July 29, 2013 · 7:13 am

Memories of Near Death

 

Dr. Raymond Moody, in his book, Life After Life, explains that near-death experiences are a cross-cultural phenomenon depicted in Biblical passages, the writings of Plato, and the Tibetan Book Of The Dead. He writes that to talk of life after death seems atavistic; a superstitious impulse born of fear, estranged from a scientific present.

In my novel, Crystal From The Hills, I write about a character, Chris Leavitt (nicknamed Crystal), who indulges his own atavisms, struggling with various lives after deaths: most immediately, the death of his friend and doppelganger, Weed; the death of his father from lung cancer; the spiritual death of his mother, mired in grief following the death of her second husband in the 9/11 attacks. Above all, Chris struggles with his own deaths: the literal and the existential. He laments the loss of youth, and acts out a lie instead of dealing with the reality of being adult. He observes the loss of freedom in the workplace, and in the street, and so pounds the pavement of Oakland in defiance. He notes the loss of his sex drive, partly resulting from methamphetamine withdrawal; partly a product of shame–for Chris, sex has brought mostly pain. Meanwhile, he is AWOL from his job; disappeared, like Weed, from his home in Richmond, where he does not belong. He returns, prodigally, to where he once did belong–the hills–to hear strident counsel of his Aunt Jenny, a vital yet aging woman who is awaiting death herself, yet holding so as to live vicariously through youth. Chis is alive yet dead: such is the life of the traumatized, wading robotic through their days(ze), hanging on to the fabric of their lives, their relationships, hoping that something will come along to reinvigorate.

For Chris, as with many who dwell in trauma, memory may provide a portal to healing. The future is in the past and the end is in the beginning. And so my story begins with the words, “He’s dead”, delivered with minimal context and shorn of feeling. Later there is recollection, and with it, plenty of feeling: a blend of terror and hope. Read…

“Chris struggled to the surface amid the unspeakably cold water. The seeming attack of the seaweed had him flailing momentarily, and looking down to see what horror was beneath his feet. The vision was human—his own face staring back at him. For a suspended eternity, Chris left his body and felt enveloping warmth. Death? He wanted to shut his eyes and hasten the end, and yet he could not look away. Then as he blinked the cold returned, as did life. Someone, or thing, was giving him a second chance, he then realized. Problem is: now he’d have to do something with that. Now he’d have some kind of new responsibility. Looking down, he saw the likeness of Weed, gazing up with terror-stricken eyes” (from the novel, Crystal From The Hills)

Don’t want to read it yet? Well, for more, check out the video: http://www.youtube.com/watch?v=l03SL0ZRPXgImage

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July 17, 2013 · 9:36 am

Last Flight to Costa Rica

 

 

On July 6th, 2013, George Lewis languished in the window seat of a Boeing 777 bound for Mexico from San Francisco. It was a quarter hour after departure time and the captain had just announced that there would be a delay. He delivered the innocuous-sounding news–“waiting for a flight plan”–in a bored voice. George Lewis felt the same way, despite this being the first day of a long-awaited vacation. Seated next to him was his wife, Jean, who greeted the captain’s words with a disgusted sigh and then reached down for a fashion magazine that she’d brought for the journey. It seemed a preemptive action, designed to counter George’s subtle nod in her direction, his supplicant overture. No chance, she was saying. Ok, we booked this thing and it’s too late to get our money back, and we’re on the plane and on our way. But don’t get any ideas. We’re not going there. Not now. In the seats ahead there were some teens gazing out the window and then pointing outward, behind their seats and over George’s head. Annoying, he thought. One teen, a disheveled skateboarder-type about two years younger than George and Jean’s now college-ensconsed only son, let out a shrill, excitable noise. Jolted and glum, George looked up past the youth’s hairy, undeoderized armpit, and stared down the doltish-looking, unsupervised child. 
        “Sorry,” said the boy, suddenly without expression. 
George softly grunted, bit down upon perfunctory forgiveness and turned back to the window by his side. Clouds. Or smoke. That’s what was behind them. He couldn’t tell, but the teens in front could. One kid was from Burlingame and was guessing there was a fire near his old school. “That’s my home, fool,” he started repeating, certain of himself but undisturbed. The other boy was from San Bruno. He reminisced about a fire in his home town from two years earlier–a national story at the time, George recalled. It was “crazy”, the boy recalled; his excitability back in force. Jean didn’t react. Her head was in her magazine, a half-fashion rag, half-gossip journal, featuring women, fully clothed, many bearing sizable bulges, each looking hopeful and happy. Glowing: that’s the expression, George noted. The cover was of the British princess whose name George couldn’t remember–a likeable, girl-next-door type who had stolen the Prince’s heart, earned her fairly tale wedding, and was now waiting on her next big day, ready to give the King-in-waiting an heir. The empowered and not-so-empowered everywomen of the world were waiting with her, living vicariously this princess dream. Meanwhile, George Lewis flashed through his mind thoughts of the skin of semi-clothed women. In Costa Rica, their ultimate destination, there would be plenty of skin, mostly of the exotic, caramel kind and not the ashen complexion of his anglo wife, or the anglo princess whom she so admired.
 
