Tag Archives: trauma

The ultimate risk of addiction treatment

 

In the field of addictions work, so-called, it is common for practitioners and later patients who integrate ideas to cast addiction as a problem of emotion.

The addictive personality is one who is pleasure and novelty seeking, and risk taking, it is said. Risk-taking except in the area of intimacy, wherein he/she is likely avoidant. Psychoanalytic theory, attachment theory, and a host of techniques derived from either, are supported by neurobiological research, which affirms that unconscious process, communication that occurs implicitly, via eye contact, body language, and voice prosody, is mediated via the prefrontal orbital areas of the brain, and nurtured (or not) in human beings during early childhood development. The role of the therapist in our society, not unlike that of the early caregiver in some respects, is to serve as an auxiliary ego, using words, reflection, tone and physicality: to connect.

Addicts and trauma survivors would appear to have something in common: a penchant for disconnection, or dissociation, as trauma researchers indicate. John Bowlby, the founder of attachment theory in the latter half of the twentieth century, offered that psychoneurosis derives from protracted separation anxiety: that children deprived of maternal care first protest, then despair, and then finally exhibit detachment, which is characterized by dissociation, a state of disembodied escapism. What latter day research indicates is that infants and toddlers’ levels of the steroid hormone cortisol maintain elevated levels when a caregiver is either absent or insensitive. If such a child is deprived of all caregiving, cortisol levels stay chronically high and therefore children will develop passive parasympathetic strategies of dissociation. Habituation of the brain to the opioid-releasing state of dissociation thus becomes a “default mode” of affect regulation. The result: a predisposition to addictive behaviors, and insecure attachment in the form of an unresponsive, intimacy-avoidant personality.

This perspective is a paradigm shift for many seeking treatment for problems of substance abuse, sexual acting out, food addiction, and such, because society’s inclination is to externalize the problem of addiction: it is the substances that are addictive, for example—not so much that a predisposition within an individual exists. Meanwhile, sex addiction is a term used by some to exert an alternative, moralistic argument against sexual promiscuity, or alternative sexual lifestyles, rather than an assessment term that draws attention to a mood or mind-altering use of behavior. Food addiction is a label that is likewise criticized for being a thinly veiled attack upon the obese, especially obese women. The problem with labels is that they elicit persecutory anxiety, especially in those prone to what Melanie Klein once termed the paranoid-schizoid position, a primitive stage of childhood development. The benefit is that labels, like any succinct form of communication, draws quick and urgent attention to problems that merit just that.

The reason why the paradigm shift is important is so that preventive measures can flourish. Education is of course important, but education in the cognitive, Socratic sense is only the beginning, not the end of the intervention. We can, as we have for decades as a mental health community, provide appropriate medical care for those whose dependencies (to opioids and alcohol, for example) merit such monitoring and focus; we can concurrently and thereafter dogmatize that the consequences of addiction (jails, institutions, and death, to quote 12-step programs) are prohibitive; we can gingerly (or not) shame addicts into realizing that their behaviors are self-centered and immature, and we can impose various consequences based upon the premise that imposing limits will alter behavior (actually, limits are a good idea, but are mostly beneficial for friends and family—not as an agent of change in treating addiction). But for real change, the following is necessary.

Consciousness. Structure. Honesty. Time. Consciousness comes first. Not consciousness of the problems outlined in the last paragraph. There’s plenty of consciousness-raising about that already. Consciousness of feeling states, beginning perhaps with bodily sensations, as mirrored, amplified, and sometimes spoken to by an observant other, perhaps a therapist: someone who will monitor the moment-to-moment reactions of the patient; modulate closeness, sensitive to the fears that may manifest as withdrawal, whether the person is aware of their defenses or not. Structure comes in the form of routines: go to therapy, 12-step meetings, work and family obligations, etcetera—those necessary things to do to support growth and recovery. Time: the re-building of this afflicted self takes time, patience, and ongoing consciousness, about things like bodily sensations, feeling states that are felt and not—about that which has been driven underground, into the unconscious, and otherwise discharged via behavior.

This recovery process is another kind of risk. The biggest risk of all: to re-attach.

 

Graeme Daniels, MFT

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Personality Disorder: the other way (part two)

 

I want to blame someone. James Masterson did also, I think. He will have argued with many over what comprises a real versus a false self, or a personality disorder—whether such a thing exists with some. Were he alive today I think he’d argue with proponents of trauma model, and possibly with authors of novels like The Woman in Cabin 10. Not that these people don’t think that personality disorders exist. They simply call them something else, because mental health services, like any commodity, ultimately, is not just something to be validated by research, or—sorry—evidence-based research. It is something to be sold to the public.

