Covert and Overt Sexual Abuse

The definition of sexual abuse in our culture can sometimes be a bit narrow.  Obviously involuntary sexual activity or activity that occurs before a person is capable of giving consent is abusive (it also results in the individual picking up the carried lust of their offender, which they will inevitably act out later in their life).  However there are numerous forms of sexual abuse that are much more subtle.  For example, exposing a child to sexually explicit material (i.e. pornography) and/or circumstances (i.e. parents/partners having sex with the door open or in the same room as a child) both create similar patterns of compensatory responses as the "traditional" examples of sexual abuse. 

Another common example is the "daddy's little girl" or "mommy's little man" situation, in which the child meets all of the spousal needs of the parent except the physical sexual needs.  They may serve as confidant, be falsely-empowered, be asked to join in on major financial choices, etc.  Also common is for a young woman to suddenly garner the attention of her father as she starts to develop sexually. 

These are all "covert" examples of sexual abuse.  Again, the reason we refer to them as sexual abuse isn't simply to be Victorian or prudish - the adult who experienced these covert behaviors as a child will develop the same set of compensatory mechanisms (often promiscuity, sexual preoccupation, and/or periods of sexual anorexia - all related to the aforementioned carried lust) as folks who went through the overt abuse.

Depression and Addiction - The Chicken or The Egg?

People with addictions who are also suffering from depression can face some real difficulties in terms of finding and maintianing sobriety.  My own experience is that many of the "chronic relapsers" I see have some underlying diagnosis that has been missed or not addressed thoroughly enough in previous recovery attempts.  Of course sometimes it's just about the their willingness too...

Something I will typically do with clients is address the PAWS material early in our relationship.  They've generally attempted recovery before without help and will invariably relate to some of the PAWS symptoms that show up.  I find the timeline particularly resonates.  I think I've posted it before, but I will again at the bottom of this post, just in case.  

If a client reports with a history of severe depression, they may or may not have the ability and/or willingness to get medicated.  Since I usually start seeing them during the "honeymoon" stage, I typically would explain PAWS to them and ask them if they'd be willing to take anti-depressants for a few months, starting now so that the meds have a couple of weeks to start working.  When they're medicated for the depression we can focus on their CD issues for awhile, and in the process of doing that we'll likely uncover a lot of the thought processes that are leading to the depression.  

Just a side-note, depression is typically anger turned inward.  If you ask a depressed person "Who is most impacted by your depression" they will tell you who they are angry at.  Then we start uncovering the resentments that are leading to the anger.  Since resentments are always about unmet expectations, helping a client either change their expectations or simply accept that they're not going to be met will usually be quite helpful.  Again, all of this can be close to impossible with a client who is not medicated, at least temporarily.  

Here's that PAWS stuff: 

Early Recovery: 
1. Acute Withdrawal (4-14 days)
Most clients are very aware of the symptoms of withdrawal of their drug of choice, so this doesn't require much explanation other than to mention that it almost never goes past 7 days unless you're dealing with a heavy stimulant user who has not detoxed in a long time.

2. Honeymoon (30 days)
This is where the client feels "cured."  The desire to drink has been magically lifted.  Sometimes this is longer or shorter than 30 days depending on previous attempts at recovery, motivation, etc., but in my experience 30 days is about right.

3. PAWS (120 days)
The worst of the PAWS symptoms happen during this period, though they continue to show up periodically for a couple more years.  This will include anhedonia, dysthimia, hypersomnia and/or insomnia, irritability, severe mood swings (particularly related to sugar intake and diet), hot flashes, cold sweats, dry mouth, difficulty focusing, sometimes difficulty speaking, overwhelming feelings of anger, pain, shame, guilt, or anything else that was repressed during the addiction, obsessive thinking about using, deep and abiding lonliness, sexual impotence, absence of sexual desire, and a general sense of feeling "not right."  The most effective treatment for PAWS symptoms is regular exercise and a balanced, sugar-free diet.

4. Middle Recovery (Next 6 months).
As the fog of PAWS starts to fade This is where the individual starts to relearn how to be social without her or his drug of choice.

Is Sex Addiction Lethal?

I have the chance to talk about sex addiction with a lot of people.  Today I had someone who mentioned that they did not believe it was lethal.  "You can't die from too much sex."

 

I suppose it is true that the act of sex usually cannot be, in and of itself, lethal.  However, I've had many experiences with folks who were dying or later died as a result of their sexual experiences.  Causes of death were things like HIV, risky partners, jealous spouses, and, of course, suicide. 

HIV is pretty self-explanatory. Most clients who have a history of engaging in anonymos sex with strangers can tell a story (or two) about accidentally winding up with a masochist (I remember a client for whom this experience was her bottom... her story was utterly, completely horrifying...)  Anytime a person goes to bed with a stranger these days there is some risk... As far as jealous spouses, does anyone remember Phil Harmann from Saturday Night Live?  The details never came out, but I have often speculated that perhaps that was what we were seeing...

Also, there are specific types of sexual expression that can be deadly by accident.  I recall reading a story of a well respected member of a community who was found dead in his bathroom after accidentally hanging himself while auto-asphyxiating (the practice of strangling oneself to increase the potentcy and speed of orgasm). 

Finally though, I would say the most common cause of death is suicide.  My experience is that the majority of those I have treated for sex addiction have stated that at one point they were actively considering taking their life or engaging in life-threatening behaviors (masturbating while driving 110 mph, etc). 

It's also wise to remember that many of the Don Juan type of sex addicts play heroic roles in their family of origin.  These are folks who kill themselves in a way where noone knows it happened.  "He fell asleep at the wheel" or "his plane crashed..."  Obviously I do not mean to imply that all deaths of this sort are suicides, but when I have a client who values his or her image (An axample might be someone like elliot spitzer) and they talk about their plans for suicide, it is typically stuff like this.

So, while I do agree with the idea that the act of sex is not lethal, I would assert that within certian groups some forms of compulsive sexual activity can contribute to an early and oftentimes unpleasent demise.

