Learner therapist (25)…… Congruence, integrity and self-defence in the anger position

Learner therapist (25)…… Congruence, integrity and self-defence in the anger position
Torrey Orton
Nov. 14, 2012

The "anger position" and congruence, integrity and self defence

One of the things that my patients struggle with is their anger. Not the anger which they know but that which they do not. They had the anger drilled out of them by their abusers early in their abused lives. They learned to hide it so as not to attract additional abuse – the abuse beyond the everyday abuse which they survived by dissimulation, pre-emption or collusion with their abusers, abetted often by abuser partners' collusion with the abusers. Failing these tactics, they caught occasional reminders of how much worse things could be than they already were.

One of these patients remarked she did not want to be in the "anger position". The disparaging of anger's reputation among the human emotion suite is systemic well beyond childhood of course. Women are often sharply aware of male aversion to their anger. Tears often get to do double duty as media for sadness and anger. If these fail, there's the backup position of self-denigration for being angry – one patient sharply calls herself "a bitch" for directly voicing her anger to others, especially other women. Then, she doubles down on it by saying "I don't want to be that person in the anger position."

Denizens of white collar work-places often report the unspoken rules of many offices mandate feeling-free interactions while the value espousals warrant 'transparency", "openness" and "honesty" – all states whose fulfilment require perceived authenticity. That is, the values have to feel real in action, not just mouthed, parroted, etc. But real = emotional in this case. And if the truth or honesty is an important honest truthfulness, then appropriate feelings are required for its expression (as were required for its perception in the first place). The plea to 'be rational' and similar encomia to feeling-free thought are among the most resilient fooleries we are beset by in our public lives, especially from various cultural and social heights.

Another patient recently explored her rage at a deeply manipulative move by her clearly incompetent boss. The rage went two ways at once: towards him for his professional chicanery and toward herself for being powerless in his face (and consequently shamed and guilty before imagined friends who she might discuss the situation with but couldn't). This bifurcation of attention reflects a lifetime's self-doubt and high achievement for her, with the doubt dominating the inner battle and achievement the outer one. All up, a lot of conflict expressed in various anxieties.

So what for patient anger?

Why does it matter? Just as satisfaction registers a pleasure with a successful action, anger registers the invasiveness of another's attack or disapproval of one's own mistake(s). The abused carry many signs of injury. One of the less obvious is injured feeling receptors and expressors. Their emotional range is confined, as was their action range, by the abuse. The distance between the ends of a feeling spectrum like irritation - anger - fury - rage are driven closer together; it's harder to express any degrees of difference. One public figure who looks and sounds like this is Malcolm Fraser. Similarly, Julia Gillard does a too good job of reducing her speech to flat, ponderous, sleep-inducing noise. They share facial immobility. Were they abused? If not, then the disease of self-restraint is much more deeply spread among the competent than I imagined.

Three steps to effective anger: becoming congruent (knowing what you feel), acknowledging integrity (deciding from what you feel) and acting in self-defence (acting from what you feel). They can be learned, usually building on some pre-existing residuals of natural capability created while preparing for engaging an established threat.

Congruence – the ground of awareness in the fizz of anger, when inside and outside are aligned

The only way to avoid congruence when repressing anger (or even irritation) is to be numb to the feeling…in which case, though, the fact of numbness will be broadcast by incongruous non-verbals like stiff faces, rigid speech delivery, and clumsy movements. This will be on display for those who want to see. We may be congruent in this way without knowing it and others assist our ignorance by not pointing out explicitly what they can see, often to their advantage in the sense of saving them from an imagined conflict they want to avoid. And around and around it goes until an explosion point is reached inevitably but unpredictably in the experience of those involved. By that time the anger is way over the top…and undirected to an appropriate or workable subject between the parties. Such explosions are the stuff of everyday couples breakdowns, tit-for-tat accusations of bullying at work and the public micro-rages we are increasingly exposed to. Emotional congruence may occur most compellingly when long gathered anger bursts on the unsuspecting and minimally deserving heads of its sources, or maybe just lookalike passers-by that trigger the gathering emotional storm. Brilliant, flaring and frightening for all because almost out of control.

How does this oh so common scenario come to play out? The persistent disapproval of any form of anger yields an effective self-restraint which fakes self-control until the actual perceived offenses pile high and wide enough to threaten suffocation. But it attracts real rage in return, it creates it, authorises it, validates it and those involved are cast into a who's to blame game that is irresolvable because the sources incite more rage. "This is what we usually do." Congruence is a starting place for engaging real issues, but not a restful one.

Integrity – is the place of truth in oneself when the real self can be used…
 

… to decide the realities we want to engage (if we can choose to do so). That real self, the reliable background to our everyday life, is the home of basic values, notably justice and fairness, and virtues like persistence and courage, which seem to be alive across all kinds of cultures, even the most spiritual, communal or familial included. These values are understood to apply equally to self and others, though their application may, unsurprisingly, lean towards self and own group. They provide a sense of direction for action and a mixture of confidence and compulsion to take action. For example,

…instead of falling into despair, Shawna got mad at what she felt was a betrayal. 'Mad' was not ideal, but it was better than depressed and full of self blame! Indeed, her anger actually seemed to lift her depression and allowed her some energy to decide what to do about taking care of herself…

 

PSYCHOTHERAPY IN AUSTRALIA
• VOL 18 NO 4 • AUGUST 2012 pg. 19

For more information visit www.margaretwehrenberg.com.