For the average consumer of psychotherapy, a diagnosis of trauma, whether that trauma is episodic, chronic, the result of fatefully aberrant events or an aggregate of quaintly termed little ts that shape development (the theorized etiology of personality disorders) is simply more palatable. The word connotes victimization by an external agent, and thus a diminished responsibility for the sufferer. Treatment encourages a present identity of a survivor (very popular), with a possible future of healing. It’s a meet-them-where-they’re-at-thing. Regarding etiology, the accent is upon recent, precipitating events, with an intellectualized nod towards distant antecedents, that complex internalization of others which blurs a simplified reality.

Trauma model practitioners pay lip service to the antecedents of trauma. Prominent authors even co-opt object relations theories without crediting them, and repackage (reframe in the jargon of the field) personality disorder as something like developmental or relational trauma. A good example is featured in Barbara Steffens’ Your Sexually Addicted Spouse, whose target readership is evident by the title. In her text, Steffens describes PTSD as “something that can last a lifetime”, and that relationship trauma entails “painful coping mechanisms ingrained in personalities” Study the work of Klein, Fairbairn, Mahler, Winnicott, Masterson or Kohut and you’d hear the echo of their theories in such pop psychology literature: that psychic pain is integrated into personality over time, generating a disordered self in which such pain is habitually defended against in relationship.

But again, while trauma model educators pay lip service to old patterns, they mostly ignore it in treatment. The reasons are two-fold: A.) Treatment doesn’t last very long in this model. It’s a two week stay in a group home of some kind, or an eight-week course at your nearby hospital. B.) Discussion of problems is intellectual, academic—therapy as education. You’re given homework, even, to solidify the association with school. This is organizing, some say. Stabilizing for the unsafe person who cannot, it is presumed, manage complexity, the uncertainty of not knowing more deeply why something is happening. They are unable to weigh or contemplate their own mind alongside those of others, which are similarly complex, and implicitly dangerous. This danger is cast as objective reality, and anyone who says otherwise is “gaslighting”. Thus, treatment prioritizes affect regulation techniques and procedures, not the contemplation of self and other; it advises the practice of coping skills, self-care activities—all of which is worthy, actually, as adjuncts to growth. Meanwhile, the model’s adherents suggest that the afflicted let go of the actions, opinions, even the feelings of difficult others, while attaching labels. Fuller contemplation is put off until some ambiguously later time, when the person may be deemed ready. I think that readiness is seldom achieved. Time passes. It doesn’t so much heal as fossilize thoughts about self and other. What’s difficult to let go of are the pat understandings imparted by practitioners who recycle the same lessons in one short-term treatment episode after another.

In a longer-term therapy model, individuals inhabit their adult roles and live their lives as opposed to dropping out of society and going to school. They are challenged to do more than learn how to self-soothe or calm down, or take time-outs when mad, or to leave that bad relationship that your friends all think is wrong, only to start another one that’s similar because you haven’t learned what you got from that bad relationship. Instead, some learn (or are challenged to learn) to hang out with confusion, the grey areas of day-to-day life; to tolerate discomfort, stay with the difficult, as Masterson was once quoted as saying. Reality is learning about one’s own mind and being open to those of others, especially those that are not so easy to detach from: bosses, spouses, children; the memory of those absent but still profoundly influential.

What’s your pain today? Who or what do you want to blame, talk about instead of understand; focus on instead of yourself? Do you really know what your pain is about, what it’s backstory is—it’s underpinning? Do you think you really know the story of others? I know. It’s not what you (I’m) thinking.

 

Graeme Daniels, MFT

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The big feelings

 

What’s your pleasure, asks your average service provider? How can I help, or rather, what would you like to consume? What’s your pain asks a therapist or a doctor. There are many symptoms, feelings to choose from: guilt and shame are the big ones…if you’re thinking long-term

Not that fear doesn’t get a look-in. Trauma casts a wide net, is part of everyone’s experience it seems, present and past. Some have it more than others, we think. Do we? To discriminate in that way is a matter of politics, and maybe economics. It depends on who is paying for the listening. On the whole therapists don’t have to decide who is the most traumatized; that is, unless you’re one of those people who thinks we ought to be making those calls, prioritizing a presumably limited, emotional resource. BTW, on the mind-economics front: I don’t agree with those who imply that if we over diagnose trauma we’ll dilute the meaning of the term, and somehow do disservice to the most acutely affected. Thankfully, whatever you think of this society, there are a lot of helping professionals in this interdependent world: roughly 30K practitioners of my discipline alone, in this state alone.

