Friday, October 27, 2017

Me, too

It isn't a new story, not to me. Not a new thing, sexual assault, rape, harassment, but having listened to dozens of victims (fine, survivors) tell their stories over dozens of years, surprisingly it never gets boring.

A man in his thirties talks about his experience as a young boy, age six, and a rabbi (rabbi!) who took his youth. You see, it is not only the priests, this is cross-cultural.

Or a woman in her twenties. She writes the details in long-hand, cannot talk about what happened to her. She is married now, hates sex.

Another man is introduced to porn and sex as a schoolboy, an older cousin. My patient cannot maintain a relationship, cannot finish what he starts, hardly ever initiates. He is addicted to online porn.

A prostitute tells me that she's had sex with hundreds of men, was told that it was all she was good for. She believed it for the longest time.

A mother brings in her daughter, says that incest is in the family and she fears that her daughter has been molested repeatedly by an uncle, her brother. The daughter will not talk about it. The mother discusses her own trauma, the abuse she suffered from him.

A young woman in her early thirties tells me that she has a choice. She can "date" her boss, or she can look for another job. There's a company retreat, required attendance, and she knows he will force the issue there.

A college student on break for the summer comes to therapy to get over an acquaintance rape. She'd been drinking. He walked her home.

Another woman recalls the tragedy of her life, a violent rape. He slit her throat, left her to die in the snow. She was under the influence, blamed herself for years.

Now there's #Me, too.

Women are opening up the proverbial can of worms, telling their stories to anyone who will listen. We are telling the world on Twitter and on other social media sites, screaming to other women that we are not alone. This happens.

Who doesn't have a #MeToo story? Find me that woman and I will tell you that likely she's (a) been very lucky or (b) she can't remember, lives in denial, head in the sand (this happens). Prove me wrong, tell me how a little girl, a young woman, a little boy, a vulnerable man, can avoid this abuse of personal boundaries. Because rape happens even if you wear long sleeves, long skirts, wear a bag over your head. It makes you all the more of a challenge, is all.

Therapists have to work out their own Me Too.  Most of us, by a certain age, have told our story countless times. We do it in classes via the small group, designed to be intimate, set up to smoke out our interface. We've had our own therapy, encourage our patients to speak with us about their experiences. Better out than in, purge it. Now this opportunity is available via social media, so much support for the survivor, no blame any longer for the victim.

This is something phenomenal and unexpected. That women would come out, one after another, after another, a seemingly endless chain of stories, amazing. That it is the rich and the famous are in the spotlight as predators, all the more incredible, but it comes as no surprise.

We might grieve that #Bill Cosby got away, a hung jury, and that #Bill O'Reilly has somehow crawled under the rock he came from. But #HarveyWeinstein has not escaped an unrelenting public eye. He will likely go to jail. And from there he'll make the movie about himself, ugly and shocking, like him. If he is smart all of the proceeds will go to the international fight against sexual assault

I'm not sure in the ten years of blogging anonymously that I've ever done a #MeToo.
Now would be the time, no? Being female, I have more than one (I think I counted four, including the father of a friend, I was 16). Here's the least emotionally damaging:
In college, a junior. I have an apartment in a co-op, am resident advisor. I accept a date from a man I know peripherally on campus, not even from class. He walks into the little apartment, closes the door, puts his hands on my shoulders and attempts to push me to the floor.
My adrenaline is greater than his, and maybe my anger, and I wrest myself free, push him out the door, lock it. Collapse. I kept the story a secret for years. It is why, to this day, FD tells me that he pities the man who tries to assault me.
This is no joke, however, having to fight off sexual assault, and it is something that I fear, as do most other women when they go out, even to their cars to go to the store in the evening, and men, too, who have been the objects of sexual assault.

That story, however, is hardly a #Metoo.  It is a survivor tale, not a victim story, and I never had him charged with attempted battery or assault. We could call it a Not me! in fact. In the treatment of rape Not Me is what we're after, but it is rare, this transition from victim to survivor, and placing the blame where it belongs, on the perpetrator, not ourselves. But that was sheer luck, pushing him out the door. If he had a gun or a knife, would I have been so bold?

There's a post on this blog, first steps toward treating rape, and it is far and above the most read on this site. Because most of the time we don't get away, and we're searching for those first steps in recovery, if not for ourselves, then for a friend, a relative.

Rape (the preferred legal designation is sexual assault) is a 1 out of 3 phenomenon for women, 1 out of 8 for men. It is possible there is even more of this crime now, or maybe less, I'm not sure. But it should be a 0 out of 3, 0 out of 10. No means No is not a new mantra.

Sexual assault begins as a violation of physical boundaries, and as such, has far reaching emotional consequences, several likely diagnoses will present soon after the event. A short list:
post-traumatic stress, 
sexual dysfunction, 
addiction to alcohol and drugs, 
intimacy fears, 

The body memories, the pain, the pregnancy and disease that go along with the trauma, these physical manifestations magnify the emotional pain.