George caught himself. He closed his eyes and winced, and then tried the action that his new therapist had taught him the previous week; this 3-second rule that members of Sex Addicts Anonymous swore by. Give yourself three seconds–that was the rule. Give yourself three seconds, acknowledge the trigger, then watch those thoughts and feelings drift by, mindful of their power, but make a choice. “George, you have choices,” his therapist exhorted. George returned a sad, defeatist look, but nodded agreeably. Now he tried to put the rule into effect. Think of the consequences. That was the next part; the next “tool” to use. The problem was guilt. Consequences? Too late, the consequences are already here, he answered sourly. Ever since Jean had caught him with his pants down, with a white towel over his ass, lying face down on that padded couch in that sordid office, sipping that honey tea supplied by…that woman; that sexy yet unglowing woman whose happiness was actually not important to George. The fleeting visions of supple skin, conjured smells of delicious oils, and hardest of all to summon, the tactile sensations of friction, were now coupled with stinging self-rebukes…George’s self loathing. Somehow, back in the therapist’s office, listening to sage, asexual counsel, he’d forgotten to ask the most important question: what do I do with the guilt? What he asked instead was a question about Jean. As George glanced tentatively in her direction, he thought of the urgent question that dominated the previous session: how do I get her trust back? he’d asked, to which the therapist was non-committal and borderline dismissive, insisting that such things were impossible to predict and that trust wounds, in his experience, were always mutual, or something like that.

George’s eyes fixed upon an overhead compartment several seats down which seemed loosened from its catch. As an attendant walked by George thought to flag the man down, alert him to the problem, the prospect of luggage tumbling out and possibly hurting someone. He’d strike an earnest tone in his voice, make sure to emphasize the threat to passenger safety; make sure that everyone–especially Jean–knew that he cared. But the moment passed. The attendant skipped by as though distracted, his impassive expression glancing over the heads of passengers all around him; past the eyes of George Lewis and out the window next to his seat. The loose compartment made an insistent clicking sound and its cover tilted outwards by an inch. It’s leaking, thought George, transferring more terms from recent therapeutic pedantry. That compartment: they think they have it locked. They think it’s airtight and that everything’s safe and tucked away, but it’s not. George knew that now. Why hadn’t he known it all along? After all, it wasn’t as though he’d not dreamed of the worst happening. In fact, he’d felt it in his gut, the foreboding. If only he’d trusted his…

He glanced at Jean, still determined not to speak to him; perhaps determined to never speak to him again. He felt a chill and stood up tall, looking over the tops of seats, over the heads of noisy teens, and into the distance. An attendant at the end of the aisle was half on a phone near the cockpit, half pleading with an agitated male passenger to return to his seat. Around them there were murmurings, and within earshot, barely, there were emerging fears rippling through the cabin, and more numerous observations of drifting, grey plumes of smoke from an area just beyond the airport control tower. Not clouds. News was filtering through the plane of something big. Someone was on the internet, disobeying the captain’s orders, which had asked for all electronic devices to be cut-off in anticipation of a take-off that was imminent a half hour earlier but now delayed indefinitely. George Lewis started to become suspicious. Reflecting on his therapist’s words, he realized he was not feeling the trust.
            “Sit down, George,” Jean said irritably, though unlike him, she seemed unperturbed by the growing unrest around her. Denial. Good, George thought: she’s still speaking to me, at least. 
            “Sorry,” he replied to her.

At that moment, the captain’s voice sounded out over the intercom, his voice now sounding more tired, not bored. The flight to Mexico City with connection to San Jose, Costa Rica, was regrettably cancelled, he announced–the result, he declared, of an airport closure in Mexico City. He followed up with some rote instructions about how to redeem ticket purchases at the airline desk in the terminal. George was half listening, and now peering out the window by his seat, just like the boys in the seats in front of him. Like a frightened child, he pressed his face against the window, straining to look through the thick double plastic to the sights behind him. He knew now that something unusual had happened. Something horrible: something the captain, and perhaps many others would not talk about for a long time.

* this short story is not based on real events, or real people. If you like this story, perhaps you might read the synopsis of my psychological fiction, entitled Crystal From The Hills.  
 

