Psychotherapy 101

 

Sigmund Freud was named the Father of Psychoanalysis. . .

He coined a term known as transference and its counterpart. This principle of thought and behavior is common to the psycho dynamics of basic human relationships and encounters and can be either a positive or a negative phenomenon. Transference and counter-transference have both diagnostic and therapeutic significance in certain forms of psychotherapy.

Insight oriented psychotherapy, for example, is highly dependent upon these processes. Transference refers to the transfer of emotions and attitudes about significant figures from ones past onto another figure in the present moment. The two figures may be totally unrelated to each other. A useful example in therapy would be a young woman subject relating to her older male therapist in the same manner she would her father who happens to be similar in age and appearance. She may have been abused or neglected by her father as a child. If so, she may develop prominent symptoms of anxiety related behaviors when she interacts with her therapist. This is a negative transference. Over time and repeated sessions the therapist can travel with her back in time to the point that she was first emotionally traumatized. Eventually, he will be able to help her make associations between current emotional symptoms and certain past events. Gradually she will develop an understanding of why certain symptoms have developed and why certain undesired behaviors exist. If the motivation to change the behavior exists, over time the negative behavior can be re-programmed to a more desirable behavior. Effective therapy is actually curative and results in personal growth and eradication of symptoms. Insight oriented therapy is not appropriate for every patient because some patients lack the potential for insight. A behaviorally related form of therapy or cognitive based therapy may be more appropriate for some patients. Some patients may only be able to benefit from therapy based on emotional support.

An interesting yet sometimes frightening form of transference (for the therapist) is known as erotic transference. When this occurs the patient develops overwhelming romantic feelings for the therapist. Firm boundaries are crucial here in order to assure that the patient is actually helped and not emotionally damaged. Even seasoned and experienced therapists sometimes require clinical supervision when attempting to proceed with cases involving this form of transference reaction. The ultimate goal is to help the patient develop an understanding of what the feelings and emotions really represent. In successful intervention the patient eventually understands that the feelings aren't love necessarily and aren't about the therapist at all but are related to someone from the past that the therapist reminds his or her unconscious mind of. This process is usually  most clinically beneficial if the therapist and client have a strong clinical alliance. When this is present the client/patient is more likely to not resist allowing the therapeutic process to flow. The therapy sessions are in essence a form of laboratory exploratory experiment. Again, this form of therapy is useful only in appropriate patients.

Counter-transference involves the emotions activated within the therapist through interacting with the subject. To be an effective therapist one must learn to interpret and know when and when not to respond to counter-transference feelings. These feelings are often intuitively based and greatly help to make or confirm the diagnosis. In certain conditions such as severe personality disorders the counter-transference experienced can be very unpleasant. Certain patients can make the therapist feel and occasionally behave in ways uncharacteristic of themselves. At my worst I may find myself tempted to yell and throw a patient out of the office. It takes a lot to get me to that point, but on occasion I realize that I am human and it happens. I always feel badly afterward. Retrospectively, I usually realize that the particular patient is usually quite accustomed to being treated as such by others. With experience you learn that such people feel in control by causing others to feel out of control. They manipulate their environment in this way. You really feel foolish when you replay the scene in your mind seeing again the look of bewildered amusement on the patient's face. At that time you know exactly what they were thinking about you. "What the hell is wrong with this fool?" Most psychiatrists would probably never admit to this happening to them before but I don't think it can be avoided completely if enough personality disorders are seen.

In conclusion, one doesn't have to be a psychotherapist to observe and benefit from the process of transference/counter-transference. It occurs all the time everyday in most forms of interaction with others. A laymans term to describe counter-transference is the well known "gut feeling." 99.9% of the time that gut feeling is right on target. People who function well on an intuitive level learn to use these gut feelings to their benefit. Those gifted with psychic potential really just are able to contact a heightened sense of awareness. They aren't really creating anything but are just able to access certain information. Psychic John Edward and others believe that we all have this potential, to a degree, to access certain information known by most as psychic. Many are greatly skeptical in regards to psychics. Some law enforcement officials have witnessed cases solved by psychics when all else has failed. I have learned to keep an open mind and remember that we are only aware of one part of one billion parts of reality. There is much more that we do not know than that which we are aware of. Most of us don't know precisely how this computer and Internet are working right now, yet it exists.

Substance Abuse Update

                   

Today was a good day, much better than most ...

Those who follow my writings know of the growing dissatisfaction and frustration I have developed toward drug addicts, in general, especially crack cocaine addicts. Despite those emotions, I continue to work part time in a detox facility. 70% of those in addiction recovery will fail within a year of starting treatment, some will fail multiple times within that 12 month period.

Who would want to bother treating a group of people with such lack of promise? I grew up around many such people which is probably where the commitment originated. At a recent CME workshop I commented to one of the presenters that I felt I could help, to some degree, any individual who was willing to comply with my recommendations and cooperate with treatment. He told me that I was grandiose in my thinking. Maybe I was. Maybe that is why I have had so many problems within my clinic over the past couple of years since beginning to treat more chronic pain cases. It has been one of the greatest learning experiences of my career if nothing else. My new sub specialty has seemed to become identification of drug abusers and criminals and removing them.