Jesus and Family Roles

My wife had a friend in grad school who used to say "you teach what you need." 

Lately I've been focusing on the five family roles in my teaching - hero, mediator, mascot, troublemaker, and...  um...  -oh yeah, lost child.  These are the roles we choose in childhood to help us get through life.  Everyone plays all the roles some of the time, but we've usually picked our primary by around the age of six.  We'll generally adopt a second one durning puberty and/or in response to a traumatic event. 

What's interesting about our roles is that they are often unaware of one another.  So if I'm playing "mediator" I can have one set of values and beliefs, but when I'm playing "mascot" I can have another.  For example, perhaps you know someone who's quite and reserved at the office, but a cutup and jokester at home?  Perhaps you've had the experience of visiting your family and, within a couple of days you "feel like a different person."  Or - and this is pretty common - haev you ever said something in anger that you would never, ever say normally?  These are examples of jumping from one role to another.  I mentioned before that we frequently have a primary role that we gravitate toward above the rest.  Often we get so good at playing this role that we forget what it is - just a role.  This one will be who we think we are - the rest will just be experienced as occasional anomalies. 

Ever decide "I'm not going to have anymore chocolate tonight" (hero role) and find your resolve weakens shortly (troublemaker role!)?  Ever eat the chocolate and then cover it up so your spouse won't notice and get mad (troublemaker and mediator)? ;-)  One part of myself sincerely and wholeheartedly resolves to not to eat anymore chocolate, but a little while later another part says "oh heck, it's just a little, no one will mind..."  This is a small example of me bouncing between roles without too much trouble...

The trick is to understand that roles are primarily concerned with self-protection and survival - which is totally normal and human - and which is also about fear.  Fear is, of course, the opposite of faith.  So when I play a role (which I do often, though I'm not usually aware of it) I'm really relying on me rather than on God.  This isn't "bad" necessarily.  In certain settings it's probably quite appropriate and valuable.  It's when I forget what I'm doing (which is most of the time) that I get into trouble...

Most of us live life in a role and don't really know it.  If sometimes my behavior doesn't match my beliefs, that's normal.  But when I forget that, even for a little while, I'm in a role.  When I'm in a role, I'm many things, but aware of my need for Christ's miraculous love and grace is not one of them.  That's the reason that I need to do personal and individual spiritual work even after I've accepted Christ.  

Ultimately the purpose of spiritual practice for me is to learn to be aware for long enough that I can be authentic and aware of my need for Christ in each moment, that I can make the decision that God wants instead of the one that will make someone else happy, the one that will make me the most money, or the one that seems safest.  I know that such places exist, but I'm often too "busy" to do the "work" necessary to get to them.

The work is, of course, just taking time to practice the habit of getting out of God's way.  Prayer is helpful for this, but for me meditation and contemplation are the practices that really help with this.  Also, I find that I have to take the time to regularly take an inventory of my own shortcomings and share them with both God and someone I trust.

Lately I've been doing... none of this.  At all.  I've been too "busy."  Busy doing what?  Well, I work sometimes (after all, I'm "superspouse" and "the provider"), and I play with my kids, but a lot of the time I'm busy judging someone else, playing with new toys or just doing whatever sounds good right now and (probably) won't get me in too much trouble...  One nice thing about sharing this (besides the hope that perhaps a few others will be able to relate to it and learn from my folly) is that it reminds me that I need to take some time to address this stuff...  That means more time asking for guidance and praying for humility.  It means time and energy devoted toward Christ.

You see, without Christ I have nothing but the role I chose (or that was chosen for me) in my family or origin.

The Way of the Follower of Christ is to give up these roles for something else.  Accepting Christ for me was/is a process, a beginning, the first step along a path (allegedly a straight and narrow path).  Accepting Christ opens a door to His Truth, reveals the only real, only authentic Self that we have in this world.  The only true and authentic Self that there is.  But seeing His Holy Spirit revealed to and within me and choosing to step toward that Revealed Self and away from these survival roles we've known our whole lives; that is The Way.

This is why being a "good person" doesn't cut it.  Even being a "good christian" doesn't cut it.  Because if Idig into the "good person/christian" I'll find someone who goes home to be all those other roles I discussed earlier.

How many christian's go through the motions, but experience that same sense of deadness, emptiness and the knowing that something is not right?  Or worse, how many of us go through the motions and are so busy running, performing acts of "good" and "service," that we don't even notice? I don't know.  I do know that lately I've been on that track.  I fall back on it, usually when i get too comfortable.  Thanks God, for helping me notice...

Here's my prayer; "Lord, comfort me when I'm afflicted.  But please Lord, please, afflict me when I'm comfortable."   ;-)  (I stole that from Richard Rogers)

Hopefully this week I can get my crap together and get out of Christ's way.  Pray for me dear reader, won't you?

Covert and Overt Sexual Abuse

The definition of sexual abuse in our culture can sometimes be a bit narrow.  Obviously involuntary sexual activity or activity that occurs before a person is capable of giving consent is abusive (it also results in the individual picking up the carried lust of their offender).  However there are numerous forms of sexual abuse that are much more subtle.  For example, exposing a child to sexually explicit material (i.e. pornography) and/or circumstances (i.e. parents/partners having sex with the door open or in the same room as a child) both create similar patterns of compensatory responses as the "traditional" examples of sexual abuse.  

Another common example is the "daddy's little girl" or "mommy's little man" situation, in which the child meets all of the spousal needs of the parent except the physical sexual needs.  They may serve as confidant, be falsely-empowered, be asked to join in on major financial choices, etc.  Also common is for a young woman to suddenly garner the attention of her father as she starts to develop sexually. 

These are all "covert" examples of sexual abuse.  Again, the reason we refer to them as sexual abuse isn't simply to be Victorian or prudish - the adult who experienced these covert behaviors as a child will develop the same set of compensatory mechanisms (often promiscuity, sexual preoccupation, and/or periods of sexual anorexia - all related to carried lust) as folks who went through the overt abuse.

Doing No Harm....