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July 15, 2013 · 9:04 am

Sex Offender Treatment: Just Say No to the Dodo

 

Talk about reductionist thinking: try this corner of the mental health industry. It’s a dark little corner, where the journeymen and women of our profession go…because someone has to, supposedly. Not that therapists are wanted, necessarily. As in the treatment mileus depicted in my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, administrators and directors of SO treatment programs, or the “supervising officers” (euphemism for correctional officers) that are actually in charge of the three-headed mon–sorry–treatment team, want straightforward instructors for implementing of program protocols. They want containment based upon a structured approach designed to elicit successful behavioral outcomes–a teleological perspective.
       Recidivism: the repetition of offending behavior. That’s the operative concept in sex offender treatment: the standard by which this entire arena of care is judged, or will be judged, if it is indeed on trial. And why not? you may ask. Surely the problem of sexual abuse needs to be addressed as aggressively as possible, with a behavioral lens front and center; with recidivism the criteria for assessing everyone in the process, participants and providers alike.
       The problem is with the research, and thereafter with the spinning upon said research for anxious listeners. At a recent presentation of sex offender treatment protocols at a CCOSO (California Coalition on Sex Offending) conference, I listened to program officials assert the need to implement a structured treatment program consisting of an RNR (Risk Needs Responsivity) model, in conjunction with Cognitive Behavioral Therapy (CBT), and that unstructured psychotherapy (unclear what that was referring to–perhaps the aforementioned “Freud stuff”) was contra-indicated (meaning, ill-advised), because its methods were not associated with a significant decrease in recidivism. By RNR model, presenters were alluding to the work of criminologists Don Andrews and James Bonta, who outlined what are termed dynamic risk factors central to treatment, alongside corresponding so-called criminogenic needs. The list of factors include some of the following: antisocial personality, antisocial cognitions, social support for crime (meaning, friends or family with criminal attitudes), impulsive behavior, family dysfunction–again, such as criminality, low education. Other factors of ancillary importance are early childhood negative experiences, family of origin stressors, age, gender, and ethnicity. Spot the issue yet? Well, the likes of Ward, Melser, and Yates (2007) did, opining that the RNR etiological theory was too general to explain criminal conduct, and as a result, was unfalsiable–meaning, not especially useful.
        As for recidivism, the research here is generally thin and unconvincing. According to Duwe and Goldman (2009), a reduction of 18% in sexual recidivism existed for one in-prison treatment program. But researcher Stephen Brake, who in 2010 published his examination of 37 studies of sex offender treatment outcomes conducted over a quarter century, found that only 41% of such studies indicated reductions in recidivism, with 37% not significantly reducing recidivism, and a remainder of studies indicating mixed, partial evidence based upon different factors (violent versus non-violent recidivism, for example). Overall, it’s been known since the early 90s (via federal reports) that sex offenders exhibit among the lowest recidivism rates (4-12%–tracked over 5 years), compared to other criminal profiles. But it’s unclear whether such findings can be attributed to specific treatment models. The authors of another meta-analysis study, Losel and Schumacker (2005), concluded that there is a significant effect of treatment on recidivism, but the studies they examined indicated treatment programs that featured not only CBT methods, but also surgical castration. Pardon me while I imagine the principals of each intervention strategy arguing over whose method worked best.
       Several critics point out basic problems with research into sex offender treatment: findings that indicate as much effect upon recidivism for no-treatment versus treatment; inadequate control groups; the fact that sex crimes are the least reported types of crimes (thus confounding statistics on recidivism). Add to this discrepancies in study designs, outcome measurement protocols, time-frames for follow-up, and what researchers have is a messy globule of information that strains against the community’s desire for straightforward action. Critics of the RNR model point out its limitations: the opinion that attention to criminogenic needs is insufficient, and that attention must be paid to individual needs, self-esteem issues, personal distress; that treatment alliance is an unassailable factor in positive treatment outcomes. Amen, I say. However, these are borderline heresies for those presenting on the topic of sex offender treatment, for sex offenders aren’t really allowed to talk about personal distress and low self esteem–at least, not until they’ve admitted to all of their crimes and then said they were sorry…like, really sorry. And so, with all this in mind, I wade into this dodgy realm of care, becoming a ‘certified’ provider of sex offender treatment. Why? because I have some clients who fit the profile, and because they are people about whom I care. I’ll nod my head at the pronouncements of those looking to codify practices and reign in the unconscious. I’ve got my eye on the Dodo.
* Stephen Brake (2010) The Effectiveness of Treatment for Adult Sex Offenders.

* Ward, Melser, and Yates (2007) Aggression and Violent Behavior, 12, 208-228.

* Losel and Schumacker (2005) The effectiveness of treatment for sexual offenders. Journal of Experimental Criminology, 1, 117-146.

