Tag Archives: Candace Orcutt

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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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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