"Do no Harm" is the crux of the Hippocratic Oath and something to which most of us aspire to. It's also not terribly practical or realistic in our profession.

I'm reminded of a session early in my career where I'm convinced I did do some harm... The client spent an hour blaming her weeping daughters for her alcoholism and the behavior that corresponded with it. I was afraid of the consequences of confronting this strong, angry woman (whom I had met only a few minutes before the session) so I let her be offensive to her daughters. I tried to reason with her for far to long; I should have said "Stop it. These girls have nothing to do with your staying in bed for days at a time and for you to blame them is ridiculous. You will stop or the session will end."

What I hadn't learned yet - and still sometimes struggle with in my personal life - is that it's vitally important that we remember to measure harm based on our own perceptions, rather than those of someone else. There's a difference between something being painful vs. something being harmful.

A family is in my office because something is not working in their life and that means that sometimes I am required to bring that to their attention in ways that feel "harmful" (though really they're just painful) to them. If there's an alcoholic family in my office and I fail to model good boundaries by confronting offensive behavior (in a respectful, but firm fashion), fail in speaking the truth as I see it (in a respectful, but firm fashion) of fail in modeling boundaries about the behavior I will and will not accept in the future, I am doing harm to the family members of the addict. This behavior will be perceived as harmful by someone who is still pre-contemplative.

Disillusion is at the root of almost all pain - pain is what happens when perception and reality clash. A successful therapist brings truth to their clients (which is often intensely painful) in a loving way and at at time when they're able to accept it.

So that's the first thought I have on doing no harm. The second is to realize that at some point in your career (probably daily at first) you're going to make the wrong decision. I encourage folks to realize that Doing No Harm in this profession is an aspirational (rather than practical) ethical goal. I've adopted a "do not harm on purpose" philosophy and I make sure I apologize if I realize I did harm.

These two things are valuable tools when it comes to abrogating the fear of doing harm.

Thoughts on Religion and Existentialism in Counseling

Zulay said:

I like that spin on it all because you can give the proper insight on such a subject because you are actually in the field. I believe that as a counselor practices and does his/her job, they will have to make judgment calls. I want to make sure I am understanding what you said. I understand that as a police officer, therapist, or anyone within the social field, we should not ever judge, we should make an ethical decision based on theory, law, or whatever legally applies. So is it not ethical to have a discussion with a client who brings up the topic on religion? I personally don't entertain it in my field because it is what is best. I do lend my ear, listen and give facts based on law and city ordinances written by the City in which I work.

Hmmm.  This is an interesting question.  I think the answer is "maybe"?

First, this has turned out to be a very long post.  So if you're going to read it, I'd suggest setting aside some time.  The readers digest version is this; Remember, if you get nothing else out of this class (or this massive post); speaking the Truth as best you understand it, helping a client see that fire burns and water gets wet, is not judgment (unless you do it from a place of "I'm better than you.)  In fact, in most circumstances, it's your job. 

The big benefit of having a theory or law to make a decision from is that there's less risk of harming the client.  So that's a significant plus and it's one of the reasons I have respect for those who choose to avoid personal disclosure in a therapeutic session.  There are some schools of thought that allow for little or no personal talk with clients.

In my experience excellence in a therapeutic context is about learning to make truth and love work together.  In conjunction these two things lead to health and healing 100% of the time as far as I can see.  Separate from one another they are somewhere between useless and dangerous.  

Truth without Love is easy to spot, because it typically is accompanied by awful pain.  Take a look at the word "disillusion"  How many of us wake up int he morning thinking "gee, I hope I get disillusioned today"?  Usually no one, because most people don't like pain (if you do like pain, we should probably talk).  Since most people do their best to avoid pain they'll generally also try to avoid disillusionment.  And yet, look at the word.  What does it mean?  It means "to remove illusion."  Well who doesn't want to see illusion fall away? Who doesn't want to see the truth?  ... Unfortunately the answer is "all of us."  Because the truth hurts.  Sometimes horribly.

One of my favorite books (even though I haven't actually read it) is called "He's just not that into you."  It's a great example of truth told without love.  I think it's a universal human experience to discover the "he (or she)" isn't that into me after pining away for him (or her) and to feel totally awful about it. 

The point is that truth told or discovered without love is often quite painful.  When someone tells me a truth in a loveless way (and this has happened to all of us) I will typically react by experiencing shame (which is always about being seen) and then go to a place of defensive anger and denial.  In fact, if you tell me the truth in a way that brings up shame I will actually be less likely to ever look at that area again.

Now let's look at Love without Truth.  How many of us have ever made a decision based on love that we later came to regret???  (Pssst...  if you're not raising your hand right now, reread the previous three paragraphs).  Love in this context is "sticky," glomming on to anything.  It can also be quite dangerous!  All of us know someone or are someone whose fallen hopelessly in love with another person who turns out to be very different than what we were thinking at the time...

Effective counseling is learning to blend these two elements; to tell someone the (sometimes horrible) truth, and to do so in love.  At the Meadows I'd get patients all the time who'd come in and say "my childhood was great. I have no trauma."  This is someone who is in denial of a truth (most people with no trauma don't require multiple grams of cocaine a day), but needs to learn this in a context of love in order to have the opportunity to possibly accept it.

So does this make sense?   Effective therapy is about teaching someone truth in a loving way.  That's what we're learning here.  These theories are useful in that they take human nature and attempt to distill it into some essential truths, which can then be shared with clients. 

Also, is anyone else impressed that I've managed to get 1000 or so words into this post without actually answering Zulay's question?

So, for Zulay, the question of the appropriateness of discussion religion in therapy and it's relationship to judgment... 

First, it's helpful to consider that religion might be thought of as a collective expression of man's attempt at grasping truth.  It's an answer to the (existential) question "why am I here?"  Some folks are keenly interested in going there in session.  I know for me, this question was what drove me to a therapists office at the age of 22, and the experience of grappling with it nearly killed me.   

