Tag Archives: psychoanalysis

March 13, 2016 · 8:29 am

The War of evidence-based psychotherapy: part two

 

Turnaround is fair play. That’s what it seems like when the champions of psychodynamic models like Jonathan Shedler caricature their CBT counterparts. As I’m no more in their offices as they are in mine, I don’t really know what they do or don’t do in their interventions, but I glean. I don’t glean that my CBT colleagues use workbooks like cookbooks, offering rote interventions that they either memorize or read from a sheet. Nor do I think that most CBT therapists interrupt when a client is speaking of family of origin material; that they scoff at such unstructured navel-gazing and inform clients that exploring the past is a waste of time. Many believe in a structured approach, one that mimics a teaching paradigm to some extent: passing out information worksheets, assigning homework…educating. I recall working in an agency that made copious use of defense analysis worksheets. Clients were meant to read along in a group or in one-on-one meetings, examples of typical defense mechanisms matched to illustrative phrases. They were meant to reflect and say, “I think I do that”, and so on, presumably so they’d learn to not exercise those habits in the future. I’d give lectures to groups on defense mechanisms, codependency—a host of topics I liked expounding upon—delivered bullet-point style, to individuals who appeared to lap up didactic material, to learn if not wholly integrate into their minds, because the learning they need isn’t academic. It simply isn’t. Anyway, the promulgaters of structured approaches think it necessary to, as they sometimes put it, set the limb (with information) before they encourage the broken patient to walk (meaning, explore). It was/is a catchy turn of phrase and powerful use of metaphor, only it doesn’t really work. The mind isn’t like a limb.

But ultimately, it doesn’t matter, this debate between proponents of CBT versus the range of psychoanalytically-derived therapies. It doesn’t matter because the establishment that drives mental health treatment has made its choice, based upon economics (the supposition that CBT is a more cost-effective approach), but justified publicly by invoking evidence-based research. Meanwhile, adherents of psychodynamic models ever hold space for a deeper, longer-lasting, sometimes abstruse and painful descent. Students of these models are on the workplace fringe unless working independently. They sometimes meet, in apparent secrecy, in ‘forums’ in hospital basements, Saturday morning church halls, to discuss their older theories like freemasons keeping one step ahead of orthodoxy. Analyst Wilfrid Bion wrote half a century ago that the role of the mental health provider was to be a container for the pathological patient who attacks his or her mind, and to operate without memory or desire so that an unfettered examination of projections and introjections can occur. His approach wouldn’t fly in most mental health agencies, psychiatrist offices today. He ethos is going to sound a lot different on a treatment plan than, say, “Client will use tools to reduce behavior X over the ensuing 90 days”, or “Take 30mgs of Effexor each day”.

The Bion line wouldn’t go on a treatment plan. It would scarcely enter a ‘team’ meeting, or a consult with a fellow professional. And it’s not because professionals don’t think there’s value in the approach of analysts like Wilfrid Bion or his latter day followers. That’s why the debate doesn’t matter, because it’s not really about which approach is better, but rather which approach is more plainly understood; about what can be quantified, studied, measured, published and disseminated widely so that insurance companies, program clinical directors, and possibly consumers—all looking to varying degrees for ‘evidence’ of what works or doesn’t work—can point to something tangible and say, “hey, this looks like it has substance to it.” It’s about what’s utilitarian, more readily conveyed across channels, such that teamwork, professional fusion—that popular if suspect notion of ‘being on the same page’—can transpire.

When I was a clinical supervisor in a mental health agency, back in the day, I used to assuage interns with non-conformist leanings that the external voices of what is evidence-based are not ‘in the room’ with them (though some try to be or think they are ‘in the room’). This ambiguous freedom comes with responsibility, to decide what’s right for a patient, which often means what ‘feels’ right for a patient, when in the dense meaning of a therapeutic moment. Those patients, the consumers of mental health services, rely upon a sage and flexible approach, and they stand to lose if providers simply conform to that which is prescribed. The notion of ‘what works’ in mental health is quasi scientific, semi-observable; the phenomena of desired outcomes in mental health tend to be thinly defined, and observable only over short durations, which doesn’t speak to the lasting and unknown changes that the consumer seeks.

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March 6, 2016 · 10:33 pm

The War of Evidence-Based Psychotherapy

 

Work in a hospital or a community health agency of any kind and you’re likely to hear the term ‘evidence-based’ at some point, fairly early actually. Also, as a consumer of services you’re likely to have heard this term applied to clinical practices of various kinds, medical and not. In the field of mental health, this term, borrowed from medical science, has largely served as the cudgel of Cognitive Behavioral Therapy (CBT) advocates eager to promote their methods and mostly derivative theories to practitioners and third party payers (i.e: insurance companies). Since the late eighties, the ‘evidence-based’ tag has been used to assert or at least imply the superiority of cognitive behavioral therapy over traditional, insight-oriented or psychodynamic approaches to mental health. The strategy has been so successful that when people speak of ‘talk therapy’, the assumption (contrary to that of, say, two generations ago) is that a psycho-educational or cognitive-behavioral approach is being referenced.

