In defense of therapuetice preconceptions and generalizing.

Our own experiences are really all we have to go on.  The goal, in my opinion, is not so much to avoid using my previous experiences with like individuals as to avoid adhering to them with too much rigidity.  Does that distinction make sense?  It's subtle, but we in academia like to discard babies and bathwater alike, so we neglect this point too often... 

I did this with a gal just today.  She reminded me of a battered wife I worked with who had been of a similar background, ethnicity and age.  We dug in and did some group work and, sure enough, she'd come into treatment out of a profoundly abusive relationship.  Interestingly though, she claims he only hit her one time, which is significantly different then the client whom I related her too...  so if I were to dig in and press her on this issue, say "he must have hit you more!" or something silly like that, that might be an example of me adhering too closely to preconceived conclusions.

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.