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July 11, 2013 · 9:39 pm

Letter to a therapist friend

 

Hi, sent you a message a few nights ago, haven’t heard back, which isn’t like you. I’m not taking that personally (unless I should be?), but I thought I’d reach out again, imagining you may still be feeling hopeless, as you were last month, mostly because of work. 
I hope this doesn’t sound self-serving, but I think my modest, self-published book about drug rehab and community mental health as a whole does provide hope to those who work in this business. Many like yourself are smothered by the platitudes of directors, administrators, and so on while otherwise feeling technocratic shards of glass pierce into their sides. I felt in your reaching words something(s) unachieved in our world: passion, bravery; risk inflected with humility. I could feel it in your depiction of that unsatisfying exchange with your manager. A “nice” man, you said. It reminded me of something an old SN once said to our group of supervisees in the three-year program: “there’s nothing nice about being nice”–it was in response to a fellow student who was struggling to manage frame issues, and justifying a lack of confrontation by declaring that confrontation was…well, not nice. In my book I am scathing, I think, about rigid adherence to procedure–the tyranny of the HR manual–when not just common sense, but common thoughtfulness, decency, but above all realness, is called for.
 
There are times when I think that the Masterson model can truly be distilled into these qualities. I reflect on my caseload at any one time and I think, with whom  do I feel spontaneous? who do I really know? what connections feel real to me? More often than not, the best work feels like a jazzy, flowing sense of knowing…something that feels right. That may sound a little soft, and a lot unreliable. It certainly doesn’t sound very “evidence-based” or scientific, or “quantifiable”. But the thing is this: it sounds reliable to me. The reason? I trust myself, whether others do or not. Doesn’t that sound wonderful? Doesn’t it sound like a gift, or a real achievement, if I’m to give myself the credit for doing the work. I’m not saying I’m getting it right with all my patients. I’m saying I can tell who I’m getting it right with, and who I’m not getting it right with.
 
I agee that being in the quadrants is tantamount to being unsober. I think this was the basis for our original discussions about blending the Masterson model with a 12-step program. I’m working on myself as I flit in and out of defenses; my therapist is fighting me, I think–thinks me defeatist in my self criticism. Among other things, I defend the hard but fair pronouncements that KS made of me last year. I realize that his cool yet cutting approach stirred something vigorous yet frightened in me. It all lingers, the hurt. I was surprised to read that you “identified” (with being seen? or the “bad” experience you referenced), as I specified being seen in a manner that felt menacing, even sadistic. Did I misunderstand you? Were you writing of being scrutinized, and by KS in particular?
 
You wrote of vulnerability in your last e-mail, “to the toxic foolishness”. I identify with this vulnerability, though I think I have some of the detachment you crave. I’m not entirely free of bad systems. Indeed, there are one or two that are threatening to ensnare me in a fight currently (perhaps more on that in a later e-mail). But TR is nearly two years in my rear view mirror, and completing the book has been, dare I say, cathartic. Anger is draining, despite the sneery, superior tone sometimes evident in the book and especially within this accompanying blog. Whether a handful of people read it (the book), or hundreds more do so, I have cleaned my own internal system of the toxic entity that once dogged me. I have gotten some peace. Like a Schizoid personality, I also have a fantasy, which I’ll share with you: you see, in the future, I imagine achieving a modest, measured (compromised?) fame for my lengthy missive to my peers. I’ll be asked what I think should happen in drug rehabs for adolescents; perhaps what should be happening in all community mental health settings. On the specifics I’ll defer, I think, as I choose to disentangle from Gordion Knots, practice something like a second step, and wait for help from those on the inside. I don’t want to abandon. I don’t want others–least not people like yourself–to give up hope. I just think I need back-up. I need the real selves to present in numbers.
 
Graeme

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July 2, 2013 · 7:05 pm

Dodos In Rehab: What’s Effective Therapy (part three)

So what do I mean by Dodos? Those familiar with decades-old arguments within the Balkan states of psychotherapy know the meaning of this allusion to Alice In Wonderful. It has something to do with games in which there are no winners. Lewis Carroll’s absurdist Dodo bird declares, “Everyone has won, and all must have prizes.” With respect to psychotherapy or mental health treatment in community settings, the Dodo bird theory posited that outcome studies for different therapies are surprisingly equivalent, or that patients were as likely to manifest positive change without receiving any kind of mental health treatment at all.

This was the conclusion of Singer and Luborsky (1975), among others. You’d think this would lend itself to less territorial disputes among professionals; less competitiveness or fewer tiresome pronouncements about what works with consumers of mental health treatment, and what doesn’t. Well, you’d think that, but you’d be wrong. I wasn’t a psychotherapist in the 70s or 80s, so I wasn’t around for the supposed arrogance of that generation’s psychoanalytic patriarchs. I work in a state containing some 30,000 licensed Marriage and Family Therapists (compared to a third less just five years ago!), which doesn’t include the thousands of other therapists operating under other licenses, or at a pre-licensed level. Waiting lists? Maybe a few therapists have ’em–those at the top of the food chain. But these days there are plenty of options for the consumer, and the consumer base demands access to care for a diverse population with diverse means. Managed care companies, who are the brokers of this access, demand concrete evidence of what is effective: behavioral change, a medical model’s reduction in symptoms, externally observed–a teleological framework. Hence the DSM and the ubiquity of reductionist thinking.