One of the reasons I teach - one of the big ones actually - is that when i was going through school this discussion of discernment vs. judgment never happened - well, more likely it did and I ignored it because completely dropping what I perceived to be judgment but which most consider morality was so darn convenient.  I loved to wage verbal war with absolutist students who wouldn't buy what I was sure was an obvious fact; "perception is reality."  Never mind that Plato disproved this irrefutably while he was arguing with the sophists 4300 years ago, I was going to stick with it come hell or high water.  

One of my favorite co-workers ever, Doug, was 72 years old and too stubborn to retire.  He was a family therapist at The Meadows for the offender sex addiction group.  These were some pretty challenging clients, and their families (particularly their spouses) could be a handful too.  On his wall he had a sign that read

"There really is nothing you must do. 
There really is no one you must please. 
There really is nowhere you must go... 
But... 
Sometimes it helps to remember
That fire burns
And water gets wet."

What it means is that actions have consequences.  And that, folks, that's a timeless Truth.  There's no getting around it - believe me, I've tried and tried and tried...  It's also the central truth that we teach our clients.  Consider REBT as an example.  The central tenet is that if I change my thoughts, it will change my emotions, which will in turn change my behavior.  That means that I am ultimately responsible for my thoughts, which means I'm responsible for my feelings, which means I'm responsible for my behavior, which means - darn it! - my mother-in-law is off the hook.  Get it?  Actions have consequences. 

So I would posit that every therapy session that's in any way useful (which requires that the clinician have a model based on truth and deliver it in love) is existential in nature.  Ultimately counseling is about teaching clients that at some level they must take responsibility. 

I think I mentioned this earlier, but the world religion comes from the Latin word relegare, which means "to bind" as in to bind together.  A person's religion is what binds their world together.  I would also argue that much of counseling is religious in nature.  Every human being on this earth has a higher power, a thing or things around which they organize their lives.  It might be their mother (one subtle but common example might be "I'll never be like her!"), it might be the opposite sex, it might be the Buddha (well, technically that's not a good example since Buddha never claimed to be God), it might be their checkbook (I heard once that if you're wondering what you're higher power is, you check register will tell you) or it might be beer.

Just as an example, how many of you reading this would change your higher power if I wrote a really compelling post?  Anyone?  Usually most of us are pretty set in this part of our thinking.  In fact, history is full of names of people who've gone to fiery, excruciating deaths to avoid changing or even speaking against their Higher Power.

Does this apply to addiction?  I think it may...  Think about the case of the terminal alcoholic, the person who drinks until they die.  Is this not one of the best examples of zealotry we can find in modern culture?  This is a really hard way to go!  Of course there's jaundice, where the skin turns yellow because the liver has stopped removing toxins from the blood.  But that's just getting started.  After jaundice we have esophageal hemorrhaging, wherein the patient gushes blood out of the bodies major orifices.  Acute pancreatitis happens as well, which is when the pancreas, which secretes the most powerful of the stomach acids - bile - starts leaking acid into the stomach cavity.  This is supposedly one of the most painful experiences a human can have – supposedly more painful than childbirth… 

And that's before you die.  Do you know that when the medical team does an autopsy of an alcoholic they have to wear special masks because when they take off the scull to examine the brain the smell of alcohol is so pungent that most folks – even these professionals - will get sick? 

It's all quite horrifying to be sure.  But… let's consider it from another angle for a moment.  Is this not, in some respects, absolutely incredible dedication?  The alcoholic who drinks until they die is someone who is willing to go to a grizzly, miserable death rather than surrender booze.  How many of us have something in our lives that we're that dedicated to?  How many of us would walk through that for our religion, whatever it may be?  I bet there are some reading this who would, but not many (By the way, my thanks to the three of you who've actually gotten this far in the post ;-))

This incidentally, is a big part of why AA works.  Alcoholism has been around since ancient Greece – that's the earliest record we have of it.  The most successful treatment program prior to AA was the sanitarium.  Lock 'em up and throw away the key.  That's the farthest medical science had got with the chronic alcoholic prior to the late 1930's.  So why did AA work where so many others had failed?  Because Bill and Bob, the two guys who founded the program, were alcoholics themselves and understood first-hand that their higher power had been booze, and they needed to find a different one.  To this day AA doesn't tell the alcoholic which Higher Power they need to believe in, but they've stuck to the idea that they need to find a new one because the booze doesn't work.

So, does religion have a place in counseling?  Directly or tangentially, I think it does (though it probably depends on how you define the word).  Sometimes it's as simple as helping the client understand what their religion really is.  Other times it's being open and taking some risks with the client, sharing some of my own experiences and mistakes, is what's necessary

Man, that was a long post.  My fingers are tired! ;-) 

By the way, I should mention that much of this comes from Pia Mellody's work, and I'm pretty sure she got a bunch of it from Cloud and Townsend.  There's a bit that comes from Lou Marzeles' "Life for the Reality Impaired" also. 

 

Birth Order Birthday Party

Yes, the birth-order characteristics are quite useful in certain circumstances. If we were in a face-to-face setting I'd teach this the way it was taught to me. I'd ask, by show of hands, how many first borns, how many middles, how many youngest and how many only's? Then I'd devide them up into groups based on birth order and say "plan a birthday party." <p> The oldests wouldn't let me get away with this for very long. They need details and directions - how can you be successful if you don't know what the professor expects? When they ask for clarification, I would deflect and say "that's all the instruction I can give you." <p> Here's the exercise would typically end up. The one of the oldests who had mobilized and lead their group discussion would present to us larger scale party that included a budget, timeline, delegated task list, guest lists, invitations (including contact information for a printer one of them knows who will get them a good deal), web site... There would be a good deal of communication in the oldest's group and probably more than a little interrupting, but it's not likely that they'd get to concerned - unless the interruptions compromised productivity. Also, the oldests would probably be the first group to finish and the ones to ask "when are we going to present?" <p> The middle children... God bless the middles. No interruptions here. There'd also be an awkward silence when I asked "what did you come up with" since they hadn't agreed on who would be the leader and no one would want to go first as it may hurt the others feelings... When one finally did reluctantly volunteer to go he or she would pleasantly explain that the birthday party would be a gathering of a few close friends and family where everyone would have a great time and no one would be excluded. If there was some delegation it would be very fair to everyone involved, because middles do prefer things to be fair.<p> The youngest children will have been laughing and joking for the majority of the group time. If they do have a plan, it will not include a budget. Once i saw a group say "we're going to rent out the stadium and invite the whole city." Generally they will have spent approximately 10% of the alloted time planning and the remainder talking, telling stories and laughing. <p>The birth order stuff isn't perfect, but it's usually a pretty solid guideline.