And, so to ….

Self-defence – the steps which stop and eventually pre-empt previously enraging threats

Self-defence may need to be either forward (assertion-aggression) or backwards (explanation, delivered assertively). So, what to do in everyday pre-rage circumstances? Start with the real anger only when timely, etc. Otherwise, acknowledge and defer the anger to a later time, place and content in order to take care of present business which is not directly implicated in the anger and loss of which would undermine most foundational conditions for engaging the anger usefully (for instance, by ending an employment relationship or intimate one prematurely).

Practising anger – some steps and tools for patients, and others

To get better at expressing anger requires practice as does your golf, singing, dancing, writing… through persistent small steps as in any skill building.
1) Start expressing anger by punching a pillow, boxercise, hitting a tree trunk with a stick, speaking somewhat louder than you normally do and increasing the volume slowly up to yelling or screaming. A good walk in the woods or on a perhaps windy beach will provide venues for this step.
2) Continue exploring it through martial arts, boxing, any gross motor sport – preferably within a meditative framework! Notice how hard it is to embody your anger without falling into freezing or wild Flight or fierce Fight (losing control).
3) Cultivate control of body mind and heart by choosing one physical discipline for long term development. Physical is critical because cultivating a capacity for appropriate expression of anger is an engagement with the freeze/fight/flight response system, all three of whose terms are physical. The FFF system readies the body for action. Those of us with repressed feelings may not even notice them coming into play because our bodies are out of tune for them. The body is our instrument of feelings in two senses: for perceiving them and expressing them. An untuned instrument will never play well.
4) Start employing anger. Build skilled competence by strategic intervention planning and execution along the lines of basic graduated skill development programs of any kind: a sequence of motivation (identifying the defence need), observation (of competent actors), approximation (visualisation of proposed actions, etc.), initiating (trialling the actions), debriefing (did well, do different, etc.), replanning, re-initiating, debriefing…..Some of the relevant communication technologies to be mastered are available in previous "Learner therapist" posts in this blog.
Finally, it should be apparent that what's proposed in this post is applicable to everyday life, not just catastrophic circumstances. Act well – congruently, integrally and self-defensively, remembering that the best defence is a good offense.

Learner therapist (26)…… Communication Intervention Techniques

Learner therapist (26)……
Communication Intervention Techniques
Torrey Orton
Oct.31, 2012

Pathways to influence

These techniques are needed for moments when you lose sight of what's intended
by others, or are shocked or distracted by your own thoughts, or wonder what the other's expression means as they are listening to your response....and so on. All are points at which you may 'lose the plot' or be thrown off guard.
I call them "intervention techniques" because they provide a variety of ways to act assertively in a range of different conversational settings and purposes. Each technique is presented with some possible words you could use to implement it. You probably won't find them all comfortable, so some rehearsal will be particularly appropriate for these.
They were originally designed as a suite of tools for taking power in employment interviews and taught to 300 members of a public sector organisation undergoing what came to be known as downsizing under the guise of "restructuring". Whole departments' positions were declared redundant and members were invited to apply for the new versions of their old work. 25 years ago this was the leading edge of organisational transformation.
No one found it liberating except the managers who imposed it, until their time came later. It is a seriously disempowering process. There are many more of them now, similarly masked in econospeak. Here are some counter-measures at the personal level. I have added more everyday relationship examples to the interview focussed ones of the original versions of these techniques.
Ethical assertion

They are also ethical, I believe. That is, these techniques are actually the normal communicative behaviour of people in balanced community with each other – couples, families, clubs, associations, workplaces – but almost never in politics or "high performance" organisations. Where you find people comfortably engaging with each other you can observe many of these techniques being used without strain on any side. In that sense they are natural, but only to relatively low pressure settings. Looking for them around you is one starting place to learning them.
There are a few underlying principles shaping these techniques:

1. Self-disclosure is the best way to lead others to be more self-disclosing
2. Taking charge of the process of the discussion is the cheapest source of power available.
3. There's a strategic relationship between these techniques which moves towards more "shared facts" or agreed approaches.
4. Questions keep assertions balanced and,
5. Keep it short – small communication steps are clearer and less demanding of brain space. The greater the pressure the smaller the steps should be to ensure everyone is brought along together
   
   
   Opening statement: this is something strongly recommended if you are opening a new topic or concern in any relationship. The purpose is to get you started talking from your point of view and making an impression that you choose, not just a response to their direction! Actually having an excuse to start talk yourself gets you into action, makes you feel you have some initiative, gets the motor running. Following are a number of approaches you could take in an opening statement.
   As part of your opening statement about how the discussion might go, consider advising that you will check out your understanding of their questions and responses to your answers because you want to avoid misunderstanding (which you know is very easy in these circumstances); so you may "jump in" at points .
   Or, you may want to mention some factor(s) beyond your control which are likely to influence your performance - such as the fact that all your children were sick last night and you've only slept 2 hours.
   Or, at least, you may want to say how interested you are in this subject and that you're looking forward to the discussion!
   The techniques…
   
   1) - Evidence: how do you know they accept what you provided as evidence of the case you are making?
   