But still, most telling is that the stories we are hearing now have been the dirty little secrets for years, feeding self-blame and anger, embarrassment, stigma, marginalization.

We might compare the experience of sexual assault to a different type of crime. Consider the man who has been a victim of frequent muggings. He tells his therapist that he this happens often, probably because he isn't a big guy. He appears vulnerable, and he is. But he tells everyone when his wallet is surrendered to a masked fellow with a gun on the street, near the alley. It doesn't even faze him anymore that this happens. He's learned to carry only one credit card.

When you read a MeToo story in the coming weeks and reflect upon your own, think about finding a way to share it, even if it anonymously. Even if it is a where do I begin, kind of thing, as it is when it comes to how many times we women are molested in our lifetimes, or approached for sex that we don't want, coerced, physically forced. We are vulnerable, and when we are young or old, unarmed and disempowered, we don't know what to do, so we do nothing.

What should we do? Tell someone, preferably a rape victim advocate, even years later. Or call the state coalition against sexual assault. Ask for someone trained on the crime at the emergency room, if it just happened. Make sure to ask for a rape kit, too.  And get some therapy, even if you think you don't need it.

Last night I listened to an interview on NPR. A female lawyer who specialized in defending sexual assault victims said that she wasn't sure that on the job sexual harassment training really does any good.* She said that the online training offered at most jobs with over fifty employees is sometimes good, never great. And she wasn't sure that any training, honestly, made any difference in the corporate world, where promotions are dangled, demotions expected. I always suspected as much, and after the prevention workshop phase of my life ended, segued to treating known perpetrators.

The lawyer's message, that prevention efforts haven't been shown effective, and that maybe it is impossible to eradicate sexual assault, seems terribly dark. But she ended on an upbeat note:

When well-respected, affluent men are outed for sexual assault, when the producers at Amazon, the managers at Fidelity, the Harvey Weinsteins, Bill O'Reillys, and even past Presidents (George H. W. Bush) must apologize, we are making progress. These high profile men influence the decisions of other high profile men, and if they go to jail, all the more so.

We can only hope.


*You might remember that I developed a series of these, offered them to corporations and schools. Online training made me obsolete and I abandoned the initiative.

Wednesday, October 11, 2017

Steven Paddock's Mental Illness

Stephen Paddock talks about is happy-go-lucky self

Unusual, isn't it, that mental health professionals aren't chiming in with a diagnosis for Stephen Paddock? We usually do. I usually do. No small crime, massacring 58 innocent people, injuring hundreds more. 

People died for doing nothing more American than listening to country music. 

Yesterday's New York Times

The Las Vegas police believe Mr. Paddock may have had a secret life. 

More accurately, he didn't advertise his intentions. We all have secret lives, and he was particularly private. But he could be friendly. He went on a gun shopping spree in October, 2016, and the salespeople found him pleasant enough.

Reports from his brother Eric Paddock:

From an early age, he focused on gaining complete control over his life and not having to rely on anyone. He cycled through a series of jobs he thought would make him rich

“He went to work for the I.R.S. because he thought that’s where the money was, but it turned out the money wasn’t there,” the younger Mr. Paddock said. “He went to the aerospace industry but the money wasn’t there either. He went to real estate and that’s where the money was.”

Which only tells us he wasn't into being poor. He went to work at the postal service, too, where his father's picture stared down at him: MOST WANTED, a doubtful coincidence.

with two failed marriages, both short and childless. Stephen Paddock started gambling. Some who met him described him as arrogant, with a strong sense of superiority. People in his life bent to his will, even his mother and brother. He went out of his way for no one

“He acted like everybody worked for him and that he was above others,” 

We can understand why the marriages didn't last.  But narcissism, loving only one's self, isn't necessarily a predictor of sociopathic behavior. It might help, certainly functions to put people off socially, distance from others (protection, exposure avoidance). The son of a psychotic bank robber, Stephen Paddock had to work hard to project an image of normal, ended up shooting for better than, superior. Feeling superior beats the alternative, masks feelings of inferiority by trying to make it so. Fool them and you can fool yourself, too. 

“I would liken him to a chess player: very analytical and a numbers guy,” 

 Mr. Paddock cherished his solitude, his brother said.

He knew that he was smart, could succeed in business, even at poker, and at the slots (there are ways to beat the house). In that cold, analytic, unemotional fashion, he could plan the logistics of a mass murder. It becomes a game, how many guns would it take, how long would he have before they discovered him, etc. The detachment from reality that tells him he's superior, different, enables him to murder. Most of us love other people, want to be a part of their world, admire how they look, how they smile. Not Paddock. If they don't admire him, serve him, he has no use for them.