The scope of this article cannot detail all of the differences between the apparently warring factions, though I will point in what I think is the right direction. First of all, a negative suggestion: ignore Psychology Today. It dilutes issues, in my opinion, versus opening the reader’s mind. It does advertise my practice capably enough, however, so that’s all I’ll say about PT for now. Second: besides combing through the one hundred and twenty plus unheralded yet worthy blog entries on this site, readers might seek out the writings of one Jonathan Shedler, psychology professor at The University of Colorado and perhaps the foremost crusader of the last decade for the restoration of the psychodynamic therapy’s public and professional image. For at least that long Shedler has been an outspoken critic not only of CBT, but of its advocates’ tactics in marketing their method to providers, third party payers, and consumers. In Working Through Rehab, my 2013 excoriation of adolescent drug treatment, I cite Shedler’s 2010 American Psychologist article, “The Efficacy of Psychodynamic Psychotherapy”, which outlines the essential features of a psychodynamic (BTW: an umbrella term for psychoanalytically-derived models) treatment, and offers comprehensive evidence for its efficacy, contrary to the dismissive claims of CBT supporters. In his latest paper, “Where is the Evidence for Evidence-based treatment”, Shedler ups the ante with scathing condemnations of research practices of CBT advocates, more or less mocking their claims. The result makes for some entertaining reading, which I shall review here.

Tracing the history of the evidence-based (movement?), Shedler calls out the National Institute of Mental Health (NIMH) as the biggest culprit of ‘evidence-based’ misinformation, starting in the late eighties. Citing research that began a decade earlier than that, he points out that studies pertaining to treatment of anxiety and depression (the two most prominent conditions presenting in MH), indicate only minor differences between experimental CBT-treated samples and control groups on outcomes measured by the Hamilton depression scale; differences that carry statistical meaning (as in not the result of chance) but, as Shedler explains, lack significance in clinical terms, as in discernible contrasts in symptoms, presenting problems. Examining a recent study by Driessen et al. (2013), Shedler derides a method wherein 341 patients were subject to 16 sessions of manualized CBT. Though the method was proclaimed as effective, Shedler points out that only 22% indicated remission of symptoms, based upon assessments taken the day treatment ended. Shedler then points to studies suggesting that even such improvements evaporate after a short period of time and that 50% of CBT recipients seek treatment again after 6 months. And these findings beg other questions: what happened to the other 50% of patients? Did they improve significantly? Did they not improve and then give up on psychotherapy?

Moving on, Shedler generalizes his observations: the average patient receiving manualized CBT is still significantly depressed after a time-limited treatment episode; that benefits assessed after laughingly short intervals after treatment typically evaporate quickly; that most ‘evidence-based’ studies are ‘shams’, suppressing evidence that doesn’t fit preconceived agendas, publication biases extolling what he calls a “master narrative”; that criteria for patients’ participation in studies excludes those who present with more than one diagnosis, or those with personality pathology, to which (I think) most therapists would respond: wait…those are the people we see. Furthermore, Shedler complains that the so-called control groups don’t accurately represent alternative models of treatment; that while prominent or even celebrity practitioners administer the CBT treatment that is studied, psychodynamic methods are carried out by graduate students given minimal training, rendering a comparison of technique unfair. Finally, there exists in research circles what Shedler calls the ‘File drawer’ effect: the phenomenon of studies, or data within studies being suppressed, as in not published, and thereafter shelved (side note: like my Tommy article between 2012 and 2014). The missing data can be inferred from what is called a funnel effect of data, wherein small samples yield a wide range of values, versus large samples which yield a narrower range. The data is then plotted on a graph which resembles a funnel. Shedler demonstrates that gaps appear on such graphs pertaining to manualized CBT research, indicating ‘invisible’ data.

Incidentally, the term ‘manualized’ used and mocked by Shedler merits some comment, as does the rest of Shedler’s arguments, of course, though I’ll shelve most of my comments until part two of this essay, likely a week hence. Anyway, Shedler’s reference to ‘manualized’ treatment is a snide rebuke of therapies that appear to make use of workbooks, often co-written by practitioners and academics. I admit that I have a few of these manuals adorning my bookshelves, though I rarely use them. They contain examples of questions posed to patients about their conditions, designed to challenge problematic thinking; suggestions for a ‘reframing’ of a problem, or examples of homework assignments given—CBT chestnuts, I guess. The comedy in Shedler’s writing—his dismissal of ‘cookbook’ technique—verges on the nasty, but what’s significant is the background context: psychodynamic or psychoanalytic therapies/methods have been taking it on the chin for some time now; dismissed as “that Freud stuff” by pedestrian instructors, psychiatrists, peddlers of psychotropic medication, or ignoramuses positioned at various nodal points in the industry; people who pull the purse strings, or who have those peoples’ collective ear(s), who have been willing to stereotype, quite ruthlessly, the forefathers of our profession. Jonathan Shedler is one of the people at last bothering to fight back. So It’s 2016 and everyone and thing has its advocates. Including the unconscious, it seems.

 

  • I shall refrain from a list of references for this article, though each can be found via Shedler’s 2015 article, “Where is the Evidence for Evidence-Based Therapy”, available online

 

 

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February 7, 2016 · 8:29 am

Listening To You

 

So I conclude this four-part introduction to my paper on Tommy with a reference to its finale: a pop hymnal that Rolling Stone author Dave Marsh once described as “a moving passage expressing that all power emanates from the mob”. For new listeners, “Listening To You”, a refrain attached to the song, “See me, feel me”, might sound a little like the “Let the Sunshine in” passage from Hair, which ran contemporaneously on Broadway in 1969. The sentiments of these songs are indeed similar: an uplifting message of hope for the future, set against the backdrop of a circular musical theme.