   "Some evidence for this is....... does that sound to you like a relevant example?"
   Note - an area in which this may be important is with questions about things like "proven ability to work as a
   member of a team" or "how will I know that you are doing what you say you will to change what we've agreed?"
   2) - Clarifying the question:
   when you don't understand what they're getting at, like:
   
   
   "....I'm not too clear what you're asking: could you say that in another way, or give me an example of what you mean...?"
       Or,
   Tell them that you are going to restate their question to them in slightly different words to test your understanding of it. Then do it.
   3) - Managing nerves:
   at the moment you are feeling nervous, say so if it is obviously going to get in the way; they will know it's happening anyway, so pretending it isn't doesn't work; saying something like the following may help:
   
   "I'm a bit nervous about this and one of the things I do when I'm nervous is.................; so it's nothing personal". Nb: this can be included in an Opening.
   A more confronting version might be:
   "I'm nervous about…. so maybe we should talk about it first before trying to deal with our main agenda…"

4) - Distraction:
when you've lost the plot for a moment and can't find it....

"Sorry, I got side-tracked for a minute... could you repeat that for me please..?"

Or,

"….and what I noticed was that…."

5) - Puzzlement at other's expression: you  are distracted by one interviewer's non-verbal response to something you're saying.

"You look a little surprised (shocked, put off, etc.) by what I'm saying... Am I getting the right impression?" If yes, then:

"What's striking you that way?"

6) - Strengths and weaknesses: one of the most difficult and unavoidable parts of many conversations

a) How to raise a question of weaknesses which may be seen to be the
difference between success and failure in this discussion?? Or, which may constrain your actual ability to do something you are discussing …

"I think I have a couple of weaknesses: x and y; I am in the process of doing something to reduce them - for example: ......"

Or,

"I'm not really too good at …. so I may have to proceed slowly, or get some experience elsewhere before starting on what we're talking about", etc. Note - this can be used in an Opening when you have a weakness like a quiet voice: invite the other(s) to signal non-verbally if they can't hear you clearly.

b) How to raise strengths which are competitively critical: that is, which are reasons why you are the candidate of choice.

"I think there are a number of strengths I have which make me particularly suitable for this position - for example:.."

7) - Suggestions:
for how the job ought to be done which go beyond the requirements of the job description or advertisement, or for factors affecting the matters you are discussing: like alternative viewpoints, new facts, persons with a stake, etc.

" There's some other things I think are important for anyone doing this job; they're not in the description, but......."

Or,

"I'd like to add a couple of things which haven't been mentioned so far."

NB - This intervention may need to be paired with Managing Nerves (3, above) for effective delivery.

 

8) – Jumping in or Interrupting - how to interrupt a process or remark to suggest re-direction, ask for clarification (see #2 above), make a suggestion (#7 above), etc.

"Excuse me a moment, but I would like to check out something you've just said before you go on, namely,..."

"Can we stop here for a minute?"

Nb – it's often useful to signal non-verbally the intent to interrupt by putting up your hand, shifting in your seat, clearing your throat; then, watch for a space and step into it with phrases like those above.

9) - Pre-empting - if you believe there is a common perception of a weakness in your performance which is likely not to be mentioned, but would be a major negative hidden influence on your chances, then.......raise it yourself! Or, if there's a hidden issue – one of those open secret things, elephant in the room – name it.

"One thing I'd like to raise is a weakness that people often say I've got....... I do (don't) think this is true because....."

Or,

"It seems to me there's something we all know: that this idea is a bit scary for everyone because we've never done anything like it before."

10) - Pause speech - acknowledging your surprise at a question - eg. -

    "I'm not too sure about that: I'll have to give it some thought for a second..."

Note - this is another way of giving yourself thinking space; your brain works at about ten times the speed of your mouth; so you can construct a hundred-word response in the time it takes to say this. This technique is an obvious relative of #2 Clarifying the question, but under greater pressure.

11) - Deflection
- to another point in the discussion when you think one issue belongs with another; or one question links to another for you.
    "Yes, I'd like to talk about that in a few minutes in connection with...."



  

Appreciation (48) – Do whales sleep

Appreciation (48) – Do whales sleep

Torrey Orton

Oct.12, 2012

Do whales sleep, or dolphins?

Australia is a biologically weird place as I was reminded by spending a few days in Noosa, Queensland. Mostly on view are varieties of holidayus australianus, with next G genetic offshoots in tow…or sometimes more towing their elders, but… Among the passing late school hols multitude wandered purposefully and utterly unperturbedly the fabulous bush turkey. It really is a turkey family bird thing, but for its tail. This is a wonder in bird land, a paddle it seems to be rather than a tail as we know them. And the paddle tail gets bigger as they get older and if they are male, which you can somewhat tell from the bright yellow wattle hanging around their necks, set off somewhat from the scraggly bald head by a red leathery collar. Finally, that paddle can be fanned in the fashion of Nth American turkeys, guinea fowl, lyre birds and so on, and then returned to paddle shape when the courting is over for the moment.