In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I chronicle my observations of this trend, among others, during my own career in community mental health from the mid-nineties to the end of the last decade, roughly. The trend away from psychoanalytically-derived models is apparent in the rhetoric of providers, program directors, glib administrators–those who pronounce the efficacy of cognitively-based models, and implicitly decry as “alternative” that which has been subject to a lesser volume of affirming research. The passages in my book that depict training scenarios in which psychoanalytic models are mocked: those are real. Trainers really do say things like “we’re not here to do Freud stuff” to clucks of amusement from sycophantic listeners who don’t know any better. The bullet points of their presentations really do assert the greater effectiveness of their chosen models, without even bothering to explore the confounding factors in such research, despite the glaring obviousness of those factors.

On one level, I don’t begrudge the advocates of CBT and other short-term treatment models. Their methods do indeed lend themselves to quantifiable measures, and those looking for a threshold of care that addresses short-term goals deserve to find providers who specialize in implementing short term models, with a focus on present-day stressors and needs as well as a philosophy that draws as much attention to a person’s strengths as it does their deficits. This, after all, is the promise of the latterly heralded strength-based movement, now prominent in schools, special needs programs, and among social workers and in community mental health settings. In these respects, I’d say that shorter term models of mental health treatment have done more to reach more people in the community, though in my opinion, the potential (and precedent) exists for the strength-based model to be integrated with a psychodynamic focus across all levels of care, as long as care is taken not to allow excitable positive thinking to obscure painful realities.

The spirit of the Dodo bird pronouncement is one of humility and mystery: a statement of not knowing that should prevail whenever the subject is the meaning of an individual’s life. There are plenty of perspectives vying for attention at the treatment planning table, and if the need for cohesion is why diversity of thought must be contained, then so be it. Those who find themselves in the right places at the right times can pick their models, the colleagues that will echo them, and be in charge for the time being. But such victories of timing should not hoodwink the public at large: the disengenuous pronouncements of those making sales pitches in this business will whither sooner or later, and those looking for more than what short term psychotherapy models have to offer will at some point stop coming back, to paraphrase a popular saying. The parallels with society’s food debate are apparent: principals of supermarket chains might credibly argue that their products cost less; that they are accessible to a wider range of people with various levels of income; that they feed more people. There is a faction of organic farmers in mix, now asking, “yes, but are you feeding them well?”

* Luborsky, L., Singer, B. (1975) Comparative studies of psychotherapy. Archives of General Psychiatry, 32, 995-1008.

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July 1, 2013 · 7:39 am

Dodos In Rehab: What’s Effective Therapy (part two)

Shedler’s comprehensive research informs us that psychodynamic practices are not only effective, but arguably more so than its rival models. The effect sizes he reports following numerous meta analyses are consistently higher than those attributed to cognitive behavioral therapy, and furthermore, the effect sizes linked to psychodynamic approaches increase over time; that is, from short-term follow up studies to longer-term follow up studies. This suggests that in-depth psychodynamic therapy sets in motion a set of changes for people that acquire momentum over time, and are ongoing.

Yet these findings don’t speak to the issues that I presented to that frozen audience in the community mental health setting–that audience, comprised as it was with overworked souls more typcially compelled to hear rote trainings in which smug pedogogues pitch bullet-pointed treatment manuals: the evidence-based droning about quantifying treatment goals and codifying methods. The irony, Shedler asserts, is that many who work under the banner of CBT actually practice methods at least derived from psychoanalysis. In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I allude to this curious trend. Writing anecdotally, I reference several terms, like “splitting”, “denial”, “failure to thrive”, and “containment”, which are used regularly in settings purportedly driven by a CBT philosophy, but which have a psychoanalytic pedigree. Shedler implies that many practitioners are unwittingly using psychodynamic language and methods; which sounds a bit like rock musicians who aren’t aware of the blues roots of their craft. He cites a study by Ablon and Jones (1998), who interviewed experts in CBT and psychoanalysis, asking them to define their models such that use of objective tools like the so-called Q-sort assessment (blind raters, listening to audio tapes of sessions, tracking specific interventions) could be understood. The psychoanalytic experts cast the umbrella psychodynamic process as follows: allowing for an unstructured dialogue, the identification of recurrent themes, linking feeling states to past experiences, and giving attention to intrapsychic defenses, and to “unacceptable” feelings. I can see in my mind the disdainful head shakes of those who think this a waste of time; something only the privileged might pay for. The CBT experts in the study emphasized a more specific focus in therapy–a process actively structured by therapists taking on didactic, teacher-like roles. They give advice, discuss goals, and focus generally on current life stressors or (in the case of those mandated into tx.), objectives assigned externally: far more popular with industry onlookers looking to streamline methodology.

