When the Diagnosis is : All of the Above

Most of us aren't Diagnostic and Statistical Manual (DSM) experts, but are aware of this thing we call the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders that therapists memorize. The bullet-point system of features at the corner of the desk is likely a well ear-marked spiral-bound copy of the bible. Docs flip easily to a suspected disorder.

"See?" we declare knowingly. "That's you."  Or more likely, "That's her."

Some of us read the patient right away. He belongs to either the anxiety disorder family, or the affective (depressive-manic) disorder tree, because so many of us do. The lucky belong to both. The experienced professional also recognizes substance abuse, eating and gambling disorders, personality disorders, everything.

Still, we work at that differential diagnosis, want to narrow the problem down, if there even is a real disorder, one that has met the full DSM criterion. Not everyone has a particular disorder, but we live in a world replete with mental and behavioral messiness, so a typical therapy visit also means someone else, someone who is not in the room, is the subject of that "See? That's her." Yes, you should worry when your partner gets a therapist.

All well and good. But what's a therapist to do when the patient begins by saying, for example, that as a kid he had an addiction to pot, and can't remember being depressed as it presents in the books, but knows he had suicidal thoughts. He will continue to say that he treated teachers as inferior beings and passive-aggressively refused to answer questions, yet never scored lower than an 90 on a test without studying. She'll tell you, too, change the gender, that she binged and purged before even knowing it would be popular in college, and that by the age of twenty started having obsessive thoughts when she saw a knife, visualizing the knife slashing her of its own accord. Or she might irrepressibly slash herself. Add to this a social network disorder that culminated in job loss, and compulsive sexual relationships on the internet. Oh, and she has a new job and she hates it.

All this without any family history, as if to say, It is my genetics that made me do it. I have a mental disorder and none of the doctors in the past have managed to narrow it down. Would you do that for me please? I'm under a lot of stress.

I look at you, do my best to read you. You return the favor, read me. I ask, How did you find me? Why me? This yields wonderful diagnostic information. Another question: What does your primary care doctor think?

Inevitably, assuming the pri-care is a family physician, the answer is: That I need counseling. I need to talk to someone like you.

Those of us who have helped people in one or two visits, who specialize in "only evaluations" or are in a hurry or don't have evening appointments might want to pass him on to another therapist. Our patient with a million symptoms and as many diagnoses and problems likely had a very messy childhood. One of my mentors once told me that if a person has been incested, that means twice a week for years.

Makes sense, right?  There are so many forms of incest, is the thing, and indeed, twice a week on the couch for years is an incredible luxury. And it usually isn't necessary, all due respect. Who has that kind of time? Job stress is at the top of the list. There is a V-code, I think, for that.

Upshot: If the patient with All of the Above* is your new patient, then settle back and relax. Feet up on the ottoman. Do the therapy that the primary care doctor has asked you to do. And don't worry about the diagnosis, the medication, or even who else you think should be in therapy. This one's yours. Embrace it.


therapydoc

All of the Above*: Not to say that there aren't a few diagnoses, but usually there are a few features of several diagnoses. One does have to go through that process, vetting those features, finding illness. All I'm saying is, don't let the diagnostic process get in the way of the therapy. Because it really can, seductive monster that it is.

Different Children

Get yourself a cup of coffee, maybe cut up some fruit. Then come back. Don't forget the napkin. And kids, remember. Your teachers can check online for that plagiarism thing.

We've talked about the trauma of childhood, how personality is shaped by things said and done.

Different children are shaped in some of the same ways. One child can come out of an abusive childhood forever needy and clingy, not having established basic trust in people, life, or himself, Don't Leave Me, Please, a song for a lifetime. No, make that a whine. This adult child wears his fear of abandonment like a badge.

Whereas another grows the proverbial chip on the shoulder; paranoia the flavor of anxiety. He's easy to anger and will attack first; a partner had best know that.

The acquisition of such personality traits is not a given by any means, or an either/or. Understand, there are many variants of children born to abusive circumstances, and many variants of abusive circumstances. But these two products of child abuse are often seen together as a couple, attracted to one another, repelled at the same time.

So we'll look at their dynamic, consider a male-male relationship, just to shake things up a bit. We could easily have chosen a heterosexual example.

Bad Boy, now in his late twenties, has suffered verbal and physical lashings from both parents and has internalized negative messages about himself. But he's not stupid. He knows that parents should never be mean to their children, even as they say, We do this for your own good. They are lying.

Some children, like him, have built in deception receptors; they sense that the people hurting them are not of stellar character. And they know that despite those reassurances that this is for their own good, that they will lose more than they gain in the process of "character development." Bad Boy still smarts from the words of such people.

Good Boy has suffered fewer personal attacks than Bad, but watched a good deal of parent on parent violence. He has also taken in his fair share of negative communication, insults, and abuse. His parents, locked into one another, wasted their personal best on their own conflictual relationship, while he identified with the victim, his mother, bleeding with her tears. He hurt when she hurt; he hurt past her being hurt. He was more vulnerable than she, only a boy, after all.

He's not stupid, either. He knows parents should be attentive, that they should be there for their children, should answer to their children's fears and emotional needs, and that his couldn't. He knows he's been cheated of a healthy childhood and he knows that his dependency, his insatiable needs from a lover, dominate his interaction in relationships. He can't help his need for feedback, his craving for love.

Love is Good Boy's drug. His lover is of a different psychic make-up, more prone to avoidance, more likely to abuse substances, enjoy rough relationships, and avoid closeness. This is unfortunate for both of them. One really can't help the other without some sort of intervention, some cognitive change.

Neither is whole, neither feels quite right. Bad Boy, the more aggressive young man, is less mature, lashes out under pressure to be emotionally intimate. (We think of intimacy as mature, but measured). Good Boy, in touch with his own desperation to be in-relation, shares all, intimate to a fault. He endangers himself.