They wander around the foot traffic looking for dropped edibles which though numerous are often passed by in favour of those in the brighter end of the bubble gum spectra – a marvel of colour, touch and taste as you can imagine if you're a graduate of the gum retention by public posting school of chewers.

Oh, and it seems whales sleep, sort of (see http://marinelife.about.com )…which wonder came to mind as we were padding the paths of Noosa National Park up the hill from the beach and around the point break. A few km's into the jaunt I saw in the distance to the southeast a spout-like puff blown out of sight quickly on the brisk prevailing breeze of the day, followed by some splashing that was running counter, both in height and direction, to the prevailing easterly wind driven white horses. We weren't the only ones attracted. Assisted in our focus on marina fauna by a pod (17 Jane counted) of dolphins searching the immediate cliff faced coastline for midday snacks, we kept looking to sea for a rerun of the puff and splash show.

More whale sightings occurred over the next 20 minutes while lunching under the sparse coverage of a couple of trees from our lunch seat of asparagus ferns and couch grass in the 45kph breeze blowing up the 20 meter cliff face. These sightings were almost on the horizon in the same configuration as the first without the spout fumes…too far to see while the slapping of tails and low breaching was clear. If whales sleep by floating on the surface, how do they do in wind driven white horses?

 

For variety, we also had our paths crossed at different points in the walk by three four-legged reptiles – a goanna, a blue tongue and a copper back (its look , not its moniker; can't find it in the guides) – and for continuity the ubiquitous bush turkeys scrabbled in the deeper groves of the rainforest side of the park. Paddles for tails. Really! See here for details - http://www.wildlife.org.au/wildlife/speciesprofile/birds/brushturkey.html

 

Learner therapist (23)……What’s neuropsych got to do with it

Learner therapist (23)……What's neuropsych got to do with it!!

Torrey Orton

Oct. 7, 2012

 

Very recently I had a reason to have my head examined. Rather, I thought I had a number of reasons…forgetting short-term goals, losing the plot in conversations, slurring words, interrupted sleep, quick to anger under pressure, forgetting the names of common items. So I contacted a neurologist who has known me for ten years both professionally and personally, presented my wonders about encroaching dementia and got wired up for nuclear and CT scans of the brain. Result: all clear, no doubt in his mind that the symptoms are normal ageing stuff. In addition, he noted that his clinical impression of me pre-scans was what the scans confirmed…no cognitive impairment.

The thing about dementia is that it is one place we discover clearly that we are brain dependent. Demented person = slowly dying person as the organic systems break down and consciousness goes with them. Consciousness disappears before the body reaches its end. In this respect, we can clearly say that the brain as an organic entity causes our demise. There are a host of other organic dysfunctions which constrain consciousness in irreversibly causal ways.

This experience provides a personal entry to my agenda here. I've been wondering, with increasing intensity over the last year, what neuropsychology really has to offer psychotherapy that's new?! That wonder spreads back towards the biopsych and neuropsych domains, with a hope that they offer major intervention types or places I had avoided or ignored because I'm basically a relationship systems person. When I first undertook university psychology at the age of 43 in 1986 I believed (and still do) that all therapists should understand statistics to the extent of knowing what kinds of truth claims arise from that perspective and how they connect with individual, couple and family work. The same goes for neuropsych, which was just a glimmer at that time.

Five years ago I read The Neuroscience of Human Relationships. (Cozolino, W.W. Norton 2006 - a 428 page book of which 85 pages are references. Looking back today I had bookmarked the following paragraph:

…As our understanding of the brain continues to expand, we gain an increasing appreciation of the manner in which early experiences, both good and bad, become transformed (1) into the substance of our nervous system via the three messenger systems. As we have seen, early neglect, stress, and trauma impact all the developmental processes we have discussed in negative and destructive ways. Neglect and abuse decrease the growth of experience-dependent neural circuits, especially of the OMPFC, anterior cingulate, and insula cortex. Perhaps it may help us all to keep in mind that when we watch a child interacting with the world, we are witnessing the building and shaping of a brain in ways that will impact the individual throughout his or her life. (p. 301-302)

If you take out the references to the brain you get the basic understandings of late 20^th century therapy. The brain references add nothing to it other than asserting indirectly that there is some organic substrate (which has seldom been in doubt) to human experience, to conscious experience (which is what makes it human, by the way). And by the way, the building and shaping of a brain is an interdependent activity, not interactive nor transformatrive. That is, what a person (brain) learns is then brought to bear on the world in which he/she exists and shapes it, too, including the other persons in that world. And so back and forth and back and…

Five years later I attended a one day program ("Focussed Neuropsychotherapy: Applied Strategies for the treatment of anxiety") on May 2, 2012 presented by Dr Pieter Rossouw (see www.mediros.com.au). I hoped to find significant therapeutic innovations arising from the organic substrate. On the whole I will say there were none. A program titled "focussed", mirroring the generalist/clinical distinction in therapists by AHPRA, offered 90% standard issue evidence-based "strategies" for addressing anxiety which have no need of a neuropsych contribution to substantiate themselves. The neuropsych bit – brain education – I have been doing ever since I learned the amygdala was the name for our threat detection capacity. The program's encouragement to draw pictures of the limbic system and associated bits was not convincing to a long term user of the other strategies.