So back to shame and guilt: When shame works it’s not so bad. It breeds humility, a sense of limitation, mortality, and equality, for we are all small. We all die. When guilt works it’s not so bad. It reminds us we can be strong, and in being strong we can be generous, and charitable—giving back to the less fortunate. Guilt precedes redemption.

what’s your pain? Do you feel bad because you hurt someone, because you are hurting someone, and you can’t seem to stop? Does that push you into shame, wherein you decide the future is hopeless, that you don’t deserve to be loved because you are so bad. Will you withdraw as a result: refuse a gift, a more banal token of support, like someone giving you a hand with something you’re not good at, a break on a bill that’s overdue? Will you beg off, saying “I’m good” because in your mind you’re not. Will you try to not need ever again so you don’t have to ask? Will you disappear because you are a monster, that man/monster Mary Shelley wrote about, and will we find you one day shivering in the North Pole?

Do you feel bad because you’re on the other side? Is someone ignoring you, not understanding, or actively pressing a heel to your nose while saying, “what?” in nonplussed self-defense, or shrugging their shoulders, saying “sorry’, though not with remorse—more with sullen helplessness. Do you feel alone, abandoned, your utter unimportance exposed? And is everyone playing the support cast of Hamlet, saying this thing is not happening? Hope. What hope do you have? Do you keep having to ask for what you want or need, everyday? Or will you retreat to your room, to your bed, to gaze at the pet or child that won’t abandon you, and who needs you also. Will you thrash about in that room, or in the streets, screaming but not speaking, hoping the guilty will get something from the noise?

 

Graeme Daniels, MFT

 

 

 

 

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Sex addiction stigma debate (part one)

 

During a local talk on sex addiction to an earnest group of Saturday morning listeners, my two female colleagues, Joanne and Gina, and I gave a modest introduction to the demographics of our business. As we sat listening to one another, we gave supportive nods, affirming all of our thoughts, though in truth, a couple of my one colleague’s ideas had me bristling. One of her chestnuts concerns the under-researched area of female sex addiction: “as shameful as this condition is for the men, it is especially stigmatizing for the women.” She also said something about men being raised with a ‘John Wayne’ model of emotional expression, and were thus constricted, suffering from intimacy disorders, which in turn impacts their partners. Everyone nodded, including me, only more faintly. I didn’t say anything contrary, partly because of time constraints, partly because of the agreeable ambience in the room, and also, frankly…I’m not sure how important this issue is.

It seems worth writing about, anyway. And arguing about, I guess. As Joanne made one or two other similarly-themed remarks, I recalled the comments of her junior colleague, Gina, from a day earlier, during a staff meeting at our shared agency. At that time the context was our much maligned room schedule board, admittedly outdated, but still in use because no one wants to take time to devise a new system, or tear down our old but beloved white board, streaked as it is with cheesy black demarcation strips and years’ worth of dry erase pen smudges. An online calendar would be best, chirped our newest colleague, proclaiming it is 2016, after all, not 1972.

Not 1972. My mind turned back to the present context and Joanne’s assertions. Frozen in time, I think. Afterwards, over coffee, I told her that I thought some of her pronouncements tired and superannuated, though I didn’t quite put it like that. How so? She queried, comfortably unoffended.

“Well, let’s take the one about women and sexual stigma. You say that women feel an extra layer of stigma in society about sex addiction, and therefore shy away from treatment or recovery, which is why we have less research about them.”

“That’s right.”

“Okay, but the point seems moot, because men aren’t seeking treatment either.” Her head sort of went crooked at this point, indicating surprise and perhaps something else; a playful rebuke, maybe. I was nit-picking, or something. Anyway, I continued. “You said later in the talk that many if not most of the men in our program are mandated: there because of a court order, or a demand from a disgruntled partner. So in my opinion the more pertinent question is this: if there are scores of untreated female sex addicts out there, why aren’t their disgruntled partners mandating treatment?”