The layered meaning of “Listening To You” is addressed in the second half of my paper, which traces the drama of Tommy, proceeding from the opening crisis (the murder of Tommy’s mother’s lover), which his parents cover up, which half-intentionally generates the deaf, dumb, and blind condition which in turn is a manifestation of Tommy’s dissociative withdrawal/silent protest against all that is dishonest. Living his life, Tommy finds a talent, pinball, and becomes a champion of the game and a kind of rock star. Later, as was de rigeur in 1969, he becomes something more than an exponent of light entertainment, something closer to a spiritual leader, inspiring youth in particular. In the midst of this, he is “cured” of his solipsistic withdrawal, transforming from a figure of eloquent silence to one that is socially engaged, if rather didactic in his promotion of “awareness”.

This latter development, to which I had listened casually for years prior to writing my paper, led me to consider other aspects of Tommy’s psychology beyond the effects of early childhood trauma while retaining consideration of that early history. In the service of this task, I turned to the writings of James Masterson and Harry Guntrip, two figures from the psychoanalytic family tree who, like John Bowlby, were writing about things like attachment and loss, schizoid withdrawal, and/or schematics of intrapsychic structure around the same time that Tommy was being made.  Drawing upon Masterson’s model of intrapsychic structure of self disorders, I played with the idea that Tommy Walker emerges as an adult displaying the features of Narcissism and Schizoid personality disorder (the combo presentation is more precisely delineated by Guntrip).

To explain, Masterson’s model is one of so-called object relations units, featuring representations of self and other, which constitute an individual’s false self (a kind of strategic way of being in the world, consisting of an aggregate of experience). According to Masterson, a person’s representations of self and other are nuanced depending upon the nature of their disorder: Borderline, Narcissistic, and Schizoid are the three main personality types his model outlines. Tommy’s Narcissism is exhibited in several ways: initially, his preoccupation with his image in mirrors seems the most obvious indicator; he is lost in himself. Later, he seems grandiose in his emergence as a star, in  his upbraiding of followers, and in his general sense of himself as a “sensation”. Like a tragic hero, he seems destined for a fall. It happens in the penultimate song, “We’re Not Gonna Take It” in which disillusioned (kids?) rebel against the restrictions of the rather farcical “holiday camp” and revolt against Tommy’s leadership. The lyrics bring to mind the kind of scenes that might have happened had fans of Woodstock not tolerated sitting in down-pouring rain, suffering lack of food, overcrowding and poor hygiene conditions for days upon end. Meanwhile, Tommy seems like an aloof figure: essentially withdrawn, somewhat paranoid and alienated, still fearful of being appropriated for others’ needs. His lingering schizoid dilemma is that of seeking attachment while protecting himself from harm, real or imagined.

The hopeful conclusion suggests a resolution of such conflicts, a transcendence of false self strategies such that Tommy and his followers can listen more intently to both outside and internal voices, integrating complex experiences of self and other instead of merely reacting against fate. More plainly, the finale promises that artists and their listeners can learn to move on from trauma, grow up, and deal with life’s triumphs and travails. If that all sounds rather trite or precious, then it may be, but at least it’s more positive or mature than “hope I die before I get old”. Then again, the opera’s libretto (if I may use that term) suggests more or less the same as what “My Generation” did four years prior to Tommy: that The Who would bond with its audience (the mods of the mid-sixties), and reflect their values, dreams, including the nihilism; their love and their hate. So Tommy ends with a refrain that you can sing in the shower, sing from behind the wheel of your car; sing by yourself or sing amongst a crowd. Take your pick, but while you sing, listen:

Listening to you, I get the music

Gazing at you, I get the heat 

Following you, I climb a mountain

I get excitement at your feet

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January 31, 2016 · 7:28 am

You Didn’t Hear It, You Didn’t See It

 

“1921” begins as a sentimental ballad, one of the few in The Who’s catalogue. The line, “I had no reason to be over-optimistic, but somehow when you smile I can brave bad weather”, is one of my favorites. Then, without reference to anything specific, the song turns: “What about the boy! What about the boy, he saw it all!”. Now, if Pete and the boys had plans to enact whatever “it” was, they didn’t let on. Actually, The Who toured with Tommy for at least two years without giving the slightest effort to elucidate the plot, at least not on stage. So it seems symbolic, this thing that Tommy Walker witnessed and shouldn’t have. Anyway, it’s more about the reaction than the event. In the next song, “Amazing Journey”, the opera introduces the famous deaf, dumb, and blind boy motif, which is the implied result of the trauma indicated but not specified in “1921”.