I took up this perception with the presenter offline so as not to disturb the other 50+ participants' gobbling up the "strategies". In response to my wonder what unique contribution neuropsych adds to the evidence-based approaches to anxiety management he volunteered that two neuropsych labelled therapist training programs in another state have been closed because that question could not be answered to the satisfaction of the providers…and maybe we could talk about it later. We have not. I have had other friables to attend to til now.

What is troubling, apart from my slight sense of deprivation at the lack of neuropsych therapeutic novelties, is the fake science that seems to accompany so much of my small reading in the domain. Some leading indicators of fake include: (1) addled causal attributions from brain scan screen patterns (lighting up in a new sense; see "transformed" in the previous quote from Cozolino); (2) covert meaning attributions from the history of thought about being human to brain functions and vice-versa (a relative of 1 above); (3) the straw man argument like cognitive therapy of anxiety is "top down" and neuropsych-informed is "bottom up", as Rossouw proposes below.

Dr. R concludes in a written-for-practitioners pre-reading article for the 02/05/12 workshop:

…Neurobiology reiterates an important psychotherapeutic principle (2): psychotherapy is not about a (albeit "good") bag of tricks, it is about the key role of the therapeutic relationship, empathy, and unconditional acceptance. These elements are not just important in the therapeutic process – neurobiology tells us they drive the efficacy of the process (1). These elements combined with a clear understanding of neurobiological information are the therapeutic makeup needed to facilitate change that has the capacity to facilitate new neural networks (1) – the ultimate aim of Neuropsychotherapy.

This is how he got there, roughly: by constructing a pseudo controversy about "top down" and "bottom up" therapy, claiming that CBT is the first and neuropsych will balance the equation. His argument runs…

In light of this debate Kabat-Zinn (2003) and later Siegel (2010) introduce the concept of mindfulness as an integrated approach (emotional-cognitive-spiritual and behavioural) and say that, when we "come to our senses", we become grounded in a mindful way of being that opens us to ourselves and to others. Siegel takes this concept further and says:

 

"A brain perspective on this experience of being fully present in the moment can shed some light on the path of bottom-up processing to liberate us from the prison of top-down" (Siegel 2010).

 

The key concept of a bottom-up (3) approach is the integration of the elements of "being" in the functionality of neural systems. For example neurobiological studies have clearly demonstrated the need for (1) a down-regulated amygdala response to facilitate synaptic communication.

 

This brings key psychotherapeutic principles like empathy and listening into play. Neurochemicals and neural communication change in the presence of these principles. Who the therapist is and the social environment of the therapeutic setting are more fundamental to facilitate new neural communications than hard core clinical information.

 

Neurobiological studies have demonstrated the need for (1) effective hippocampal firing for enhanced neural growth and new synaptic communication. Emotional safety and good nutrition are vital to facilitate effective hippocampal activity (2).

(emphasis supplied)

 

I don't know who this "top down" practitioner is, though there must be some handbook driven types in our trade, as in any. The rest would offer simple suggestions / techniques which augmented thought reconstruction (cbt) with exercise, meditative practices, sleep and eating regulation and task reduction or scheduling to "down regulate" stress. The more integrated therapists would include suggestions of sharing currently bothersome experiences with appropriate family members and/or friends. These amount to implementation of the biopsychosocialcultural (or spiritual) paradigm most health practitioners have claimed at least organisationally to support for 25+ years.

Ordinary language for everyday life

So whenever you hear or read someone touting the wonders of neuropsych for therapeutic applications consider the following linguistic adjustments to their spiels:

Replace 'neuronal' with 'perceptual'; replace 'neural networks' with 'habit(s)'; replace 'plasticity' with 'learning'; replace 'brain' with 'mind' and you will have what you already know about the mind or self in action with therapeutic assistance, or even without it.

Perhaps I'm churlish. The neuropsychs are just doing what most social scientists do: seek to extend a handful of insights and a sketch of a construct to every aspect of a human domain - in this case, psychotherapy. The move is made by explicit or implicit claims (mostly the latter) that the existing constructs are actually the new ones in mufti…or just outmoded because not evidence-based science. How could they do otherwise?

Maybe the unique neuropsych contribution will be available when every patient can be cheaply scanned for a few days or weeks (to get personally unique data) which can tell them and us that what they feel – anxious, etc. – is now confirmed as what they feel because blinking lights are attached?

The incommensurability category mistake – synaptic firing and everyday perception operate at different speeds and levels of integration

The experience of anxiety is fed by perceptions of danger which overwhelm existing capabilities. That overwhelm is at the level of everyday language and reflection and interaction…the daily world, not the neural, the neural-networking or the brain. That is, as with relativity physics, it may be so that everything is relative, but not in daily life. Newtonian physics applies there. The theories of that physics sit in the relative universe, but for us in our daily lives they are not supplanted by it.