But get this: the investigators measured therapist adherence to models without regard to what therapists believed they were applying: Beck’s treatment model, apparently. Upon reading verbatim transcripts, investigators of this study tracked the following variables: quality of therapeutic alliance; addressing cognitive distortions by patients; patients’ experience of emotion; gaining awareness from previously implicit meanings and feelings. The thing is, only one of these variables truly belongs to the canon of cognitive behavioral therapy–addressing cognitive distortions. Therapeutic alliance and the importance of establishing therapeutic alliance is a concept that has been written about in psychoanalytic literature for decades. Implicit process? Practically synonymous with the unconscious. And BTW: only one of these variables, focus on cognitive distortions, was associated with poorer treatment outcomes. Oops! Regarding the ambiguous term “experiencing”, there is a fascinating breakdown of meaning by researchers: Shedler refers to the experiencing of feelings to distinguish it from a defensive expression of feeling, or an absence of feeling. A person can, for example, be speaking of him or herself and their life, and be doing so truthfully, but also intellectually; that is, without emotion. Also, a person can be speaking emotionally, but focused upon external phenomena, and thus be blocked from learning how events relate to self. The premises of psychodynamic treatment call for people to integrate thought and emotion, reflect upon self and other, and to recognize needs and viewpoints of self and other in such a manner that holds each in equilibrium–neither subordinate to the other, ultimately.

These were among the things I hoped to stir in my patients/clients when I worked in community mental health. They were the variables of treatment success I suggested to newer therapists as I later became a clinical supervisor. Roughly, and anecdotally speaking, these were the outcomes that were clearly sought by the consumers of all this dross we call therapy.

* Ablon, J., Jones, E. (1998) How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive behavioral therapy. Psychotherapy Research, 9, 71-83.

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June 30, 2013 · 10:23 pm

Dodos In Rehab: What’s Effective Therapy (part one)

Not that long ago I was speaking to a group of practitioners in a community mental health setting, posing a series of challenges designed to tease out what biases exist regarding the above question: what makes for a positive therapeutic outcome, and how do we know who’s doing what kind of therapy?

“How many of you consider that you are practicing evidence-based methods?” A dominant percentage in the room raised their hands, uncertainly in some cases. “How many consider yourselves CBT or solution-focused therapists?”, implying a chestnut belief in mental health circles: Cognitive Behavioral Therapy, or models similar to it, are the scientifically-based, empirically supported models of psychotherapeutic care. Roughly the same proportion of practitioners raised their hands after the second question. I then asked the audience to consider factors in outcome studies: time frames for follow up (were outcome measures made within 48 hours of treatment completion? 2 years? five?) What was the method of data collection (clinician assessment? participant self-report?) How did researchers determine what methods were actually being used in psychotherapy sessions? Among the practitioners, there was a smattering of speculations, but none knew definitively how the pronouncement “evidence-base” was being arrived at. I further asked if any in the room made audio tape recordings of their sessions, or made verbatim transcripts of sessions and then submitted them for scrutiny of methods. No one raised their hand. Someone shrugged and called out, “who does that?” I admitted that few did, but then asked one more volley of questions: given that mental health treatment is a confidential undertaking, and the likelihood that few psychotherapists subject their methods to rigorous scrutiny, how is it that researchers know who is doing what kind of therapy? I pointed my finger at my audience: how would they know you are CBT therapists?

The commonplace belief that psychodynamic models of therapy are not effective, or that pronouncements as to its efficacy are not grounded in science, is getting debunked. Meta-analyses of studies are accumulating, presenting effect sizes of close to or above 1.0 (this refers to a standard deviation above a normal distribution, and .8 is considered a large effect). This is the reporting of Jonathan Shedler, whose famous article in the March 2010 edition of American Psychologist is changing minds in professional circles. He is one of many sources quoted in my own non-fiction book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment. I worked in this business for fifteen years, originally under the supervision of professionals who frequently spoke in psychodynamic terms, affording me a rich, comprehensive lens through which I could work with and understand my clients in long-term residential care. Over time this influence was eroded, as shorter term models, with their myopic treatment goals, and sometimes insipid criteria for change (example objective: “reduce instances of tearfulness from 8 out of 10 occasions to 5”), increasingly impinged upon the treatment culture. Imagination, thoughtfulness, even common sense was being squeezed out, in favor of a supposedly utilitarian approach that presented common denominators for care. A reductionist assessment of symptoms, based largely upon Aaron Beck’s depression inventories, prevailed as the means by which treatment progress, and thereafter effective outcomes, were measured. Meanwhile, within the dusty crevices of program operations manuals, there existed old articulations of purpose that aimed for an implicitly internal process, the “core” experiences of the suffering individual in treatment.