Though, only a small percentage of my practice is actually pain management, the majority of my stress originates from substance abusing sociopaths disguised as normal patients. I suppose I have always felt compelled to accept a challenge and this has led to taking on patients that most other doctors would refuse to treat. I am pleased with the progress made in establishing better defined limits for those patients likely to benefit from treatment and those who are high risk and a waste of time. Medical school gives the false impression that a good doc will one day stamp out most pestilence and disease. Advancing along in the training process reveals a more clear truth in that there is a limited amount of patients in which a physician can make a major and lasting improvement in their condition. This is especially true for the specialty of psychiatry. Even though we have trillion dollar miracle pills for certain conditions, those pills aren't worth diddly squat if the patient doesn't comply with your instructions for taking the medication. So even in the best of circumstances we may significantly improve the lives of 50-60% of our patients, usually the patients able to comply well with treatment.

I find that most physicians avoid or shy away from treating severe anxiety and chronic pain because of the infiltration of the medical community by substance abusers who may put their license at risk. In my state, usually, persons who break the law with behaviors such as altering prescriptions, calling in their own refills, obtaining meds fraudulently, or selling controlled drugs are not aggressively prosecuted in my experience. The DEA system is set up more toward finding and weeding out physicians who prescribe inappropriately. This system has created a more concentrated and vicious population of substance abusers and divided physicians into those who will treat and those who won't treat. I'm still one who follows my conscience when it comes to treating chronic pain with opioid medications and severe anxiety with benzodiazepines. I still believe that about 75% of these patients benefit from the use of these medications when appropriately used. It is the other 25% of those seeking treatment for these disorders that carry a very high risk and cause problems for well intending physicians.

I have learned that most of these people in that 25% bracket are just sociopathic and must be identified as so and dismissed or avoided. They can be offered treatment for substance abuse but most will refuse or not comply due to their denial and lack of useful insight. It isn't considered a challenge to treat one who doesn't want appropriate treatment but is more so an exercise in futility. My practice had to release over 50 patients for violations of the controlled drug use agreement or outright criminal behavior during 2006. I will not allow those bad apples to cause me to deny treatment to my honest patients who do benefit by refusing to prescribe any controlled drugs where I feel appropriate.

I believe in principle, and the threat of having my DEA license suspended hasn't stopped me from doing what I feel is ethical and the right thing to do. I went before the State Medical Board in an informal inquiry last year to defend my developing practice policies in regards to the matter of prescribing schedule 2 narcotics. The main advice I received was to make sure my Continuing Medical Education was up to date and to improve my chart documentation and know when to refer or dismiss inappropriate patients. I tried to use the opportunity to shed more light on the practice environment for the average practitioner outside the metropolitan areas. It was made clear to me that wasn't included in their scope of concerns. Basically, I was told to work on saving my own hide and forget about social science. This caused me to feel conflicted and depressed for a while. I finally accepted that the only way to survive in the world of private practice is to practice self preservation which is to treat as few high risk patients as possible by learning to quickly identify those who probably aren't sincere about help and allowing them to flow downstream to the next unsuspecting but compassionate practitioner. This may be a bit poignant but this is reality in our health care system. Also accept referrals from reliable sources only. Eliminate walk-ins without a referral from a legitimate provider. Use well defined written agreements signed by you and the patient. Enforce violations of the agreement promptly and effectively. Improve communication with pharmacies and become working partners with law enforcement.

Today was a good day because in it I felt some hope. I saw a recovering alcoholic with panic disorder who had been sober and clean for almost 6 months and was working a full time job and handling his stressors without the use of alcohol. I had met him in detox several months ago. Today, I wished him well and felt good about being involved with his treatment. I also saw a chronic pain patient with Post-traumatic Stress Disorder who I feared greatly was primarily a substance abuser during previous visits. Today we talked about how the evils of incest had affected her life and her ability to mother her 4 children. She expressed readiness to accept help from an outside agency with the 2 oldest kids whose behaviors have become unmanageable. She arrived at this decision herself despite opposition from family members who offered no better solutions yet were critical of her. Today I know that she heard me and I felt more comfortable that she wouldn't choose to medicate herself into numbness as a primary coping mechanism. Finally, I saw a young post-partum mother who was on methadone for chronic pain for the past 13 years for pain associated with spina bifida. She had no significant history of substance abuse or mental illness. Her OB-GYN saw her through a successful pregnancy last November and had the courage to keep her on her methadone to avoid the complications that would arrive through withdrawal if it were stopped. He then had to refer her to a primary care doc whose main agenda was to taper her off the methadone. Methadone can be a miracle for one with a chronic pain syndrome and no substance abuse issues. It is perfectly legal for any doctor to prescribe it for the purpose of chronic pain control but not for addiction maintenance. Most doctors avoid it due to risks and inviting the Federal government into their practices. I thought she was a perfect patient for me to treat and accepted her care without a problem. She rose from near despair to elation upon discovering she could get the help she needed from me. I felt good about the decisions I made over the past year refusing to allow addicts to make me be unable to provide care to the truly needy. Today was a very good day.