This incident, understood to be the murder Tommy’s mother’s lover by Tommy’s father (or the reverse for those who may have watched the film first), leads to the presumed psychosomatic reaction, manifest as Tommy’s disability. In my paper (reminder: due to be published in The Journal of Culture and Psychology next month), I don’t dispute this popular interpretation, but rather color the event in psychoanalytic theory, and open the matter of Tommy Walker’s early developmental history to further discussion. In covering the possibilities, I employ the theories of Melanie Klein, John Bowlby, plus the observations of researchers Jude Cassidy, and Besel Van der Kolk. Fancifully, I compare Tommy to Hamlet in so far as both protagonists suffer trauma that is as much about secrecy and lies as it is about violent horror. In the refrain of “1921”, Tommy’s parents, anxious that their son has witnessed their crime, exhort him, “You didn’t hear it, you didn’t see, you won’t say nothing to no one ever in your life”, and so on. Like many trauma victims, Tommy absorbs the message but extends the parameters of the injunction. He develops pervasive habits of dissociation, acting out, avoidance.

Then again, it’s possible that the crisis of “1921” is culmination of an already insecure attachment, perhaps established during Tommy’s infancy. Bowlby would at least argue that such a predisposition is attributable to external events: the back-drop of World War, the likely depression of Tommy’s mother in the aftermath of her husband’s earlier disappearance. Bowlby’s followers would assume that Tommy is afflicted with the consequences of maternal unavailability. Attachment researchers might speculate that his symptoms constitute avoidant, ambivalent, or most likely, disorganized attachment. Kleinians, meanwhile, might suggest that Tommy’s deaf, dumb and blind condition is an attack upon bad objects, and at least imply that such aggression, experienced within the murky back and forth of intrapsychic projections and introjections, had been within him since birth.

Cassidy’s paper, “Truth, Lies, and Intimacy”, is the centerpiece of an argument that Tommy suffers not so much from witnessing a murder, but from the distorted narrative that surrounds this horror. She and others, including Bowlby, suggest that distorted narratives lead to a profound confusion which prevents individuals from storing memories properly, hence flashbacks, nightmares, and other disturbances linked to complex PTSD. Of these, none are clearly indicated by Tommy’s affliction. Beyond defiant, he is like the early Who, lost in his own world and marching to the beat of a different drummer (BTW: rock has never known a more different drummer than Keith Moon), and his residues are behavioral, while his internal world is opaque. More than harmed, he is broken, alienated from society, even reality, and it’s hard finding a way back. This idea is axiomatic for many artists, psychologists, and historians, who reflect on this phenomenon, knowing it personally, but extrapolating, imagining collective obsessions around unresolved pieces of historical narrative: the assassination of JFK, the subjugation of Native Americans; conspiracy theories relating to area 51, even 9-11.

Now, had the narrative of Tommy lingered on things like flashbacks, nightmares, or broken alienation, the opera might have ground to a halt, become a drag, as the contemporaneous hippies might have thought. So credit Townsend for staying in the context of light entertainment, making it fun, giving Tommy a talent–pinball–for him to play with (his therapy), instead of wallowing in self-pity and gazing at himself in mirrors. How very rock and roll, I say. Then, when he’s either bored or emptied by games, he grows up a little, notices that his fans relate to him, and decides to broaden his message, speak out. He becomes a spiritual guru. How very late sixties, I say. So, rock stars mature. The paranoid-schizoid becomes a depressive, and it’s all fun and games until–well, someone gets hurt–and then something must be done, though what that something is…is unclear and problematic. After all, the play’s the thing.

 

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January 24, 2016 · 8:42 am

Your mind must learn to roam

A line from “Acid Queen”, one of the lesser famous yet wonderful songs from Tommy, The Who’s iconic 1969 rock opera, and the subject of my forthcoming article in the March issue of The Journal of Culture and Psychology. I reference the song “Acid Queen” in my paper, in a section that tracks the opera’s plot-line, thin that it is, plus its themes. The Acid Queen is a seductress, representing sex, drugs and rock and roll, that triumvirate of original rock and roll sin that, like the devil that once seduced blues musicians (the 20s and 30s blues myth), will tear the soul apart. In “Acid Queen”, a narrator ambiguously instructs that Tommy, or the listener, must “gather your wits and hold on fast”, for growing up, with or without rock and roll, is not easy. Straightforward narrative is not one of Tommy‘s strong points, yet a narrative replete with such ideas is what Pete Townshend wanted to give his music, and rock music in general.

In the 1960s, rock had an emerging narrative, albeit one that was mostly implied, and rarely made explicit. Previously, movies and books with a rock and roll ethos existed, but the most in-depth pop artifacts of the period (Catcher in the Rye, or On The Road) seem more like older cousins of the fledgling ‘rock’ sensibility. The groundwork for a different spirit lay in the context of the era: a relatively prosperous space following world war wherein youth had newfound access to disposable income, plus an evolving electronic media that would galvanize voices against the next war on the docket. I think those post-war kids demanded an art form to truly call their own, and rock and roll, more so than pop, jazz, or even blues, was it. In the 50s, rock and roll’s earliest fans, its infants, seemed to have modest needs, basic social needs: to go out and dance, and thumb its nose at adult squares; to have sexual freedom, and flex muscles. Social conscience, an awareness of life beyond borders of various kinds, of political or spiritual purpose: rock’s adolescent period, the now so-called classic rock period, developed a more mature (if still imperfect) outlook.