Of Brainwashing and Arguing

It might be too late for this to get noticed by the majority of the class, but I think the answer to the question regarding my opinion on the matter is that it would likely be inappropriate to voice heavily in this setting.  None of you plunked down money to hear me talk about politics or morality and I have little expertise worth paying for in either topic.  I am here because I love to teach future therapists and because (hopefully) many of you want to learn.

My hunch is that entering into the debate could lead some of you who feel strongly about the issue to have less passion about learning.  What a pity that would be!  Thus taking a strong stand on the issue would contradict my stated purpose.

As a therapist, this is also true.  Your job is to help others heal.  You do this by providing an environment where people feel safe, accepted and loved.  I've had clients come to me who are clearly sex addicts and have zero interest in working on it.  They're here to quit drinking or drugging or whatever.  Can I treat a sex-addict who is disinterested in addressing that issue?  You bet!  I can be of some service by accepting him or her where they're at and seeing where we can go.   Arguing about whether or not their a sex addict will simply drive them to someone else's office...

Hopefully that makes sense. 

A bit more on the argument piece... Studies show that when there is debate between two sides, those talking move farther away from the "center" so to speak.  Not surprising.  What is surprising though is that the audience typically does the same.  If you watched two people debating something, by the end of the discussion you will generally have sided with one member of the talk or the other and your own opinion will be more akin to theirs even if you had started out at a more moderate position!

What's REALLY interesting about that, is that if I'm unscrupulous I can use this to really mess with your head.  Let's say I wanted to convince you that - and I'm trying to come up with something fairly neutral here - that cigarettes don't cause cancer.  One way I could do this would be to put two people in front of you, one arguing passionately that science on this matter is inconclusive and the other arguing equally passionately that cigarettes are actually healthy and good for you!  Sounds ridiculous, right?  Well, studies show that often by the end of the conversation if it's a topic you have interest and those speaking have "expert" credibility in your mind, by the time the discussion is over you'll lean toward one or the other. Which are you more likely to side with?  The majority of the audience will have forgotten that they formerly believed that cigarettes cause cancer.  They will now be deciding between the lesser of two crazy positions and be pulled in the direction that I want them to.  Muhuhahaha... 

So, there's a lesson in brainwashing 101.  Next time you watch tv news or listen to the radio, look at the topic and see what's being debated.  If you put your mind to it you could find this technique being used with regularity...

 

Rigidity and Racism in Family Systems

The experience of braking away from family norms can carry some deeply significant consequences.  In cases where the family system is rigid and unyeilding, in can end relationships.  In addiction counseling, we frequently see clients who must choose between alignment with the family and continuing their addictive behavior or choose an essential departure from family norms, which can mean expulsion from the family system. 

Many who come to see a counselor will be from family systems that were rigid in nature, that is to say, families that do not accept deviations in thought or opinion. Often, but not always, these family systems have a patriarch (or matriarch) who plays the Higher Power role. Children who come from this sort of family system will frequently display oppositional characteristics toward authority.  Sometimes these oppositional characteristics will be overt, as in the rebellious, angry client who tells you where to stick your theories, therapies and jargon.  Clinically though, it will often appear more subtlety, as with clients who are consistently late or breaking appointments, who say yes when they mean no, are (often sincerely) forgetful of assignments or tasks, or who behave in similar power-garnering ways.  It's no surprise then that such clients also frequently have spirituality issues (they'll become rigid or rebellious in relationship to their Higher Power), and struggle to make connections in intimate relationships due to difficulties with trust.

The opposite of a rigid family system is a family system that has is permissive in nature. In this sort of family, anything goes. The children are often expected to take care of themselves and will sometimes be related to by their parents more as siblings or friends then progeny. Clients who come a permissive family system are usually deeply anxious and don't know why. This anxiety often finds it roots at the age of 4 or 5 where it suddenly dawns on the child that although mom and dad are going to provide some of the essentials for survival, socially and emotionally speaking they are all alone.

As counselors, what we do with these folks is try to bring them back to the middle. With clients who come from a rigid background, there are two tasks. The first is to aide the client in the process called individuation. Individuation is helping the client decide who they are outside their family system, i.e. "Client, what are your goals, beliefs, values and desires?" Ideally individuation is accomplished in adolescence, but this is rarely the case with clients seeking clinical help. After individuation, the goal is to help the client get back to the middle. Clients who grow up in rigid households will drift to extremes; either becoming the person their parents wanted and expected, or becoming the precise opposite, much to the chagrin of the family.

With some situations, such as the overt racism in his family of origin brought by one client, it is less about guiding the client back to "the middle" and more about helping with values clarification and the combination of guilt and anxiety. In situations where overt racism was present growing up there will often be a certain level of anxiety that manifests when talking members of one of the minority groups that the family system had rallied against. Commonly the client will realize that the information that has been provided from his family system is insufficient and incongruous, but to still carry some fear that he'll say the wrong thing and guilt that he still has those messages with you at some level. 

Making mistakes.

That sounds about right to me. We are all "beggars." My life's pretty good some days, and a mess on others.

My friend Tom liked to say "I find no matter what I do, I've always got problems. But today my problem is that the engine in the boat I keep at my lake house won't work. That's a pretty good problem to have. I think life is at least partly about improving the quality of my problems."

I tell that story to couples I work with especially. I say "I can't solve all your problems, and even if I could you'd just have a bunch more by next week anyway. But I can teach you to see that they're not as important as you think they are..."