So different! What are they doing together? The simmering one, his anger palpable, actually feels safe with one who wants him, needs him, adores him, and he has talked with him about his childhood. He's talked some, not a lot.

The one who craves intimacy isn't happy with the volatility of their relationship, but feels safe, ironically, with someone who seems so strong. Tough. Strong. Same thing?

The dynamic is captured, frozen early in their relationship.

Bad Boy knows that if anyone metes out punishment, it will be him. Good Boy is willing to risk that, knowing there's little he would do to endanger his lover's favor. He'll keep the conflict to a minimum, and the dynamic is just that, conflict at a minimum. The verbal sniping is uni-directional, from Bad Boy to Good Boy, never the other way around. To both of them it is relatively tame compared to what they had as children. But painful.

Bad won't work to please Good. He's not going to change, he says. This is me; I won't commit. I'm my own man. He has that edge, well-hewn over a lifetime.

The most important people in my world were never there for me. I don't need them, or you, or anyone else.

He thinks he has overcome his dependency needs and is annoyed at the dependency of his partner, although he needs him to be this way, dependent, to feel safe.

Such a conundrum.

Then it sometimes happens that Good Boy is let in, sometimes for quite awhile, and things get very affectionate. This is when being in-relation for Good Boy is wonderful, but most scary to Bad Boy. The intimacy tweaks at his primitive, unconscious, failed familial relations, which is where it gets dangerous.

Feeling violated by the intimacy, Bad has to stop the tweaking. He's entitled to his privacy; the rule is he gets to be secretive, gets his space. So he lashes out when violated in the name of intimacy, pushes Good Boy away.

Good: Where have you been?

Bad: You don't need to know. You have no right to know.

Good: Oh, sorry.

These games may be described as dances in the various self-help books at Borders. Go there and read them before they close all the book stores and you can't get an education for free off-line anymore. I personally prefer the feel of books to the glow of the screen.

But back to our story:

Bad Boy becomes mean and immature, aggressive and spiteful when Good wants more of him than he's comfortable giving. Bad Boy becomes abusive like the people who raised him. Transgenerational? No question.

Good Boy takes it. Ironically, he's perceived by his aggressive partner as smarter and more accomplished, and he is, but insecure.

Bad, even though he's less educated, less accomplished, even though he feels inadequate by comparison, is only safe because Good is this way, insecure. Bad Boy benefits by association, too, with an accomplished partner, and owns some of that accomplishment (in-relation).

And he stays on top by sniping when his partner is most vulnerable, when he says, Don't leave me, please.

It's a hot button. You don't own me, his refrain.

Some of us see relations more as opera than dance.

It is the needier, sadder partner who comes for therapy. Tougher, perhaps more wounded people, the bad ones, don't voluntarily risk exposure, the stuff of therapy. It's an art, of course, therapy, peeling back all those layers, and takes forever sometimes. Exacted carefully, it shouldn't hurt, but not everyone knows this.

So angry people like Bad Boy mostly come to therapy when they're court- ordered, or when Good Boy can take it no longer, forces the issue and leaves. And he's not likely to want to take that step, so in love.

It's the needier sadder partner, who comes to understand (in therapy) that his tough lover really needs his sweetness, his warmth and tenderness, but in small doses.

Affection can be overwhelming, a reminder of what a person didn't have as a child. And as a child, Bad learned, Don't get sad, get mad. He's a master at putting on the brakes when reminded of what he didn't have, when he begins to grieve, unconsciously. He reflexively pushes tears and all tenderness away.

His defense,

I don't have to tell you.

You have no right to know;

you don't own me

completes an emotional feedback loop. Only a strong person can say things like,

Because, that's why.

Good Boy could never talk back in this way, it's not nice. Good Boy's greatest mistake is that he misinterprets that resoluteness as strength, and he associates strength as potentially protective, as often happens in child abuse.

Nevertheless, he'd like a way into his lover's psyche. How do you gain entry to a gate that's been locked, double locked, triple locked, then locked again?

Couples therapists label the interactive dynamics for Good Boy, who comes to treatment. We'll do the psychoeducation, draw the feedback loops, assist in highlighting the childhood relationship systems of our patients. (It's what you pay us for.)

But when one partner is in therapy and the other is not, it is expecting too much to send the attendee home to teach, especially if the other is already on the defensive and doesn't want an education.

So we'll say to Good Boy,

When he's mean, tell him, 'I know what you're doing, and I just want you to know, you don't have to do this.'

Good can get even more specific and say,

'I know you need to push me away. It's okay. I just want you to know, I won't hurt you. I would never say those things to you, those things your momma/poppa said to you. You know that by now. Don't you?'

Changes in these relationships, these homeostatic feedback loops so deeply rooted in the psyche, can take years, literally, with therapy. That's why most individual therapists will say, Forget him. Change you. Become independent. Don't be so desperate. Find someone nicer. All good advice.

And so easy, right?

copyright 2008, therapydoc

EDITS: Things I took out of this essay for one reason or another, yet feel are still relevant.

In adult relationships we become the mothers, the fathers, the sisters, the brothers, the best friends and enemies of our significant others. For better or worse. Recognizing where they need to be better, how they feel worse, this is the essence of a couple diagnostic.

The types of loving parents you read about on the Mommy Blogs are as illusory as fairy tales in the minds of abused children.

In couples treatment, when we suggest to the healthier partner that he or she model positive parenting, it can be a huge stretch, very difficult to enact, and the audience is booing, scoffing.

It's always that trust thing.

In individual therapies the therapist can take on the role of the good parent. Or the bad parent, when therapy is stressful. Or when we take a vacation.