In my book I make considerable reference to the work of Fonagy and Bateman (2008) whose mentalization-based treatment model (a psychoanalytically-derived technique) has yielded enormously positive results. At 5 year follow ups, 87% of patients who originally presenting with psychiatric symptoms and measures of social functioning consistent with Borderline Personality Disorder dx. continue to present criteria for the diagnosis, compared to 13% of those patients who received Fonagy and Bateman’s psychodynamic treatment. The centerpiece of Fonagy’s model is this concept of mentalization: the ability to experience another’s mind; to mentalize. Attachment research and decades of clinical observation has revealed the significant problems of those who present for care in community mental health care settings: poor impulse control, low self esteem, lack of empathy, or sensitivity for others’ needs and feelings; the inability to soothe uncomfortable feeling states–the aggregate of deficits that culminate in self destructive, anti-social attitudes and behaviors; drug abuse. Utilizing an index designated as SWAP (Shedler-Westin Assessment Procedure, available at http://www.SWAPassessment.org), Jonathan Shedler coalesces some of the factors that yield positive treatment outcomes from a broader, in-depth perspective: increased capacity for sensitivity; attention to others’ needs and feelings; recognizing others viewpoints, even when feelings run high; healthy use of humor, knowledge of consequences of behavior; linking of feeling states to past experiences; the ability to soothe negative affect (w/out substances). All this constitutes an attempt to operationalize mental health, via clinician report; a means of assessing mental health not just from the absence of symptoms as delineated by past or present versions of the DSM, but by the presence of capacities, strengths and resources that are internal.

* Bateman and Fonagy (2008) An 8-year follow up of patients treated for Borderline Personality Disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165, 631-638.

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June 27, 2013 · 8:36 am

Sprawling, muddled and hard to follow

Consider the following beta elements: Hitchcock, Bolinas, fire, towering infernos, The Wizard of Oz, terrorism, telecommunications, and Birnum Wood. A meaningless collection of terms? Maybe…that’s what you’d think upon a quick read through of my novel, Crystal From The Hills. My “sprawling”, “muddled” brainchild was written intermittently over the last three years, and is currently receiving a smattering of appreciation, interspersed with triage-like criticisms, some valid and useful, some merely indicative of a drive-by reading. It’s early days yet. Mostly there is silence and the resounding feel of indifference. As with Weed, my villain, there is an overriding absence.

It’s to be expected. I’m not sure what kind of readership I’m aiming for, except for one of fantasy: an ardent following that reads things over and over again, ever searching for nuance. One review suggested a Joycean or Proust-admiring following–wrong. A book of minutia? The word implies triviality, or meaninglessness. I guess Wilfred Bion’s concept of beta elements doesn’t register for average readers; it doesn’t resonate. What do I mean? you may wonder…may wonder. Well, here goes, again: in drama, as in life, there is repetition; repetition that reveals. That’s basic Freud. The paraphenalia of society serve as microcosms of existence, illustrating the unconscious while it fills out the canvas of life. Chris Leavitt’s life is a canvas of elements, speaking in code and then blended into an inchoate mass. Alfred Hitchcock was a fan of psychoanalysis, which informs the themes of CFTH; the same is true of the many motion picture references contained in the novel. Other examples: Macbeth was a man who denied reality, and who failed to understand clues. Fires are part of the back-story of the protagonist, while towering infernos and terrorism now fuel the paranoia of American culture. Texting, e-mail, and the ubiquity of cell phones may dominate as mediums of communication, but it is ancient oral traditions that will whisper truths and pass them along, perhaps especially in small towns in West Marin County, where cell phone towers don’t exist still. Bolinas: the Luddite enclave. May the best grass roots movements of the future be born amongst your wooded seclusion. Within the mass of elements there is order and meaning, and for the attentive observer (as in reader), there is a pattern; an internal logic that ultimately should not baffle. Thus, events unfold in a manner that should feel familiar, perhaps like deja vu. There is a sense of things congealing with centripetal urgency (oops! careful Graeme–that’s a lot of syllables you’re stacking there.)

I guess not everyone will see things as I see them. That, after all, is the point of Crystal From The Hills. Take, for example, a climax of sex in CFTH (not the only climax). A critic has complained that a sexual episode between Chris and his girlfriend Jill–a clumsy grapple and possible rape–retroactively colors their relationship. My response: this passage is foreshadowed about once every ten pages of the novel without actually revealing the event (of course, I’m doing that here). Colors the relationship? The protagonist is guilt-ridden yet avoidant; Jill? she is conflicted: contemptuous and shamefaced, yet uncertain in her revenge. The explicit revealing towards the end is matched by the undercurrent that develops over the course of the narrative. The unconscious in which I place faith enables the reader to find logic and continuity in the unfolding. Meanwhile, the psychologically-minded know that the traumatized take their time, forget and distort, and even when finding clarity, they gauge the safety of those poised to hear their secrets. Is it safe to let you know what’s really been happening? How far have you made it into the novel? Are you ready to hear what its characters really have to say?

