October 20, 2013

Dear Colleagues,
It has been another busy month. Many of you attended the conference last week with Terrence Gorski, "Current Trends in Addiction Treatment." Terry gave a vivid, compelling picture of the addict in recovery and the forces he faces. He took a practical, pragmatic approach to helping people change, who are trapped in intractable patterns of self-destructive behavior. Like a CMT therapist, Terry talked about giving the addict "permission" to change. Susan Landes talked about bridging the gap between psychotherapy and twelve-step programs. She reported on a recent dissertation documenting the degree of bias that psychology graduate students have for alcoholic patients in contrast to patients with depression. Patsy Wood gave a masterful review of the current understanding of addiction after an overview of Control Mastery Theory. In the afternoon, Claire Arbour presented a very nice case and Lynn Bertram, a psychiatrist with specialization in substance abuse, rounded out the panel that discussed several cases of patients in recovery.

Yesterday, Marshall Bush and I hosted the second seminar in New Directions in CMT. We heard excellent presentations by Joe Cristofalo, Ginger Rhodes, and Heather Clague, who explored their contributions in their personal areas of interest and expertise. Joe talked about Addiction Recovery and compulsive self-destructive behavior. Joe is hoping to develop his ideas into a paper with Susan Landes. He is also thinking of using Lynn O'Connor's Interpersonal Guilt Questionnaire (IGQ) in a research study to assess patients in recovery, further developing and sharpening questions about guilt and shame in that population.

Ginger, who has extensive experience with complex trauma survivors as well as political refugees who have undergone torture, talked about the tension between maintaining safety in therapy and how much can a therapist "nudge" traumatized patients to challenge their fears. She hopes to write a paper bringing together the Trauma school with the Control Mastery community.

Heather gave a wonderful presentation, "The Cooperator's Dilemma, Mutuality, Vulnerability, and the Importance of Limits," focusing mostly on children but including chimps, dogs, and elephants. She explored parenting issues (which overlap completely with therapist issues) again looking at the interesting dilemma of how much to support vs challenge a child (or patient), looking at the role of limits, and weighing the needs of the caregiver (parent or therapist) in the equation. Heather is also preparing her material for a paper or possibly a book.

The purpose of these seminars is to give our members who are thinking about theory and research a forum to present their ideas and crystallize them for eventual publication. We are also helping to plan research projects to test these ideas. Marshall and I have agreed to continue to offer an opportunity for people to come together to present and clarify their ideas in an intimate setting. We are going to offer a monthly seminar on Saturday mornings, probably from 9 am to noon for CE credits. The next meeting will be in early December. We will focus on ways to develop research projects to start to test some of the interesting theoretical propositions developed in the last two meetings.

We are also going to start to develop a catalog of "Next Step" research ideas to test CMT in an organized, methodical way. We want to think about which theoretical questions about CMT have been answered and what next logical questions need to be addressed in a research context. There is a large literature of research studies testing Joe Weiss' theory listed on the SFPRG website under "publications." You can go particularly to controlmastery.org for papers that can be downloaded. Also go to eparg.org for a comprehensive list of papers and current research projects that Lynn O'Connor is working on. To further research and to further Control Mastery Theory, we want to provide ideas for a set of potential next research projects to new dissertation students. If you have ideas or interest in research, if you have clinical/theoretical ideas you are working on, or if you want to hear others who are working on their own ideas, please email me or Marshall, or come to the next seminar in December. Check here next month for clarification for exact dates and time.

By the time this is published, we will already have had the 3rd annual SFPRG Art Show and fundraiser October 26, 2013. I hope to see you all there. Have a wonderful month.

Steve Foreman

Joe Cristofalo discussed a paper that is in the works on how CMT can be useful in working with clients in addiction recovery and their particular vulnerability to self-punishment. These clients have an acute need to make up ground on their emotional development and have a high likelihood of having been exposed to trauma in addicted families and as a result of their own substance abuse histories. One of the findings in Lynn O'Connor's 1997 study of the Interpersonal Guilt Questionnaire was that the drug addicted group was significantly higher on all subscales of the IGQ-45 including the self-hate scale.

Referring to the work of Bessel van der Kolk and Robert Sapolsky it was noted that recovering clients also have a high susceptibility to autonomic arousal and stress response. This discussion highlighted the importance of recovering clients developing the ability to manage negative arousal and lower autonomic reactivity.

A case illustration showed how CMT helps in reducing guilt, unconscious worries about oneself and unworthiness by shedding light on the pathogenic beliefs that keep these in place. CMT thereby affects a shift away from the corrosive/invasive unconscious concerns that manifest as obsessiveness and self-punishment and toward a disposition to self-care. CMT helps reformulate traumatic experiences that are the underpinnings of pathogenic beliefs. CMT emphasizes the importance of safety in the therapy relationship and an approach of a case-specific attentiveness to the clients concerns which can directly disconfirm the lack of attunement, unpredictability and unreliability that are common in alcohol/drug families of origin and which are then reenacted in the client's substance abusing history.