Self-doubt still plagues me too, unless I'm doing something that I've survived failure at. As a professor, therapist and public speaker (three things I've done a lot in my life) I have made pretty much every imaginable mistake (actually, the CLC thing this week was a new one, so almost every imaginable mistake ;-)), and lived to tell the tail. I remember being completely terrified for about my first four months at The Meadows because here I was at a world class treatment center, and I couldn't figure out who the weak link was. You know how they say if you're playing poker and you don't know who the sucker at the table is, it's you? I was pretty sure it was me. I was quite scared! Then one day, it happened. In front of a peer a client chewed me up and spit me out. Then her family did too. Then one of the other client's parents, who had been observing the group, said "this is total crap. We're leaving." They went down to my supervisors office, chewed him out, and took their kid home.

I thought I'd better get my bags packed. I called my supervisor and he said "Hey, tell me next time someone's coming to my office all pissed off, ok?" I said "OK." and waited. He said "Have a good weekend." I said "... OK." And hung up. Then I went home.

After that day I was a lot less nervous. See, one of the things I'd feared the most was that a client wouldn't like me. Then it happened, and I survived it, and then all the sudden, it didn't bother me as much. There were countless other fears I had as a therapist (and teacher, and speaker). Many of them came true. And I grew from the experiences. Teaching therapists is like teaching electricians; you want to give them the necessary information so they know enough not to kill themselves or someone else, but once that's done they have to go do the job until they get good at it. Grad school is learning enough that you can't hurt people, your internship and first two or three years are about actually learning to do the work. So, no need to get to worried just yet.

Sex Addiction Resources

At The Meadows we would offer the sex addicts a celibacy contract. The ones who stuck with it often struggled with sleeplessness, headaches, nausea... I think Pat Carnes lists 15 regularly reported symptoms of sex addiction withdrawl. Carnes, by the way, is the Michael Jordan of sex addiction. For clients who think they might be sex addicts, you might consider referring them to "Out of the Shadows." For clinicians and/or clients who want more detailed information on diagnosis and treatment, "Don't call it Love" is excellent, though a little dated nowadays, and his newest project - I think it's called facing the shadow? - walks through 18 stages of recovery or something like that? His work is thorough and pretty impressive. For success I've found it needs to be coupled with 12-step work as all sex addiction is essentially about loneliness and dichotomizing the personality.

Sex Addiction and Arousal Templates

Sexual addiction is actually very trendy these days, thanks to the internet. Have you all heard of an "arousal template"? It's basically a fancy word for "what floats your boat." An example of an arousal template would be a adolescent male walking home from school, who happens to look into a neighbors window and catches a couple having sex. If this experience is a sexually powerful for him, that is, it creates a high, he may try to replicate it by looking into other windows or, later, drilling holes in locker room walls, etc.

Not infrequently an arousal template is related to sexual abuse. I remember working with a client who was raped in early adolescence by a man 20 years older than her. She grew up and married, not one, not two, but four different men (at different times) who were all about 20 years older than her.

So the sneaky part of this is that these porn folks on the web understand it. So when you look at porn - I mean, that is, well, I'm sure none of YOU have ever actually seen pornography on the internet, but, you know, let's say your clients may have... so, uh, when your clients look at porn, there are often advertisements for other porn sites that are at the "next level" so to speak. That is a "normal" porn site will show advertisements for voyeur or foot fetish sites in an effort to snag the viewers arousal template, because once they hit that, you're hooked. I once worked with a client whose struggle was looking at pornographic images of women being strangled while under water. There are web sites for that. At least two of them...

Context in Therapy

I keep the class comfortable and do my best to always be clear that we are all on equal footing here. One of my favorite supervisors ever, Mike Graham at The Meadows, had a sign on his wall that said "no one cares how much you know until they know how much you care." It's tempting as a clinician (and as a professor) to allow the built in power-differential to create an environment where I am the guru and you are the student. But ultimately that doesn't work because it's based on a lie. The fact is that we're all worth the exact same, because we're all precious children of God. Now given, you are paying me, so I'd better having something useful to tell you or you'll be upset, but the casual atmosphere I keep both as a professor and clinician is really designed to get away from the idea of the therapist guru and closer toward the idea that we're all a bunch of schmoes who have to figure life out together.

For more on this idea buy a copy of Sheldon Kopp's book, "If you see the Buddha on the Road, Kill Him!" Kopp has some concepts that I adamantly disagree with, but for the most part that book is totally brilliant as far as understanding the contextfrom which therapy happens. Classes and coursework are all about content, which, frankly, is not all that useful much of the time. context (in contrast to content) is everything other than the content. It's the feeling I get sitting in your office, it's the subtle read of your body language, it's noticing if my connection with my Higher Power is stronger or weaker in your presence... context cannot be taught. It really can't even be written about, though I'm giving it the good 'ol "college try" (sorry. couldn't resist.). context has to be repeatedly experienced, and gradually integrated. But here's the trick - and remember this because it's probably the most useful thing I'll say in this course - when it comes to healing, context is what matters. One of my wife's favorite professors always said "They'll forget everything you tell them, but they'll remember the relationship." That's context.

In my opinion, most great therapist aren't taught, they're born. Occasionally there are training programs where context shows up, most often, I think, by accident. I was lucky. I went to grad school at a place that understood this, and I interned at a place (The Meadows) where the clinical staff lived it (to the degree that such a thing is possible anyway). My hope is that by setting up the class within a context of respect and equality you will start to pick it up too. This class is information that you'll use on rare occasion in your clinical life. If start to understand the context you'll be moving closer to becoming a healer, which, really, is what many of us are seeking.

Interesting Article on Addiction

http://www.cnn.com/2009/HEALTH/04/15/addiction.cold.turkey.pill/index.html 

LSD as a sacrement

I heard that LSD was originally administered as a spiritual sacrament. Bill Wilson, co-founder of alcoholics anonymous, is said to have experimented with it so see if it could be used to bring about a sudden spiritual awakening in newly recovering alcoholics. Supposedly with supervision and proper spiritual preparation the LSD experience was quite liberating. Many of those who partook eventually left their professional lives to become full-time seekers of spiritual truth.