The Who weren’t the first, or even the most successful artists to push the limits of the form, or inspire society. Clearly, The Beatles, Bob Dylan, The Rolling Stones, and arguably several others were more impactful at the time. Also, The Who were unlikely heroes from the outset of their career: beyond rebellious, they were noisy, nihilistic, and sort of remote from the sexy, peace-loving milieu of the sixties. Boasting “I hope I die before I get old” in “My Generation”, they seemed the antithesis of mature in 1965. If you want proof of this, look no further than footage of their performance at the flower power-inaugurating Monterey Pop Festival of 1967. Observe the ferocity of their act, the extra layer of violence within their notorious instrument-smashing finale. The Who weren’t just breaking through to an American audience that night. They were staking out a position that ran against the grain.

Yet they were raised to fame alongside the aspirations, lies and traumas of the period, and despite the immaturity, the ugliness on the surface, they were as idealistic as any of their peers. Their violence, as oblique as an intelligent audience intuited it to be, was contained within their art and was therefore no more anti-social than a war movie or a western, but no less revolutionary than long hair or a picture of a Campbell’s soup can. Their loudness was an insistence upon being heard, at once petulant and logical; detonating of harmony yet music to the ears. Their legendary squabbles, conflicts of personality, were a microcosm of democratic values, rock and roll style. After a few years of roaming thus, on the road, from stage to stage (The Who were the first British Invasion band to build a following through incessant touring) they arrived at the decade’s climax, stealing the show at Woodstock, and delivering for an unsuspecting (even) larger audience a character–a mythic character–that was uniquely a product of the rock and roll experience.

Tommy Walker is a child of war: his caregivers are stolid and traumatized, and he is disoriented by their emotional absence. Acting out occurs, a crisis happens, and a secondary trauma concretizes insecure attachment, and begins the drama. Thereafter, Tommy goes inward, retreats from this older generation. Disillusioned (or some primitive version of that), he finds his own music within himself (a “vibration” that brings the raucous music of The Who to mind); he plays unusual games, discovers pinball, and becomes a bizarre celebrity through his talent–a rock star of sorts. He finds his voice, literally and symbolically, and seeks to redress social wrongs through spiritual awareness. And his celebrity, ultimately, is a different kind of hero. Not only talented, he is a unique voice, a social leader, reflecting the expectations of a new audience: that he be thoughtful; that he represent the values of youth, and be engaged with the world. Above all, that he be honest.

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January 17, 2016 · 9:33 am

Ever since I was a young boy

 
(opening line of “Pinball Wizard”)

Well, relative young boy. More like since I was a late teen or even an early twenty-something. That’s how long I’ve wanted to have an article, essay, story or something published in a bona fide professional or academic journal, about anything, but especially about the following subject. It’s happening finally, so it’s time to explain what it is; what it means to me, and what it might mean to others. See, it’s an everything and nothing thing, this paper I’ve written: a big deal and not.

The paper has an impossible title: “A Question of Pathology: object relations, attachment patterns, and a disorder of self within the rock opera TOMMY”. I can imagine eyelids weighing heavily over the first several words, that dense, psychoanalytic jargon. Only the last three words spark interest, jolting the pop consciousness. Not for everyone, I guess. For those of a younger generation, The Who’s iconic double album of 1969 may be little more than a crusty artifact of classic rock, one whose moment and meaning has long since past. Wasn’t the main guy in The Who busted for child porn some years ago? some might query. Others might know snatches of their songs: “Baba O’Riley”, “Won’t Get Fooled Again”, “Who Are You”, and “Eminence Front” will all be familiar to CSI fans, viewers of car commercials, or whatever the products were that my favorite band sold out to. Though their days are surely numbered, The Who continue to tour like cabaret acts of previous eras, even as their two surviving members, Roger Daltrey and Pete Townsend, glide past the age of seventy. They grind out the hits and the show goes on, seeming more professional than ever, actually. But their relevance to the world around them seems–if not diminished–then perhaps just less clear as time moves on.

That wasn’t the case back in the 80s when I first heard their music, or saw the odd video of theirs on MTV. I didn’t listen to them much at first, but knew of them, was aware they were deemed cool by peers who seemed to speak about music with authority. My family alluded to The Who, but were not fans. “Just noise” my sister opined on occasion, though she seems more respectful today, in deference to me I think. “Didn’t they smash their instruments?” my mother would incuriously ask, just hoping to join in the conversation somehow.  In my household, lighthearted pop dominated: jazzy sounds of Sinatra, Streisand, or the rockabilly of Elvis  stirred my father’s blood; the loving, cheerful beat music of The Beatles or The Bay City Rollers were my sister’s favorites; maybe a wistful Simon & Garfunkel ballad made it into the mix. Don’t get me wrong, I liked all that stuff, but it didn’t move me as The Who later did. Until I was a later teen, music didn’t speak to who I was, or who I wanted to be. Thirty years later it’s still hard to explain who I wanted to be, or how bands like The Who helped. All I can say is that rock and roll seemed more than commonly important back then. Its leading lights had much more than talent, or “class”, as the generation above me uses that term. Instead, there was something else, something more desperate. The giants of the classic rock era had brains and guts, and they played their music like music itself was about to die.