Might Wanna Skip This One

   

I find that no truly original ideas or memories exist...

Chances are that in the history of man, somewhere at some time to some degree, some human brain has experienced that exact information. This realization initially crushed my ego because arrival at truth often reveals that I wasn't the first. My narcissistic injury is somewhat repaired by the knowledge that advancing our collective thinking in the context of certain moral and ethical standards is what truly connects us with divinity.

These words may suggest that I am stoned out of my mind with some substance of abuse but that is not the case, I can assure you. This is an example of that zone we can sometimes reach during those wee hours of the night when the ability to sleep vanishes. All of the background garbage thinking and self judging and criticism are at the lowest possible level. Truth begins to flow through the mind. Some refer to this as a period of deep meditation. Out of a sea of many thoughts the mind must assign value to those most cherished.

I just remembered the dream I was awakened from by a knock inside my head. The dream was actually violent in nature and simple about logs of a variety of sizes falling into a small but deep stream of water. I was trying to advise others how to avoid being crushed or pinned and drowned by the gigantic logs while attempting to save myself. It was hard to communicate this to these vague other people. Simultaneously, there was an area with many much smaller branches and twigs on the bank that I worked feverishly to clear away as the dream took on indescribable dimensions of the fertile soil being penetrated in a gradual manner and souls being released as I jumped and chanted in jubilation and amazement. These words can only describe in a superficial and simplistic manner the visual imagery and emotional tone of the memory of the dream I was experiencing several minutes ago.

To the average reader this material again may seem consistent with one who is psychotic or high as hell from a mind altering substance. I can assure you once again I am not but more so just free associating through the use of a keyboard. This entry may only have meaning for myself when I reflect upon it at a later time  I suppose that since my writing is just a hobby and I have no intention of profiting financially from it at anytime that every now and then it is ok to just use the space here to just write totally off the top of my head. I hate restrictions but understand the necessity for them.

I think my original point for this entry was an attempt at illustrating the context of the reality of this individual human's thinking and thoughts. I learned from Deepak Choprah, author/spritualist/physician that the human brain is usually aware of one part out of a billion parts of the total of reality. Most of what really exists can't even be imagined and we can't even imagine that we can't imagine it. As an example, quantum physics suggests that if you think you understand quantum physics then you don't understand quantum physics.

The closest we can come to an acceptable understanding of ultimate reality is through the concept and idea of God. God is so hard for us to comprehend and communicate to others that it sometimes frustrates us to the point we respond aggressively or judgmentally toward our fellow man or we justify making him or her an enemy and attempt to destroy that individual or individuals in the name of righteousness. It stretches from Cain and Abel to George and Saddam from an idealistic view. It will continue.

For the political finale today I wish to comment on the idea of conspiracy theories. I'm certain that what I have written so far will really make people trust and believe me.(not) It does really help make my point, however. I never suggest that people smoke pot or drop acid but the few people that really catch my drift for this entry will likely be stoned out of their gourd. I just wrote it as it flowed to me. You'll either get it or you won't have read this far anyway. This final point is that I want to state my awareness that 95% of conspiracy theory material is total B.S. Certain people in certain high places, however, are intelligent and crafty enough to capitalize on this fact and use it to their advantage. Remember that 5% of conspiracy theory is not theory at all but totally true. For most people it all boils down simply to "who do you trust the most?" I have a clear understanding of deception and things not appearing to be what they are because of my background and experience. I don't expect all others to think in the same manner as myself. There are those who fully trust my thinking, then there are those who absolutely and totally reject my ideas. I can accept that. I am learning to ignore those who don't see the same light as myself. Why bother? I'm an abstract thinker much of the time and am aware that concrete thinkers won't always be compatible with most of my views. In reality, there are two sides to every story with the real truth laying somewhere near the middle. That, my friend, is a fact.

What this meandering leads me to finally write is that there is a 100% chance that we have never been told a fraction of truth about 9/11 and the true extent of the involvement of our government and what the real intentions are there. I think it's ok to admit that sometimes it is better not to know the truth because then you don't have to ruin your plans and start dealing with it. This is sometimes referred to as willful ignorance, which at times I too have been guilty of. As far as UFO's, space visitors, AIDs and crack conspiracies, JFK, RFK, MLK, NSA, FISA, FEMA, CIA, FBI, PNAC, skull and bones, free masons, crop circles, pyramids... I just do not know. I do firmly believe in that 5% truth principle. On the other hand, I am convinced that the true 9/11 conspiracy theory is the one the government wants us to believe. When the true facts are placed on the table the story the public has been given by the government is ludicrous. At this point, I'll rest my case.

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