She was unperturbed by this challenge, but still waffled with unconvincing polemics. Husbands and boyfriends are less forgiving, she opined, and also—many of those women’s partners are also sex addicts; that women are more judgmental of each other’s sexuality than men are. She spoke with authority on these points, as if she had volumes of data at her disposal. We don’t know these things, I contested, though I sort of agreed with the middle assertion, while thinking the first and the third contradicted each other. We danced around items of research for a bit, eventually dissolving the ‘evidence-based’ part of the discussion and finally dropping into what’s left: what people actually think, which is what matters. I countered her first idea: “While there may be something to your first point—the humiliated male being an especially unforgiving figure—I’m not sure that history or tradition shows that the cuckolded man is a fiercer image than the ‘hell hath no fury’ woman. But regardless, as Gina would say, this is not 1272, or 1972, and by the way, millennials don’t even know who John Wayne was.”

“What’s your point?”

“My point is this: over the last generation, possibly two, most of the scarlet-lettering that happens in society—at least that which gets media attention—has been aimed at men. Or maybe you can tell me: who would be the female equivalents of Tiger Woods, Anthony Wiener, Elliot Spitzer…Bill Clinton?”

“That’s different,” she said, a bit sharply. It was on.

 

Graeme Daniels, MFT

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And sharks do not eat gas tanks

 

It’s not as though suspension of disbelief isn’t a thing. In Ian McEwan’s The Cement Garden, the reader has to believe that three children, whose parents have both died of separate illnesses in quick succession, can live undetected by neighbors, schools, police or social services, for several weeks, even as corpses rot in their home’s basement. In Jaws, that trauma-inducing film of my youth, the viewer must accept (or not think too much about) if wanting an optimal thrill, that sharks might leap across boat decks or swallow gas tanks.

In my novel, Venus Looks Down On A Praise Vole, there are numerous events, plot points and situations that stagger credulity to one degree or another, though none are fantastical in nature. Somewhat mundanely, the reader is meant to believe that my protagonist, Dr. Daniel Pierce, a psychologist, can pursue a career while regularly drinking in between sessions; that he could spend several hours in the company of a transgendered individual (admittedly in a pre-op stage) and not notice the person’s transformation; that he could forget names and patient details, not maintain adequate records, stop listening to people, actively dislike some of his patients, and still be a practicing clinician.

Well, that’s why he’s taking a break from his practice. Daniel Pierce goes on hiatus. That’s the opening plot point: his recognition of his falling apart, his need to stop working and deal with issues, some bad habits, and some losses: the estrangement of his son, the recent passing of his wife. But before he’s even fashioned a plan of restful inaction, his working life pushes back, or rather pulls him back into a working stance, only it will be a much different day on the job, what happens next. It will suspend his disbelief, make him think before the adventure’s done that he’s being seduced, patronized, rescued, recruited, chased…scapegoated.

Perhaps the most difficult event to accept is Pierce’s meeting of a former client in a sober living home. Kirkus reviews made this complaint, thinking it unrealistic that a psychologist would drop out of society, drop into a rehab-like environment, and meet one of his former patients, and even have the man as a roommate. Even if I hadn’t given cursory hints that this might happen—indicating that my unnamed setting is a small town; a hackneyed statement that the world is small—I’d grumble about this critique. After all, what’s so hard to accept? That a mental health professional would have a drug or drinking problem, need treatment or a retreat? That he wouldn’t take special care to avoid contact with his client base? Perhaps my reviewer isn’t aware that certain professionals—doctors and airline pilots, for example—do require or demand segregated, occupation-specific services, precisely because of this concern. It’s actually quite strange that the accommodations that are afforded these professional groups aren’t made for psychologists and other professional counselors.

But for me, this rather ordinary discussion misses an important point: namely, that a strict adherence to what is orthodox or realistic isn’t the most important aspect of a fiction; hence the term fiction. I had Daniel Pierce leave the structure he was in, or the rut he was in, because in order to regain his vitality and sense of mission, he has to leave not only his comfort zone, but almost his entire frame of reference. That’s an equally important axiom of drama, surely. Therefore, he has to perform an impromptu therapy in the most unlikely of circumstances; he has to not conform, challenge authority in ways he never has before. He has to observe ugliness that he’d previously been sheltered from; rethink gender, justice, his oldest notions of fitting in. In being responsible, being anything close to a heroic figure, he must consider that he may be right or wrong about the judgments he ultimately makes, but make his decision anyway.