It was easy to get in arguments with friends (Ultimately, I wouldn’t bother with family) about whose favorite artist had the best chops, or the smartest lyrics; about which band was the only one that really mattered. My band was The Who, and for about ten years in my late teens and into my twenties, I was more devoted to them than I was to any girlfriend; more knowledgeable about their story and catalogue than I was of any author’s oeuvre, or any psychological theorist’s body of work. Had I been a thug, I might have defended them against critics like a hard-core gang member. Had they toured regularly during this period I might have followed them like Grateful Dead fans followed their heroes. I was down for The Who, and if I’d had the opportunity, the right context, and the confidence, I would have written about them also.

And so, to the paper. It started around 2006, when I was taking part in a study group with the West Coast Masterson Institute, led by my friend Joe Farley. In illustrating some point long since forgotten, Joe made some comment about modern musicals, narratives and psychopathology, and might have mentioned Tommy–I don’t recall the specifics. Anyway, we talked further, and Joe suggested I write up my then idea, which was to give the The Who’s deaf, dumb and blind boy a diagnosis or two. It was a fanciful suggestion, but little did Joe know how serious I was. Sometime later I presented him with a 3000 word essay that he thought worthy of passing on to Dr. Masterson, then still active and living in New York. Well, Dr. Masterson (who vaguely recalled meeting me once) read the paper, liked it apparently, but said it was too long for the institute’s then newsletter. Instead, he suggested I hawk it to academic journals, which I’ve been doing ever since.

Now, if you’ve ever submitted a manuscript to an academic journal, you are likely familiar with the lengthy delays, re-writes, and rejections that often follow. Between 2007 and 2012 I submitted my paper to about a half a dozen different journals: one Bay Area-based, the rest national, and in two cases, internationally-based. This might not seem like an ambitious spreading of the net, but let me explain something: When you submit to an academic journal, editors request that you not submit concurrently to other journals, as they are committing themselves to a rigorous review of submitted work and wish to have assurances that they are not wasting their time lest an author’s head be turned by another. Fair enough, but the commitment meant that I’d spend close to a year with each journal consecutively, four out of six of which expressed significant interest, requests for re-writes, before ultimately rejecting my work following a staff voting process.

By 2012, I was jaded with the sporadic task, forgetful of my original purpose, and ready to mothball my paper to the shelf, there to sit amongst my self-published, occasionally lauded but nonetheless un-celebrated collection of novels. Then in 2014, two things happened. First, The Who announced its 50th anniversary tour–likely its last. Secondly, I read an article in another journal, a psychoanalytic review of Henry James’ Portrait Of A Lady, that was similar in structure and style to my paper. Now, the journal in question had already rejected my work, but as I glanced at my 2007 list of prospects, I saw that there was one journal I’d yet to solicit: The Journal of Culture and Psychology.  What did I have to lose except a bit more hope and narcissistic fuel? I thought, and thus I submitted my journeyman paper once again.

A familiar pattern ensued, save for one aspect: in the spring of last year, the journal contacted me, saying they were enthusiastically interested, but requesting changes. Sigh. Here we go again, I thought. Still, I soldiered through, reminding myself that this was, after all, a labor of love and there are much worse ways to spend my time than writing about my favorite rock band’s most famous work. Anyway, I made the changes, working hard on the paper over a space of a month, and resubmitted. I went about my life as patiently as ever until September when I received an e-mail suggesting I had just a week to meet the journal’s deadline for re-submission. Huh? I e-mailed a polite WTF to the editor, and within three days received an embarrassed admission that my re-submitted manuscript had been misplaced–lost in their system. I laughed sardonically, thinking this thing was just not meant to be. But once again I re-submitted, this time thinking what’s another six months or so in the life of an itinerant piece of literature. By this time, the lifetime of the project was a fifth of the length of The Who’s career. An apt parallel was happening, I mused.

The journal moved swiftly thereafter, however, and in early October I was told the paper was accepted. Hooray. Three months later, its modicum of copyediting completed, I was informed of a March 2016 publication. So that’s the backstory. My commentary on the paper itself is still to come.

 

 

 

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January 4, 2016 · 8:49 am

Somewhere in the notes

 

Somewhere in a pile of notes I found the sheets that I’d used last year for the presentation in Marin. There were several problems, and that wasn’t counting the main problem from last year: I’d taken too many sheets, overestimated, as is my habit, the size of my class. This year I’d get that part right, by taking fewer copies. But looking over a page, it occurred to me that I might not take any. First of all, the print was too bulbous and thus barely legible, the result of having been copied too many times. And the reason for that? The sheets were old, outdated. See, the top half was all about the DSM-IV.

As I groaned, I logged onto a DSM V site on my laptop, not having my expensive, thick volume with me. That’s one of those false norms, I thought, referring to the habit of placing books of presumed importance on the shelves of my office. Truth is I hardly do any reading there. My office is where I talk and listen, but not read. If I have a break or cancellation I make calls, or go for a coffee, or hit the phone and read e-mail, my favorite internet sites. I don’t read at my office, not in the old-fashioned sense at least. That I do at home, so there I was ready to read, but frustrated by an empty hand. Not for long. I found the necessary file, and soon I was scrolling down over the details of Narcissistic, Borderline and Schizoid disorders, the subjects of my forthcoming presentation. Having not bothered to review the now three year old descriptions, I was feeling precipitately sheepish, but also prejudiced. Footnotes about Schizoid personality regarding the less than 1% diagnosed with that condition had me scoffing with disdain, thinking some things will ever be missed, but the rest had me raising an eyebrow. Ten minutes later I was left impressed by the inclusion of fresh elements, or elements spoken of for years by many, but exiled from a generation by the DSM-IV edition. See, it’s now indicated in the diagnostic lexicon that Narcissistic personalities manifest an underlying vulnerability, one that has clinical utility, which is a crucial implication. Meanwhile, the new volume notes that Borderline personalities are not only labile in their relationships and emotions, but more broadly, disorganized in various aspects of their lives, and prone to fierce self-criticism.