A 1969 newspaper story described him as a “glib, smooth talking ‘confidence man,’ who is egotistic and arrogant.”

That's about Stephen's father, Benjamin Patrick (Hoskins) Paddock, who had a long rap sheet, bad checks, stealing cars, robbing banks.  

Benjamin Paddock was arrested when Stephen was 7 years old. If he didn't know why his father disappeared, it is likely he knew that he was a criminal, and at some point found out. It is possible his father even contacted him while on the lam, when he evaded law enforcement after his escape from prison. 

For certain Stephen knew he would have to rely upon himself, that his mother needed help. In school in California, wanting to win a contest, he apparently cheated. Others accused him. He merely smiled, as if to say, I can do that, I'm above those rules, better than you. Make it so. 

Investing in real estate in Los Angeles made him a millionaire. But he personally attended to the buildings, treated tenants well, wanted them to be happy. So he wasn't detached from people who depended upon him, who could see him as somebody. I would bet he tipped well at the hotel.

a midlevel high roller, capable of losing $100,000 in one session, . . . Mr. Paddock may have lost that amount at the Red Rock Casino in Las Vegas within the last few months.

This could be when he began to lose his sense of self, shake up those manufactured feelings of superiority that kept him going, provided him a reason to love himself.

The story skips to Paddock's total detachment, social isolation from his neighbors in Nevada.  

Mr. McKay (a neighbor) yelled out, “Merry Christmas!” Mr. Paddock kept walking. “He said nothing,” Mr. McKay said. “Not a word. No eye contact.”

It may seem that I'm making a case here for personality, narcissism or schizoid (below) but there are other diagnoses that apply. When we diagnose there are two types of diagnostic categories, one personality, the other the primary disorder, like alcoholism, or depression. Briefly, let's look at the options based on that short narrative.

(1) Gambling addiction

He stopped working to gamble full time, compulsive behavior that makes a rich man poor. But having nobody home waiting for him, the addiction wouldn't come to anyone's attention.  

Gambling, like using cocaine, can lead to crime to recoup one's losses. That he might be reduced to that, become like his father, might have stressed him. He took comfort in making money legally.  

If we might think he had a grudge because of his losses, then we would think he would act out on a casino, not innocent people, perhaps bomb the hotel. But his state indicates that the human race is the target, specifically happy people going to concerts. They're happy, he's not. Been there, done that his whole life. 

So far, calling Paddock's problem a gambling addiction doesn't explain much, but another diagnosis might 

(2) Bipolar Disorder

Mania is the "high" end of the bipolar spectrum, and it presents as excessive energy, no need for sleep, excessive everything, irresponsible spending and behavior. The "low" pole, depression, is vegetative. That Paddock gambled for very high stakes indicates a preference to excessive and a need for stimulation, what some people call an alcoholic personality (no surprise, there can be an association between the two disorders). Paddock wanted an even better win. An exceptionally big win.

So many lives.  An exceptional number of lives.

(3) Depression

The father, a bank robber, had suicidal thoughts, one of the symptoms of depression, and at the end of his life, the son completed the act, killed himself, along with the others. 
 I'll take you all down with me. 
He might have thought that, likely wasn't the cocky, cheery man he liked to present in public. (But who is?) Certainly plausible for a depressed man with no children who ultimately couldn't control his life, could fail at the casino and at online poker, couldn't keep a wife. Wasn't enough to keep a father and lost him at a vulnerable age, seven. 

neighbor suggested that Stephen Paddock did seemed depressed. And quirky. One of the features of depression is avoiding socialization, presenting as irritable, unapproachable. There are many different diagnoses, all types of depression, and again, it is the opposite pole in bipolar disorder.

So maybe we're back to bipolar disorder.. 

But depression, remember, is often a secondary diagnosis, can be caused by all kinds of disorders, like alcoholism, eating disordersattention deficit disorder, high functioning autism, borderline personality disorderobsessive compulsive disorder, the list goes on and on.  

(4) Schizophrenia

We would be remiss if we didn't look at schizophrenia, at its worst a type of psychosis, unmanageable without medication (like bipolar disorder). Maybe he heard voices in his head that screamed: 

People are evil. You are evil. Kill many, as many as possible, and kill yourself. Tell no one about us (the voices). 

The voices only come out at night, when he's about to go to sleep. So he stays up and gambles to have something to do, to keep them at bay, sleeps during the day to avoid the pain and torture of these demons and their escalating, damning voices. Voices in the head can wear a person down. A man might cave.

And his brother mentioned that he seemed tired, not himself. Perhaps he couldn't fight the voices anymore.

(5) Social phobia/anxiety

He didn't speak with classmates as a child, kept to himself, and apparently ignored neighbors as an adult. A
 solitary man who played solitary games, slot machines. No desire to join a neighborhood poker games drinking beer with friends (loved online poker), or go to a Dodgers playoff game, perhaps, just to be with people, to be a part of something. 