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June 24, 2013 · 7:22 am

Crystal takes it on the chin

Pardon the deflection. Actually, it’s me that’s taking the hits, the most important ones from sources yet to be revealed. But I’ll tell you what they’re saying, and why it stings.

I’ve asked people to put their thoughts down in writing so that I can track feedback. With Crystal From The Hills I’ve given them 140,000 words, or thereabouts. I’m getting about 250 back, on average–not that they should write more–but it isn’t fair is it? Where’s the balance? The triage of my not-so-picaresque (according to my harshest critics) yarn has yielded some of the following: words like “muddled”, “unwieldy” (referring to prose), and “not making sense”. With respect to certain elements, such as those calling for psychological terms, a passing knowledge of psychoanalysis, I’d agree that a perceptive, though not necessarily learned reading is required if one is to fully appreciate my tale of trauma, disordered identity, and social conscience.

Action? This brings me to the biggest complaint: what’s happening? some ask. Or worse, where’s the happy ending? Where’s the hope? What am I doing? I wonder: d’ya think I’m gettin’ the wrong people to read my stuff. D’ya think? I know. Try not to be defensive, right? These people are telling me what’s out there; what the average reader is looking for. Do I want you, average reader? do I need you?

Apparently, but maybe I can help…just a bit. Just a nudge, a hint here and there to clue you in as to what I’m doing, and why? Please.

So, first of all, with respect to my much maligned “flurries” of exposition, with respect to workplaces, memories related to fire, make-overs, terrorism, ruminations on women’s opinions, telecommunications: it’s all necessary. It’s all a story, the aggregate of these fragments. Believe me, I worked hard to make all these pieces add up and lodge in the reader’s mind. They are referenced circularly, but not repetitively, and the story of CFTH–it’s plot–runs alongside this collage of reality. Sorry, fans of the unfettered narrative flow, if I’m making life difficult.

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June 12, 2013 · 6:39 am

Working In Rehab: a numbers game

Check this out: Do you like numbers? Ok, here’s a few statistics: according to the Treatment Episode Data Set (TEDS) report, as published online by the Substance Abuse and Mental Health Services Administration (SAMHSA), almost 2 million people were admitted for substance abuse treatment in 2010 across the United States, and just over 2 million people were admitted for the same problem in 2009. These are the most recent years for which such statistics exist. The average number treated over the five years prior to this was between 1.8 and 1.9 million people per year, admitted to just over 13,000 facilities licensed or certified to treat individuals for substance abuse. According to the same data tables, between 7 and 8 percent of these admissions—again, on average—are kids. By kids, I mean ages 12-17, and most of these kids are between 15 and 17. That’s about 150,000 teens per year entering programs, in outpatient or inpatient settings—rehab, as the shorthand goes—for the treatment of substance abuse. And by the way, substance abuse is only one of many problems these kids have. This is the kind of information you’ll find in my forthcoming book about drug rehab and teens, due out soon–though, don’t be misled: my book won’t be dominated by numbers. In fact, you’ll see (I hope) that it takes a skeptical view in general of the application of numbers to my profession.

You see, my profession, that of a therapist, is about making a personal connection with people. I know that sounds like sanguine bullshit, but unlike the average entrepreneur, I’m not selling a product alongside a transient interaction that purports to represent commitment. I’m talking about a solid idea that’s quietly being marginalized in the business of mental health services: it’s the relationship(s) that heal. Not so, according to the larger systems in charge: hospitals, insurance companies; managed care. For them, it’s about “quantifiable” aims, that which can be tracked in terms of symptoms, so-called “scales”, tests of one sort or another. Go to a program, especially a hospital based program and you’ll hear the mantra: tests, tests, we must do tests. Later there will be estimates, both of prognosis, and of the money involved. It’s a reductionist process. Why? Because those paying say so, that’s why. They’ve even enlisted scientists to this cause. By scientists I mean researchers of mental health, people scrambling to publish studies whose findings will rubber stamp the proposed treatment approaches. The process here is tautological: find that which confirms efficacy of the pre-ordained standards. Make it understood that the most cost-effective approaches are the best. Proselytize use of those models that are the easiest to train to the growing numbers of fledgling professionals who are eager for jobs and at best secondarily concerned as to what they’re teaching.

How do I know people like me are looking for jobs? If you don’t believe me, believe a ph.d. Hey, that rhymes. In a report for the California department of Mental Health in 2009, John Shea indicated that positions for social workers, marriage and family therapists, and other counselors would grow by 22%, 21%, and 33% respectively (projected until 2016). His report indicated that over 22,000 people held MFT licenses at that time. That number now stands at over 33,000 according to department statistics. Whoa, that’s growth for you. I wonder if the jobs will run out. At what point does the Board of Behavioral Sciences start making its licensing exams harder to pass, thus titrating the numbers coming into the field. There. That’s a token for those who may wonder who I am to say what’s happening in the business of drug treatment. My question back: who do I need to be?

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