Neurons and neural networks undoubtedly underpin our conscious and sub-conscious experience, but that experience is not accessible to direct inspection. Similarly, being on time in a particular place for a particular purpose with a particular person is a meaningful expectation and achievement – for people, that is. Maybe not for neural networks, except where their incapacities prohibit being on time, etc., for which we then excuse their human owners for an objective fault not of their making.

I close with a plea: please tell me what is uniquely noteworthy about neuropsych for my therapy? Help me out here.

 

Learner therapist (24)……A little rewiring!!

Learner therapist (24)……A little rewiring!!

Torrey Orton

Oct. 01, 2012

 

Rewiring, or experience-dependent brain plasticity

The experience

Ten days ago I tripped on the 6 inch front step at the Fertility Control Clinic as I turned from a delivery guy holding a 2 litre milk container and a ½ kg. loaf of bread in my left hand and the day's newspaper in my right. Refusing to let go of the goods, I fell forward catching myself with my full hands. This went fine on the left with the cushion of the milk and bread (which came out of it unscathed) but my right thumb was severely scrunched, still bluish five days later though somewhat less swollen (it still had a bit of bee sting-like puffiness).

I had made two mistakes: starting to move before I had the stuff safely in my grip and preferring the goods over my safety (a bad application of the good training which makes me agile with packages) as I started to fall. This mistake is similar to one 10 years ago when I passed out in a local street, realising just before I did that I was going to do so (that fainting feeling you may have heard about if not experienced) and wondering to myself where I could sit down. By the end of that wonder I was out cold with major skull fracture and headed for a visit to the ER. Should have just sat down on the spot and saved the concussion. Wondering instead about where to sit was habitual action taking over – the latter a pattern dominated by my sense of public propriety not of safety, to my surprise after the fact. What a dumb thing to do.

Rewiring, type one

My present re-wiring focusses around various highly repeated everyday activities like tying shoes, buttoning shirts, writing by hand, opening doors, opening keyed locks, shaking hands and a host of fine-tuning applications which require thumb to index manipulation of objects (winding a traditional watch, opening cardboard milk boxes and chip packages for example). I now know why European door handles are superior to our globular ones. They do not require thumbs.

As the days have passed since the accident, I try the more difficult right-handed tasks like unlocking our keyed front door with a thumbed grip to test the pain involved. Same with shirt buttoning and pants zipping (you can do a calculation of the daily number of events for a man from this list).

Then, there's the clumsiness factor. Winding my watch left handed was impossible from the first night. As a result of my clumsiness, coupled with incapacity (try turning a firmly closed screw top on an unopened, pressurized jar without a fully working thumb), I developed work-arounds like avoiding some tasks requiring a normal right thumb. One set of these was various ways of achieving a near thumb effectiveness between the four fingers of the same hand. For example, turning a door key by gripping it between index and middle fingers. Testing when the lock is sticky! Fall back position: use my left hand.

Do not mistake this for a merely behavioural activity. I have to decide each time what to do…to press on with the left hand cuff button or leave it undone because my thumb's too stiff that morning. Notice, I might get away with buttoning a shirt left handed after a while, but left cuff left handed – not likely in this life. Similarly with fly zipping, door handle turning, sock-pulling (on, up or off). Sometimes I can go for the left hand (door opening especially).

These are all internal negotiations. Over the time since injury I notice that I'm increasingly approaching repeat usages with a pre-emptive awareness – that something (maybe) to be worked around is coming up and I should get ready for it, consider an alternative 'technology' to the old right hand thumb driven one.

Rewiring, type two

As for combination internal and external negotiations of my world, there's the socio-cultural domain of hand-shaking. Shaking hands is a core part of my professional life, done with every patient (until now!) at start and finish of sessions. I find myself breaking this golden rule to avoid the explanatory caution at first encounter (that my thumb has to be protected from shocks) or the experience of a partially withheld shake by someone who knows and unconsciously expects my normally firm, full grip. This simple matter invokes a series of barely registered reflections like:

• I shouldn't impose my unavoidable shortcoming on the others.
  
• The injury draws attention to me rather than where I want it – on them.
  
• It's too clumsy (that word now describing interpersonal perceptions and intentions) to mention or do, so don't do it at all.
  
• Oh, I forgot to offer my hand…
  
• Try the left-handed shake!!
  
• ….
  

Rewiring unstrung

Then, there's accidental re-wounding, the reopening of old wounds perhaps. I did this, too, a few days back by theatre parking under pressure (self-induced more than situational), missing the bay on the first go and retracing my path three meters to have a more direct go, turning the wheel with intense focus and caught my already offended thumb on the wheel's cross strut. Just a little rap, but right on the most injured 2 mm of the first joint which roused that unrelenting, rolling pain which you have to wait three minutes to subside. A morphine worthy event if it had continued.

On the other hand, a nothing event compared to real long term trauma, but instructive for another take on what sustains trauma: accident as much as intent – or, rather, in this case overwhelming of my self-protective intent (stop pain) by my personal achievement intent (get the car in the spot meeting some timeliness and beauty of execution criteria both of which are automatic and were functionally irrelevant at the time)!!