Love and Hate

The opposite of love isn't hate, it's indifference.  Hatred is the word we use for deep, deep victim-anger.  You were victimized, so anger makes sense.  If we were working together I would counsel you that anger is an important part of the grieving process, but one in which people sometimes get stuck.  

"That which we do not own, owns us."  Carl Jung. My hunch is that what you're talking about here is a profound grief process that will open itself to you when you're ready for it.  There is no rush, though your anger may continue to "own you" until you are willing to let it become pain.  The tough part about pain is that it's vulnerable – anger feels much safer.   In your life I'm guessing that safety was a rare and much needed commodity…

The AA's wife

She might consider attending al-anon for a year or two, though I'm sure she's been told as much.  I've frequently seen situations where the spouse attending al-anon faithfully for a year or two serves as the catalyst necessary for the cessation of drinking for the alcoholic

 Well, attending is a good start, but in order for it to work she has to attend, get a sponsor and work the steps.  Attending a meeting is like going to the emergency room; it's worth the trip, but only if you talk to the doctor.

Addiction's Start

 My experience is that almost all addicts start their addictions during junior high school. Some transition to other stuff later (i.e. the kid who has her first drink in seventh grade but doesn't find meth till 17) but generally an individual who develops an addiction will have their first use during junior high. In fact, whenever I find someone who has an addiction who doesn't report it starting in junior high I look for a behavioral addiction. With men I ask about compulsivity in their masturbation habits and look to see if it's blossomed into sex addiction, with young women I discuss body image issues and see how those have played out in their lives. Almost always the addiction gets going during adolescence in one respect or another...

Drinking and Diabetes

I love the diabetes example as a metaphor for the disease model of alcoholism. If I find out I'm diabetic, I learn quickly that I am powerless over the condition and need to modify my lifestyle or face some disappointing consequences.

I also apply this idea when clients say "well, I'm an alcoholic. That's why I drank." No, that's not true. If I'm a diabetic and I eat a donut and go into a coma, did I go into a coma because I'm a diabetic? No way! I went into a coma because I ate a donut. Once I know I'm an alcoholic, if I drink, it's because I chose not to take care of myself and do the things I needed to do. I chose not to call my sponsor, go to therapy, eat right, sleep enough, etc. Drinking prior to understanding I'm an alcoholic isn't a choice, but once I see that I have a disease, the decision is mine.

Genetic Predisposition to ETOH

I liken it to having a genetic predisposition to become a professional basketball player. Is it required? Well, not necessarily... Mugsey Bogues was 5 foot, 3 inches tall. (here's a picture of him guarding Michael Jordan). He probably didn't have a genetic predisposition to being a basketball star, but managed to find a way to make it happen anyhow. That said, most NBA players are taller than that. Yao Ming of the Houston Rockets is 7 feet, 6 inches tall. I'd say he had pretty high susceptibility. ;-) 

Addiction in the family

I too struggle when I see young people who have no guidance. It is a lonely way to grow up and profoundly damaging (see my post on the "lost child" syndrome for more info on that).

Also noteworthy is that alcoholism frequently will skip a generation. I cannot tell you how many times I've seen clients whose parents didn't drink or use, but who have grandparents on one or both sides who did so to excess.

This is because we, as human beings, during our process of individuation (which usually starts in our early teens) will make a list of some things our parents didn't do well that we want to correct when we're adults. But here's the trick - we will almost always over-correct. Ask any 15 year old "what's the worst thing about your parents?" and you'll find in what area they're going to be sure to over-correct.

Kids whose parents are alcoholics or addicts tend to go one of two ways. Either they repeat the cycle, or the become angry, judgmental and uptight in their determination not to do so. They succeed in avoiding drinking, but they're often fear-based, which leads them to be hyper-controlling fixers of their loved ones. Such individuals sometimes marry alcoholics, and frequently find their progeny turning that direction.

That's part of why I always, always, suggest that family members of addicts I see pursue counseling, an al-anon family group, or both. The inversion of the cycle is still the cycle, it just looks different.

Shame existence Binds

Adoption is almost always worth looking into with a client. Often, but of course not always, a child who was given up for adoption will have a subtle but deeply felt "shame-existence bind," which is a situation where I feel ashamed to exist. The client is sometimes aware of this, but frequently they are not. In either case the shame bind will manifest itself in either overt or covert suicidality; including risk-taking, using drugs or alcohol to an excess, or self-sabotage just when their ship is about to come in. <p>Shame-existence binds don't just show up with clients who were adopted - I'd say they are actually relatively common clinically. If you find one it's best treated in a group setting where rapport has been established by the client with both the group and the practitioner. Have the client affirm "I have the right to exist," making eye-contact with one individual in the group at a time going all the way around the room. The reactions vary, but often there will be tears by the fourth or fifth person, and it will "break" after six or seven. If you don't have a group to work with, have the client practice "I am worthy" and "I have a right to exist" as affirmations hundreds of times daily for a month. For many the chance is significant and measurable.

Test Anxiety and the Importance of Doing Your Own Work

As far as test anxiety goes, you're right on in terms of noticing that your limbic system getting keyed up feels a bit like a stimulant use. As I understand it (remember, I'm a therapist, not a biologist) your limbic system is that part of your old brain which controls your fight or flight mechanism. If you're exposed to a situation that replicates a previously experienced traumatic event your amigdala gets pumping and releases a bunch of adrenalin into your system and you will feel like you just had 2-3 cups of coffee. The difficulty with that is that when that happens to us, some of our ability to reason logically gets impaired as well. But it's normal.

A quick word to everyone on test anxiety: Relax! ;-) Obviously it's important that you learn a lot from your experience in graduate school, but don't get too stressed out. The fact is that being a therapist is like being an electrician: Education is provided mostly to lay a foundation that prevents you from hurting yourself or someone else. The real learning of the art of psych-therapy takes place on the job.