But this doesn't mean he had a fear of people, or that he wanted to be with people, just lacked the confidence to initiate friendship. People with social phobia come to therapy because they want to join in, want to connect with others. 

We're not feeling that with Stephen Paddock. If he went to therapy for social skills training, we would have already heard about it.

(6) Schizoid personality disorder 

Here the pattern of detachment from social relationships, deliberate, is by definition the most salient feature-- no desire to be with people, not even family. The disorder is marked not only by the dearth of relationships, but indifference to praise or criticism and a palpable emotional chill or flat  personality affect. 

And little interest in sexual experiences with others, yet we hear Paddock hired prostitutes. And more important, he was nice to his tenants, the people who needed him, who admired him.

Also, the symptoms of schizoid disorder cannot concur in another, such as bipolar or schizophrenia, depression with psychotic features, or autism spectrum disorder. So it is a tough call, and we rarely see them in an outpatient clinical population. If we do, engaging the patient is extremely difficult. When he doesn't return we suspect premorbid schizophrenia, might even reach out to an emergency contact on an intake form. 

(7) Narcissistic Personality Disorder

That grandiosity, wanting himself to be better than everyone else, special, and the feeling that he has that he is unique, gifted, works to enhance low self-esteem. Sufferers of NPD are fragile emotionally, and lack empathy with others, are described as self-centered, arrogant, manipulative and demanding, harboring fantasies of success. They seek admiration and attention, are intolerant of criticism, suffer "narcissistic injuries" when criticized, are antagonized, angry, irritable and vengeful.

Enough said.

(8) Antisocial Personality Disorder

This is the one commonly referred to as sociopathic, or psychopathic. Features include a pattern of disregard for others, or violations of their rights; failure to conform to social norms with respect to lawful behavior; deceitfulness, conning; impulsivity; irritability; reckless disregard for the safety of others; consistent irresponsibility; lack of remorse; evidence of conduct disorder before the age of 15; and that the occurance of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

One need not have them all. Paddock tied up many of them in one day. 

Now you see why everyone's so reluctant to put a ring on the diagnosis? 

There are life circumstances, reasons these disorders unfold as they do, although it is tempting to blame genetics. Therapy in early childhood for someone like Stephen Paddock might have gone a long way. But the family didn't have resources for that. The boys drank powdered milk. And he didn't seek therapy when he could afford it. If he did, we can predict he would be the type of patient that if we failed to flatter, and continue to flatter, would lash out at us, threaten to sue us, or otherwise make us feel like a fool. .

What happened to bring out the very worst in this man? 

A boy has a father who is above the law, takes from others, ruthlessly. A Most Wanted man, and a fugitive. The father is incarcerated when the boy is 7, but escapes. He is in hiding for six years before capture. The boy theoretically knows none of this, but we don't know if he hadn't been contacted, sworn to secrecy. 
Tell no one we talked.
Now they are in collusion. 

His mother has moved the family to a small community, a place where people don't know her. She struggles, has no money, like most of her neighbors. Her eldest son is aloof, seems arrogant to classmates. Like his father, he doesn't play by the rules, either. He has no friends. He's learned that he needs to depend upon himself if he'll ever get out of that place. 

He tries various jobs, finds a niche in real estate, invests in properties that sky rocket, ensures an early retirement for his mother and his brother.  Somebody had to do it, and it is important to him that he be somebody. Maybe somebody other than a man like his father.

We call this conflict in therapy. Do I make it legally, or as a conman, like my father. My feeling is that he synthesized the two, found ways to beat the house, but played the slots legally (more on this in that article cited above).

Either way, he's socially detached, maybe because of the shame of having an incarcerated father, a failure, a pariah, a psychopath. And this is fifty percent of his DNA. He went to school, he knows this. He has to keep his father a secret, too. It isn't something you can brag to people about. 

There's trauma beyond the shame, perhaps intrusive thoughts about the man's methods, waving guns, behaving in a violent fashion (we should have included Post Traumatic Stress Disorder above). PTSD is one of those diagnoses that coexists, causes depression and other anxiety disorders, especially hypervigilance (wanting to own guns, perhaps). 

But maybe also identification: My father, myself. Larger than life, a man on the run, a cloud covering everything. A black mark. Or, at some point, admiration. A genius. I'm like him. People are tools.

At some point he tires of real estate, retreats to the casino because he's good at this, gambling. He's systematic, counts cards, hogs the slot machine. It is a happier place, the casino. But nobody wins all of the time, and inside he's still harboring very real negative feelings, jealousy and envy toward others, people who have normal lives, normal fathers. 

He can change that, even the score with one formidable, unthinkable act of violence. 


What's Going to Be with Our Kids?