 

 

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The Black Stallion

 

If you’ve never seen this film, do so, for it will teach you something plain about the wild or the traumatized, human or not. I saw the film when it first came out, in 1979 when I was a newly emigrated child, feeling like child actor Kelly Reno looked in this film: dumbstruck and wide-eyed, trying to adjust to a new life. It’s not clear in the story where Reno’s character, Alec, and his father are going on their story-opening sea cruise, only that the boy is lonely and quiet, the father garrulous yet preoccupied with gambling on a ship that seems less-than-family friendly. A collector, drifter (possibly a grifter), and storyteller, he gives Alec a tiny model of an exotic black horse, foreshadowing the subsequent attachment, but he is implicitly neglectful. He seems less so when a storm hits and the smallish trawler is threatened with a wreck. By this time, Alec has become enamored of the eponymous wild horse, being kept in storage on a lower deck of the ship, cruelly mistreated by its Arab owners. As the ship capsizes Alec is thrown overboard, though not before freeing the animal from its restraints. Meanwhile, his father is missing, having tried but failed to secure a lifeboat. Treading water, Alec sees the horse flailing through the waves but managing to swim, so he latches on to the severed restraint ropes and is thereafter pulled to safety.

Sometime later Alec wakes up on a deserted island beach, apparently safe but also marooned. He sees the horse at a distance, and in spurts over what may have been days, possibly weeks. The animal appears watchful but wary. If Alec approaches, the horse gallops away with impressive speed, seemingly frightened, and distrustful of humanity, naturally, if not from life experience. However, when Alec is threatened by a snake, the horse appears out of nowhere and stomps upon the serpent, killing it. Alec, determined to make a friend of the horse, persists with his approaches, offering leafy snacks and coaxing the beast towards him. Finally, in an intimate scene, the two make contact on the beach. Alec steps forward and then stops, withdraws, then approaches again. The horse, likewise coy, does the same. After a few minutes of this sequence, remarkably filmed, they inch closer and finally touch. The scene feels like an attachment drama played out. It seems fanciful to compare this dance to that which happens between me and a reluctant client, but what can I say. I am reminded.

Soon the boy is riding bare-back on the horse as it gallops across beach-kissing waves. The cinematography that captures this is iconic. Later, Alec is discovered by fisherman and ostensibly rescued, though the fishermen misunderstand about the horse. The bond between boy and animal is conveyed as the horse wades into the water, following the boat which might have left him behind, despite Alec’s beseeching protests. The scene of the horse chasing the fishing boat, determined to follow Alec, is one of the most beautiful in cinema, climaxing as it does the film’s better first half. Back home Alec is welcomed as a Robinson Crusoe-like hero (we learn his father was killed in the wreck). Black, as Alec nicknames or christens the horse, is temporarily kept near his and his mother’s rural home, but he runs away from this strange western domesticity, wild as ever. Incorrigibly so, says Henry, a retired racehorse jockey played by Mickey Rooney, who has found and caught the horse. With Henry’s help, Alec learns to tame the animal, but recalling Black’s speed on the island beach, he convinces the former jockey to train both he and Black for the racetrack. To do this, Henry and Alec must also persuade Alec’s widowed mother that their plan is worthwhile, and above all, safe. As the mother, Teri Garr plays a similar role to the one she’d played in Close Encounters two years earlier. Irritable yet sympathetic, jaded by masculine risk-taking but ultimately forced to indulge it, she is a bystander witnessing a compulsion. This comparatively predictable second half leads to a climactic match race at a professional event before thousands of spectators.

While the outcome might be foreseeable the execution of this footage is anything but. Without stirring music, and with minimal dialogue, the race finale recalls the earlier scenes on the beach while the soundtrack re-enters the silent bond between rider and horse, adding only the vivid sounds of hooves thundering against a sandy track. Black initially falters, disturbed by the racing protocols—the entrapment of the “gate”—but once in his stride, instinct and power takes over. And this is what sententious art has to say about trauma: our native selves will prevail. Over several laps Black bridges the gap between himself and his rivals. As he passes them and victoriously sprints across the line, the exultation of the crowd is finally heard, returning from a dim background. It is as if the director were finally letting them, and the viewer, share in this moment.

Check out The Black Stallion. Be reminded of something.

 

 

 

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You must not run away

 

“No one is after you! No one, I say! You all ran away–and now I know why. I sat by the lake, and there came a fly. The fly ran away in fear of the frog, who ran from the cat, who ran from the dog. The dog ran away in fear of the pig, who ran from the cow, she was so big! The cow ran away from the fox, who ran as fast as he could in fear of the man. That man heard a thump, and away he. It was just a sheep, with an old tin can.

I looked at them all, and then I could tell they all had no fear, and now all was well. They all went away. They all waved goodbye. SO…I sat by the lake and looked at the sky.”

–from A Fly Went By, by Mike McClintock

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