This is for everyone (not just you Brittany) - I think that a lot of us have some unresolved school trauma and perhaps some severely shaming experiences related to success, or lack thereof, academically. If you're feeling strong discomfort about papers, tests, and the like, it may be a sign that you have some perfectionism tendencies to look at clinically. If this is an issue, consider addressing it with a therapist.

For all of you, please, please, please get your own therapy before, during and after the process of becoming a therapist -what you don't see in yourself you won't see in someone else! This is particularly important if (like me) you come from a family system with addiction - there's usually a lot to undo there. Therapists without insight are not just unhelpful; some are just plain dangerous because they reinforce (rather than challenge) distorted belief systems in their clients.

Greg

AA works because II

Yup. My favorite example is the alcoholic who drinks themselves to death. Most folks know or know of someone who has done that. I used to work with a guy who lost his license as a surgeon due to his addiction, got into recovery and became a therapist. He'd walk us through the process of drinking yourself to death, and it was really amazing. Aesophogeal (sp?) hemoraging (blood coming out of places that shouldn't bleed), acute pacreatitus (which leads to bile leaking into the abdominal cavity and eating away at all sorts of important organs), liver failure (jaundice due to poisons not being taken from the bloodstream).... the list goes on and on. These are hideously painful side-effects of drinking. did you konw that when they do an autopsy on an alcoholic the people in the room have to wear special maskes? Because when they take out the brain the smell of alcohol is so pungent that they'll get sick if they don't have a mask on. And these aren't pedestrians, these are professional autopsy-ers. Can you believe that? So what kind of passion, what kind of dedication does it take to drink to that point? Pancreatitus is supposed to be the most painful thing a human being can experience, and I'm pretty sure it usually happens relatively early in late-stage alcoholism... The zealotry of the late stage alcoholic is truly, horrifyingly amazing, isn't it? Few and far between are the folks who are that dedicated to anything....

he truth is, as a therapist I am usually not able to be of much help to an active addict. It's a bit depressing to be honest. Ever hear this joke? Q:"How many therapists does it take to change a lightbulb?" A: "Only one, but the lightbulb has to really want to change." Ha! The addict who is not at the point of wanting a miracle is usually not at a point of being willing to surrender their "religion" so to speak. And can I blame 'em? Who in this class, if I wrote a REALLY compelling post on the message board, would give up your religion? Anyone? No takers, huh? ;-)

Religion can be casually defined a system of beliefs and values around which I organize my life and behavior. By that definition addiction to cocaine for example would easily be a religion. Thinking of it this way is VERY helpful for me as a therapist (and, on a personal level, as a family member) because it helps me keep my perspective. History is full of people who went to a bloody, gory, painful death to avoid denouncing their religion. So is there some key phrase, so poignant question, that I can ask a client (or family member) during this session that's going to convince him or her to lay down their addiction if they are not ready? Not a snowball's chance in hell.

People do not change their fundamental belief system until the pain of staying the same outweighs the fear of change, and sadly, for many death precedes that.

Can you tell I have some passion about this topic? ;-)

I will say that the book "Motivational Interviewing" has some really useful techniques for helping some resistant addicts walk toward powerlessness. There's a lot to learn in this class, but this piece about addiction being a lot like a religion is probably one of the most useful things I've come to in my career. Perhaps it will be useful to a few of you as well...

One idea as to why AA works

I think it's very difficult effectively therapize in the addiction field without addressing spirituality. 

In my lectures at The Meadows I frequently ask patients why they think AA works. First they come up with some answers, then I tell them my theory;"It's because the two guys who put AA together were alcoholics themselves and they realized that booze had become their higher power. Steps two and three in AA aren't about finding God, they're about realizing that booze has been the god we followed, and since that's obviously not working maybe we should try something else." This can be a really effective lesson for many addicts, especially those who grew up in spiritually abusive settings and as such are struggling with the whole "higher power" thing in the 12-steps.

This example is particularly interesting when you compare an active, long-term addict with a religious zealot. Both adapt every element of thier day-to-day life so that it serves what they believe in. Generally both prefer to keep the company of like-minded friends.  And of course, both are willing to face horrific consequences, sometimes even including a gruesome death, rather than challenge their commitment to what they believe in. 

Ultimately the addict is, by my way of thinking, one who has built a religion out of thier substance or behavior.  That's part of why statistics on addiction are so mind-bogglingly poor - recovery is a tough sell.  Think of how rarely human beings are willing to reexamine their deepest and most treasured beliefs - it doesn't come up often.  When it does come up, think of how rarely any of us is willing to walk through the unbelievable pain of restructuring our worldview from the bottom up... 

Adapted lost children

The wallflower piece can actually be one of the most acute types of trauma an individual can go through, and it's also frequently one of the most difficult because the trauma is so covert. Children become scapegoats by meeting the negative attention needs of their parents - it is very common for "wallflowers" who are typically referred to as "lost children" in family systems therapy, to be very well-behaved for the first 12 or 13 years of their life. They may present as shy or well-adjusted, but they are inevitably profoundly lonely and beleive that they are inherently flawed. Usually in Jr. High School this loneliness becomes so overwhelming that they'll adapt to take on one of the other roles, that is hero, mascot, mediator, or scapegoat. One way to know if you did this is to ask yourself "what's my worst fear?" If the answer is "being ignored, misunderstood or not heard," then it's probably a safe bet that your role in the family system was lost child...

Suicide and Anger

I appreciate you sharing some of your personal experiences there suzy.  That's been my experience with suicide as well - there's often a perception that no one would care...

One tip - suicidality is (almost) always about anger.  If you ask a client "who would be most effect/impacted if you were to follow through on your suicidal ideas?" the answer you get will usually be the individual(s) at whom the anger is directed.

Sometimes the client is not aware of the anger, or has some strong beliefs that they "shouldn't" be angry.  If that's the case I usually ask "what's not fair?"  Anger is the outward expression of the inward thought "this is not fair."  So if I say "in your life, what's not fair?" I can usually get a pretty good idea of where that anger is pointed at and we can start to move toward some more effective ways of expressing the emotion as well as considering any cognitive distortions that might be behind it...

posted to my class today...