The clinic training year is off to a great start. We have our largest group of trainees and will have two more students from Norway joining us in January. With a group this large we need plenty of referrals, so please keep us in mind.

This fall we have made the transition into the world of electronic records. John Snyder did a wonderful job of researching the possibilities, finding an appropriate fit and then coordinating the training. We are now using electronic records for our complete patient chart, including the research protocol. We look forward to seeing how this changes our ability to track not only research but also patient care.

Again, we appreciate keeping us in mind for your referrals. Just contact Jessica Broitman or Carol Drucker.

Thank you to all who renewed your annual membership with SFPRG. Special thanks to those new to the organization supporting us with your dues for the first time.

If you have not filled out a profile on our website, please consider doing so. It is a way for our members to find others to refer to as well as a resource for the general public. We will be deleting profiles of people who did not renew their membership in the coming weeks.

You can print out the membership roster from our website.
Step 1: Login under Membership - remember your Login name is your email. Contact Rob in the office (sfprg@sfprg.org) if you do not remember your password.
Step 2: Click Member Directory from the menu
Step 3: Click Printable Directory in the upper right
Step 4: Print

Part 6 appeared in the August Newsletter

Therapy Technique
The first step in helping patients change behavior and step out of pathological identifications is for the therapist to recognize when specific problematic behaviors of the patient are pathological identifications, that is when they are almost exact repetitions of their parents' problematic behaviors, feelings and attitudes. Therapists have their own way of explaining pathology in their patients. Some tend to see problematic behaviors as deriving from poorly modulated aggressive and sexual drives, maladaptive defenses, disordered attachment, or disordered development of the self. They may see their patients as having problems with affect regulation or negatives schemas. Whatever else may be going on, when a therapist recognizes that the patient is exhibiting a specific pattern of behavior that comes directly from the parent's playbook of problematic behaviors, it should tip off the therapist to the dynamic of pathological identification. The therapist should be alerted to the possibility that the patient may be playing the role of their parent in order to avoid awareness of their feelings about what the parent did in order to protect the parent at their own expense.

When taking the history, the therapist can ask if the pathological behavior in which the patient is engaging is familiar to the patient. Did she do it before? When did it start? Did the patient remember anyone else doing it -- a parent, a sibling? Was it done to her or to someone else? How did the parents treat each other?

If the behavior is familiar and if the patient recognizes she is repeating a behavior she witnessed or experienced before, that may be enough to allow her to change. Charlie, who got himself into trouble with the IRS before his first child was born, was able to rectify his back taxes after just realizing he was repeating a messy situation his father had been in before, for no apparent good reason. Often a patient will ask incredulously, "Why would I repeat such a problem that my parent had? Why would I do something so stupid?"

Understanding that the patient's motivation is to protect his parent is often quite surprising but orienting to the patient. Patients present to therapy with very negative theories about themselves. They often believe they are selfish, evil, and hateful. Psychologically, the whole purpose of reenacting their parents' mistakes is unconsciously to take the heat off their parents and put it on themselves. Consciously, they believe they are the problem and their parents are quite ideal and acceptable. Sharing with a patient that he is really trying to protect his parent at his own psychological expense often goes against his fundamental theory of himself.

Patients may feel guilty seeing themselves in too much of a positive light. If the patient is not so bad, it means his parent may not be so good. Patients may become anxious starting to see their parent in a more negative light, leading to greater awareness of negative feelings toward the parent and concern they may turn away from the parent, as William worried he would do to his elderly father.

Rather than focusing on the patient's negative feelings toward the parent or the parents' negative behaviors directly, it may be less threatening for the therapist to begin by observing how caring the patient is for her parent. Patients may repress memories and feelings about their parents' negative behaviors but they are generally quite aware that they are worried about their parents and care about them.

Once the therapist has established that the patient is worried about his parent, it is not too much of a leap to link the fact that the patient's worry and concern may make it difficult to think about his negative feelings toward his parent. The therapist should be going only as quickly as the patient allows. Therapists should never impose theories and hypothetical experiences on the patient that the patient doesn't confirm with real memories and feelings.

The therapist's technique should be to start with the patient's memories and associations and explore feelings about those memories. As the patient feels safe to remember more and allow feelings about those memories (without damaging the parent, the therapist, or himself), he will have access to more memories (3).
(To be continued.)

SFPRG has offices up for rent. Now is your chance if you ever wanted to have an office in a beautiful national park! We signed a 5 year lease renewal with The Presidio. Contact Rob in the office if you are interested. 415-561-6771 or sfprg@sfprg.org