Tag Archives: psychodynamic therapy

The long and the short of it: a dialogue

 

So, the zeitgeist in sex addiction for so long has been to question whether sex addiction is an excuse—ya know, something that lets creepy, no-good scoundrels (heterosexual men, basically) off the hook, absolving them of…whatever the assessment of addiction is meant to let them off the hook from. Punishment, presumably: punishment from courts, employers, wives and girlfriends. Wives and girlfriends mostly. If a man has a sex addiction then he has a disease. He has an affliction, merits compassion and support, not judgement. Cue the next bit wherein someone says it’s understandable that betrayed partners would launch into a volley of judgement upon discovery of secretive behavior. They’ve been traumatized, after all, and not just by the addictive behaviors, the obsessive use of porn and prostitutes, plus those sleazy hook-ups and online affairs. Beyond that, these partners have been lied to incessantly; subjected to years of obfuscation, counter-accusations of paranoia, controlling behavior. Now the cat’s out of the bag he wants compassion, cries this beleaguered figure! Seriously? After years of being told I’m crazy I’m supposed to just accept his abject apology and then go along with this crap about addiction, while thinking what? Oh, poor thing, he just can’t help it. Let me tell you something, I’m…

Okay, I don’t hear that so much—that I’m-about-to-march-out-of-this-office diatribe. But I do hear of it from those who have previously been to therapists who tread a little close to the door marked GIVING ADVICE. Their “educational” comments carry an inflection of sympathy—too much sympathy for the angry person who is looking for someone to be angry with them, sort of. Yes, tsk tsk, exudes the right-minded listener instead, regarding that misbehaving other. What may follow next is a flurry of suppositions: how pervasively has this behavior, plus the secrecy, affected your life? How many conversations, potential intimate moments have gone awry because he was elsewhere emotionally, not truly present with you? What about the diminishing of romance, of your sex life, even? How many times have you been denied sex because he was with someone else, or thinking of someone else, taking care of himself, forgetting about you? How many times did he come home late from work? Now you know what that was about. And think about all the money that’s been spent, or the time that’s been wasted. No wonder his career has stalled, and how has that affected you, burdened you, given that you work also, plus you do the lion’s share of stuff for the kids. Treatment? For him? The person who really needs compassion and support is YOU.

There’s a subtext to such counsel, one that is rarely made explicit because that would render the message ironic. The task is to insinuate the potential for revenge while maintaining the position of victim/survivor. So, that subtext, stripped of its artifice, goes something like this: ya know, there’s a silver lining to all of this. If you’re honest, this relationship has had problems for years and until now you weren’t sure how much the problem was him versus you. You thought he had fallen out of love with you, thought you were a B, like what your last boyfriend thought, plus what your sister used to say about you. Anyway, do you have any idea how this could be used to your advantage? Do you have any idea how much this lets YOU off the hook? From now on being difficult is no longer your problem. You being difficult becomes your entitlement. Yes, I know you didn’t want this. I get that this was your worst nightmare, besides something terrible happening to your kids, of course. And I know that thinking he’s out of control will keep you up at night, worrying where he’s at when he’s traveling—who is he with, and whether he’d leave you high and dry. But think about it: this addiction thing can be the punctuation of all arguments for the forseeable future, and you can leverage his guilt. Believe me, sister, you may have the pain, but now he’ll get the blame at last.

             In most niche fields in psychotherapy, this kind of subtext, as well as the manifest content would be tagged as scapegoating. In psychiatry we have the term identified patient to in fact direct clinical attention to a systemic problem versus a “one-body”, internal or intrapsychic disorder, as it may be termed within a psychodynamic framework. In sex addiction treatment, however, the singular focus upon the acting out person’s “problem” is a virtual orthodoxy, reflecting an alliance of social and professional forces: on the one hand, the mores of social justice, which counter-privileges the perspective of underprivileged populations, especially women; on the other hand, a traditionalist objection that posits sexual betrayal as the most sensitive of personal offenses—an offense that clears the table of mutuality, allowing for an old-fashioned script of who’s been good and who’s been bad. Yes, says the offended partner, “I am no angel”. Translation: that’s all we’re going to say on that subject for a very long time, maybe ever. That’s the flip side of the “excuse” phenomenon. Reductionism, short term interventions, simplify and thus remove not only ambiguity, but also responsibility that might otherwise be dispersed; the addiction treatment stratagem, peopled by professionals with first-responder heroism encoded within their approaches, makes supportive gestures easier, confrontation of problem behavior more, shall we say, economical. Whoa, wait a minute, hold the phone, says a sex addiction specialist. Oh, I see. A dialogue:

Specialist: Are you saying that’s what a therapist would say to a non-acting out partner? We don’t give those kind of messages to non-acting out partners. Well, okay, we might say some of those things but not to encourage revenge, and you have to remember that most partners in these situations have been gaslighted and then traumatized by their discoveries. After all, do you have any idea what it’s like to pick up your partner’s phone, and by accident (maybe) read a thread between him and some other woman that is obviously sexualized, and know in your gut that it’s been going on for years. So of course we hold the acting out person’s feet to the fire. Of course we encourage polygraph tests, full disclosure. That’s necessary and fair for the partner so she can begin to heal…with the truth, the full truth of his past and present behavior. But anyway, we do counsel the women that the issue may be complex and that at some point it would be important to address in couples therapy some of the long-standing communication issues within the couple relationship.

Me: Really? At what point would you begin that?