Plasticity is one thing, competence another?

Is it any wonder that all really "hard-wired" habits, those acquired over years in the crucibles of life - family, schools and clubs – are resistant to change even with serious application of focus and energy?? They are really complicated, complex and multi-domainal; they touch most aspects of the patient's life. They are constantly reinforced in everyday relationships which reproduce even the merest inkling of the originally compromising formative experience(s).

A thorough description of the detailed actions of thought and feeling required to relearn to button a shirt effectively (a measure of time, completeness and pain factors all occurring intertwined, not in sequence) could take a page or more. Those of you who recall the history of attempts to completely analyse the process of learning to ride a bicycle may remember that the researchers gave up after they got to around 350 pages of documentation. For an alternative access to these phenomena, watch your child learning such things for the first time, to the point they can successfully dress themselves in one of their normal dress styles. Analysis won't help you or them, but application will and does lead to learning, eventually.

Incongruously, this may be why successful survivals of long term abuse(s) have trouble getting their whole lives together, especially in the relationship domain. But then, who doesn't have this trouble ? I still haven't managed a Windsor knot after all these years, or to successfully avoid self-damage in the pursuit of truth, beauty or justice. I did wind my watch right-handed after one day by finding a purchase on the stem which just hurt a bit, valuing the propriety of wearing my watch over pain reduction. On the other hand buttoning my top shirt button under a tie is still off limits 12 days later.

 

Appreciation (47) – A bridge too far??

Appreciation (47) – A bridge too far??

Torrey Orton

Sept. 29, 2012

 

In the middle of nowhere…

 

The brilliantly new warning sign said "Narrow bridge…Do not pass…one lane only" with the standard converging diagrammatic in case you missed the meaning. There should have been a real old wood from top to pilings one track country bridge on the slightly renovated country track (dirt all the way with more or less grading to distinguish the in-use parts). Instead, in the middle of nowhere there appeared down the hillside run of the track we were walking a bridged creek - newly paved, edged and cambered. And what a bridge: two real enough lanes that farm trucks could pass each other at the same time, if they could get there, or leave once arrived; concrete and steel from abutments to shiny traffic barring guard rails along its edges.

The track leading down to the bridge could carry a road grader and a half, but the track up the other side dwindled quickly to the remnants of a gold field era cart track, now rutted and fallen tree-blocked and barely micro size four wheel driveable, leaving the tree aside. The classic once was a road that now is to nowhere. Said shiny signage actually was on this remnant track side of the bridge, not the graded stretch we had in initially come down…a track you can now see couldn't have supported any traffic for the sign to inform. Amazing.

It left us wondering what was in somebody's mind to not merely repair but totally replace the original crossing…replaced with a structure of such monumental wholeness that no imaginable rain could wash it away (which is probably what happened to its precursor…an unimaginable rain that is, whose remnant evidence lined the narrow gorge spanned by the bridge). We thought maybe it was a requirement of someone to keep fire access open, the countryside being that Brisbane Ranges scrub which has often gone in a flash, though not recently in this area (Spring Creek). What were they thinking?? Whatever, its realisation has been complete. One could only dream of such efficient road renovation in more populated areas.

Learner therapist (22)……Telling people what they “need” to hear

Learner therapist (22)……Telling people what they "need" to hear
Torrey Orton
Sept. 9, 2012

"What you need to do is…"

