so quickly and is so densely packed with ideas, it’s hard to believe it’s only 107 minutes long. Even the scenes that are gratuitously violent—and there are a few—seemed like breaks for my much taxed yet entertained concentration.

            The plot is as follows: Jay and Seth are old friends, actors/comedians or writers, reuniting in LA. At first Jay seems like a slacker visiting his more famous buddy (everyone is playing themselves), but really he’s an introvert: he craves down time, video games, weed and junk food. The last thing he needs is to hang out with Seth’s pretentious friends, headed by James Franco, the coolest kid on the block, whose party draws a who’s who of tweenie Hollywood. So, at the party, the likes of Michael Cera, Rhianna, and Emily Watson are present, being requisitely cool, yet patronizing Jay’s outsider vibe cuz he’s a friend of Seth. But the truth is they smell a hater. Craig’s Robinson’s (character?) calls him out, saying Jay is a hipster: someone compulsively “negative” about all the things one is supposed to like if attending parties like this. Actually, Jay is Holden Caulfield transported to the 21st century: he is sensitive, if self-righteous; brave, yet conflicted. Above all, he’s an alienated soul. In an ass-backwards sort of way, the cool people have him pegged.

            The initial drama (and it seems more like drama than comedy at this point) appears to be that of a friendship going south. Yawn. Not exactly a deep premise for a film about people who seem to still be in their twenties—reminds me of a novel I wrote, to be honest. At the party, Seth, a born politician, tries to make it all smooth, but to no avail. He introduces Jay to James Franco, who becomes insufferably pedantic when Jay fails to idealize his home’s artwork. A meeting with the unconvincingly “nice” Jonah Hill is similarly awkward, and before long Jay is looking uncomfortable, desperate to get away from all these sycophants, these successful people. Jonesin’ for a cigarette, he implores Seth to join him on a run to a convenience store. As they walk out, it seems like a friendship-tearing watershed is about to happen, and nothing but pre-movie hype, or leaks from the set or promo department would clue anyone in as to what’s about to happen.    

            Next thing we know a glass wall is being shattered, and fleetingly it seems like a movie cut from the cloth of Crash or Falling Down is about to unfold. Moments later, as a series of blue light beams spear down from above and “suck up” handfuls of extras into the sky, it seems more like The War Of The Worlds is the blueprint. Either way the yawning should stop. A chase is on, with explosions all around. Terrified, Jay and Seth rush back to the scene of the party to cue the film’s first real joke: the party’s still going while everyone is oblivious to the mayhem outside. As Seth jabbers about earthquakes, Jay’s mind is spinning, having noticed the cosmic elements of the attack. He tries to bear witness to what he’s seen, but inevitably, his weirdness is reinforced by his manic explanations, and everyone looks at him like he’s crazy. Predictably, Seth commits the film’s first act of betrayal, joining the others in their dismissing of Jay. But soon there is comeuppance as partygoers hear commotion, step outside and face the burning hills of Hollywood. While some may have thought a South Central revolution has occurred, such assumptions are quickly shattered as the earth opens up, swallowing up most of the film’s cameo stars. Most hilarious is Michael Cera, who seems to enjoy playing a tweaked out superjerk who gets impaled by a streetlamp. 

            Horror film rules: those who deny get wasted, except those who also deny but are meant to learn something life-affirming as part of the story. Next, as the rat-pack holes up in James Franco’s bachelor pad, reality testing begins. It’s OMG time, sprinkled with lots of LOL. First task is to gather food and other supplies, and argue about who gets what. The middle section of the film is a satire upon all things to do with Hollywood and actors, riddled with obscene improv. On the surface, the dick jokes, the homophobic play, and general grossness may seem tasteless or old hat, but the dialogue is inspired lunacy, not so much written as spoken on the fly, as if this was a film made during a slumber party, with the cameras rolling after the actors got high and then stayed up all night. Despite the chaos, a series of themes are insinuated. First is the self-effacing idea that actors are really pussies instead of action figures, and the first lesson observed by all these divas is the importance of not being a fraud. Several scenes follow in which the guys are portrayed as feckless and woefully un-resourceful—unable to share either water or even a Milky Way bar. 