Specialist: Well, we wouldn’t. Our program’s only two weeks long, so we’re more about offering support and education—getting them started, teaching them about addiction and coaching boundaries, that sort of thing.

Me: Ah yes, getting them started. Reminds me of the “let’s get ‘em in the door” ethos of drug treatment; the “let’s fill some beds” mantra that program administrators used to utter to intake coordinators. It’s familiar to me, that get-them-started-then-forget-em-when-they’re-gone thing.

Specialist: It’s not like that. We give them referrals to couples therapists, people who truly know about sex addiction and understand about the traumatic impacts upon partners

Me: So, that “complexity” you spoke of—is that a euphemism for shared responsibility for a bad relationship, or do you imagine or hope that follow-up support groups and couples’ therapy will fossilize the dichotomous roles of victims and perpetrator?

No answer. Or none that isn’t a glib reiteration of previous points, anyway. So much for dialogue. I’ll just cast my mind back to those scores of books and academic papers, or that conference or two where revered figures in our profession were asked before an earnest crowd, what are the most significant factors in a positive therapeutic outcome? The therapeutic relationship, a gnomic elder would reply. I know, because I’ve heard that response more than once, and I’ve watched intently as heads nod in acknowledgement of the word. The therapeutic relationship. It seems to say everything and nothing, doesn’t it? Maybe it sounds like an offhand remark, or a platitude, and perhaps it is, though it’s not quite the oldest idea in modern psychology. Freud took a while, I think, to come upon the idea of the transference-love phenomenon in analysis—or the transference-hate equivalent. Before this, he’d traversed failed experiments in hypnosis, techniques like the talking cure, even the more resilient practice of free association, until discovering that a patient’s resistance to care, based upon feelings transferred from prior experience and relationships, is the most important hurdle to surpass if treatment is to succeed. I think our profession’s truest elders still think this the key to positive outcomes. Free association, as in a stream of unfettered thought, doesn’t come easily, yet that outcome is more important than most people think. And a clinician’s countertransference is part of the equation: he or she uses their internal experience and reflects something back that points to something missing in the patient–a lost self experience, as many have written of it. It’s a slow process, one that may take months or even years.

There are many who enter a psychotherapy episode, or who provide care, who simply do not understand this mysterious exchange. Some may think the magic happens in moments of inspiration—change on a relative dime because of a divine taking in. Yes, you work through that conflict with that person whom you had to endure for a spell and later, when they’re gone and no longer stirring your resistance, you reflect upon how they really helped you, and so maybe you’ll go back one day and tell them how they changed your life by telling you a blunt truth days before never having to see you again. Yes, that’s how that happens. Do they last, these prescriptive plans, these outlines of change that many leave therapy with. Do those galvanizing confrontations that didn’t stick before stick ever after? We like to think so. If we’re honest, we think not.

Leave a comment

Filed under Uncategorized

The old scripts

 

A man sits in a conference room, chatting collegially with a pair of co-workers, ostensibly leading a meeting. Technically, the man is in charge, but he prefers to keep things informal, not throw his weight around. Soon they will be joined by another man—everyone’s boss—who appears to not have such reservations. As a kid, he will have been a problem, this man: if not an out-and-out bully, then maybe just a nuisance; tagged as having attention deficit disorder, and needing a good dose of meds in order to follow directives, play well with others. Today, an observing psychiatrist might say he has poor audience; meaning, a blind spot keeping him from knowing where he treads. A less generous opinion would be that he doesn’t care. He walks into a room and simply expects people to drop what they’re doing and focus on him. It’s how he got to where he is, he might say. His turn to give directives, direct play. That is, if he notices.

The first man has had a different life. Until now, his once subordination to either bullies or the inattentive has been dormant. He’d worked hard, quietly achieved a certain status within the organization, and earned his graduation to civil society, mostly spared the obnoxious company of autocrats whom he’d suffered plenty enough as a younger man. When the boss walks in he begins talking louder than anyone else, instantly turning the heads of everyone present. That other collegial exchange is now relegated in importance, which immediately stirs in the first man a dreadful anger. What is this feeling? the man wonders…later. In the moment, his thoughts go blank as his adrenaline surges, followed soon by a chill sensation. Bad, implicit memories. Anxiety. The resultant compromise between states is a halting, passive, as in barely discernible complaint: “I guess we’ll postpone our talk until later.”

In models of psychoanalytic psychotherapy, espoused by the likes of James Masterson, treatment proceeds with the following assumption: that individuals develop self and other representations, based upon an accumulation of experience of ourselves in relationship with others, which in turn forms a psychological structure that is activated in times of stress. Our explicit (conscious) and implicit (unconscious) understanding of ourselves and others is an aggregate of our object relations (experience with caretakers), derived from early development, and nurtured over time. The task of therapy is to make sense of one’s own mind and that of a therapist, even though manifest content tends to eschew focus on the therapist, especially early in the process.

Self identities—meaning, strategies of being in relationship—are often fixed and rigid by the time therapy begins. They constitute a way of getting by, but not of growing, or of being happy. A kind of quantum phenomenon collapses time, disorienting the distressed patient, who experiences new stressors with an old psychological structure, and therefore people are dimly reminded of unfinished business, though presented with fresh choices. Though I am few people’s idea of an autocrat, I might tread on toes this day, and look into fleetingly bewildered, scared eyes; hear the opening strains of quickly defended selves. I wonder what they’ll say.

 

Graeme Daniels, MFT

Leave a comment

Filed under Uncategorized

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

Leave a comment

Filed under Uncategorized

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.

Leave a comment

Filed under Uncategorized