These distinctions have been less emphasized over the last two decades as far as I can tell, and the impact upon training programs has been profound. The last time I provided a training to interns regarding James Masterson’s disorder of self model, I found that students, like my contemporaneous colleagues, tended not to observe the helplessness defense of the Borderline, or the exquisite sensitivity of the Narcissist–at least, not such that these qualities would determine the style of intervention. My biggest challenge over the next two Wednesdays is to convince relative novices not to explain too much, or to find solutions, problem solve or give ‘tools’ to their patients. It will be too late for some. Those committed to CBT, DBT, or whatever other fashionable methodology exists will want to know what to do long before they really understand who they’re sitting with. That’s the nature of our business, especially at the ground level, where everything is meant to happen quickly.

What’s meant to happen is difficult because patients in psychotherapy are largely unaware of how they block their own growth, or behave self-destructively. Therapists who think that statement disrespectful–not sufficiently positive–collude with the defensive intrapsychic structures of their patients. To the person engaged in a flight into health, proclaiming positive change in the immediate aftermath of calamity, they nod in passive support, vaguely unaware but not speaking to the patient’s likely effort to not deal with past damage. Regarding the patient who is late, not making appointments, saying “I hope you can find it in your heart to not charge”, they give slack, believing they are being flexible, empathetic, “meeting the person where they’re at”. To the person who is detached from emotion, uttering phrases like “it is what it is”, brushing off loss and pain, they are virtually applauding. Such “interventions” don’t hold people responsible for their behaviors or foster a sense of reality, and are actually disrespectful, for they don’t hold the standard or expectation of maturity.

I know I’ve thought these things for years, so I don’t really need the DSM-V to change anything with its subtly added footnotes. I just need to organize my notes.

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December 13, 2015 · 6:54 pm

The Orb

 

The spherical object sits atop a glass coffee table between myself and my patients, apparently inert save for the qualities Maggie, Ray, and Joe assign to it, and which they absorb. Maggie, my regular ten o’clock on a Wednesday, gives the object a forlorn glance whenever she feels stuck in thought. Briefly, it seems there may be inspiration in its translucent green, or refuge in its fetching diamond patterns. Soon her eyes move away, tracking mid-morning light spearing in from the East. Maggie notes the illusion of choice.

Others make a tactile move. Reaching for the object, Ray sometimes remembers that despite paying for the hour, he is a visitor and therefore asks permission to handle my belongings. “What is this?” he more specifically asks, a fraction of a second before an entitled, if gentle seizing. “It’s an orb,” I say proudly. I found this thing in a consignment store about five years ago, and was struck then by its occultish mystique; its compelling, Kubrickian appeal. Placing it center stage in my office, I imagined it might pique interest, or perhaps graze the unconscious, stirring wonder of an alien presence amid frenzied thoughts about self. Ray appears to envy the undisturbed demeanor of the orb, thinking it a symbol of coveted stolidity. I’ve known him to study it in detail, gazing about its every inch as if determined to see inside to discover secret contents, like a way of being. Like many objects that remind of childhood, the orb is shiny and promissory of concealed riches, a garden of delights within. In such memories, I think the world is like Christmas morning: made up of rainbow pastures ever beckoning yet beyond reach, teasing with magic, and not yet disappointing with empty spaces, the residue of a dull, grown-up’s contrivance.

Maggie says she gets lost when she “spaces” on objects like the orb. Her purpose is escapist, she declares ambivalently. The orb, the seductive toy, compels rumination: a speculative inventory of its details; an imagined backstory as to its production, even its merchandising. Upon hearing my tale of discovery and purchase, she cooed like I’d just described the story of an abandoned animal rescued by me. Had Maggie found it, the orb would have spurred a poem, and thereafter a ceremonial place in her heart. In session, after frozen minutes contemplating the orb’s essence, Maggie’s foiling of herself is complete: she has forgotten something, the terrible thoughts and then feelings that search for release, only to find a dead end doorway. Sometimes I envy the orb also, though not in the sense of wanting its qualities; more in that Kleinian, spoiling the object sense of the word. At these times I want rid of my cursed ornament and its solipsistic, self-blocking evil.

