Friday, February 21, 2014

Left-handed Armenians

Within the next half-a-year I may be compelled to take a college course in chemical dependency.  This is because my wife and I are hoping to relocate to a western state, whose Counseling Board requires such a course for licensees – apparently even those who have been working for a long time and have treated many substance dependents in the course of a varied practice.  (In the ’90’s, my graduate counseling program included substance-related courses as electives not core, and I found the subject as boring as lint.)

Though I am not entirely averse to returning to college at age sixty-two, I am in “philosophical” disagreement with the requirement to complete a drug-specific course.  To me, this would be no different than having to take any of the following classes:

* Treatment of ambidextrous masturbators
* Psychotherapy of female chocolate abusers
            -- milk chocolate
            -- dark chocolate
* Group therapy of texting-while-driving adolescents
* Victims of bullying
* Treating the symmetrical eyebrow-pulling obsessive-compulsive trichotillomanic
            -- simultaneous pulling
            -- sequential pulling
* Crisis intervention for latency-age intellectualizers
* The power- and fame-addicted man (or woman)
* Helping the “Adjuster” Adult Child of Alcoholics

My point is that people have pains and unmet needs that bring forth many – maybe an infinite number of – reactive and self-medicative behaviors, symptoms, which are the indicators of disorders, not the disorders themselves.  Is a cough a disease in itself, not a symptom of an irritation, obstruction, respiratory disturbance or worse?  Is a patient with AIDS well served by a physician who only treats the pain and disfigurement of lesions?  If you have the flu, would you go to a doctor who knows about runny but not congested noses, and who believes your problem is “runny nose disorder”?

Despite the fact that political correctness has created the “disease” of alcoholism, clinical evidence shows that addicted people are self-medicating people, and they are medicating away historical pain (which leads to contemporary suffering).  What is the pain?  Anxiety.  Depression.  Identity impairment.  Anxiety that blossomed in an insecure or abusive, suppressive, reversal-of-dependency home.  Depression that formed in a cold or angry home that had no empathy.  Identity failure, which grew from depression, which grew from the tamping down of the child’s emotional fire and compass.  Clients presenting, during early sessions, with symptoms such as food abuse or “excoriation disorder” (skin-picking, DSM 5) descend quickly enough to the deeper issues of cause – what is this tension, what is this emptiness that craves to be filled?  Because therapists work against pain in many of its forms, we do focus on the distress that symptoms, themselves, often lead to.  And symptom-management can have, in controlled environments and with very committed clients, deep effects.  An example is Masterson’s work with adolescent Borderlines in an inpatient setting:

“Today, in supervision, as I see the problems most therapists have in understanding and managing acting out, I wish that they could have had that experience in that unique crucible.  Only after we have become professionals at setting limits in order to survive did we learn that it had a far more important and profound psychodynamic effect.  We saw adolescents become depressed as they controlled their behavior – i.e., the first link between affect and defense.

“It was now clear to us that the acting out was a defense against the depression.”*

Once the adolescents’ depression was unmasked, absent the covering symptom of acting out, depth process could follow the line down to the “abandonment depression” – botch of the maternal bond in the first years of life – at the seat of patients’ personality disorder.

I have always been proud, though quietly, of the descriptor “generalist” counselor, because my meaning of it is someone who works beneath the smorgasbord of surface manifestations – the symptoms, the act-outs, the specialty disorders, the left-handed glue sniffers – to the why’s and to the source of pain.  If you come to me with a drinking problem, yes, I will try to help you stop drinking.  But by looking beneath it to your depression, your self-esteem, your father, your self, I’ll also help you not need to drink.

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* James F. Masterson, M.D. and Ralph Klein, M.D., editors, Psychotherapy of the Disorders of the Self, 1989, p. xiv.

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Comments are welcome, but I'd suggest you first read "Feeling-centered therapy" and "Ocean and boat" for a basic introduction to my kind of theory and therapy.