A friend challenged me a while back with the proposition that "you can't tell someone something they don't want to hear". So I started on the spot (at the time in an Art Nouveau café/bistro frequented by Collette in Besancon, France in the early 1900's) to demonstrate how I could do that. My first move was to contradict her assertion, which got her attention, so to speak…the rest I want to explore somewhat more systematically as an approach to patient education / awareness in therapy.
The methods / techniques of confronting must vary with the vulnerability of the patient, the therapist and the present state of the therapy relationship. The principle form of variation is the intensity of the truth claim made for the conflicting opinion on offer from the therapist. Truth intensity is expressed, apart from non-verbal components (volume, pace, gesture) by choice of modal verbs – could, should, must, might – and the level of truth claim: e.g. I guess, I suppose, I imagine, I believe, I'm sure, it is the case that, and so on…ascending to scriptural or other canonical claims of irrefutability.
Variable vulnerabilities
These variations are the 'how' of telling someone what they do (may!) not want to hear and are more important than the 'what'. The what provides the conscious motive for taking action. There are three easily assessed and communicated whats: (a) a patient's emotional misalignment with their present concerns, (b) a misapprehension of what's happening – the facts, and (c) inappropriate beliefs or values for dealing with their concerns about what's happening.
On the whole, the success of any effort to tell somebody something against their immediate sense of need for an offer will fail, no matter how relevant, shapely, timely the offered information is. This is because the offer has to be perceived as an offer of help; that is, as arising from the therapist's positive intent towards the patient. This is the primary motivation of an offer, not the 'what'. If positive intent is in short supply or at the time not in view, then the patient will perceive the offer as a preface to a manipulation and back off as much as they can.
Don't ease in
This fact is the background to the idea that a difficult conversation can never be "eased into" successfully. The effort to ease in will be perceived as what it is – not the real message, just making small talk when big talk is expected and necessary. Rather, the patient will perceive a cover-up, a deception, occurring. Therein lies the undisclosed vulnerability of the easing-in therapist, signalling the therapist's doubt about containing the consequences of the confrontation. Doubt is what patients already have plenty of themselves.
The overall aim of therapy I understand to be the building of a conversation which is a normal, effective adult conversation with appropriate turn-taking, etc. I give patients various kinds of evidence which they can use to test whether they are getting better, and to mark eventually that they are finished with our work. One kind of evidence has to do with jointly conducting the agenda and process of our therapeutic conversations.
A simple, learnable system for effective therapeutic conversation is the three step chunking device of Entry, Action and Close with Checking for effectiveness at each step along the way. This system is a means of engaging any kind of actually or probably or possibly conflictful context. For example, see The Negotiator (1998) for an extended example of walking along the fringe of violence without either denying its possibility or falling into it (a fantasy we may have about all perceived conflicts). Every time one side or the other picks up the phone to initiate a call a new entry has to be created by the person calling. This is often pro-forma, but if matters are emotionally dense, for whatever reasons, some attention must be paid to details like acknowledging the existing feelings.
The whats of therapy
Back to the whats mentioned earlier. I'm going to focus on confronting patients about (a) their personal (in)congruence, (b) their (mis)understanding of "the facts" and (c) the beliefs (including values) through which they interpret the world. These are the 'what' of confronting, the reasons I would want to confront a patient – that they do not know what they feel, that they do not have the facts in hand and/or that they hold incorrect beliefs about the world (and so miss some of the facts).
The system in brief – a short example
This example will show a different what in action in each step and the movement from one step to another through engaging the whats of the discussion. This is merely a sketch. Each chunk might take more time to work through.
Entry
– the entry step seeks to make reliable contact with the other person, set a notional agenda for mutual attention and make the first move into the action step; it establishes the imagined interaction's purpose, process and outcome.

1. their personal (in)congruence:
   X had been talking about his childhood abuse by a family friend in a calm and fluent manner with lots of detail about time, place and action. We'd been working around his anger and overpowering anxieties for some weeks when this story came up. It was almost scripted. Subsequently it turned out he'd told the story to other therapists and a psychiatrist without the feeling of the event getting through, nor being asked for.

After few minutes I said:

I'm not sure where you're going with this, why it's important to you…your expression is a bit blank but the story is a major trauma. Can you tell me what you're feeling now?

Check* - Does it feel right to look into this now?
Action – action is where the work proposed in the entry gets done, or at least attempted;
to continue this example:

1. (mis)understanding of "the facts"
   X identifies a little distress after telling the story because he's not too sure if what he said is true, if it really happened exactly as he said…maybe even it didn't really happen?? No one else who knew it happened has talked about it– not his grandmother, nor his parents, even to this day 30+ years later. (This family silence becomes the near source of his continuing trauma, the engine of repeated doubt and anxiety of catastrophic proportions.)

So I said,

No, you're wrong about that. Memory works like this…. Memory is never perfect. In addition, your difficulty with the fact of memory's fallibility is magnified by your family rule against exploring it, which among other things may makes you feel it is wrong of you to want to clarify the memories….we've talked about your parents active resistance to such exploration often over the last months….

Check* - Is this matter clearer than it was at the start?

Close
– is when a clear end to the action is achieved, for the moment. Possibly a new entry is proposed either immediately or at some specific time / place in the future. Doing so provides continuity and, more important, evidence of commitment to the relationship (appearing above as "positive intent").
Finally X said,

1. the beliefs (including values) through which they interpret the world –
   Yes, it's clearer and I think I now see that expecting perfect facts is one way I hold myself to ransom with my fallibility and guilt…it's hard to see clearly, but that abuse was not my fault...I'm caught in a system of denial…

And I replied,

So maybe we can look more deeply at how that system is spread throughout your life, not just your family of origin…

Check* - Is what we've done so far moving in the direction(s) you want, need…?


There's a start on telling people things they may not want to hear. There's a host of fine points for different situations, vulnerabilities and relationship statuses. You may have noticed that Checking could have the result of stopping a step in its tracks and forcing a return to the previous one. That's the price of effective communication. Knowing that itself can help bridge steps which feel like they are moving back more often than forward. I've been working with X about this for 18 months.
Maybe next round I'll provide a few extended vignettes of confrontations which have been extremely high volatility and also resonating effectiveness for their participants…both me and them.

*Checking is a sub-step throughout usually made by the therapist to ensure a good fit of process and content is maintained. Patients can be expected over time to provide checking themselves, too. It should prevent misunderstandings or misinterpretations, and consequently reduce unintended deceptions both ways. For each of the three domains of confrontation ask things like:

(a) their personal (in)congruence,- How does this feel to you now? How's your breathing, tightness now?

(b) (mis)understanding of "the facts" - Is this matter clearer than it was at the start? What do you see as the key facts in your struggle now?

(c) the beliefs (including values) through which they interpret the world - Is what we're doing now moving in the direction(s) you want, need…?