            Jay is the voice of sanity and the film’s moral center, and Baruchel plays this role with remarkable freshness, even charm. He squints, bewildered as his peers flitter in and out of delusion. Jonah Hill says this drama is like a “sleepover”; he’s trying to stay positive, “make this fun”. Jay introduces to their consciousness the possibility that a Biblical “End of Days” scenario is occurring, and likens the blue beams he’s seen to events depicted in the Book of Revelation. The others scoff, all except Craig, who is the next character to manifest a heroic streak. A party/survival scene crasher arrives in the form of Danny McBride, who steals food, water, masturbates on the plants, etcetera. If this is hell, then he’s a devil’s helper, a Caliban taking his revenge on everyone responsible for his lifelong ostracism, about which he expresses self pity with grim, unapologetic delivery. Franco, whose home Danny is shitting on, is the most offended, so next a theme about how society expels the unwanted is played out. In the midst of this, one of the funniest and most clever scenes involves the return of a cameo star. Emily Watson breaks in, looking for refuge. Initially, she is relieved to find familiar faces, but when she overhears the guys talking about rape in the hallway outside her bedroom, she loses it and becomes something like Hermione on crack, taking out a phallic balloon model (of course) with an axe. On the one hand, this scene is an excuse for a few Harry Potter jokes, but it also depicts another aspect of Jay’s outsider morality. In truth, it seems misguided for him to raise the specter of rape, appealing for guys’ sensitivity in light of Watson’s outnumbered and vulnerable status. They, of course, feel accused rather than enlightened, and an important message is sent—albeit through humor—about empathy being lost amid the noise of defensiveness.

            Still, something has been sparked by Jay’s consciousness raising: namely, an attention to ulterior, if not unconscious motives. Soon guys are challenging Jay’s self-righteousness, questioning his self-proclaimed honor, pointing out that he’s been lying about avoiding Seth’s company in recent months. Losing his temper, Jay strikes Jonah Hill, whose “nice guy” quality Jay has always hated and distrusted, and storms out. There’s a nice, incisive moment wherein Seth turns away, hurt but also hapless, hiding. His habit of passivity is likewise being called out, and thereafter a comic drama about denied rage ensues. The comedy takes the lead, so it seems fitting that this theme is expressed through demonic possession, with Jonah Hill performing the parody, first of Mia Farrow from Rosemary’s Baby, and then, naturally, becoming the possessed creature of The Exorcist, hilariously mocking Jay’s Hollywood-taught attempt at an exorcism: “Is it compelling, Jay? Really? It’s not that compelling!”

            These guys have all seen too many movies. Save for Jay, movies are their religion, their only reference points for what is real. As the film nears a climax, Franco’s home is destroyed, and the guys are forced into the streets to survive. Craig plays the hero and attacks the “Red Dragon”, the ultimate villain whose appearance, Jay has foreseen via Bible passages he’s found, strangely enough, in Franco’s home. (side note niggle: is it credible that Franco would own a Bible?) But just as he’s being devoured by the beast, a blue beam appears, and Craig is saved. The others witness this and rejoice, now realizing how to survive this ordeal. But hasty attempts to “be good” aren’t gonna work, no matter how entertaining they may be for the viewer. Heroism, or goodness, must be spontaneous and real. To survive, one must no longer be fake. This leads to another hilarious, not to mention suspenseful finale, in which Franco’s pretensions, his arrogance, lead to his downfall. While being “sucked up” (to heaven, they presume), he gloats at Danny McBride as he begins to rise. Immediately, he is punished for this unsportsmanlike conduct, and is dropped back into McBride’s lap, left to his mercy. Meanwhile, in order to survive, Jay and Seth must resolve their conflict, their flat estrangement, with quick decisions, inspired action, and genuine brotherly love. Do they survive together, reunite for real? Or, do they go their separate ways? You know the answer. In the end of (the day), this is a movie, and togetherness—love—always prevails.

            This Is The End finishes on a cop out note, making a hipster joke out of Jay and Seth’s heavenly ascension to the tune of a Whitney Houston song. It’s a funny scene, successful in beating back tears that might—emphasize might—have been shed in watching this bit climax the film. Yeah, it’s a movie, but it’s a guy’s movie: in the end, what we do is drink beer, masturbate or fuck chicks (or try to, at least), take a hit of something, say fucked up things, and party til’ we drop. BFF.   

 

Merry Christmas Nick

   

 

 

 

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