Joe on the other hand satisfies the repressed urge, performing that which I can’t do myself. And he does it ingeniously: without conflict, self-consciousness; without giving it a moment’s thought, bless him. He doesn’t even ask permission. Slumping on my couch, his slovenly adolescent frame stretched out, he grabs at the orb on his way down and begins a gifted juggling act as part of a session norm. Over the course of fifty minutes he intermittently tosses the orb from one hand to the other, ignoring its aesthetic value entirely, instead focusing upon the action; the soothing, mind-and-body organizing action. For Joe, the object is a baseball substitute, which is in turn a sublimation of something, but isn’t any longer since Joe got kicked off the team for smoking too much weed. But hey, repression doesn’t really work, I say encouragingly. “Damn right,” he replies, a little too pumped by the notion. I clarify that defenses, like people, aren’t meant to be perfect. “Right on,” he says after a seemingly thoughtful pause—a pause which breaks his rhythm, causing the orb to sail beyond the unadapting reach of his left hand, descending like a breaking curve ball towards the perfect glass of the coffee table. A moment later I am shaken by the cracking sound of impact, the vision of a spiderweb pattern now spread over splintered glass. “Oops,” says Joe, looking inert.

**this story is a fiction

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December 6, 2015 · 5:50 pm

Neuroplasticity and a dog’s guilt

 

So let’s tie the dog story in with that thing about neuroplasticity, the previous blog essay. Recall that according to the likes of Daniella Schiller, retriggered memories can be ‘reconsolidated’, that is re-scripted or deleted if, during a critical period, a subject is given either a protein-blocking agent, or is presented with new data that contradicts a conditioned response. Other researchers Gorman and Roose interpret that the timing of interventions must therefore exist in proximity to reactivation of traumatic material, as the Schiller experiments imply.

Skeptical analyst Richard Tuch challenges this finding, suggesting that the material of analytic patients is too complex to be modified by such behavioral techniques.

So let’s look at my shaggy dog story and identify the different elements that seem relevant to the issue: the CS or conditioned stimulus; the conditioned response, or CR; the observed outcome of an informal effort to reconsolidate. To recap: a car rolls down a slight incline, bumping into another car because…well, we’re not sure why, but it seems as if a dog had something to do with it. You see, a taciturn Doberman had been sitting in the driver’s seat at the time of rolling, so I speculate that the animal had inadvertently dislodged the car’s emergency brake, thus sending the vehicle on its way. When the owner (not ‘driver’—the distinction was important to her) appeared minutes later, she seemed concerned, but more defensive than, say, remorseful about the accident, or relieved that the misadventure hadn’t caused more harm.

My friend, another therapist, tried to intervene on this latter point, timing his explanation of averted consequences about as proximately as was possible to the accident, the putative trauma. But was it the trauma? What actually happened in this scene, and did it lend itself to things like reconsolidation of new data, contradicting a conditioned response and so on. It didn’t appear so. As I’ve previous written, the woman in question appeared to bristle at my friend’s sober counsel, rejecting it on what I sometimes describe as ‘process’ not ‘content’ terms. Meaning, her response—‘I don’t need to be counseled’—seemed not so much a rejection of an observation (the ‘someone could have been hurt’ truism), but rather of my friend’s prerogative to make the point, regardless of its validity.

In this instance, it seemed important to consider not only the timing of an intervention, or even the nature of the intervention (a confrontation versus, say, an empathetic overture) but firstly, to consider what exactly had been stirred in the woman. Not that I’m feeling critical of my friend—what he said was necessary for someone to say—I’m merely interested in a different phenomenon. By my passive and thus detached observation, it seemed from the outset that the woman was far from horrified by the disastrous possibilities of her car rolling down a hill. Initially at least, there was no sense that she would thereafter feel afraid to get in her car, or park it elsewhere, or even leave her dog in the car unattended. Immediately, she seemed more concerned with the matter of blame: whether she was being cast as the driver versus the owner; whether she’d be held responsible for the apparent damage to the vehicle her car and dog had lightly struck. If I were to guess I’d say she was embarrassed at being the center of negative attention, the object of suspicion, perhaps ridicule, due to the absurdist nature of the scene. Her backstory—or trauma, if you like—likely had little to do with car accidents, much less tragedy, but rather a memory of public humiliation, entailing a dressing down by righteous figures, perhaps more commonly male. That’s my guess.

And so it seemed that my friend’s intervention failed—partly because of its timing, I suspect (she might have been open to instruction later)—but more pertinently, because the experienced and therefore salient trauma material was not contradicted by the intervention, because it did not constitute ‘new’ data in the sense that is being discussed. If the negative memory is about humiliation and blame, then the CS—being criticized, especially by a man, or a stranger—perhaps reconsolidated old data, rather than introduce a cautionary tale about driving or concern for others, the putatively intended ‘new’ data. Therefore, a CR—defend oneself—was readily enacted and was, if you like, reinforced by the ensuing interaction, though in my opinion, the woman’s reaction was inflected more by her projections than by reality, which again, analysts would cite as complicating factors which…wait, I think I know what you might be thinking.

Are we over-thinking this?

If you really think this then you should probably stop reading my blog, and don’t even bother with my books, because you will often think this of me. Anyway, I wonder if the woman will re-visit this episode, perhaps talk it over with someone she trusts; someone who might, in turn, instruct her as my friend did, to which she might say, “That’s what this guy said, who saw what happened”—in response to which an astute and curious listener might begin a different process, introducing a new layer of data. See, that person might ask, “And what was that like? Did it stir anything up for you?”

 

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November 23, 2015 · 6:46 am

Working Through: the bad news about neuroplasticity

 

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

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

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

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

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

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

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

 

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

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

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

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